• Race and population level health statistics

    Whenever I write about population level health statistics, inevitably some people feel a need to email, post, tweet, or message me about their belief that it all comes down to race. The US looks bad with respect to life expectancy? It’s race. We look bad with respect to birth outcomes? It’s race. We are obese, or have high levels of drug abuse or sexually transmitted diseases? It’s race.

    And then they get angry when I don’t respond.

    Let me be clear: I have no problem, per se, with the question itself. It’s somewhat natural for individuals to question whether race or ethnicity has some impact. What bothers me is the fact that so many people act as if they’re the first to ask about it, as if no one else has thought of this before. What bothers me more is when some of these same people ignore what we know from existing research about disparities, or the fact that other Western democracies are increasingly becoming more diverse, but without such disparities.

    Most frustrating is when it’s not questions, but assertions, often made with no evidence whatsoever. No links, no studies, no data. Just a belief – they just know – that some races are going to die earlier, be more obese, have more teen sex, or something. They almost always believe that’s it’s minorities that are bringing down our statistics. From our own comments:

    What other industrial countries have a comparable racial demographic to the U.S.? I realize the religious Left refuses to use “nuance”, science, and reams of data on race to join the reality-based community, but can you commit a sin here for your readers and tell us how white Americans compare to “peer” white Europeans, for example?

    I don’t even want to respond to this notion that if only we could look at “whites”, then the US would do well. It completely ignores the fact that there’s no reason to believe that “whites” do the best. It ignores the fact that Japan has one of the highest life expectancies around. It ignores the Hispanic paradox. With a growing Hispanic population, you’d expect our numbers in the US to be going up.

    It also ignores the fact that some of these studies have been done, in particular this one on 55-65 year olds (page 261):

    Comparisons with England have already demonstrated that the U.S. health disadvantage appears to persist across racial and ethnic groups in the United States and among college-educated and upper income populations (Banks et al., 2006; Martinson et al., 2011a, 2011b)

    Here, from later in the report (page 268, emphasis mine):

    What specific factors explain the unfavorable birth outcomes (e.g., high infant mortality rates) experienced in the United States, which exist even after adjusting for race, ethnicity, and maternal education?

    I’l be the first to say that I wished the evidence base here was deeper. The number of studies that focus on this exact question is small. But those that do exist point to the fact that even “advantaged” Americans do worse than their counterparts in other countries (page 269):

    Four studies have now reported this pattern (Avendano et al., 2009, 2010; Banks et al., 2006; Martinson et al., 2011a), but some of them looked only at education and not other variables (Avendano et al., 2010), or are restricted to comparisons of a narrow age group in only two countries (Banks et al., 2006). Replication with more focused criteria would help confirm the finding.

    We need more than these, but let’s acknowledge that the data that we do have favor the hypothesis that it’s not something inherent in race, or our demographics, that causes us to do so poorly. Let’s stop assuming the opposite is true.

    But that’s not even the worst of it. So many of the things presented in the report show that it’s not death at old age that’s bringing us down. It’s death at a young age, when racial biological characteristics and genetics aren’t a factor. It’s accidents, it’s violence, and it’s infant mortality. Still – people scream “race!” Yes, race is a factor. The report is explicit about that. Just not in the way many think (pages 167-8):

    In many countries, a variety of health outcomes vary markedly by race and ethnicity (Agency for Healthcare Research and Quality, 2011; Commission on Social Determinants of Health, 2008). These health disparities often mirror large differences in income, wealth, education, occupation, and neighborhood conditions among people of different races and ethnicities, differences that reflect a historical legacy of discrimination (Acevedo-Garcia et al., 2008; Bleich et al., 2012; Cullen et al., 2012; Williams, 1999; Williams and Collins, 1995, 2001).7 For example, in the United States, blacks with the same level of education as whites have lower incomes, as well as markedly lower levels of accumulated wealth even at the same level of income (Braveman et al., 2005; Kawachi et al., 2005). Living in a society with a high degree of racial inequality may harm the health of society at large—not only of those who experience disadvantage—in the same ways that some researchers have argued that relative economic inequality may be detrimental to society at large, for example, by undermining social cohesion and trust (Wilkinson and Pickett, 2009) or by affecting individuals’ sense of their relative social standing (Marmot, 2006). Unfortunately, as noted below, data are lacking to compare degrees of racial inequality across high income countries.

