Racial, Ethnic and Socioeconomic Health Disparities in the US Richard Lichtenstein Ph.D., MPH University of Michigan School of Public Health June, 2010

Racial, Ethnic and Socioeconomic Health Disparities in the US

Richard Lichtenstein Ph.D., MPH

University of Michigan

School of Public Health

June, 2010

Why is the health status of African Americans worse than the health status of Caucasian

Americans?

Health Status is a Function of:

• Biology/Genetics

• Lifestyle/Behavior

• Social/Societal Characteristics

• Physical Environment (“Total Ecology”)

• Medical Care

Tarlov, A.R. “Public Policy Frameworks for Improving Population Health.” Annals of the New York Academy of Sciences 896:281-293 (1999)

Impact of Various Domains on Early Deaths in a Population

Behavioral Patterns

40%

Medical Care10%

Genetics30%

Environment 5%

Social Circumstances

15%Source

McGinnis, et al, Health Affairs 21: 78.

March/April 2002

A major area of research on Health Disparities today is called:

THE SOCIAL DETERMINANTS OF HEALTH

(SDOH)

GENERAL MODEL OF SOCIAL DETERMINANTS

Discrimination

Quality of living area

Access to Services

Social Factors

Social Support

Stress

Fundamental Factors: Money, Power, Prestige

Health

Disease

Self Regulation/Management

Adoption of Preventive Behavior

Individual risk factors

Personal Factors

CUES, NYAM, 2000

Outcomes

Diagram by Whitehead M and Dahlgren C, in “What can be done about inequities and health?”, The Lancet, 338, 8774, 26 October 1991, 1059-1063.

Poverty is the Major Factor in Health Disparities

Which Racial or Ethnic Group Accounts for the Most People in Poverty in the US?

Number of Persons Below Poverty Level By Race, 2007

0

10,000

20,000

30,000

40,000

All races White Black Asian Hispanic

Source: Health, United States, 2009, Table 3

In T

hou

sand

s

Percent of Persons Below Poverty Level By Race, 2007


Per

cen

t b

elow

pov

erty

Why is there a relationship between socioeconomic status

and race?

What is Race?

What is Race?

• Race is not a biological determinant

• “Race is a social construct, a social classification based on phenotype, that governs the distribution of risks and opportunities in our race-conscious society.”

Camara Phyllis Jones, Am J Epidemiol, 154: 299-304 (2001)

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

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

Beware of treating Race and Ethnicity as Monolithic Concepts

• Is everyone who is black poor?

• Do all Latino sub-groups experience the same degree of unequal health compared to whites?

What are Health Disparities?

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).

Demographic and Health Characteristics of People on the

Eastside of Detroit

Table 1: Socio-Demographic Characteristics of Eastside and Central Detroit in Comparison to City of

Detroit and the National Average

Source: 1U.S. Bureau of the Census, 2006-2008 American Community Survey 3-Year Estimates2Detroit data from www.CHIMart.org, 1999-2001 data

http://www.chimart.org/

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*2006 Data from Health, United States, 2009 Table 26**Infant deaths/1000 live births, Health, United States, 2009, Table 19

http://www.chimart.org/

Health Disparities

Life Expectancy at Birth by Race and Sex, 1970-2006

55

60

65

70

75

80

85

1970

1980

1990

1992

1994

1996

1998

2000

2002

2004

2006

Yea

rs

White Male

White Female

Black Male

Black Female


0200400600800

10001200

Age

-Adj

uste

d D

eath

Rat

e

White Black Am. Indian or Alaskan Asian/Pacific Islander Hispanic

Age-Adjusted Death RatesDue to All Causes,

by Race and Hispanic Origin, 2006


Age-adjusted Death Rates by Race, 2006

0

50

100

150

200

250

300

350

All Race & Sex White Black

Dea

ths

per

100,

000 Disease of Heart

Ischemic Heart Disease

Cerebrovascular Disease

Prostate Cancer

Breast Cancer

Diabetes Mellitus

Homicide


New York Times, December 2, 2009

Native American Death Rates Compared to All Races

YEARS OF POTENTIAL LIFE LOST

Years of Potential Life Lostdue to Ischemic Heart Disease,

by race and Hispanic origin, 2006

0

200

400

600

800

1000

1200

2006

Yea

rs lo

st*



* Age-adjusted years lost before age 75 per 100,000 population under 75 years of age.

Years of Potential Life Lostdue to Diabetes Mellitus,


0

100

200

300

400

Yea

rs lo

st*


2006



Years of Potential Life Lostdue to Homicide,


0

200

400

600

800

1000

Yea

rs lo

st*


2006



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 1996-1998 1999-2005

White Female

Black Female

Per

cent

of

Pat

ient

s (%

)


Infant Mortality Rates by Race*United States, 1970-2006

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

2004

2005

2006

All races

White

Black


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

MexicanCentral and South American

Infant mortality rates by detailed race and Hispanic origin of mother: United States, 2005

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.

