Black/White Comparisons of Premature Mortality for Public Health Program Planning - District of Columbia

Analyses of mortality patterns in the United States have shown differences in health status by race (1-4). These mortality data are an important component of public health planning to obtain the same standards of health for minority and nonminority populations. However, mortality measures based solely on race obscure the role of potential risk factors such as cigarette smoking (5,6), alcohol and drug use (7), blood pressure, diet, educational attainment, income, occupation, and adequacy of health care (1,8,9). Examining the burden of preventable mortality associated with these risk factors helps to focus the public health planning process on the gap between the current burden of mortality and the lesser burden achievable through specific interventions (10).

The District of Columbia Commission of Public Health analyzed its mortality data for 1980-1986 to determine the adequacy of current prevention and control activities and to identify possible gaps in public health services. These data were analyzed using three measures:

1. age-adjusted mortality, 2) premature deaths (deaths occurring before age 70), and 3) years of potential life lost before age 65 (YPLL) (11). Age-adjustment was performed by the direct method using the 1970 population as the standard.

In addition, "excess deaths" were calculated using the definition of the Secretary's Tas Force on Black and Minority Health of the U.S. Department of Health and Human Services (1). This estimate reflects the difference between the number of observed deaths before age 70 in the black population and the number that would be expected if the black population had the same age- and sex-specific mortality rates as the white population. Excess YPLL for blacks also were calculated to determine the difference between observed and expected YPLL.

During 1980-1986, 47,694 resident deaths occurred in the District of Columbia, resulting in an average annual age-adjusted mortality rate of 973 per 100,000 population. Among blacks, the average annual age-adjusted mortality rate was 1092 per 100,000 population, exceeding the rate for whites (692 per 100,000) by 37%. Mortality rates were highest for black males, followed by white males, black females, and white females (Figure 1).

Compared with white males in the District, black males had higher mortality rates for sudden infant death syndrome (SIDS) (rate ratio (RR)=4.7), suicide and homicide (RR=2.5), prematurity (RR=2.2), chronic liver disease and cirrhosis (RR=2.1), and unintentional injuries (RR=2.1). Compared with white females, black females had higher mortality rates for diabetes (RR=3.6), SIDS (RR=3.0), prematurity (RR=2.3), chronic liver disease and cirrhosis (RR=2.0), and pneumonia and influenza (RR=1.6). Overall, blacks had lower mortality rates than whites for congenital anomalies (RR=0.7) and chronic obstructive lung disease (RR=0.7).

In the District, as in the nation, YPLL rates were highest for black males, followed by black females, white males, and white females (Figure 2). When compared with white males, District black males had higher YPLL rates for SIDS (RR=5.1), cerebrovascular disease (RR=4.5), suicide and homicide (RR=3.6), and diabetes (RR=3.3) (Table 1). Compared with white females, black females had higher YPLL rates for diabetes (RR=10.3), pneumonia and influenza (RR=8.4), heart disease (RR= 3.9), and chronic liver disease and cirrhosis (RR=3.6) (Table 1).

Blacks in the District had an average annual total of 1493 excess premature deaths and 28,606 excess YPLL when compared with whites. Total premature deaths and YPLL in the District were twice those expected if black mortality rates were equal to white rates. Although black males constitute 46% of the District's black population, they accounted for 66% of the excess premature deaths and 69% of the excess YPLL (12). Reported by: M Levy, MD, State Epidemiologist, and staff, District of Columbia Commission of Public Health. Epidemiology Program Office, CDC.

Editorial Note

Editorial Note: The Secretary's Task Force on Black and Minority Health uses "excess deaths" as the primary indicator of the disparity in health status between minority and nonminority populations (1). During 1979-1981, blacks and other minorities in the United States had an average annual 58,942 deaths in excess of what was expected based on rates for whites (1). These excess deaths represent 42% of deaths occurring to blacks less than 70 years of age. Cardiovascular disease (heart disease and stroke), homicide, cancer, and infant mortality were the leading causes of these excess deaths.