    In the United States, racial and ethnic groups that have historically experienced discrimination,8 including blacks, Native Americans, and Hispanics, may suffer ill health effects from these experiences. The health effects may result both from material deprivation and other conditions that directly damage health and from physiologic mechanisms involved in reactions to stress (see below). Such stress, which has been linked with smoking (Purnell et al., 2012) and hypertension (Sims et al., 2012), can result not only from overtly discriminatory experiences but also from a pervasive vigilance about whether harmful incidents will occur to themselves or their families (Krieger et al., 2011; Nuru-Jeter et al., 2009). A relative difference in social standing or a sense of social exclusion for any reason may induce stress and influence one’s sense of self-worth or control, which may in turn influence subsequent economic success, health-related behaviors, and health outcomes (Dunn, 2010; Umberson et al., 2008).

    Racial disparities, old and new, are absolutely, positively impacting minorities’ health negatively. But that’s not because those minorities are somehow deficient in some way, it’s because the US health care system (and society at large) treats them differently. The disturbingly bad outcomes for minorities aren’t bringing down the standing of the United States. In many ways, it’s just the opposite.

    Almost all the findings you can point to that show minorities fare worse here are an indictment of the United States, not an excuse for it.


    • Kevin Drum has been writing recently about the connection between environmental lead (especially from leaded gasoline) and violent crime. See


      This points out another way in which an environmental factor (e.g. living in an auto-dense big city) can be highly correlated with race. The impact of childhood exposure to lead, of course, goes far beyond crime.

    • This is why people need to watch the Unnatural Causes documentary series (http://www.unnaturalcauses.org/), which helps explain disparities from a number of perspectives. Odds are your local health department has a copy.

      Also, helping to explain that racism is much more a factor than race is Camara Jones’s article “Confronting Institutionalized Racism” ), or most anything else by Jones. For instance, according to BRFSS data, blacks who say that most people think they are white experience about the same level of health as whites!

    • A recent study (http://capsules.kaiserhealthnews.org/index.php/2012/07/medicaid-expansion-reduces-mortality-study-finds/) showed that Medicaid expansion reduced mortality. I have come to believe that health insurance is the missing key. Simply, access to health care decreases the chance that you will die prematurely or suffer with moribund conditions. I am confident that if we had universal health insurance like so many of our international peers those disparities would lesson over a decade or two.

    • That’s only a part of it. How will health insurance keep people from being shot? Or prevent obesity? Or shield people from lead, radon, or other air contaminants? Or ensure they practice safe sex?

      Further, we also need to lower morbidity. Do we simply celebrate that people with AIDS live longer now? Or do we keep trying to prevent AIDS in the first place? Insurance and access to care is a critical factor, but it’s not the only one.

    • I run into that belief with juvenile crime: everyone assumes it is ‘those’ people who commit juvenile crime. When being interviewed by a local tv reporter years ago, I was dumbfounded when she asked me the same kind of question. I gave her the same response I give now; it is not so much the color issue as it is the economic issue. It is no small coincidence that the vast, vast majority of kids in juvenile court are poor. Poverty just grinds you down spiritually, mentally, morally, and physically. It is hard to make your life better when you worry about your next meal or your cold hands or your lack of books.

      There is no economic or moral reason why all Americans should not have a place to live, plenty of food, health care, and decent clothing. We have the money; we just allocate it so poorly.

    • One other thing relevant here. Say, for example, that African Americans have worse health statistics (infant mortality, violet deaths, life expectancy etc). This means nothing on its own unless it can be shown to be endogenous rather than related to the perticular strata in our class society that many in this community have been relegated too. Best, Simon.

    • There are many reasons why USA does worse in these measures and race is an important one.

      Infant mortality is in part because US Americans get more fertility treatment and have more multiple births along with black Americas having higher infant mortality perhaps for cultural or genetic reasons.

      Premature accidental death is partly due to the fact that we drive more and faster.

      Consider how badly native people groups do in Canada and Aboriginals do in Australia. Native people and blacks do better in the USA than native people groups do in Canada and Aboriginals do in Australia but they makeup a bigger part of the population.

      Also one not note on race you cannot compare blacks in the USA with blacks in Canada because for a long time now Canada has had an immigration policy that only allows people who do not need to immigrate because they already have a decent life, those with education and or wealth, to immigrate.

      So do you believe that we should look at what they do in North Dakota and Utah as a model? After all North Dakota and Utah do as well as the Europeans. Perhaps the rest pf the country should do what they do in North Dakota and Utah.

