racial, ethnic and socioeconomic health disparities in the us
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Racial, Ethnic and Socioeconomic Health Disparities in the US. Richard Lichtenstein Ph.D., MPH University of Michigan School of Public Health June 2007. Fair or Poor Health among Adults 18 years and older by family income, race, and Hispanic origin, 2004. - PowerPoint PPT PresentationTRANSCRIPT
Racial, Ethnic and Socioeconomic Health Disparities in the US
Richard Lichtenstein Ph.D., MPH
University of Michigan
School of Public Health
June 2007
Fair or Poor Health among Adults18 years and older by family income, race,
and Hispanic origin, 2004
0
5
10
15
20
25
30
Per
cent
White, non-Hispanic Black, non-Hispanic Hispanic
Poor Near Poor Non-Poor
Source: Health, United States, 2006 Table 60
Why are Poverty and Race/Ethnicity Related to
Health?
What Racial/Ethnic Group Accounts for the Most Poor
People in the US?
Number of Persons Below Poverty Level By Race, 2004
0
10000
20000
30000
40000
All races White Black Asian Hispanic
Source: Health, United States, 2006, Table 3
In T
hou
sand
s
Percent of Persons Below Poverty Level By Race, 2003
0%
5%
10%
15%
20%
25%
All races White Black Asian Hispanic or Latino
Source: Health, United States, 2006, Table 3
Per
cen
t b
elow
pov
erty
Figure 2.6Percent of Persons with Incomes Below
Poverty Level by Age
0
5
10
15
20
25
30
35
City of Detroit Wayne CountyDetroit PMSA* Michigan
Source: U.S. Bureau of the Census, Census 2000 Supplementary Survey* Primary Metropolitan Statistical Area
What is Race?
What is Race?
• “Race is a social construct, a social classification based on phenotype, that governs the distribution of risks and opportunities in our race-conscious society.”
• Race is not a biological determinant.
Camara Phyllis Jones
What is Race?
• “Although ethnicity reflects cultural heritage, race measures a societally imposed identity and consequent exposure to the societal constraints associated with that particular identity.”
Camara Phyllis Jones
What is Race?
Phenotypically and/or geographically distinctive sub-specific group, composed of individuals inhabiting a defined geographical and/or ecological region, and possessing characteristic phenotypic and gene frequencies that distinguish it from other such groups.
The number of racial groups that one wishes to recognize within a species is usually arbitrary but suitable for the purposes under investigation.
Dictionary of Genetics (1990)
Race Varies by Country
• “This assigned race varies among countries…In the United States I am clearly labeled Black, while in Brazil I would be just as clearly labeled White and in South Africa I would be clearly labeled "colored." It is likely that, if I stayed long enough in any one of these settings, my health profile would become that of the group to which I had been assigned, even though I would have the same genetic endowment in all three settings.”
Camara Phyllis Jones
Health Disparities or Health Inequalities are inequities that
are related to differences in health status or medical
treatment that are unfair to disadvantaged people and that
are avoidable
Braverman and Tarimo, Soc Sci and Med:54:1621-1635 (2002).
“Pursuing equity in health care means striving to reduce avoidable disparities in physical and psychological well-being—
and in the determinants of that well-being—that are systematically observed between groups of people with different levels of underlying social privilege, i.e.,
wealth, power or prestige.”
Braverman and Tarimo, Soc Sci and Med:54:1621-1635 (2002).
