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OBJECTIVES: This study examined the prevalence, social correlates, and clustering of cardiovascul... more OBJECTIVES: This study examined the prevalence, social correlates, and clustering of cardiovascular disease risk factors in a predominantly Black, poor, urban community. METHODS: Associations of risk factor prevalences with sociodemographic variables were examined in a population-based sample of 695 men and women aged 18 to 65 years living in Central Harlem. RESULTS: One third of the men and women were hypertensive, 48% of the men and 41% of the women were smokers, 25% of the men and 49% of the women were overweight, and 23% of the men and 35% of the women reported no leisure-time physical activity over the past month. More than 80% of the men and women had at least 1 of these risk factors, and 9% of the men and 19% of the women had 3 or more risk factors. Income and education were inversely related to hypertension, smoking, and physical inactivity. Having 3 or more risk factors was associated with low income and low education (extreme odds ratio [OR] = 10.2, 95% confidence interval...
Objectives. Profound and growing disparities exist in oral health among certain US populations. W... more Objectives. Profound and growing disparities exist in oral health among certain US populations. We sought here to determine the prevalence of oral health complaints among Harlem adults by measures of social class, as well as their access to oral health care. Methods. A population-based survey of adults in Central Harlem was conducted from 1992 to 1994. Two questions on oral health were included: whether participants had experienced problems with their teeth or gums during the past 12 months and, if so, whether they had seen a dentist. Results. Of 50 health conditions queried about, problems with teeth or gums were the chief complaint among participants (30%). Those more likely to report oral health problems than other participants had annual household incomes of less than $9000 (36%), were unemployed (34%), and lacked health insurance (34%). The privately insured were almost twice as likely to have seen a dentist for oral health problems (87%) than were the uninsured (48%). Conclusi...
The New York City neighborhood of Harlem has mortality rates that are among the highest in the Un... more The New York City neighborhood of Harlem has mortality rates that are among the highest in the United States. In absolute numbers, cardiovascular disease and cancer account for the overwhelming majority of deaths, especially among men, and these deaths occur at relatively young ages. The aim of this research was to examine self-reported smoking habits according to measures of socioeconomic status among Harlem men and women, in order to estimate the contribution of tobacco consumption to Harlem's remarkably high excess mortality. During 1992-1994, in-person interviews were conducted among 695 Harlem adults aged 18-65 years who were randomly selected from dwelling unit enumeration lists. The self-reported prevalence of current smoking was strikingly high among both men (48%) and women (41 %), even among highly educated men (38%). The 21% of respondents without working telephones reported an even higher prevalence of current smoking (61 %), indicating that national and state-based estimates which rely on telephone surveys may seriously underestimate the prevalence of smoking in poor urban communities. Among persons aged 35-64 years, the smoking attributable fractions for selected causes of death were larger in Harlem than in either New York City as a whole or the entire United States for both men and women. Tobacco consumption is likely to be one of several important mediators of the high numbers of premature deaths in Harlem.
Drawing on international experiences, Viroj Tangcharoensathien and colleagues argue that immediat... more Drawing on international experiences, Viroj Tangcharoensathien and colleagues argue that immediate extensive action to contain local transmission of new infectious diseases protects health systems from being overwhelmed • Cross-sectoral coordinated action and an effective test, trace, quarantine, and treatment system for covid-19 patients are also vital • Effective governance is needed to ensure citizen adherence to public health measures and social interventions that are key to protect health delivery systems from disruption
In 2015, after nearly a century of annual increases, US life expectancy began 3 consecutive years... more In 2015, after nearly a century of annual increases, US life expectancy began 3 consecutive years of decreases associated with increased mortality rates among young and middle-aged adults of all races. 1 This reversal forms an important context for the analysis by Ferdows and colleagues, 2 whose study examines county-level mortality trends between 1968 and 2016, focusing specifically on older