      Life expectancy by US country:

      Life expectancy by US state:

      It is about culture (and to a lesser extent genetics) and we seem to be a bit culturally wild here in the USA, especially our black population (reason not established).

      Perhaps we are wrong to assume that you are and advocate of an NHS for the USA but that is how we read you and so when we see you post how low the USA ranks we protest, All we are saying is that it seems not about healthcare and/or public policy but about culture and maybe genetics and so an NHS for the USA will probably not narrow the difference much.

      If it is not about culture and genetics access to healthcare then why do Hispanics, who of the major groups, have the least access to health care have lower than average infant mortality (and BTW rate of multiple births) and higher than average life expectancy.

    • “Low Life Expectancy in the United States: Is the Health Care System at Fault?”
      Samuel H. Preston, Jessica Ho
      Population Studies Center
      University of Pennsylvania

      “The question that we have posed is much simpler: does a poor performance by the US health care system account for the low international ranking of longevity in the US? Our answer is, “no”.


    • The text of the first link should have been: “Life expectancy by country”. Sorry.

    • I agree with you here:

      There is no economic or moral reason why all Americans should not have a place to live, plenty of food, health care, and decent clothing. We have the money; we just allocate it so poorly.

      But this is questionable:

      Poverty just grinds you down spiritually, mentally, morally, and physically. It is hard to make your life better when you worry about your next meal or your cold hands or your lack of books.

      I could just as well tell a story were wealth makes one fat and lazy and poverty makes one lean and hungry and thus hard working and successful. The poorest county in the USA is Kiryas Joel, not much crime there. Poor Chinese immigrants and their children seem to not have a high rate of crime, neither BTW do poor Hispanic immigrants. It is attitude/culture. It may be our fault but it seems to me not to be as simple as you make it out to be.

    • Since you mention Japan, permit me to point out that ethnic Japanese who move to (or are born in) the US, quickly end up just as obese as the general population around them. (And Japan itself does have problems with metabolic syndrome, since white collar workers are too busy to worry about eating well. Also, there are large variations within Japan due to local dietary habits/culture; Okinawa is (or used to be) very good, Kochi Prefecture, where the most popular meal is off scale in its glycemic index) does poorly.)

    • @David J. Littleboy

      From the Eight Americas study

      Life expectancy by race in the US in 2001 ranged from 86.7 for Asian females to 68.7 for black males, a gap of 18 y. Analysis of life expectancy by county of residence and by the combination of race and county of residence (referred to as “race-county” in this paper) demonstrates even larger disparities [23]. County-level analysis of mortality for 1997–2001 (pooled over 5 y to increase sample size) demonstrates a 22.5-y gap in life expectancy between males in southwest South Dakota and females in Stearns County, Minnesota (see Dataset S1 for life expectancy by county). When race-county combinations are considered, life expectancy disparities are dramatically larger. For example, Native American males in the cluster of Bennet, Jackson, Mellette, Shannon, Todd, and Washabaugh Counties in South Dakota had a life expectancy of 58 y in 1997–2001, compared to Asian females in Bergen County, New Jersey, with a life expectancy of 91 y, a gap of 33 y (see also Figure 1). Mortality inequalities in subgroups within race-counties, such as those defined based on socioeconomic status (SES), may be even larger. Because of small sample size and the absence of individual-level linked data needed to study race-county-SES combinations, it is currently not possible to study mortality patterns within race groups in small geographic areas, or even states. The largest measurable gaps observed in the US to-date are those revealed by examining the inequalities across race-county groups.

      Asians in the USA seem to live even longer than Asians in Japan.

    • BTW I know a woman who had fertility treatments and had multiple multiple births of about 10 births total 2 children survive. These fertility treatments occur much more in the USA than elsewhere. They are perhaps an issue of too much access rather than too little but what do they do to your statistics?

    • Health at a Glance: Europe 2012

      Around two-thirds of the deaths that occur during the first year of life are neonatal deaths (i.e. during the first four weeks). Birth defects, prematurity and other conditions arising during pregnancy are the principal factors contributing to neonatal mortality in developed countries. With an increasing number of women deferring childbearing and a rise in multiple births linked with fertility treatments, the number of pre-term births has tended to increase (see Indicator 1.8 “Infant health: Low birth weight” ). In a number of higher-income countries, this has contributed to a leveling-off of the downward trend in infant mortality rates over the past few years. For deaths beyond a month (post neonatal mortality), there tends to be a greater range of causes – the most common being SIDS (sudden infant death syndrome), birth defects, infections and accidents.