| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
RESEARCH |
The authors are with the Department of Public Health, Erasmus University Rotterdam, Rotterdam, the Netherlands.
Correspondence: Requests for reprints should be sent to Jan H. Richardus, MD, PhD, Department of Public Health, Erasmus University Rotterdam, Postbox 1738, 3000 DR Rotterdam, The Netherlands (e-mail: richardus{at}mgz.fgg.eur.nl).
 |
ABSTRACT |
|---|
 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
|---|
Objectives. This study determined the degree to which Black–White differences in infectious disease mortality are explained by income and education and the extent to which infectious diseases contribute to Black–White differences in all-cause mortality.
Methods. A sample population of the National Longitudinal Mortality Study from 1979 through 1981 was analyzed and followed up through 1989.
Results. Infectious disease mortality among Blacks was higher than among Whites, with a relative risk of 1.53 after adjustment for age and sex and 1.34 after further adjustment for income and education. Death from infectious diseases contributed to 9.3% of the difference in all-cause mortality.
Conclusions. In the United States, infectious diseases account for nearly 10% of the excess all-cause mortality rates in Blacks compared with Whites.
|
INTRODUCTION |
|---|
|
TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
|---|
Overviews of Black–White differences in mortality from infectious diseases are available from a few studies, such as a study on deaths preventable by medical intervention.4 In that study, however, no estimate was made of the contribution of income and other socioeconomic indicators to the differences that were observed.4 In addition, no study has provided an overview of the full range of infectious diseases. Because these diseases together account for a considerable proportion of all deaths in the United States,5 their contribution to the Black–White difference in all-cause mortality might be substantial.
The objectives of this report are (1) to determine the degree to which these mortality differences are explained by socioeconomic indicators such as income and education and (2) to determine the extent to which (certain categories of) infectious diseases contribute to the Black–White difference in all-cause mortality. This knowledge is particularly important because many infectious diseases are preventable, and deaths that might result from these diseases are therefore avoidable.
|
METHODS |
|---|
|
TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
|---|
Individual records in the data source were classified by race/ethnicity, as determined by the question "What is the race of each person in this household?" In this report, we focus on the categories White and Black.
Family income was defined as the total combined income of all members of the respondent's family. Four annual income levels were distinguished: $25 000 or more, $15 000 to $24 999, $10 000 to $14 999, and less than $10 000.
Four education levels were differentiated: at least some years of college, 4 years of high school, 1 to 3 years of high school, and elementary school.
The classification developed by Pinner et al.5 was used to categorize International Classification of Diseases, 9th Revision, codes representing infectious diseases as the underlying cause of death.
The sample was categorized into 3 age groups on the basis of age at the start of follow-up: 20 to 39, 40 to 59, and 
60 years. The child and adolescent age group (0 to 19 years) was excluded because of insufficient numbers of deaths for meaningful analysis.
Death rates by sex and 5-year age group were calculated by dividing the number of deaths by the number of person-days during the same period. We calculated standardized mortality ratios on the basis of race/ethnicity, using death rates by age and sex for all Blacks and Whites as the standard. Multiplying the standardized mortality ratios by national death rates yielded the age- and sex-standardized death rates presented in Table 2
.
|
|
RESULTS |
|---|
|
TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
|---|
Table 1 shows differences between Blacks and Whites in mortality from specific infectious disease categories. The disease categories with significant differences in rate ratios after adjustment for family income and education were tuberculosis, septicemia, HIV/AIDS, and infections of the kidneys and urinary tract.
|
shows the absolute contributions of infectious disease mortality to the differences between Blacks and Whites in total mortality. Although death due to all infectious diseases constituted only 4.9% of all causes of death, these diseases did contribute to 9.3% of the difference in all-cause mortality rates between Blacks and Whites. Seventy-one percent was attributable to the disease categories tuberculosis, septicemia, HIV or AIDS, and infections of the kidneys and urinary tract. |
DISCUSSION |
|---|
|
TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
|---|
Income, education, and several known risk factors such as smoking, diabetes, and increased blood pressure, cholesterol, body mass index, and alcohol intake are known to contribute only partly to the excess deaths in the Black population.3 Other factors—probably specific to certain infectious diseases—also are involved. The infectious disease categories with a significantly higher rate ratio among Blacks, even after adjustment for family income and education, were tuberculosis, HIV/AIDS, septicemia, and infections of the kidneys and urinary tract.
Increased risk of tuberculosis associated with race/ethnicity is primarily accounted for by socioeconomic factors other than income and education and, in particular, by crowding.10 Also, case-fatality rates among Blacks are more than twice those of Whites.11 Finally, comorbidity of HIV and tuberculosis is a common phenomenon and appears to be more frequent in Blacks.12 The effect of this comorbidity on death registration is unknown.