Racial and ethnic inequities in COVID-19 mortality have been well documented, but little prior re... more Racial and ethnic inequities in COVID-19 mortality have been well documented, but little prior research has assessed the combined roles of race and ethnicity and educational attainment. OBJECTIVE To measure inequality in COVID-19 mortality jointly by race and ethnicity and educational attainment. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study analyzed data on COVID-19 mortality from the 50 US states and the District of Columbia for the full calendar year 2020. It included all persons in the United States aged 25 years or older and analyzed them in subgroups jointly stratified by age, sex, race and ethnicity, and educational attainment. MAIN OUTCOMES AND MEASURES Population-based cumulative mortality rates attributed to COVID-19.F RESULTS Among 219.1 million adults aged 25 years or older (113.3 million women [51.7%]; mean [SD] age, 51.3 [16.8] years), 376 125 COVID-19 deaths were reported. Age-adjusted cumulative mortality rates per 100 000 ranged from 54.4 (95% CI, 49.8-59.0 per 100 000 population) among Asian women with some college to 699.0 (95% CI, 612.9-785.0 per 100 000 population) among Native Hawaiian and Other Pacific Islander men with a high school degree or less. Racial and ethnic inequalities in COVID-19 mortality rates remained when comparing within educational attainment categories (median rate ratio reduction, 17% [IQR, 0%-25%] for education-stratified estimates vs unstratified, with non-Hispanic White individuals as the reference). If all groups had experienced the same mortality rates as college-educated non-Hispanic White individuals, there would have been 48% fewer COVID-19 deaths among adults aged 25 years or older overall, including 71% fewer deaths among racial and ethnic minority populations and 89% fewer deaths among racial and ethnic minority populations aged 25 to 64 years. Public health research and practice should attend to the ways in which populations that share socioeconomic characteristics may still experience racial and ethnic inequity in the distribution of risk factors for SARS-CoV-2 exposure and infection fatality rates (eg, housing, occupation, and prior health status). This study suggests that a majority of deaths among racial and ethnic minority populations could have been averted had all groups experienced the same mortality rate as college-educated non-Hispanic White individuals, thus highlighting the importance of eliminating joint racial-socioeconomic health inequities.
medRxiv (Cold Spring Harbor Laboratory), Oct 6, 2020
Prior research has identified higher rates of COVID-19 mortality among people of color (relative ... more Prior research has identified higher rates of COVID-19 mortality among people of color (relative to non-Hispanic whites) and populations in high-poverty neighborhoods (relative to wealthier neighborhoods). It is unclear, however, whether non-Hispanic whites in high-poverty neighborhoods experience elevated mortality, or whether people of color living in wealthy areas are relatively protected. Exploring socioeconomic position in combination with race/ethnicity can lead to a more detailed understanding of the specific processes that result in COVID-19 inequities. We used census and individual-level mortality data for the non-Hispanic white, non-Hispanic Black, and Hispanic/Latinx populations of Cook County, Illinois, USA. We excluded deaths related to nursing homes and other institutions. We calculated age and gender-adjusted mortality rates by race/ethnicity, census tract poverty quartile, and age group (0-64 and ≥65 years). Within all racial/ethnic groups, COVID-19 mortality rates were greatest in the highest-poverty quartile and lowest in the lowest-poverty quartile. The mortality rate for younger non-Hispanic whites in the highest-poverty quartile was 13.5 times that of younger non-Hispanic whites in the lowest-poverty quartile (95% CI: 8.5, 21.4). For young people in the highest-poverty quartile, the non-Hispanic white and Black mortality rates were similar. Among younger people in the lowest-poverty quartile, non-Hispanic Black and Hispanic/Latinx people had mortality rates nearly three times that of non-Hispanic whites. For the older population, the mortality rate among non-Hispanic whites in the highest-poverty quartile was less than that of lowest-poverty non-Hispanic Black and Hispanic/Latinx populations. Our findings suggest racial/ethnic inequalities in COVID-19 mortality are partly, but not entirely, attributable to the higher average socioeconomic position of non-Hispanic whites relative to the non-Hispanic Black and Hispanic/Latinx populations. Future research on health equity in COVID-19 outcomes should collect and analyze individual-level data on the potential mechanisms driving population distributions of exposure, severe illness, and death.
