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8
BLACK AMERICANS' HEALTH
391
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William H. Johnson
Convalescents Mom Somewhere (1941-1942)
Gouache, pen and ink
National Museum of American Art, Smithsonian Institution,
Gift of the Harmon Foundation
OCR for page 393
Who will live and who will die and
how much handicap and disability will burden their lives depend in large
part on conditions of education, environment, and employment as well as
on access to adequate medical services. Health is not only an important
"good" in itself, it is also a determinant of life options during the entire life
span. For example, lack of prenatal care leads to greater likelihood of infant
death, neurological damage, or developmental impairment; childhood ill-
nesses and unhealthy conditions can reduce learning potential; adolescent
childbearing, substance abuse, and injuries cause enormous personal, social,
and health effects; impaired health or chronic disability in adults contributes
to low earning capacity and unemployment; and chronic poor health among
older adults can lead to premature retirement and loss of ability for self-care
and independent living. Health status is therefore an important indicator of
a group's social position as well as of its present and future well-being.
OVERV! EW
This chapter provides data describing trends in black health status and the
differential rates of illness, disability, and death that persist between black
and white Americans. The discussion focuses on conditions that sustain the
continuing health differentials between blacks and whites. We consider bio-
medical, environmental, and social factors that contribute to the health
outcomes for blacks within defined periods of the life span, giving particular
393
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A COMMON DESTINY: BLACKS AND AMERICAN SOCIETY
attention to poverty and those sociocultural factors that influence access to
health services.
Although multiple factors contribute to the persistent health disadvantages
of blacks, poverty may be the most profound and pervasive determinant.
There has been a consistent finding across communities and nations that
persons of the lowest socioeconomic status have higher death rates. In a
classic study, Kitagawa and Hauser (1973) found that there was a gradient of
mortality rates with steady increases from the highest to the lowest social
classes. Mortality rates were higher as socioeconomic status declined for both
whites and blacks, whether that status was measured by family income,
educational level, or occupation. For people of the lowest status, overall
mortality was 80 percent greater than for those at the highest socioeconomic
level. In addition to increased mortality, almost every form of disease and
disability is more prevalent among the poor.
Because of the relationship between poverty and health, and because pov-
erty has been a persistent problem for blacks in the United States, it is to be
expected that blacks' greater poverty is responsible for much of the black-
white health disparity. Poverty rates among children cause special concern
for their future health status. Poverty in childhood often means lack of
proper nutrition, unsafe housing, and poor access to health care or other
resources needed for healthy growth and development.
During much of the period covered in this study, there was open segrega-
tion of medical facilities in the United States. In the 25-year period before
1965, persistent barriers to access to preventive, primary, and hospital care
influenced the quality of life and the patterns of illness observed among
blacks.
Organizations such as the Medical Committee on Human Rights, the
National Medical Association, and the Student National Medical Association
played important roles in efforts to end discrimination in health care facilities
and in health professional schools. Following the 1954 Brown Supreme Court
decision, which declared segregation in public schools unconstitutional, ef-
forts to desegregate health care facilities intensified.
Important events that led to more equal access to medical care for blacks
were the Civil Rights Act in 1964 and the Medicaid and Medicare legislation
in 1965. Title VI of the Civil Rights Act prohibited racial discrimination in
any institution receiving federal funds, thus giving hospitals a powerful in-
centive to alter their practices. Hospitals receiving federal funds were forbid-
den to deny admission to patients, to subject patients to separate treatments,
or to deny admitting privileges to medical personnel solely on the basis of
race. Access to health care was further increased when litigation in the 1960s
explicitly defined the obligation of hospitals using; federally provided con
~ ~ ~ 1 ~ ~ ~
. · ~ 1 . . .1 · (~ ~ · . 1 . . 1
struct~on tunds to meet their tree care requirements and to serve those
unable to pay.
A second method of addressing blacks' unequal access to health care con-
cerned their underrepresentation in the medical care professions. During the
1960s and 1970s many efforts were mounted to enlarge the representation
394
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BLACK AMERICANS' HEALTH
FIGURE 8-1 Life expectancy at birth, by race and sex, 1950-1985.
-
cn 70
-
llJ
A:
65
60
55
White Females _
-
Black Females
White Males
-
. -
ol I I I I I I I
1950 1955 1960 1965 1970 1975 1980 1985
YEAR
Source: Data from the National Center for Health Statistics.
Of blacks and other minorities in the health professions. It was believed that
access to health care for poor blacks would improve if there were more black
physicians. This belief prompted some medical schools to recruit more black
and other minority students and to channel them into primary care special-
t~es.
