“Introduction
In 1985, the US Department of Health and Human Services (HHS) Secretary Margaret M. Heckler issued the Report of the Secretary’s Task Force on Black and Minority Health, also known as the Heckler Report. The landmark report found that the Black population had strikingly higher mortality rates than the White population, resulting in almost 60 000 excess deaths a year relative to the White population. Race offers no intrinsic biological reason for those categorized as Black individuals to have worse outcomes than White individuals, indicating therefore that these disparities are driven by the burden of acquired risk factors, influence of social determinants of health, limitations in access to care, and structural barriers indicative of bias (ie, structural racism). [..]
Methods
We used national US death certificate data from the Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research (CDC WONDER) for the years 1999 through 2020. For this period, we obtained the annual life expectancy by 5-year age groups from the National Center for Health Statistics life tables. [..]
Results
From 1999 to 2011, the age-adjusted excess mortality rate declined from 404 to 211 excess deaths per 100 000 individuals among Black males (1999-2007, P for trend < .001; 2007-2011, P for trend < .001). However, the rate plateaued from 2012 through 2019 (P for trend = .98), with a subsequent single-year increase in 2020 to 395, rates not seen since 2000. Among Black females, the estimated age-adjusted excess mortality rate declined from 224 excess deaths per 100 000 individuals in 1999 to 87 in 2015 (P for trend <.001). There was no significant change between 2016 and 2019 (P for trend = .71), but in 2020 rates increased to 192—levels not seen since 2005. Although a similar pattern was observed in the total number of excess deaths, in 2020 the number of excess deaths among both Black males and Black females was higher than in any other year of the entire study period (79 801 and 47 545 excess deaths, respectively). In relative terms, over the study period the age-adjusted mortality rate ranged from 21% to 40% higher among Black males and from 13% to 31% higher among Black females compared with their White counterparts.
In 1999, the excess years of potential life lost for Black males and Black females were 14 964 and 10 806 per 100 000 people, respectively. There was a continuous decline until 2011 among males (P for trend < .001), and until 2012 among females (P for trend < .001). Then there was a plateau until 2019 for both groups (P for trend = .26 for males and P for trend = .90 for females), after which the rate of excess years of potential life lost increased in 2020 to rates similar to those of 2001 and 2005 among Black males and Black females, respectively. Although there was a reduction in absolute numbers of years of potential life lost from 1999 through 2019, in 2020 the total excess years of potential life lost reached its highest number among Black males (2 898 669 years) and reached numbers similar to those in 1999 among Black females (1 940 604 years). The annual years of potential life lost rate ratio followed a similar pattern over the 22-year period. [..]
In 2020, the highest excess age-adjusted mortality rate among Black males was for deaths due to COVID-19 (80 per 100 000 individuals), whereas it was only second to heart disease among Black females (47 per 100 000 individuals). Similarly, the excess years of potential life lost due to COVID-19 (per 100 000 individuals) was 2572 among Black males and 1759 among Black females, in both groups ranking third below conditions from the perinatal period and heart disease. [..]
The maximum excess death rate occurred among those between the ages of 75 and 79 years, reaching 1302 per 100 000 males and 677 per 100 000 females. The greatest difference in years of potential life lost rate between the Black population and the White population was among those younger than 1 year (59 232 per 100 000 Black males and 53 061 per 100 000 Black females), decreasing to its minimum among those between the ages of 1 and 14 years. Consistent with the excess mortality pattern, the rate of excess years of potential life lost increased with age among males older than 15 years and among females older than 20 years, increasing up to those aged 65 to 69 years old and decreasing among those older. [..]
Discussion
In this study of US mortality data from 1999 through 2020, an estimated 997 623 excess deaths occurred among Black males and 628 464 excess deaths among Black females relative to their White counterparts—accounting for a total of 1.63 million excess deaths. These excess deaths corresponded to a total of 47 million and 35 million excess years of potential life lost among Black males and Black females, respectively. After a period of progress from 1999 to the early 2010s, improvements stalled at least through 2020 when, coincident with the first year of the pandemic, the number of excess deaths increased abruptly and exceeded that of any previous year of the study. Moreover, even at the lowest of excess of deaths and years of potential life lost there were more than 50 000 annual excess deaths and 3 million annual excess years of potential life lost among the Black population compared with the White population. Differences in loss of life were most prominent among infants, with Black-White mortality and years of potential life lost rate ratios greater than 2.3 among those younger than 1 year old. Heart disease in both sexes and cancer in males were the largest drivers of differences in excess deaths. Broadly, these findings indicate that current efforts to curb or eliminate mortality disparities have been minimally effective, and progress, when made, has been fragile. [..]
The excess deaths and years of potential life lost were elevated among most of the major causes of death, even though heart disease was the most prominent. This is consistent with a study by Kyalwazi and colleagues who found that, despite a decline in the absolute difference, age-adjusted cardiovascular mortality rates were persistently higher among the Black population than among the White population from 1999 to 2019. It is likely that disparities in rates of hypertension control and other factors associated with heart disease are in part responsible for this excess loss of life. Cancer was also an important source of the disparity. Both heart disease and cancer have modifiable risk factors that are importantly affected by social determinants of health. Targeted and renewed efforts aimed at diseases that disproportionately drive differences are necessary to make sure clinical advancements are experienced uniformly across the population.
The sobering disparity noted in this study among infants and during childhood accounted for a markedly elevated number of excess deaths and an even more pronounced disparity in years of potential life lost. This excess mortality occurred in a period of life of highest vulnerability and warrants new dedicated public health initiatives targeting early childhood health. After childhood, the excess deaths and years of potential life lost became evident in early adulthood and generally increased with age. This finding is consistent with a recent report by the National Academies of Sciences, Engineering, and Medicine that found consistently higher mortality rates among Black adults aged 25 through 65 years from 1990 to 2017 compared with other racial and ethnic groups of the same age, despite increasing trends among their White counterparts and regardless of educational attainment or geography. These alarming excess deaths in working-aged groups may be the most socially disruptive given the destabilizing effect on productivity and economic gains for Black families, potentially contributing to the perpetuation of generational racial disparities. Among those older than 65 years, these disparity metrics declined, as would be expected because of the persistently lower average lifespan among the Black population. [..]
The Black population in the US, regardless of cause or the burden of risk factors, continue to die at much greater rates than the White population, with dramatic long-run consequences when accounting for the effect of premature mortality. These metrics, especially years of potential life lost, are suitable for public reporting and may inspire strategies directed toward more in-depth root-cause analysis and where qualified by evidence of efficacy, implementation of steps to improve these disparities. As such, an annual publicly reported metric of race-based years of potential life lost may be useful for national accountability. Excess mortality and years of potential life lost by race could serve as a major national (and local) gauge of progress toward achieving health equity. Although achieving equity in these metrics may need persistent multigenerational efforts, it is crucial to advance rapidly in that direction.”
Full article, C Caraballo, DS Massey, CD Ndumele et al. JAMA, 2023.5.16