Some Data on Detroit and Some Neighborhoods in
Detroit
Population by RaceCity of Detroit Health Dept. and Michigan Residents, 2003
Black83%
White12%
Other5%
Other4%
White82%
Black14%
City of Detroit Health Dept. Michigan
Source: U.S. Bureau of the Census, Census 2000 Supplementary Survey:http://www.census.gov/acs/
Demographic Characteristics of the Eastside of Detroit
Table 1: Sociodemographic Characteristics of Eastside and Central Detroit in Comparison to City of
Detroit and the National AverageCharacteristic 48213 48201/08/16/23 City of Detroit National
Average* Median Income
$24,633 $18,045 $29,526 $37,005
% Below Poverty
33.63% 40.74% 28.32% 12.4%
% High school graduates
60.43%
64.25% 67.62% 80.4%
% African-American
96.14% 73.03% 80.54% 12.3%
% Single parent household
40.11% 38.46% 32.97% 16.4%
*2000 Census, www.census.govDetroit data from www.chimart.org, 1999-2001 data
Table II: Health Status Characteristics of the Eastside in Comparison to the City of Detroit and the
U.S. Population
Age Adjusted Mortality Rates (per 100,000)
48213 City of Detroit National Average*
Heart disease 405.02 411.34 240.8 Homicide 49.34 41.03 6.1 HIV/AIDS 24.92 14.16 4.9 Cancer (all types) 242.28 239.89 193.5 Diabetes Mellitus 35.12 34.0 25.4 Infant Mortality** 17.94 14.77 7.0
Detroit data from www.chimart.org, 1999-2001 data*2002 Data from Health, United States, 2005 Table 29**Infant deaths/1000 live births, Health United States Table 25
Life Expectancy at Birth by Race and Sex, 1970-2003
55
60
65
70
75
80
85
1970
1980
1990
1992
1994
1996
1998
2000
2002
WhiteMale
WhiteFemale
BlackMale
BlackFemale
Source: Health, United States, 2005, Table 27, http://www.cdc.gov/nchs/data/hus/hus05.pdf#summary
Why Do Blacks Have a Shorter Life Expectancy Than Whites?
Age-Adjusted Death RatesDue to All Causes,
by Race and Hispanic Origin, 2003
0
200
400
600
800
1000
1200
Age
-Ad
just
ed D
eath
Rat
e
White BlackAm. Indian or Alaskan Asian/Pacific IslanderHispanic
Source: Health, United States, 2005, Table 29http://www.cdc.gov/nchs/data/hus/hus05.pdf#summary
Years of Potential Life Lostdue to Ischemic Heart Disease,
by race and Hispanic origin, 2003
0200400600800
10001200
Yea
rs l
ost*
2003
White BlackAm. Indian or Alaskan Asian/Pacific IslanderHispanic
Source: Health, United States, 2005, Table 30http://www.cdc.gov/nchs/data/hus/hus05.pdf#summary
* Age-adjusted years lost before age 75 per 100,000 population under 75 years of age.
Years of Potential Life Lostdue to Cerebrovascular Diseases,by race and Hispanic origin, 2003
0
200
400
600
Yea
rs lo
st*
White BlackAm. Indian or Alaskan Asian/Pacific IslanderHispanic
Source: Health, United States, 2005, Table 30
http://www.cdc.gov/nchs/data/hus/hus05.pdf#summary
* Age-adjusted years lost before age 75 per 100,000 population under 75 years of age.
Years of Potential Life Lostdue to Breast Cancer,
Females by race and Hispanic origin, 2003
0
150
300
450
600
Yea
rs lo
st*
2003
White BlackAm. Indian or Alaskan Asian/Pacific IslanderHispanic
Source: Health, United States, 2005, Table 30
http://www.cdc.gov/nchs/data/hus/hus05.pdf#summary* Age-adjusted years lost before age 75 per 100,000 population under 75 years of age.
Years of Potential Life Lostdue to Prostate Cancer,
Males by race and Hispanic origin, 2003
0
40
80
120
160
Yea
rs lo
st*
White BlackAm. Indian or Alaskan Asian/Pacific IslanderHispanic
Source: Health, United States, 2005, Table 30
http://www.cdc.gov/nchs/data/hus/hus05.pdf#summary
* Age-adjusted years lost before age 75 per 100,000 population under 75 years of age.
