Challenges and Successes in Reducing Health Disparities Workshop Summary (2008) / Chapter Skim
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Appendix C: Eight Americas: Investigating Mortality Disparities Across Races, Counties, and Race-Counties in the United States
Appendix C: Eight Americas: Investigating Mortality Disparities Across Races, Counties, and Race-Counties in the United States
Pages 129-160
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Appendix C 129
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Harvard University Initiative for Global Health, and Center for Population and Development Studies, Harvard University, Cambridge, Massachusetts. Center for Population and Development Studies, Harvard University, Cambridge, Massachusetts.
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We divided the race-county combinations of the US population into eight distinct groups, referred to as the ‘‘eight Americas,'' to explore the causes of the disparities that can inform specific public health intervention policies and programs. Methods and Findings The eight Americas were defined based on race, location of the county of residence, population density, race-specific county-level per capita income, and cumulative homicide rate.
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Because policies aimed at reducing fundamental socioeconomic inequalities are currently practically absent in the US, health disparities will have to be at least partly addressed through public health strategies that reduce risk factors for chronic diseases and injuries. The Editors' Summary of this article follows the references.
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Data on risk factor exposure and health-care access and utilization are even more limited, as there are almost no sources of information on these variables by race and county. In order to investigate the causes of the observed race-county mortality disparities, within the limitations posed by sample size, we have divided US race-counties into eight subgroups based on a number of sociodemographic and geographical variables, referred to as the ‘‘eight Americas.'' In addition to examining the role of specific diseases in age-specific and all-age mortality disparities, the eight Americas analysis identifies distinct subgroups, based on a small number of sociodemographic and geographical indicators, towards whom public health and medical interventions may be targeted.
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We then divided the entire US population (the race-county units) into eight distinct subgroups, the eight Americas, based on the location of the county of residence, population density, per capita income of the county of residence in 1990, and cumulative homicide rate (averaged between 1991 and 2001 to reduce sensitivity to outlier years)
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(A) Life expectancy at birth for black males and females.
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Capita High School Definition 1 Asian 10.4 $21,566 80% Asians living in counties where Pacific Islanders make up less than 40% of total Asian population 2 Northland low- 3.6 $17,758 83% Whites in northern plains and Dakotas with 1990 county-level income rural white per capita income below $11,775 and population density less 2 than 100 persons/km 3 Middle America 214.0 $24,640 84% All other whites not included in Americas 2 and 4, Asians not in America 1, and Native Americans not in America 5 4 Low-income whites 16.6 $16,390 72% Whites in Appalachia and the Mississippi Valley with 1990 in Appalachia and the county-level per capita income below $11,775 Mississippi Valley 5 Western Native 1.0 $10,029 69% Native American populations in the mountain and plains areas, American predominantly on reservations 6 Black Middle 23.4 $15,412 75% All other black populations living in countries not included in America Americas 7 and 8 7 Southern low-income 5.8 $10,463 61% Blacks living in counties in the Mississippi Valley and the 2 rural black Deep South with population density below 100 persons/km , 1990 county-level per capita income below $7,500, and total population size above 1,000 persons (to avoid small numbers) 8 High-risk urban black 7.5 $14,800 72% Urban populations of more than 150,000 blacks living in counties with cumulative probability of homicide death between 15 and 74 y greater than 1.0% Population, income per capita, and education were calculated for race-county combinations from the 2000 US census.
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. Race was defined according to the 1977 US Office of Management and Budget definition of the four race groups (Asians, blacks, Native Americans, and whites)
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. The bias for Native Americans observed in national data is unlikely to affect our estimates because the grouping used in the eight Americas distinguishes those Native Americans who primarily live on or near reservations (America 5)
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. RESULTS Definition of the Eight Americas Table 1 summarizes the characteristics of the eight Americas (see also Figures S1 and S2)
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America 6 represents the rest of black America, living mostly in urban or semi-urban counties. Mortality Experiences of the Eight Americas Figure 3 summarizes the mortality experiences for the eight Americas between 1982 and 2001, divided into broad age groups and diseases in Figure 4A for 2001.
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80 70 60 2000 1990 1996 1984 1986 1988 1998 1994 1992 1982 Year Figure 3. Life Expectancy at Birth in the Eight Americas (1982–2001)
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Probability of death by sex, age, and disease for the eight Americas in 2001.
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. The eight Americas classification reveals that within the white population there is a wide variation in health experience that cannot be explained by differences in average income: low-income white rural populations in Minnesota, the Dakotas, Iowa, Montana, and Nebraska (America 2)
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Age and Disease Patterns of Mortality in the Eight Americas Figure 4 shows mortality risk in four age groups (0–4, 15–44, 45–64, and 65–74 y) for the eight Americas, and further compares Americas 1 and 8 with countries and regions at a range of mortality levels including Japan, the United Kingdom, the Russian Federation, and the high-mortality coun tries of sub-Saharan Africa.
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Probability of death between the ages of 15 and 59 y in the eight Americas from all causes.
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For both males and females, the rates of routine checkup are slightly higher in Americas 6, 7, and 8, the groups with mortality disadvantage. DISCUSSION The eight Americas in this paper consist of distinct subgroups of the US population defined based on a small number of sociodemographic and geographical indicators including race, the location of the county of residence, population density, race-specific county-level per capita income, and cumulative homicide rate.
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. The grouping used in the eight Americas distinguished between those Native Americans who primarily live on or near reservations (America 5)
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The findings on persistent health disparities in the eight Americas raise the question of why, as a society, we have failed to narrow health gaps between distinct and large subgroups of the US population. Opportunities and interventions to reduce health inequalities include (1)
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The diseases with the largest contribution to mortality disparities across the eight Americas are chronic diseases and injuries with well-established risk factors, including alcohol use, tobacco smoking, overweight and o besity, and elevated blood pressure, cholesterol, and glucose. These risk factors are also the leading cause of burden of disease in the nation as a whole (Figure 7)
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First, there is a need to use systematic epidemiological and economic analyses to identify effective and cost-effective health interventions -- whether targeting populations or individuals -- that would make the biggest difference to those with the worst health. Given the distinct epidemiological, geographical, and socio demographic profiles of the eight Americas, the leading interventions may be different for each, although some common core strategies may exist (e.g., common core cardiovascular disease prevention strategies)
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(2000) Trends and disparities in coronary heart disease, stroke, and other cardiovascular diseases in the United States: Findings of the national conference on cardiovascular disease prevention.
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Mortality dif ferences between black and white men in the USA: Contribution of income and other risk factors among men screened for the MRFIT. MRFIT Research Group.
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(2003) Estimates of global and regional potential health gains from reducing multiple major risk factors.
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They eventually settled on the idea of there being ‘‘eight Americas,'' defined on the basis of race-county, population density, income, and homicide rate. Each group contains millions or tens of millions of people.
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At the same time, the public health system should also improve the way in which it deals with risk factors for chronic diseases and injuries so that groups with the highest death rates receive larger benefits. Additional Information Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0030260.
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