Racial, Ethnic and Socioeconomic Health Disparities in the US

1
Racial, Ethnic and Socioeconomic Health
Disparities in the US

• Richard Lichtenstein Ph.D., MPH
• University of Michigan
• School of Public Health
• June 2007

2
Fair or Poor Health among Adults18 years and
older by family income, race, and Hispanic
origin, 2004
Source Health, United States, 2006 Table 60
3
Why are Poverty and Race/Ethnicity Related to
Health?
4
What Racial/Ethnic Group Accounts for the Most
Poor People in the US?
5
Number of Persons Below Poverty Level By Race,
2004
In Thousands
Source Health, United States, 2006, Table 3
6
Percent of Persons Below Poverty Level By Race,
2003
Percent below poverty
Source Health, United States, 2006, Table 3
7
Figure 2.6Percent of Persons with Incomes Below
Poverty Level by Age
Source U.S. Bureau of the Census, Census 2000
Supplementary Survey Primary Metropolitan
Statistical Area
8
What is Race?
9
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
10
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
11
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)
12
Race Varies by Country

• This assigned race varies among countriesIn 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
13
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
Med541621-1635 (2002).
14
Pursuing equity in health care means striving to
reduce avoidable disparities in physical and
psychological well-beingand in the determinants
of that well-beingthat 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
Med541621-1635 (2002).
15
Some Data on Detroit and Some Neighborhoods in
Detroit
16
Population by RaceCity of Detroit Health Dept.
and Michigan Residents, 2003
City of Detroit Health Dept.
Michigan
Source U.S. Bureau of the Census, Census 2000
Supplementary Surveyhttp//www.census.gov/acs/
17
Demographic Characteristics of the Eastside of
Detroit
18
Table 1 Sociodemographic Characteristics of
Eastside and Central Detroit in Comparison to
City of Detroit and the National Average
2000 Census, www.census.gov Detroit data from
www.chimart.org, 1999-2001 data
19
Table II Health Status Characteristics of the
Eastside in Comparison to the City of Detroit and
the U.S. Population
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
20
Life Expectancy at Birth by Race and Sex,
1970-2003
Source Health, United States, 2005, Table 27,
http//www.cdc.gov/nchs/data/hus/hus05.pdfsumma
ry
21
Why Do Blacks Have a Shorter Life Expectancy Than
Whites?
22
Age-Adjusted Death RatesDue to All Causes, by
Race and Hispanic Origin, 2003
Source Health, United States, 2005, Table
29 http//www.cdc.gov/nchs/data/hus/hus05.pdfsumm
ary
23
Years of Potential Life Lostdue to Ischemic
Heart Disease,by race and Hispanic origin, 2003
Age-adjusted years lost before age 75 per
100,000 population under 75 years of age.
Source Health, United States, 2005, Table
30 http//www.cdc.gov/nchs/data/hus/hus05.pdfsumm
ary
24
Years of Potential Life Lostdue to
Cerebrovascular Diseases,by race and Hispanic
origin, 2003
Source Health, United States, 2005, Table
30 http//www.cdc.gov/nchs/data/hus/hus05.pdfsumm
ary
Age-adjusted years lost before age 75 per
100,000 population under 75 years of age.
25
Years of Potential Life Lostdue to Breast
Cancer, Females by race and Hispanic origin, 2003
Source Health, United States, 2005, Table
30 http//www.cdc.gov/nchs/data/hus/hus05.pdfsumm
ary
Age-adjusted years lost before age 75 per
100,000 population under 75 years of age.
26
Years of Potential Life Lostdue to Prostate
Cancer, Males by race and Hispanic origin, 2003
Source Health, United States, 2005, Table
30 http//www.cdc.gov/nchs/data/hus/hus05.pdfsumm
ary
Age-adjusted years lost before age 75 per
100,000 population under 75 years of age.
27
Years of Potential Life Lostdue to Diabetes
Mellitus,by race and Hispanic origin, 2003
Source Health, United States, 2005, Table
30 http//www.cdc.gov/nchs/data/hus/hus05.pdfsumm
ary
Age-adjusted years lost before age 75 per
100,000 population under 75 years of age.
28
Years of Potential Life Lostdue to HIV
Infection,by race and Hispanic origin, 2003
Source Health, United States, 2005, Table
30 http//www.cdc.gov/nchs/data/hus/hus05.pdfsumm
ary
Age-adjusted years lost before age 75 per