Years of Potential Life Lostdue to Diabetes Mellitus,
by race and Hispanic origin, 2003
0
100
200
300
400
Yea
rs lo
st*
White BlackAm. Indian or Alaskan Asian/Pacific IslanderHispanic
Source: Health, United States, 2005, Table 30
http://www.cdc.gov/nchs/data/hus/hus05.pdf#summary* Age-adjusted years lost before age 75 per 100,000 population under 75 years of age.
Years of Potential Life Lostdue to HIV Infection,
by race and Hispanic origin, 2003
0
300
600
900
Yea
rs lo
st*
White BlackAm. Indian or Alaskan Asian/Pacific IslanderHispanic
Source: Health, United States, 2005, Table 30
http://www.cdc.gov/nchs/data/hus/hus05.pdf#summary * Age-adjusted years lost before age 75 per 100,000 population under 75 years of age.
Years of Potential Life Lostdue to Homicide,
by race and Hispanic origin, 2003
0
200
400
600
800
1000
Yea
rs lo
st*
White BlackAm. Indian or Alaskan Asian/Pacific IslanderHispanic
Source: Health, United States, 2005, Table 30
http://www.cdc.gov/nchs/data/hus/hus05.pdf#summary* Age-adjusted years lost before age 75 per 100,000 population under 75 years of age.
5 Year Relative Survival Rates for Breast Cancer
50
60
70
80
90
100
1974-79 1980-82 1983-85 1986-88 1989-91 1992-94 1996-2002
White Female
Black Female
Per
cen
t of
Pat
ien
ts (
%)
Source: Health, United States, 2006, Table 54: http://www.cdc.gov/nchs/data/hus/hus06.pdf#summary
Infant Mortality Rates by Race*United States, 1970-2003
0
10
20
30
40
1970
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
All races White Black
Source: Health, United States, 2006, Table 22
Dea
ths
per
1,0
00 L
ive
Bir
ths
*Race of mother
0 2 4 6 8 10 12 14 16
Black, not Hispanic
Hispanic (total)
Puerto Rican
White, not Hispanic
Cuban
Mexican
Japanese
Chinese
Hawaiian
Central and South American
Figure 24. Infant mortality rates by detailed race and Hispanic origin of mother: United States, 1999-2001
NOTES: Infant is defined as under 1 year of age. Persons of Hispanic origin may be of any race. The race groups, Asian or Pacific Islander and American Indian or Alaska Native, include persons of Hispanic and non-Hispanic origin. See Data Table for data points graphed and additional notes.
SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics, National Linked Birth/Infant Death Data Sets.
Infant per 1,000 live births
Other Hispanic
Filipino
Centers for Disease Control and Prevention, National Center for Health Statistics. Health, United States, 2004
Asian or Pacific Islander (total)
Other Asian or Pacific Islander
American Indian or Alaska Native
IMR for US in 2004 was 6.37
NOTE: The US placed 180 out of 221 countries (higher is better)
Source: CIA World Factbook: https://www.cia.gov/cia/publications/factbook/geos/us.html#People (accessed May 06, 2007 )
Infant Mortality Rate* by Country
0
2
4
6
8
10
12
14
16
18
Infa
nt M
orta
lity
Rat
e
2003
Hong Kong
Japan
France
Canada
Cuba
US
Costa Rica
Russia
Romania
Source: Health, United States, 2006, Table 25
*IMR: Deaths of infants under 1 year per 1,000 live births
U.S.