Infant per 1,000 live births

Other Hispanic

Centers for Disease Control and Prevention, National Center for Health Statistics. Health, United States, 2009

Asian or Pacific Islander (total)

American Indian or Alaska Native

Infant Mortality Rate by Race (of mother), 2001-2006

0

5

10

15

20

25

1980 1985 1990 1995 2000 2003 2005 2006

Infa

nt M

orta

lity

Rat

e

White

Black


IMR: Deaths of infants under 1 year per 1,000 live births

International Rankings for Infant Mortality1960 and 2006

1960 2006

Hong Kong 26 1

Singapore 21 2

Japan 19 2

Finland 6 4

Norway 3 6

Czech Republic 4 7

Portugal 35 7

Belgium 11 -

Austria 24 9

Greece 25 10

Ireland 18 10

Germany 22 12

France 16 12

Spain 28 12

Denmark 8 12

Israel 20 16

Switzerland 7 17

Italy 27 -

1960 2006

Netherlands 2 17

Australia 5 20

England and Wales 9 21

New Zealand 10 23

Scotland 13 19

Canada 15 -

Cuba 23 24

Hungary 31 25

Northern Ireland 14 22

Poland 32 26

United States 12 28

Slovakia 17 27

Chile 36 29

Puerto Rico 27 -

Costa Rica 35 30

Russian Federation --- 31

Bulgaria 30 -

Romania 36 32Source: Health, United States, 2009, Table 22

IMR - International Rankings 2009

Source: CIA – The World Factbook: (accessed May 14, 2010)

Country Infant Mortality Rate (deaths/1000 live births)

Rank

Angola 180.21 1

Afghanistan 153.14 2

Liberia 138.24 3

Niger 116.66 4

Mali 115.86 5

-- -- --

United States 6.22 180

-- -- --

France 3.33 217

Iceland 3.23 218

Macau 3.22 219

Hong Kong 2.92 220

Japan 2.79 221

Sweden 2.75 222

Bermuda 2.46 223

Singapore 2.31 224

Infant Mortality Rates by mother’s education, race, and Hispanic origin, 2003-2005

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


Low Birth Weight* by Race and Ancestry of Mother, 2007

0

4

8

12

16

Per

cen

t L

ow B

irth

W

eigh

t B

irth

s

White Black Arab Ancestry HispanicAncestry

City of DetroitWayne CountyWayne County Health Dept.Michigan

Source: Division for Vital Records and Health Statistics, Michigan Department of Community Health, 2007

*less than 2500 grams

Activities of Daily Living (ADL) and Instrumental ADL (2008)

0

1

2

3

4

5

6

7

8

ADL IADL

Per

cent

age

18+

yrs

Exp

erie

ncin

g Im

pair

men

t

<$35,000 $35,000-$49,999 $50,000-$74,999 $75,000-$99,999 $100,000 or more

Source: National Health Interview Survey, 2008

Percent with Fair or Poor Self-Rated Health Status, 2007

0 5 10 15 20 25 30

TotalWhiteBlack

PoorNear-PoorNon-Poor

<18 years65+

Male Female

MetropolitanNon-Metropolitan


Percent

Fair or Poor Health among Adults18 years and older by family income, race,

and Hispanic origin, 2007

0

5

10

15

20

25

White, non-Hispanic Black, non-Hispanic Hispanic

Per

cen

t

Poor Near Poor Non-Poor


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.

http://projects.washingtonpost.com/staff/email/mary+otto/

Utilization of ServicesHealth Insurance is important to Access,

but it is not the only factor

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.

Percentage With Access Problems

0

5

10

15

20

25

30

35

All Persons

Medicare

Private

Medicaid

Uninsured

Percent of Children under 18 with No Usual Source of Care

by Insurance Type, 2006-2007

33.6

5.2 3

0

5

10

15

20

25

30

35

40

Uninsured Medicaid Private

Per

cen

t w

ith

no

usu

al s

ourc

e of

car

e

Source: Health United States, 2009, Table 75

Vaccinations among Children 19-35 months old by Poverty Status and Race, 2007

60

65

70

75

80

85

White, non-Hispanic Black, non-Hispanic Hispanic

Per

cen

t re

ceiv

ing

com

bin

ed s

erie

s

Poor

Non-Poor


Proportion of Live Births with Late* or No Prenatal Care, by Race and Ethnicity of

Mother, 2006

3.2

5.7

8.1

3.1

5

0

1

2

3

4

5

6

7

8

9

White Black American Indian or Alaskan Native

Asian or Pacific Islander

Hispanic Origin

Per

cent

of

Liv

e B

irth

s

Source: Health, United States, 2009, Table 7 (37 states, DC and NYC)

*third trimester*third trimester

Children under 6 with no physician contactswithin last year, by race, and Hispanic origin,

and poverty status, 2005-2006

0

2

4

6

8

10

12

Per

cent

wit

hout

a v

isit

All race White, non-Hispanic

Black, non-Hispanic*

Hispanic

Poor

Near Poor

Nonpoor

AVERAGE all children under 6 without a health care visit in 2005-6 – 6.1%* Estimates are for 2004/2005 (data not available for 2005-2006)Source: Health, United States, 2008, Table 82

Persons with Hospital Stay in the Past Year*, By Poverty and Insurance Status, 2007


* Persons under 65 years of age* Persons under 65 years of age

0

2

4

6

8

10

12

Poor Near Poor Non-Poor

Per

cent

of

pers

ons

Poverty and Insurance Status

Insured

Uninsured >12 mths

Avoidable Hospitalizations - Adults 18-64 yrs old by household income* and race, 1989-1991

0

2

4

6

8

10

12

14

16

18

20

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, Figure 48

* Median household income in Zip code of residence

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, Figure 24

*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

34.9

26.4

0

10

20

30

40

50

60

70

80

Per

cen

t or

rat

e

White Black

Rate of Surgery5yr 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.

http://www.ncbi.nlm.nih.gov.proxy.lib.umich.edu/entrez/utils/fref.fcgi?itool=AbstractPlus-def&PrId=3051&uid=10519898&db=pubmed&url=http://content.nejm.org.proxy.lib.umich.edu/cgi/pmidlookup?view=short&pmid=10519898&promo=ONFLNS19

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

WhiteBlack

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.

Will the Passage of Health (Insurance) Reform, which will

provide insurance coverage to 32 Million more Americans,

eliminate Health Disparities?

Documents

Racial, Ethnic and Socioeconomic Health Disparities in the US Richard Lichtenstein Ph.D., MPH University of Michigan School of Public Health June, 2010