In the United States, non-Hispanic Black (NHB), Hispanic, and non-Hispanic American Indian/Alaska... more In the United States, non-Hispanic Black (NHB), Hispanic, and non-Hispanic American Indian/Alaska Native (NHAIAN) populations experience excess COVID-19 mortality, compared to the non-Hispanic White (NHW) population, but racial/ethnic differences in age at death are not known. The release of national COVID-19 death data by racial/ethnic group now permits analysis of age-specific mortality rates for these groups and the non-Hispanic Asian or Pacific Islander (NHAPI) population. Our objectives were to examine variation in age-specific COVID-19 mortality rates by racial/ethnicity and to calculate the impact of this mortality using years of potential life lost (YPLL). This cross-sectional study used the recently publicly available data on US COVID-19 deaths with reported race/ethnicity, for the time period
ImportanceIn the US, Black individuals die younger than White individuals and have less household... more ImportanceIn the US, Black individuals die younger than White individuals and have less household wealth, a legacy of slavery, ongoing discrimination, and discriminatory public policies. The role of wealth inequality in mediating racial health inequities is unclear.ObjectiveTo assess the contribution of wealth inequities to the longevity gap that exists between Black and White individuals in the US and to model the potential effects of reparations payments on this gap.Design, Setting, and ParticipantsThis cohort study analyzed the association between wealth and survival among participants in the Health and Retirement Study, a nationally representative panel study of community-dwelling noninstitutionalized US adults 50 years or older that assessed data collected from April 1992 to July 2019. Participants included 7339 non-Hispanic Black (hereinafter Black) and 26 162 non-Hispanic White (hereinafter White) respondents. Data were analyzed from January 1 to September 17, 2022.ExposuresH...
ABSTRACTBackgroundIn February 2022, following the rescinding of a Massachusetts statewide school ... more ABSTRACTBackgroundIn February 2022, following the rescinding of a Massachusetts statewide school masking mandate, only two cities (Boston and neighboring Chelsea) out of 79 school districts in the greater-Boston area, maintained masking requirements in K-12 schools. This provided an opportunity to examine the impact of removing masking on COVID-19 case rates among students and staff in the public-school setting.MethodsWe used difference-in-differences for staggered policy adoption to compare incidence of COVID-19 cases among students and staff in greater-Boston area school districts that lifted masking requirements to those that had not yet lifted masking requirements during the 2021-2022 school year.ResultsBefore the statewide school masking policy was lifted, there was no statistically significant difference in case rate trajectories between school districts. However, weekly and cumulative case rates were significantly higher in students and staff in school districts that removed ...
The impact of COVID-19 has been disproportionately felt by populations experiencing structural ra... more The impact of COVID-19 has been disproportionately felt by populations experiencing structural racial-and ethnicity-based discrimination. Here, we describe opportunities for COVID-19 response and recovery efforts to help build more equal and resilient societies, through investments in: (i) interventions focused on explicitly addressing racial and ethnicity-based discrimination; (ii) interventions supporting the delivery of universal services, and in ways that address compounding and intersecting drivers of exclusion and marginalization; and (iii) cross-cutting enabling measures, such as participatory mechanisms and data disaggregation. More than two years since the first SARS-CoV-2 infections were reported, the COVID-19 pandemic remains an acute global emergency 1 . While many countries have successfully vaccinated significant portions of their populations, stark global inequities remain with imbalance in the global distribution of vaccines 2,3 , and potential new variants could further threaten the ability of governments to recover from the inter-connected health, economic, and broader human rights crises. Within countries, the impact of COVID-19 has been disproportionately felt by populations experiencing structural racial-and ethnicity-based discrimination. Indeed, where disaggregated epidemiologic data are available, COVID-19 morbidity and mortality rates are often significantly higher among people of African descent, indigenous peoples, and ethnic groups or other minoritized groups experiencing discrimination . This reflects what social
In 2015, after nearly a century of annual increases, US life expectancy began 3 consecutive years... more In 2015, after nearly a century of annual increases, US life expectancy began 3 consecutive years of decreases associated with increased mortality rates among young and middle-aged adults of all races. 1 This reversal forms an important context for the analysis by Ferdows and colleagues, 2 whose study examines county-level mortality trends between 1968 and 2016, focusing specifically on older
New York City Department of Health and Mental Hygiene, 2004
has, throughout its history, paid special attention to improving the health of the City's most vu... more has, throughout its history, paid special attention to improving the health of the City's most vulnerable residents. From the late 1800s, when the Department developed sanitation programs to improve living conditions in tenement neighborhoods, to the early 1900s, when public health physicians were dispatched doorto-door in poor areas of the City, to the 1990s, when new programs were developed to fight tuberculosis and HIV/AIDS, the Health Department has recognized that social and economic factors are inextricably linked to health. While great gains have occurred in improving overall health and reducing health disparities, the persistence of racial, ethnic, economic, or other social inequalities in health is unacceptable. Eliminating health inequalities must involve investment on four fronts: improving access to and the quality of preventive health care, promoting healthy life choices, creating social and physical environments supportive of healthy living, and reducing the burden of poverty and other social disadvantage. Reaching these goals requires a broad and detailed understanding of which groups are most vulnerable, the patterns of illnesses and risk factors among these groups, and how disparities change over time. We hope this report is useful to all our partners in this effort.
