More Information on Health Disparities

A Tale of Three Cities: Racial and Ethnic Disparities in Premature Mortality in the District of Columbia, 2005

October 22, 2008
Annette B. Ramirez de Arellano, Dr.PH., Sidney Wolfe, M.D., Kate Resnevic, Alejandro Necochea, M.D., M.P.H.

Full Report (pdf)
Introduction and Methods
Overall Years of Potential Life Lost
Premature Mortality by Sex
Premature Mortality by Race/Ethnicity - Part 1
Premature Mortality by Race/Ethnicity - Part 2
Sex Differentials within Subgroups - Part 1
Sex Differentials within Subgroups - Part 2
Discussion and Implications for Policy

Results – Premature Mortality by Race/Ethnicity - Part 1

Premature Mortality by Race/Ethnicity - Part 1

During the past 25 years there has been growing recognition that the United States suffers from wide racial and ethnic disparities in terms of both health status and access to care. The publication of the Department of Health and Human Services Report of the Secretary’s Task Force on Black and MinorityHealth in 1985 documented many of these disparities, and led to a new focus on the health of minorities. This has in turn resulted in greater surveillance and in better and more complete data on the health of specific groups. It has also  prompted more interventions to improve the health of those segments of the population that are at particular risk for ill health and injuries.

Nevertheless, recent data indicate that racial disparities are still extremely large and pervasive across different indicators of health status. And these have not narrowed over time.[1] Indeed, the co-existence of an expanded capacity to control disease with the persistence of inequalities appears to have exacerbated racial and socio-economic disparities in health by tilting these new capabilities towards those that are already better off. New technologies and treatments, while reducing disease, can ironically widen socio-economic disparities in health.  In the words of Phelan and Link, “When we develop the ability to control disease and death, the benefits of this new-found ability are distributed according to resources of knowledge, money, power, prestige, and beneficial social connections.”[2]

Researchers have therefore focused on “fundamental causes” of disparities in health, looking at the social determinants of health and disease. These include differences in natural capital (environmental resources), human capital (education), material capital (occupation, employment, income) and social capital (social support and community empowerment). These “capitals” are seldom equitably distributed and tend to cluster or overlap.  Because advantages often feed on each other, those who are better endowed with respect to one also tend to be better off with respect to the others. Understanding the pathways through which these factors interact to further or thwart better health has therefore become a major focus in addressing existing disparities.

The growing literature on disparities has shown that where you stand in the social hierarchy is intimately related to your health and life expectancy. And these social distinctions operate even for people above a threshold of material well-being, as Marmot has documented, a phenomenon that he has called “the status syndrome.” His studies have shown that “autonomy – how much control you have over your life – and the opportunities you have for full social engagement and participation are crucial for health, well-being, and longevity.”[3] Conversely, in societies in which prejudice, poverty, powerlessness and ill health are self-reinforcing, segments of the population face multiple barriers to break out of the cycle and overcome their cumulative disadvantages.

As the nation’s political capital and seat of government, the District of Columbia reflects and refracts much of what is happening in the nation as a whole. At the same time, the District has a very particular economy and demographic composition that make it distinctive, and that amplify trends that are less salient elsewhere. D.C. has the following characteristics:[4]

  • The population of the District is predominantly black. In 2006, blacks constituted 56.5 percent of the total number of inhabitants in the nation’s capital, while accounting for 12.8 percent of the population of the United States. Conversely, non-Hispanic whites comprised 31.7 percent of the District’s inhabitants, in contrast to 66.4 percent for the U.S. as a whole. Hispanics are under-represented in D.C., where they account for 8.2 percent of the population, compared to 14.8 percent for the U.S. as a whole.
  • District neighborhoods are characterized by racial segregation. Although no longer legitimized by law, residential segregation by race is a reality in many American cities, including the nation’s capital. As a result, blacks constitute an overwhelming majority of the population in certain wards. In Wards 7 and 8, blacks account for 96.9 and 91.8 percent of the total population, respectively.[5] Because race and poverty tend to be associated in the U.S., these wards are also the ones with the lowest family incomes in the city.[6] Not unexpectedly, they also have the worst health indicators. Ward 7, for example, has the highest rates of six out of the nine adult chronic conditions examined in a recent health assessment of the District.[7] Among the other three conditions, Ward 8 had the worst indices for two of them. And these two wards had the highest age-adjusted mortality rates for all of the eight causes of premature mortality among those 18-64 years old.[8] Because of these phenomena, Williams and Collins have argued that “racial residential segregation is the cornerstone on which black-white disparities in health status have been built in the U.S. Segregation… shapes socioeconomic conditions for blacks not only at the individual and household levels but also at the neighborhood and community levels.” [9]
  • Like blacks, although to a lesser extent, Hispanics tend to cluster geographically; in 2000, one ward (Ward 1) had a population that was 23.4 percent Hispanic.[10] Among the remaining seven wards, the Hispanic share of the population varied between 0.9 percent and 12.8 percent.[11] This tendency towards concentration and exclusion has health implications. While ethnic enclaves created by such residential patterns once allowed newcomers to adapt gradually, providing them the social supports needed to navigate a new language and culture, the resulting longer-term residential segregation can also isolate minorities, trapping them in neighborhoods in which jobs are scarce and economic mobility is limited. This trend may have increased with gentrification, although this process may also have dispersed the population once living in transitional neighborhoods.
  • D.C. has a smaller proportion of persons under 5 years of age (6.0 percent vs. 6.8 percent) and under age 18 (19.8 percent vs. 24.6 percent).[12]  
  • The population of the District has a significantly higher level of education that the U.S.: 39.1 percent of D.C. inhabitants have a bachelor’s degree or higher, compared to 24.4 percent for the country as whole.[13] 
  • Poverty and socio-economic disparities are masked by higher median household and per capital incomes. While the District’s individuals and households are more affluent than the country as a whole (median household income is $46,211 in the District and $44,334 in the U.S.; per capita income is $28,659 in D.C. and $21,587 in the U.S.), D.C. has a significantly higher proportion of its population falling under the poverty level: 18.3 percent, compared to 12.7 percent for the U.S.[14]

It is against this backdrop that the data on YPLL should be examined. Table 3 presents the proportion of YPLL attributed to the five principal causes of potential loss, by cause and demographic subgroup.