100,000 population under 75 years of age.
29
Years of Potential Life Lostdue to Homicide,by
race and Hispanic origin, 2003
Source Health, United States, 2005, Table
30 http//www.cdc.gov/nchs/data/hus/hus05.pdfsumm
ary
Age-adjusted years lost before age 75 per
100,000 population under 75 years of age.
30
5 Year Relative Survival Rates for Breast Cancer
White Female
Percent of Patients ()
Black Female
Source Health, United States, 2006, Table 54
http//www.cdc.gov/nchs/data/hus/hus06.pdfsummary
31
Infant Mortality Rates by RaceUnited States,
1970-2003
Deaths per 1,000 Live Births
Source Health, United States, 2006, Table 22
Race of mother
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IMR for US in 2004 was 6.37NOTE The US placed
180 out of 221 countries (higher is better)
Source CIA World Factbook https//www.cia.gov/ci
a/publications/factbook/geos/us.htmlPeople
(accessed May 06, 2007 )
35
Infant Mortality Rate by Country
U.S.
IMR Deaths of infants under 1 year per 1,000
live births
Source Health, United States, 2006, Table 25
36
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
37
IMR - International Rankings 2007
Country Infant mortality rate
Rank (deaths/1,000 live births)
  Angola 184.44 1 Sierra Leone 158.27
2 Afghanistan 157.43 3 Liberia
149.73 4 Niger 116.83 5 - - - United
States 6.37 180 - - - Norway 3.64 214
Finland 3.52 215 France 3.41 216
Iceland 3.27 217 Hong Kong 2.94 218
Japan 2.80 219 Sweden 2.76 220
Singapore 2.30 221
Source CIA The World Factbook
https//www.cia.gov/cia/publications/factbook/rank
order/2091rank.html (accessed May 06, 2007)
38
Infant Mortality by Race of Mother, 2005
excludes Detroit
Source Division for Vital Records and Health
Statistics, Michigan Department of Community
Health, 2007 http//www.mdch.state.mi.us/pha/osr/
InDxMain/Infsum05.asp
39
Infant Mortality Rates by mothers education,
race, and Hispanic origin, 2000-2003
Source Health, United States, 2006, Table 20
40
Activity Limitation among Adults by family
income, race, and Hispanic origin, 2004
Source Health, United States, 2006, Table 58
41
No Health Insurance Coverage among persons under
65, by race and Hispanic origin, 2004
Source Health, United States, 2006, Table 135.
42
Vaccinations among Children 19-35 months old by
Poverty Status and Race, 2004
Source Health, United States, 2006, Table 81.
43
Percent of Children under 18 with no Usual
Source of Care by insurance type, 2003-2004
Source Health United States, 2006, Table 76.
44
Children under 6 with no physician
contactswithin last year, by Race and Poverty
Status, 2003-2004
Source Health, United States, 2006, Table 79
45
Asthma Hospitalizations - Children 1-14 yrs of
age by household income and race, 1989-1991
Median household income in Zip code of residence
Source Health, United States, 1998, Table 21
46
UNEQUAL TREATMENT
47
Black/White and SES Differences When Patients
Have Same Diagnosis
48
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.
49
Institute of Medicine ReportUnequal
TreatmentRacial 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, Unequal Treatment, 2002
50
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

51
Racial Disparities In Early Stage Lung Cancer
Treatment
Source Bach et. al,. Racial differences in the
treatment of early-stage lung cancer. N Engl J
Med. 1999 Oct 14341(16)1198-205.
52
Racial Disparities In Re-Perfusion Therapy after
Acute Myocardial Infarction (odds ratio)
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 1579(6)722-6.
53
Racial Disparities In Rehabilitation Services
after Hip Fracture (odds ratio)
Source Harada et. al,. Patterns of
rehabilitation utilization after hip fracture in
acute hospitals and skilled nursing facilities.
Med Care. 2000 Nov38(11)1119-30.
54
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 of Emergency Medicine,
vol. 35(1), pp.11-16.
55
Other Barriers to Receipt of Care
56
Percentage With Access Problems
57
The Uninsured by Race and IncomeNon-Elderly,
Calendar Year 2003
Source ERIU tabulation of 2004 CPS data. Data
may represent more of a point in time estimate
than a true full-year estimate.
58
For Want of a Dentist Pr. George's Boy Dies After
Bacteria From Tooth Spread to Brain By Mary
Otto Washington 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.