While the chapter presents facts about past and current health disadvan-
tages of blacks compared with whites, the focus on problem areas should
not leave the impression that most black Americans are unhealthy. Over the
past 50 years, blacks' health status and life expectancies have improved a
great deal. A general overview of this point can be made by considering
trends in mortality and life expectancy.
A useful summary index of the effects of differing mortality rates is the
average (mean) life expectancy at birth. It is calculated on the basis of age-
specific death rates as of a given date, and it estimates the number of years
that will be lived on the average by individuals born in a particular year,
assuming a constancy of then-current age-specific mortality rates.) Figure
8-1 summarizes trends in black-white differences in life expectancy at birth.
In the 1950-1985 time span, death rates fell for both races, particularly for
black females, but whites continued to enjoy an advantage over blacks. The
difference in life expectancy of black and white men decreased from a gap of
about 11 years in 1940 to a 6-year difference in 1960 and has shown little
1. Mean life expectancy at birth is calculated by methods analogous to the calculation of
mean lifetime earnings and employment used in Chapter 6.
395
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A COMMON DESTINY: BLACKS AND AMERICAN SOCIETY
improvement since then. Among women, there has been a consistent pat-
tern of relative improvement for blacks, and the racial gap in the mid-1980s
was less than one-half its size in 1940. As a result, the advantage in life
expectancy black women enjoy over black men increased during this period.
The life expectancy of a black male in 1985 (65.3 years) is lower than that
already achieved by white males in 1950, 66.5 years (National Center for
Health Statistics, 1988:80-81~.
Projections of mortality rates into the future are necessarily uncertain,
particularly given the current epidemic of acquired immune deficiency syn-
drome (AIDS). Nonetheless, we estimate that if the 1950-1985 trends
continue, life expectancies for black and white women will converge in the
first half of the twenty-first century, but no convergence to white rates can
be foreseen for black men (R. Farley, 1985~.
These summary statements conceal a complex pattern of age-specific and
cause-specif~c changes (Farley and Allen, 1987; U.S. Department of Health
and Human Services, 1985e). Among children under age 15, there have been
consistent and large decreases in the risk of death, but the death rates for black
children are 30 percent to 50 percent higher than those for white children.
Between 1950 and the late 1960s, mortality rates actually rose among adult
men, especially black men, and fell at a very slow rate among adult women of
both races. The last two decades have been characterized by rapid declines in
mortality rates, declines that were not foreseen by health experts. Rates have
fallen for almost all race-sex groups, but the decline at the older ages, 60 and
above, has been unusually sharp, redacting, perhaps, improvements in the
income level of the elderly and the government's assumption of many health
care costs with Medicare (Crimmins, 1981~. Contagious and infectious diseases
were more common causes of death among blacks than among whites in
1940, but that specific cause of disparity has been reduced.
Mortality from heart disease declined slowly between 1940 and the mid-
1960s and more rapidly afterward. The pace of change was more rapid for
women than men among both races. Improved detection and treatment of
hypertension, and changes in smoking, diet, and exercise were factors influ-
encing the reductions. There is still a large disparity and excess of black
deaths from heart diseases. Mortality from suicide remains much higher for
whites than blacks, while cirrhosis and diabetes death rates, although declin-
ing rapidly since the late 1960s, remain higher for blacks (R. Farley, 1985~.
Two causes of death merit special attention, cancer and homicide. If data
from the 1930s and early 1940s are accurate, then blacks formerly had
considerably lower cancer mortality rates than whites (Lilienfeld et al., 1972~.
This has changed in a dramatic manner. Since the 1940s, there have been
particularly sharp increases in death rates from lung cancer for both races,
but the rise has been greater among blacks, especially black men. Mortality
from other types of cancer has held steady or declined among whites in the
last two decades but has increased among blacks. Thus, there is now a
substantial excess in cancer mortality among blacks. Homicide has a particu-
larly large impact on average life expectancy since its usual victims are young
396
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BLACK AMERICANS' HEALTH
adults. Although recent trends show lower homicide rates among blacks, it
remains a leading cause of death for black men.
The U.S. Department of Health and Human Services (HHS) Report of the
Secreta~y's Task Force on Black and Minority Health (1986b) identified six medical
conditions for which the gaps in mortality between whites and blacks are the
greatest. The six causes of death, taken together, account for about 86
percent of the excess black mortality in relation to the white population:
accidents and homicides (35.1 percent), infant mortality (26.9 percent),
heart disease and stroke (14.4 percent), cirrhosis (4.9 percent), cancer (3.8
percent), and diabetes (1.0 percent).2 The report did not attempt to encom-
pass the full dimensions of disparities in health status; while the mortality
data for these six conditions are important, they do not capture the full
personal and societal costs of deaths from other causes and of chronic or
acute illness. In particular, this methodology has omitted important health
problems of black children.