In the 5 years since one of us published "#Black LivesMatter -A Challenge to the Medical and Publ... more In the 5 years since one of us published "#Black LivesMatter -A Challenge to the Medical and Public Health Communities" in the Journal, we have seen a sea change in the recognition of racism as a durable feature of U.S. society and of its high cost in Black lives. Elected officials, corporate leaders, and academics alike use the slogan "Black Lives Matter," which has also been widely adopted by members of the public, who by the millions protested the extrajudicial killing of George Floyd. 2 With this change comes growing recognition that racism has a structural basis and is embedded in long-standing social policy. This framing is captured by the term "structural racism." There is no "official" definition of structural racism -or of the closely related concepts of systemic and institutional racism -although multiple definitions have been offered. All definitions make clear that racism is not simply the result of private prejudices held by individuals, 8 but is also produced and reproduced by laws, rules, and practices, sanctioned and even implemented by various levels of government, and embedded in the economic system as well as in cultural and societal norms. Confronting racism, therefore, requires not only changing individual attitudes, but also transforming and dismantling the policies and institutions that undergird the U.S. racial hierarchy. As a legacy of African enslavement, structural racism affects both population and individual health in three interrelated domains: redlining and racialized residential segregation, mass incarceration and police violence, and unequal medical care. These examples, among others, share certain cardinal features: harms are historically grounded, involve multiple institutions, and rely on racist cultural tropes.
In the United States, non-Hispanic Black (NHB), Hispanic, and non-Hispanic American Indian/Alaska... more In the United States, non-Hispanic Black (NHB), Hispanic, and non-Hispanic American Indian/Alaska Native (NHAIAN) populations experience excess COVID-19 mortality, compared to the non-Hispanic White (NHW) population, but racial/ethnic differences in age at death are not known. The release of national COVID-19 death data by racial/ethnic group now permits analysis of age-specific mortality rates for these groups and the non-Hispanic Asian or Pacific Islander (NHAPI) population. Our objectives were to examine variation in age-specific COVID-19 mortality rates by racial/ethnicity and to calculate the impact of this mortality using years of potential life lost (YPLL). This cross-sectional study used the recently publicly available data on US COVID-19 deaths with reported race/ethnicity, for the time period
BackgroundIn the United States, Black Americans are suffering from significantly disproportionate... more BackgroundIn the United States, Black Americans are suffering from significantly disproportionate incidence and mortality rates of COVID-19. The potential for racial-justice interventions, including reparations payments, to ameliorate these disparities has not been adequately explored.MethodsWe compared the COVID-19 time-varying Rt curves of relatively disparate polities in terms of social equity (South Korea vs. Louisiana). Next, we considered a range of reproductive ratios to back-calculate the transmission rates βi→j for 4 cells of the simplified next-generation matrix (from which R0 is calculated for structured models) for the outbreak in Louisiana. Lastly, we modeled the effect that monetary payments as reparations for Black American descendants of persons enslaved in the U.S. would have had on pre-intervention βi→j.ResultsOnce their respective epidemics begin to propagate, Louisiana displays Rt values with an absolute difference of 1.3 to 2.5 compared to South Korea. It also t...
Despite growing interest in understanding how social factors drive poor health outcomes, many aca... more Despite growing interest in understanding how social factors drive poor health outcomes, many academics, policy makers, scientists, elected officials, journalists, and others responsible for defining and responding to the public discourse remain reluctant to identify racism as a root cause of racial health inequities. In this conceptual report, the third in a Series on equity and equality in health in the USA, we use a contemporary and historical perspective to discuss research and interventions that grapple with the implications of what is known as structural racism on population health and health inequities. Structural racism refers to the totality of ways in which societies foster racial discrimination through mutually reinforcing systems of housing, education, employment, earnings, benefits, credit, media, health care, and criminal justice. These patterns and practices in turn reinforce discriminatory beliefs, values, and distribution of resources. We argue that a focus on struc...
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