International Rankings for Infant Mortality1960 and 2002
1960 2002
Hong Kong 26 1
Sweden 1 2
Singapore 21 3
Finland 6 4
Japan 18 4
Spain 28 6
Norway 3 7
Austria 24 8
France 15 8
Czech Republic 4 10
Germany 22 11
Denmark 8 12
Switzerland 7 13
Italy 29 14
N. Ireland 13 14
Belgium 20 16
Australia 5 17
Netherlands 2 17
Portugal 35 17
Ireland 17 20
England/Wales 9 21
Scotland 12 22
Canada 14 23
Israel 19 23
Greece 25 25
New Zealnd 10 26
Cuba 23 27
U.S. 11 28
Hungary 31 29
Poland 32 30
Slovakia 16 31
Chile 36 32
Puerto Rico 27 33
Costa Rica 33 34
Russian F. n/a 35
Bulgaria 30 36
Romania 34 37
1960 2002
IMR - International Rankings 2007
Source: CIA – The World Factbook: https://www.cia.gov/cia/publications/factbook/rankorder/2091rank.html (accessed May 06, 2007)
Country Infant mortality rate Rank (deaths/1,000 live births)
Angola 184.44 1Sierra Leone 158.27 2Afghanistan 157.43 3Liberia 149.73 4 Niger 116.83 5---United States 6.37 180---Norway 3.64 214 Finland 3.52 215France 3.41 216 Iceland 3.27 217 Hong Kong 2.94 218 Japan 2.80 219 Sweden 2.76 220 Singapore 2.30 221
Infant Mortality by Race of Mother, 2005
0
5
10
15
20
25
Dea
ths
per
1,0
00
live
bir
ths
Total White Black
City of Detroit Wayne County* Michigan
Source: Division for Vital Records and Health Statistics, Michigan Department of Community Health, 2007http://www.mdch.state.mi.us/pha/osr/InDxMain/Infsum05.asp
*=excludes Detroit
Infant Mortality Rates by mother’s education, race, and Hispanic origin, 2000-2003
0
3
6
9
12
15
IMR
Less than 12 years 12 years 13+ years
Years of Education
White, non-Hispanic Black, non-HispanicHispanic American Indian or Alaska NativeAsian or Pacific Islander
Source: Health, United States, 2006, Table 20
Activity Limitation among Adults by family income, race, and Hispanic
origin, 2004
0
5
10
15
20
25
30
Per
cent
wit
h li
mit
atio
n
All races White, non-Hispanic
Black, non-Hispanic
Hispanic
Poor Near poor Nonpoor
Source: Health, United States, 2006, Table 58
No Health Insurance Coverage among persons under 65, by race and Hispanic origin, 2004
05
10152025303540
White, non-Hispanic
Black, non-Hispanic
AmericanIndian and
AlaskanNative
Asian Hispanic orLatino
Per
cent
uni
nsur
ed
Source: Health, United States, 2006, Table 135.
Vaccinations among Children 19-35 months old by Poverty Status and Race, 2004
60
65
70
75
80
85
Per
cent
rec
eivi
ng
com
bine
d se
ries
All races White, non-Hispanic
Black, non-Hispanic
Hispanic
Poor
Non-Poor
Source: Health, United States, 2006, Table 81.
Percent of Children under 18 with no Usual Source of Care
by insurance type, 2003-2004
28.8
4.62.3
0
5
10
15
20
25
30
35
Uninsured Medicaid Private
Per
cen
t w
ith
no
usu
al s
ourc
e of
car
e
Source: Health United States, 2006, Table 76.
Children under 6 with no physician contactswithin last year, by Race and Poverty Status, 2003-
2004
0
2
4
6
8
10
12
Per
cent
wit
hout
a v
isit
All races White, non-Hispanic
Black, non-Hispanic
Hispanic
Poor
Near Poor
Nonpoor
Source: Health, United States, 2006, Table 79
Asthma Hospitalizations - Children 1-14 yrs of age by household income* and race, 1989-
1991
0
1
2
3
4
5
6
7
8
Dis
char
ges
per
1,00
0 po
pula
tion
All races White Black
<$20,000
$20,000-$29,999
$30,000-$39,999
$40,000+
Source: Health, United States, 1998, Table 21
*Median household income in Zip code of residence
UNEQUAL TREATMENT
Black/White and SES Differences When Patients Have
Same Diagnosis
“The health system is less responsive to black patients then
to white patients.” (Epstein and Ayanian, 2001)
The same is true for low vs. high income patients.