In the rest of this chapter we analyze the health status of black Americans
across the life span, using the following divisions: pregnancy and infancy;
childhood (ages 1-14~; adolescents and young adults (ages 15-24~; adult-
hood (ages 25-65~; and older adults (over age 65) . For each period of life, a
few conditions of highest concern have been selected for analysis. In making
these choices consideration has been given to magnitude, severity, distribu-
tion, and knowledge of contributory factors. We also emphasize the poten-
tial for prevention.
The black population has benefited from advances in medicine, but not
equally with whites. From birth to advanced old age, blacks at each stage of
the life cycle still die at higher rates (except for adult black women since 1970)
and suffer disproportionately from a wide range of adverse health conditions.
When national health objectives for 1990 were established by the Public
Health Service (U.S. Department of Health and Human Services, 1980), the
black-white disparity in the late 1970s was so great that it did not appear
possible to overcome it in the short term. In the areas of infant mortality and
deaths by injury, separate and unequal goals for blacks and whites were set.
For many of the objectives set by the Public Health Service, the national
targets were achieved before 1990 for whites but not for blacks (U.S. Depart-
ment of Health and Human Sen~ces, 1986d). Based on recent trends, blacks
are not projected to achieve equality in health by 1990 or in the near future.
PREGNANCY AND INFANCY
Infant mortality, the rate at which children die before their first birthday,
serves both nationally and internationally as an indicator of the overall status
2. Access death expresses the difference between the number of deaths actually observed in a
minority group and the number of deaths that would have occurred if that group had experi-
enced the same death rates for each age and sex as in the white population.
397
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A COMMON DESTINY: BLACKS AND AMERICAN SOCIETY
TABLE 8-l Infant Mortality Rates in Various Countries,
1984
Country
Japan
Sweden
Finland
Switzerland
Denmark
France
The Netherlands
Norway
Canada
~-
omgapore
Australia
United States, white
Federal Republic of
Germany
Great Britain
opam
German Democratic
Republic
Belgium
Austria
Italy
New Zealand
Israel
Greece
Cuba
Czechoslovakia
Bulgaria
United States, black
Infant Mortality Rate
6
6.4
6.5
7.5
7.7
8.2
8.3
8.3
8.5
8.8
9.2
9.4
9.6
9.6
9.7
10.0
10.7
11.4
11.6
11.6
12.8
14.1
15.0
15.3
16.1
18.4
Notes: The infant mortality rate is deaths per 1,000. Rankings are Tom
lowest to highest infant mortality rates based on the latest data available
for countries with at least 1 million population and with complete
counts of live births and infant deaths, as indicated by the United
Nations (1985).
Of the health of a community or a nation. Infant mortality in the United
States, 10.6 deaths per 1,000 live births in 1985, remains persistently higher
than the rate in many other developed nations; Finland, Japan, and Sweden
enjoy the world's lowest rates, less than 7 deaths per 1,000 live births
(National Center for Health Statistics, 1987c:94~; see Table 8-1.
Black rates of infant mortality have remained at approximately twice the
rate for whites over the course of this century despite impressive improve-
ments for all groups in reduced infant mortality. In 1985, the infant mortal-
ity rate for whites was 9.3, for blacks 18.2. After relative stagnation in the
1960s, the infant mortality rate began a rapid decline (see Figure 8-2~. The
accumulating evidence (McCormick, 1985) indicates that a major factor in
398
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BLACK AMERICANS' HEALTH
FIGURE 8-2 Infant mortality rates, by race, 1940-1985.
75
70
65
c`' 60
55
m 50
o 45
As 40
co
I
C)
as
35
30
25
20
15
10
5
o
\ Relative
- \ ~Black/White Odds/ \
t-.
i.
, ~
'I,
. . I
. . .
\~ck Infant Mortality
White Infant Mortality
- ,,
1 1 1 1 1 1 1 1To
1970 1975 19801985
1940 1945 1950 1955 1960 1965
YEAR
Source: Data Mom the Nanona1 Center for Health Statistics.
2.0
1.9
o
1.8 ~
of:
G
oh
1.7 O
>
1.6
1.5
the rapid decline after the 1960s has been the increased survival of low-
birthweight infants, largely attributed to high-technology, hospital-based
management and regional neonatal intensive care units.
