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

Discussion and Implications for Policy

DISCUSSION

Many jurisdictions refer to their “leading causes of death” or “priority health problems” without specifying what yardstick they are using to rank different conditions or what they seek to accomplish. While crude mortality rates may provide a useful approximation of the problems that should be attacked, years of potential life lost is a more accurate indicator of the impact of premature deaths that are more amenable to prevention.  Moreover, YPLL may be a fairer and more ethically appropriate measure of health status, since it weights each person’s death by the amount of possible life foregone.[1]

The use of YPLL using data for the District of Columbia points out the extent to which specific subgroups of the population are at particular risk of premature death. In 2000 the U.S. Department of Health and Human Services called for a national plan to eliminate health disparities among the different segments of the U.S. population.[2] The data above show the extent to which the District of Columbia is falling short of this goal. When the YPLL data for the District are compared with those nationally, it is obvious that whites and Hispanics in D.C. have better life chances than their counterparts throughout the nation. Blacks in the District, however, at much greater risk for premature death than blacks in the U.S. as a whole. The use of YPLL therefore highlights the extent to which the District of Columbia magnifies the ethnic/racial disparities that afflict the nation. 

Although the nation’s capital prides itself in its diversity of races and cultures, it has little to boast about in terms of health outcomes as measured in years of potential life lost. The breakdowns by race and sex show that different subgroups are at differential risk, and that the losses due to ill health and violence are far from evenly distributed. Blacks are at considerably higher risk than whites and Hispanics for most causes of death, particularly for homicide and HIV. And each of the subgroups examined – blacks, whites, Hispanics – reflect different priorities in terms of reducing premature losses. Any citywide campaign that does not take this into account is therefore bound to fail. In terms of health and life expectancy, blacks, whites and Hispanics can be said to live in different cities even when they share the same urban space.

The data also highlight the extent to which traditional chronic conditions affecting individuals have been superseded as causes of premature death by causes linked to social behavior, including homicides, injuries and HIV, in accounting for years of potential life lost. While chronic conditions account for most of the premature losses among whites, that is not the case for blacks and Hispanics, who together constitute more than 63 percent of the total D.C. population. 

While the media speak of acts of “random violence” occurring in the District, the fact is that the existing violence is far from random. Instead, it primarily affects some areas and specific segments of the population, and has had a marked differential effect on certain subgroups.   Among young black men the impact of violence is particularly evident from the use of YPLL. It is therefore not surprising that the District is using a variety of measures – including more stringent gun-control measures, checkpoints and the imposition of curfews – to curb the rate of homicides. These, while necessary, may not be sufficient to address the problem. A more comprehensive strategy has to include upgrading housing quality, insuring more equitable access to goods and services, creating communities that foster social networks and boost opportunities for economic redevelopment in blighted areas.  

Among Hispanics, the more than 4-fold differential in rates of YPLL between the sexes suggests different exposures to risk. The prevailing gender-based division of labor, together with distinct cultural expectations regarding male and female behaviors, appear to place men at greater risk or, conversely, to protect women against some potential premature deaths. And the fact that the gender divide is not only one of magnitude but also of type, with each sex being particularly vulnerable to given conditions, emphasizes the need to customize health messages by subgroup as well as by gender.

The complicated etiology of premature deaths in the District means that, as Link and Phelan have stated, public health activities have to transcend their current boundaries and look not just at what health professionals do but also at the array of human actions that have important health consequences.[3] In the nation’s capital, YPLL rates provide eloquent testimony that being a numerical majority does not protect against being disadvantaged. The foreshortened lives of blacks in the District of Columbia may represent individual tragedies, but they also represent a collective failure of the body politic. By “giving simple statistical expression to the harsh reality of death at younger ages,”[4] the indicator of years of potential life lost underscores those populations that are very much at risk.

IMPLICATIONS FOR POLICY

The District of Columbia has been called a “city etched by divides” by its own Chamber of Commerce.[5] Similarly, the D.C. Fiscal Policy Institute has described the District as having “two economies:” one characterized by stable jobs, a construction boom, and neighborhood revitalization; the other, by lagging wages, persistent unemployment and inadequate services.[6] The data on YPLL mirror this situation, dramatizing the racial dimension and health implications of this duality.