Table 3. Proportion of Years of Potential Life Lost (YPLL) Before Age 70, District of Columbia and United States: 2005, Blacks, Whites, Hispanics, Both Sexes, 5 Principal Causes of Death

Cause of Death

Whites (%)

Blacks (%)

Hispanics (%)

D.C.

U.S.

D.C.

U.S.

D.C.

U.S.

Homicide

*

*

15.7

9.5

10.8

6.9

Cancer

18.7

19.5

11.8

15.2

12.3

15.6

Heart Disease

6.6

13.4

11.9

15.5

*

10.5

HIV

6.3

*

10.5

*

*

*

Accidents

13.9

20.4

*

10.7

12.4

19.2

Perinatal Period

14.8

5.5

8.9

8.5

7.3

7.2

Congenital Anomalies

*

3.5

*

*

11.0

*

TOTAL

60.3

62.3

58.8

59.4

53.8

59.4

* Data not included because cause of death is not among the top five for YPLL for that population. Causes with the highest share are indicated in bold for each group.  

As shown in Table 3, the relative importance of the main causes of YPLL varies for each of the District’s subgroups, each group having a different top cause for YPLL (indicated in bold). While homicide represents the main cause of potential life lost among blacks and ranks 4th among Hispanics, this cause does not even appear among the top five for whites. Homicides, which are associated with the availability of handguns, prevalence of felony-level crimes, and drug use, are primarily confined to specific circumstances and neighborhoods, largely sparing others. Furthermore, in the U.S. homicides rates are directly correlated with income inequalities: among states, the higher the income inequality, the higher the homicide rate.[15] This phenomenon has been found within the city of Chicago and in the Canadian provinces and may also be occurring in D.C. And because assailants tend to be similar to their victims, the pattern has a differential impact on certain communities. 

In the District, cancer assumes a higher priority as a cause of YPLL for whites than for the other two groups. This, however, does not mean that the rate for cancer is higher for whites;[16] rather, this particular cause of death represents a larger share of YPLL for the white population. Among Hispanics, accidents account for the largest proportion of YPLL in D.C. as well as nationally. And congenital anomalies, ranking 3rd   in D.C., are a source of major loss for Hispanics, yet this cause does not rank among the top five for whites or blacks. Any attempt at designing effective interventions in the District of Columbia will therefore have to take these differences into account.

Table 3 also reflects the fact that, even within given ethnic groups, the major causes of premature death differ when the District is compared to the nation in general. Thus, among whites, accidents rank 1st nationally but 3rd in D.C. And, among blacks, heart disease is the principal cause of YPLL nationally, but ranks 2nd in the District. Among Hispanics, however, accidents constitute the major cause of premature loss both in the U.S. and in D.C. At least part of the difference can be attributed to deaths on the job. Many Latinos, particularly recent immigrants, work at high-risk jobs in the construction and service sectors. Their risks are compounded by language barriers that hinder understanding of the job and its risks, and limit access to safety precautions.[17]



[1] David R. Williams and Chiquita Collins, Racial Residential Segregation: A Fundamental Cause of Racial Disparities in Health. Public Health Reports, September-October 2001, Vol. 116: 405.

[2] Jo C. Phelan and Bruce G. Link, Controlling Disease and Creating Disparities: A Fundamental Cause Perspective. The Journals of Gerontology Series B: Psychological Sciences and Social Sciences 60 (2005): S27-S33.

[3] Michael Marmot, The Status Syndrome: How Social Standing Affects Our Health and Longevity. New York: Times Books, Henry Holt and Co., 2004: 2.

[4] All data are for 2006. U.S. Census Bureau, State and County QuickFacts. District of Columbia. http://quickfacts.census.gov/qfd/states/11000.html 

[5] Nicole Lurie et al. RAND Health Working Paper: Assessing Health and Health Care in the District of Columbia. January 2008: x.

[6] Ibid.

[7] Lurie et al, op. cit.: xvi.

[8] Ibid.

[9] David R. Williams and Chiquita Collins, Racial Residential Segregation: A fundamental Cause of Racial Disparities in Health. Public Health Reports.  September-October 2001, Vol. 116: 405.

[10] Lurie, et al. op. cit.: x.

[11] Ibid.

[12] All data are for 2006. U.S. Census Bureau, State & County QuickFacts. District of Columbia. http://quickfacts.census.gov/qfd/states/11000.html

[13] Ibid.

[14] Ibid.

[15] M. Daly, M. Wilson and S Vasdev. Income Inequality and Homicide Rates in the United States and Canada. Canadian Journal of Criminology 43, 2001: 219-236, cited in Marmot, op. cit.: 100-101.

[16] Indeed, as is seen in Table 5, the YPLL rate for cancer among blacks is almost 3-fold that for whites.

[17] Latinos dying on job at higher rates than others. Los Angeles Times, June 06, 2008. http://articles.latimes.com/2008/jun/06/business/fi-latino6

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