The national average figures for infant mortality do not show all the
disparities between blacks and whites in infant mortality rates across the
United States. Black infant mortality rates show considerable variations by
region. During 1982-1984, the black infant mortality rate was lowest in the
Mountain and Pacific states (15.4 and 16.2 deaths per 1,000 live births,
respectively), and highest in the East North Central states (21.7), particularly
in Illinois (23.3) and Michigan (23.7) (National Center for Health Statistics,
1987c:Table 14~. Across states, the lowest state mortality rate for black
infants (12.5) was higher than the highest state mortality rate (10.1) for
white infants.
N EONATAL AN D POSTN EONATAL MORTALITY
During the first half of this century most of the infant mortality was
postneonatal (deaths between 28 days and 1 year) and was caused by low
living standards and infectious disease. After 1960, with improved living
standards and major advances in control of infection, neonatal mortality
399
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A COMMON DESTINY: BLACKS AND AMERICAN SOCIETY
(death prior to 28 days) became the major component of infant mortality.
Low birthweight, 2,500 grams (5.5 pounds) or less, is the major predictor
of neonatal mortality and accounts for 60 percent of all infant deaths. Cur-
rently, 20 percent of postneonatal deaths are attributed to low birthweight
(Institute of Medicine, 1985:29) .
The relationship between birthweight and infant mortality has been re-
peatedly documented. For infants born weighing less than 2,500 grams, the
mortality rate rapidly increases with decreasing birthweight until infants
weighing less than 1,000 grams (1.5 pounds) have only a 20 percent chance
of survival under optimal care. Compared with normal birthweight infants,
low-birthweight infants are almost 40 times more likely to die in the neonatal
period; for very low birthweight (1,500 grams or less) infants, the relative
risk of neonatal death is much greater.
The marked gap in the infant mortality rate between whites and blacks
mirrors the more than twofold difference in the rates of low birthweight and
very low birthweight between the two groups. Blacks are twice as likely as
whites to have low-birthweight infants: black rates are 12.4 per 1,000 live
births, and white rates are 5.6 (National Center for Health Statistics,
1987c:27~. This increased risk for blacks also occurs for very low birthweight
babies: 2.56 percent for blacks and 0.92 percent for whites (National Center
for Health Statistics, 1987c:77~. Blacks account for 16.2 percent of all live
births but 30 percent of all low-birthweight newborns and 34 percent of
very low birthweight newborns. In the neonatal period there is a survival
advantage of black infants in the low-birthweight range, but it is overwhelm-
ingly offset by the high percentage of low-birthweight black infants.
Some low-birthweight babies are very small but born at full term. How-
ever, most low-birthweight infants are born prematurely (preterm). An ana-
lytic review of the trends, causes, and preventive approaches to low birth-
weight (Institute of Medicine, 1985) identified a high-risk profile that in-
cluded such demographic factors as poverty, low educational level, unmar-
ried status, and black race; medical factors such as poor obstetrical history,
very young or very old age of childbearing, and urogenital infections; and
behavioral factors such as use of tobacco, alcohol, or illegal drugs, exposure
to toxic substances, and absent or inadequate prenatal care. The report
highlighted the importance of black race as a high-risk factor and emphasized
the urgent need for research to investigate causes of racial differences in
birthweight.
The Institute of Medicine (IOM) study showed that babies born in the
United States have the best chance, worldwide, for survival at low birth-
weights, a condition attributed to the excellence of sophisticated perinatal
medical services. However, these medical triumphs are offset by the fact that
the United States has continued to have a far higher percentage of low-
birthweight babies over the past 25 years than other comparable industrial
. , .
zeu nations.
A national study of low-birthweight births to 2 million white women and
418,000 black women for 1973-1983 showed that the racial disparity in
400
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BLACK AMERICANS' HEALTH
birthweights is increasing (Kleinman and Kessel, 1987~. Births of infants with
moderately low birthweights (between 3.3 and 5.5 pounds) decreased much
more among whites (16 percent) than among blacks (6 percent). Rates of
very low birthweights (less than 3.3 pounds) decreased 3 percent among
whites but increased 13 percent among blacks. The study emphasized that
preterm birth, not low birthweight per se, is the primary cause of perinatal
mortality. Over the decade studied, preterm low birthweight has remained
constant and low birthweight at term declined.