During 1980-1986 in the District of Columbia, the major causes of excess premature deaths in blacks were heart disease (24%), cancer (18%), suicide and homicide (7%)*, and unintentional injuries (6%). As in the nation, blacks in the District had higher YPLL rates than did whites for many leading causes of death (11). In contrast to the rankings for excess premature mortality, the leading causes of excess YPLL were homicide (15%), heart disease (13%), unintentional injuries (9%), cancer (9%), and prematurity (8%). The measure of excess YPLL emphasizes the disparity in mortality between blacks and whites by accentuating those causes of death that disproportionately affect young blacks. For example, homicide ranked third as a cause of excess premature mortality, but these intentional injuries were the leading cause of excess YPLL.

Public health planning based on excess YPLL suggests a need for more emphasis on prevention of homicide, heart disease, unintentional injuries, and cancer for the black population in the District and in the nation (13,14). Such prevention efforts at the local level may include 1) outreach programs and other measures to increase the use and quality of preventive health services and 2) implementation of school and community education in programs to encourage healthy behaviors. Although previously reported, the elevated YPLL rates for pneumonia and influenza, diabetes, and SIDS in the black population warrant further study and the development of interventions (1,15,16). States and cities with large minority populations may find the approach to mortality analyses used by the District helpful for establishing priorities and evaluating public health programs. References

1. US Department of Health and Human Services. Report of the Secretary's Task Force on Black and Minority Health. Washington, DC: US Department of Health and Human Services, 1985. 2.Health Resources and Services Administration. Health status of minorities and low-income groups. 2nd ed. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, 1985; DHHS publication no. (HRSA)HRS-P-DV-85-1. 3.Keith VM, Smith DP. The current differential in black and white life expectancy. Demography 1988;25:625-32. 4.National Center for Health Statistics. US decennial life tables for 1979-81. Vol. II: State life tables--no. 9 District of Columbia. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, 1986; DHHS publication no. (PHS)86-1151-9. 5.CDC. Reducing the health consequences of smoking: 25 years of progress--a report of the Surgeon General, 1989. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, 1989; DHHS publication no. (CDC)89-8411. 6.CDC. Cigarette smoking among blacks and other minority populations. MMWR 1987;36: 404-7. 7.Alcohol, Drug Abuse, and Mental Health Administration. National Institute on Drug Abuse: national household survey on drug abuse--main findings, 1985. Washington, DC: US Department of Health and Human Services, Public Health Service, 1988; DHHS publication no. (ADM)88-1586. 8.Atkinson D. The health of minorities in North Carolina. Raleigh, North Carolina: North Carolina Department of Human Resources, Division of Health Services, 1987. (SCHS studies; no. 43). 9.Wing S. Social inequalities in the decline of coronary mortality (Editorial). Am J Public Health 1988;78:1415-6. 10.Amler RW, Dull HB, eds. Closing the gap: the burden of unnecessary illness. New York: Oxford University Press, 1987. 11.CDC. Premature mortality in the United States: public health issues in the use of years of potential life lost. MMWR 1986;35(suppl 2S):2S-3S. 12.District of Columbia Department of Human Services. Vital statistics of the District of Columbia, 1985. Washington, DC: District of Columbia Department of Human Services, Research and Statistics Division, 1988. 13.CDC. Premature mortality due to homicides--United States, 1968-1985. MMWR 1988; 37:543-5. 14.CDC. Impact of homicide on years of potential life lost in Michigan's black population. MMWR 1989;38:4-6,11. 15.CDC. Premature mortality due to sudden infant death syndrome. MMWR 1986;35:169-70. 16.CDC. Trends in diabetes mellitus mortality. MMWR 1988;37:769-73. *When the category "suicide and homicide" was delineated further, homicide accounted for all excess deaths, whereas suicide was not in excess.

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