HIV/AIDS has been identified as 1 of the 3 leading causes of death in Black males, next to diseases of the heart and cancer. The already considerable disparity in deaths due to HIV/AIDS between Blacks and Whites has increased over the past 15 years,13 and this has made a large contribution to the increasing Black–White differences in life expectancy.14 Excess mortality in Blacks due to HIV/AIDS is not related to income and education, and several other contributing factors have been suggested. These include behavioral differences,15 differences in underlying prevalence or exposure to various etiologic agents causing AIDS-defining conditions such as tuberculosis,16 and differences in access to care and therapy for HIV-related conditions.17
Explanation of higher mortality rate ratios in Blacks for septicemia and infections of the kidneys and urinary tract would require further investigation of the epidemiology of these diseases and responsible pathogens, as well as review of the validity of diagnostic information recorded on death certificates.
This study underlines again that marked differences in mortality exist between racial/ethnic groups in the United States. These differences cannot be explained fully by the considerable differences in income and education between Black–White communities. Increased mortality in Blacks compared with Whites must be explained largely by socioeconomic and other factors that are associated with specific circumstances of the Black population.
|
Acknowledgments |
|---|
|
Footnotes |
|---|
Accepted for publication September 26, 2000.
|
References |
|---|
|
TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
|---|
2. Sorlie P, Rogot E, Anderson R, Johnson NJ, Backlund E. Black-white mortality differences by family income. Lancet. 1992;340:346–350.[Medline]
3. Davey Smith G, Neaton JD, Wentworth D, Stamler R. Mortality differences between black and white men in the USA: the contribution of income and other risk factors among men screened for the MRFIT. Lancet.1998;351:934–939.[Medline]
4.
Schwartz E, Kofie VY, Rivo M, Tuckson RV. Black/white comparisons of deaths preventable by medical intervention: United States and the District of Columbia. Int J Epidemiol.1990;19:591–598.
5. Pinner RW, Teutsch SM, Simonsen L, et al. Trends in infectious diseases mortality in the United States. JAMA. 1996;275:189–193.[Abstract]
6. Rogot E, Sorlie PD, Johnson NJ, Glover CS, Treasure D. A Mortality Study of One Million Persons by Demographic, Social, and Economic Factors: 1979–1981 Follow-Up. Bethesda, Md: National Institutes of Health; 1988. NIH publication 88-2896.
7.
Sorlie PD, Backlund E, Keller JB. US mortality by economic, demographic, and social characteristics: the National Longitudinal Mortality Study. Am J Public Health. 1995;85:949–956.
8. The Current Population Survey: Design and Methodology. Washington, DC: US Bureau of the Census; 1978. Technical Paper 40.
9. Otten MW, Teutsch SM, Williamson DF, Marks JS. The effect of known risk factors on the excess mortality of black adults in the United States. JAMA. 1990;263:845–850.[Abstract]
10.
Cantwell MF, McKenna MT, McCray E, Onorato IM. Tuberculosis and race/ethnicity in the United States: impact of socioeconomic status. Am J Respir Crit Care Med. 1998;157:1016–1020.
11. Tuberculosis in blacks—United States. MMWR Morb Mortal Wkly Rep. 1987;36:212–220.[Medline]
12. Lopez J, Welvaart H, Ford W, Kerndt P. HIV prevalence and risk behaviors among patients attending Los Angeles County tuberculosis clinics: 1993–1996. Ann Epidemiol.1998;8:168–174.[Medline]
13. Feldman RH, Fulwood R. The three leading causes of death in African Americans: barriers to reducing excess disparity and improving health behaviors. J Health Care Poor Underserved. 1999;10:45–71.[Medline]
14.
Kochanek KD, Maurer JD, Rosenberg HM. Why did black life expectancy decline from 1984 through 1989 in the United States? Am J Public Health.1994;84:938–944.
15. Moran JS, Aral SO, Jenkins WC, Peterman TA, Alexander ER. The impact of sexually transmitted diseases on minority populations. Public Health Rep. 1989;104:560–565.[Medline]
16. Hu DJ, Fleming PL, Castro KG, et al. How important is race/ethnicity as an indicator of risk for specific AIDS-defining conditions? J Acquir Immune Defic Syndr Hum Retrovirol. 1995;10:374–380.[Medline]
17.
Gornick ME, Eggers PW, Reilly TW, et al. Effects of race and income on mortality and use of services among Medicare beneficiaries. N Engl J Med. 1996;335:791–799.
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