The breakdown of YPLL by race, sex, and cause underscores the need for broad-based interventions at the same time that it suggests priorities for immediate action.

1. The District should make use of the striking disparities in YPLL documented in this report to set health priorities and monitor existing disparities. The indicator is easy to calculate and easy to understand, and will highlight those causes that account for the greatest burden of life lost. Furthermore, by focusing on premature deaths, it emphasizes factors and conditions that are amenable to prevention.

2. Violence among blacks has to be treated as the epidemic it has become. As in other outbreaks, all three components of the epidemiological triad – host, agent and environment –   have to be taken into account in combating premature deaths, particularly among males. The recent U.S. Supreme Court decision against D.C.’s gun laws presents an opportunity to rethink the issue of firearms and their availability. This is especially necessary given that the prior restrictions were not extremely effective in preventing premature losses due to homicide. Although the Court struck down D.C.’s ban on handguns as incompatible with Second Amendment rights, the ruling did not imply that the right to bear arms is absolute. Washington D.C. therefore needs to adopt new regulations that will curtail the misuse of firearms within the current law and insure the protection of the public’s health. The fact that violence is shortening the lives of so many D.C. residents should be part of the rationale for adopting new measures. Ongoing mapping and tracking of homicides needs to be accompanied by broader interventions to break the vicious cycle of violence and poor health. Those communities or neighborhoods identified as high risk can also be redesigned to promote safer spaces for the population as a whole. Principles of “defensible space” which have been found to enhance a sense of security and increase residents’ ability to monitor their surroundings should be adopted.

3. Educational preventive campaigns need to target specific subgroups, neighborhoods, and causes. Spokespersons should reflect the issues each community faces, and project the message of a caring, concerned city government that values its constituents.   Community-based organizations must be enlisted and made partners in the fight against premature deaths. Many of these organizations are already coping with the realities of blighted lives; they are well-prepared to address the causes as well as to remedy the results of poverty and powerlessness.

4.  The high rate of YPLL due to congenital anomalies among Hispanics in D.C. requires particular attention. While national folic acid fortification has reduced the incidence of some congenital anomalies among all groups throughout the country, it has had a greater impact on high-income groups, thereby increasing disparities by socio-economic status.[7] To the extent that certain ethnic and racial groups are disproportionately poor, they have lagged in benefiting from the fortification policy. The promotion of folic acid consumption among women of childbearing age therefore needs to zero in on those groups, including Hispanics, who are not reaping the benefits of fortification and are thus at greater risk for birth defects. 



[1] CJL Murray, The Infant Mortality Rate, Life Expectancy at Birth and a Linear Index of Mortality as Measures of General Health Status. International Journal of Epidemiology 17 (1988): 126.

[2] U.S. Department of Health and Human Services. Health People 2010. 2nd edition. Understanding and improving health and objectives for improving health; 2 volumes. Washington, D.C.: U.S. Government Printing Office, 2000.

[3] Bruce G. Link and Jo C. Phelan, McKeown and the Idea that Social Conditions Are Fundamental Causes of Disease. American Journal of Public Health. 92 (5) May 2002: 730-732.

[4] Romeder and McWhinnie, op. cit.: 150.

[5] June 2007 report quoted in Sylvia Moreno, Poverty Rate Grows Amid an Economic Boom: D.C.C’s Poorest Left Behind By Renewal, Report Finds. Washington Post, October 24, 2007: B01. http://www.washingtonpost.com/wp-dyn/content/article/10/23/AR2007102302230­­.html

[6] Ed Lazere, D.C.’s Two Economies: Many Residents Are Falling Behind Despite the City’s Revitalization. D.C. Fiscal Policy Institute. October 2007. http://www.D.C.fpi.org/10-24-07DC.pdf

[7] Jennifer Beam Dowd and Allison E. Aiello, Did national folic acid fortification reduce socioeconomic and racial disparities in folate status in the U.S. International Journal of Epidemiology 2008; 1-8.

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