During the decade of study, blacks were found to be more highly concen-
trated than whites in high-risk socioeconomic groups. Furthermore, even
blacks who were at low risk in terms of age, marital status, and education
had a somewhat higher incidence of preterm delivery than whites who were
at high risk in terms of the same factors (17.2 for blacks and 15.1 for whites
per 1,000 live births) . Causes of this persistence of black-white differences in
birthweight even among black mothers at lower risk were not completely
explained. This study also found that the overall contribution of teenage
births to low birthweight has been overemphasized: if all teenage births had
been prevented in 1983, the low-birthweight rates would have decreased by
only 8 percent for whites and 3 percent for blacks.
Lieberman and colleagues (1987) concluded that race is not an independ-
ent risk factor and that the black-white differences in prematurity rates are
attributable to specific medical and socioeconomic characteristics. This study
of a hospital-based cohort of 8,903 black and white women found the rate
of prematurity to be a function of the number of risk factors present regard-
less of which particular risk was present. When single marital status, age
under 20 years, on welfare, high school not completed, and maternal anemia
were included as factors, essentially all the racial variation in prematurity was
explained. A prospective study of a cohort of 29,415 Asian, black, and white
pregnant women in a Kaiser-Permanente health maintenance organization
considered patterns of mean birthweight and low birthweight; after exami-
nation of 22 variables, it was concluded that ethnicity is not an independent
risk factor (Shiono et al., 1986~.
It is likely that intergenerational effects of socioeconomic conditions on
the growth and development of a mother from prebirth to childhood may
influence the intrauterine growth of her child. Since many middle-class
blacks are the first generation in their family to achieve that status, the
designation by current income may mask the effects of maternal childhood
poverty. A research project is planned to track the birth histories of a cohort
of blacks who have an intergenerational history of sustained economic advan-
tage. This group will be drawn from descendants of black physicians who
were graduates of Meharry Medical College early in the century (Samuel
Kessel, personal communication, l988~. Since the highest infant death rates
are associated with preterm birth, research is increasingly being directed to
this problem. However, on the basis of existing knowledge, a great many
medical conditions that predispose to prematurity could be prevented by
appropriate prenatal care.
401
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A COMMON DESTINY: BLACKS AND AMERICAN SOCIETY
signs of access to care. Some of the sensitive indicators such as low birth-
weight in neonates, as discussed, have already shown slowed decline or
reversals. There are concerns that the adverse effects are pervasive across the
life course.
Many of the problems responsible for the current gap in health conditions
between blacks and whites are problems for which medical knowledge is
deficient, for example, knowledge of the causes of hypertension, low birth-
weight, or cancer of the prostate. But progress in health status does not
always depend on full knowledge of causation. There has been significant
recent progress in reducing rates of hypertension among blacks, without
further knowledge of its primary causes.
Preventive health services and systematic programs of outreach have dem-
onstrated their effectiveness in prenatal and infant care. The same concepts
apply to other periods of the life span and to such problems as teenage
pregnancy, hypertension, AIDS, and to the long-term care that is likely to
be a major health problem of the black elderly in the near future.
There is also growing awareness of the importance of interventions that
provide early treatment or prevent health-damaging personal behaviors relat-
ing to sexually transmitted diseases, smoking, drugs, and alcohol. In the
specific Oloyectz~es for the Nathan (U.S. Department of Health and Human
Services, 1980), the overall goal set by the surgeon general was to improve
the health habits of youth and by 1990 to reduce deaths among people aged
15-24 by at least 20 percent, from a 1977 baseline of 115 to fewer than 93
per 100,000. Progress has been made but the goals have not yet been met.
A midcourse review by HHS of the status of these objectives in 1986 showed
that none of them were met for black youth regarding sexually transmitted
diseases, smoking, drugs, or alcohol (U.S. Department of Health and Hu-
man Services, 1986b).
Many of the problems that contribute to the differentials in health status
are not subject to a simple medical solution, but require an understanding
of social and individual behavior and an appreciation for comprehensive
interdisciplinary approaches. The disparities in black and white rates of ho-
micide, teenage pregnancy, or AIDS are not likely to be eliminated purely
by medical science even with the best public health expertise available.
Due to progress in the prevention and cure of most infectious diseases,
chronic diseases are now a significant source of illness in the United States
and other developed countries. For both blacks and whites, behavioral fac-
tors are crucial in the development and management of these chronic dis-
eases. The combination of these behavioral factors with fewer resources to
meet daily needs, less opportunity to obtain these resources, and less power
to overcome disadvantaged circumstances largely accounts for blacks' poorer
health status.
~I.' 1-.'
440
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BLACK AMERICANS' HEALTH
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450
Representative terms from entire chapter:
health statistics