Institute of Medicine ReportUnequal Treatment
“Racial and ethnic minorities tend to receive a lower quality of healthcare than non-minorities,
even when access-related factors, such as patients’ insurance status
and income, are controlled.”IOM, IOM, Unequal Treatment, 2002Unequal Treatment, 2002
Studies have shown this to be true for patients with:
• Heart attacks and heart disease (PTCA and CABGS)
• Peripheral vascular disease of the lower extremities (amputation vs. re-vascularization)
• ESRD (transplants vs. dialysis)• Small-cell carcinoma of the lungs• Psychiatric problems• Many more diagnoses
Racial Disparities In Early Stage Lung Cancer Treatment
76.6
34.9
64
26.4
0
10
20
30
40
50
60
70
80
Per
cen
t
White Black
Rate of Surgery
5yr Survival Rate
Source: Bach et. al,. Racial differences in the treatment of early-stage lung cancer. N Engl J Med. 1999 Oct 14;341(16):1198-205.
Racial Disparities In Re-Perfusion Therapy after Acute Myocardial Infarction (odds ratio)
0
0.10.20.30.40.50.60.7
0.80.9
1
Rat
io
CABG PTCA Thrombolytics
White
Black
Source: Weitzman et. al,. Gender, racial, and geographic differences in the performance of cardiac diagnostic and therapeutic procedures for hospitalized acute myocardial infarction in four states. Am J Cardiol. 1997 Mar 15;79(6):722-6.
Racial Disparities In Rehabilitation Services after Hip Fracture (odds ratio)
0
0.2
0.4
0.6
0.8
1
1.2
1.4
Rat
io
Acute Rehab SNU Rehab No Rehab
White
Black
Source: Harada et. al,. Patterns of rehabilitation utilization after hip fracture in acute hospitals and skilled nursing facilities. Med Care. 2000 Nov;38(11):1119-30.
Inadequate Analgesic Administration
• Black patients with isolated long-bone fractures were less likely to receive analgesics than whites, despite similar pain complaints, in an urban ED in Atlanta.– Study controlled for multiple confounders, including
time since injury, total time in ED, need for fracture reduction.
• Author previously found that Hispanic ethnicity was a risk factor for inadequate analgesia.
Source: Todd et al. (2000) “Ethnicity and Analgesic Practice” Annals ofSource: Todd et al. (2000) “Ethnicity and Analgesic Practice” Annals ofEmergency Medicine, vol. 35(1), pp.11-16.Emergency Medicine, vol. 35(1), pp.11-16.
Other Barriers to Receipt of Care
Percentage With Access Problems
0
5
10
15
20
25
30
35
All Persons
Medicare
Private
Medicaid
Uninsured
The Uninsured by Race and IncomeNon-Elderly, Calendar Year 2003*
0
5
10
15
20
25
30
35
40
Per
cent
uni
nsur
ed
All Races White Black Asian/Pac AmInd/Alask
Hispanic
<100%poverty 100-200% >400%
Source: ERIU tabulation of 2004 CPS data. *Data may represent more of a “point in time” estimate than a true full-year estimate.
For Want of a DentistPr. George's Boy Dies After Bacteria From Tooth Spread to BrainBy Mary OttoWashington Post Staff WriterWednesday, February 28, 2007; Page B01
Twelve-year-old Deamonte Driver died of a toothache Sunday.
A routine, $80 tooth extraction might have saved him.
If his mother had been insured.
If his family had not lost its Medicaid.
If Medicaid dentists weren't so hard to find.
If his mother hadn't been focused on getting a dentist for his brother, who had six rotted teeth.
Deamonte's death and the ultimate cost of his care, which could total more than $250,000, underscore an often-overlooked concern in the debate over universal health coverage: dental care.