Excess black mortality in the United States and in selected black and white high-poverty areas, 1980-2000

Objectives. Black working-aged residents of urban high-poverty areas suffered severe excess mortality in 1980 and 1990. Our goal in this study was to determine whether this trend persisted in 2000.Methods. We analyzed death certificate and census data to estimate age-standardized all-cause and cause-specific mortality among 16- to 64-year-old Blacks and Whites nationwide and in selected urban and rural high-poverty areas.Results. Urban men''s mortality rate estimates peaked in 1990 and declined between 1990 and 2000 back to or below 1980 levels. Evidence of excess mortality declines among urban or rural women and among rural men was modest, with some increases. Between 1980 and 2000, there was little decline in chronic disease mortality among men and women in most areas, and in some instances there were increases.Conclusions. In 2000, despite improved economic conditions, working-age residents of the study areas still died disproportionately of early onset of chronic disease, suggesting an entrenched burden of disease and unmet health care needs. The lack of consistent improvement in death rates among working-age residents of high-poverty areas since 1980 necessitates reflection and concerted action given that sustainable progress has been elusive for this age group.In their seminal article, McCord and Freeman estimated that in 1980 Black male youths in Harlem, New York City, were less likely to survive to the age of 65 years than were male youths in Bangladesh.¹ Mortality rates in 1980 were approximately 6 times greater among Harlem women aged 25 to 34 years and Harlem men aged 35 to 44 years than among White women and men in the same age groups nationwide. Geronimus et al. estimated that Black youths in a geographically diverse set of US high-poverty urban areas faced even worse mortality outcomes through middle age in 1990 than in 1980, including when these youths were compared with Black residents of equally poor rural communities.^2,3These striking findings suggest that national or statewide studies of population mortality may conceal important local variations. In addition, comparisons that include all age groups may obscure trends among working-age adults. For example, measures of life expectancy may be disproportionately influenced by survival probabilities of elderly people and infants, with life expectancy increasing with increased access to tertiary care. Variations in mortality among working-age adults may be more sensitive to circumstances that affect chronic disease trajectories, including access to and continuity of primary care, health education, work environments, neighborhood conditions, and the extent to which competing work and family obligations trigger sustained stress responses.^4–6Whether the severe mortality profiles of Black urban working-age adults persisted through the end of the 20th century is unknown. The 1990s witnessed significant socioeconomic, population health, and health care changes with potentially countervailing effects. On the positive side, the middle to late 1990s saw unprecedented economic growth, unemployment rates fell to all-time lows, poverty was deconcentrated in urban centers,⁷ highly active antiretroviral therapy became widely available, and the incidence of homicide declined.⁸Yet, the extent to which economic growth affected residents of segregated urban communities varied by race and gender, with low-skilled Black men, in particular, being “left behind.”^9–11 For poor mothers, Aid to Families with Dependent Children was replaced with Temporary Assistance to Needy Families, establishing lifetime limits, setting stringent work requirements, and reducing Medicaid enrollments. Studies revealed that Temporary Assistance to Needy Families participants expressed pride in employment but reported exhaustion and chronic anxiety, with possibly adverse health implications.^6,12,13 Poor Black individuals faced additional challenges to accessing medical care in the context of a more privatized, market-based health care delivery system¹⁴; the movement of private practitioners out of the inner city¹⁵; and lack of health insurance for the working poor. Gentrification may have reduced the presence of inner-city federally qualified health centers.¹⁶ Antiretroviral treatment was less available to high-poverty populations than to more advantaged groups.^17,18In light of these competing and significant changes to the socioeconomic, health, and medical care landscape during the 1990s, we extended the analyses of McCord and Freeman¹ and Geronimus et al.^2,3 to the year 2000, the most recent year for which necessary census data were available.