In the last two decades, Black Americans have suffered 1.63 million excess deaths and lost more than 80 million years of life compared to white Americans, according to a new analysis that is the first comprehensive attempt to quantify the impact of health disparities by tallying years of potential life lost.
The analysis showed improvement was made in narrowing long-standing health gaps between Black and white Americans between 1999 and 2011, but progress stalled through 2019. The Covid-19 pandemic, which disproportionately killed people who were Black, Hispanic, Native American, and Pacific Islander, then rapidly increased the number of excess deaths in Black populations.
The findings, published Tuesday in the Journal of the American Medical Association by a group of physicians and health equity scholars, follow a number of studies confirming that health disparities cause Black Americans to die at younger ages than white Americans. The authors said they undertook the new analysis hoping to highlight just how large and horrific that toll has become and add urgency to efforts to end the crisis of premature Black deaths.
“Despite billions of dollars flowing into health care and a lot of rhetoric about health equity, we’re failing to make progress,” said Harlan Krumholz, a cardiologist and professor of medicine at Yale who directs the university’s Center for Outcomes Research and Evaluation and was the study’s senior author. “It’s not understood as a national emergency.”
For years, veteran health equity scholar David Williams has likened the toll of premature Black deaths to a fully loaded jumbo jet falling out of the sky each day, and questioned why more has not been done. The new study similarly illuminates the depressing calculus of health disparities. “It’s grandmothers, fathers, loved ones, children,” said Krumholz. “We need to think about all these empty chairs at the dinner table. It’s a staggering loss.”
A separate paper in the same issue of JAMA estimated that the economic burden of health disparities on non-white racial and ethnic groups in America in 2018 was more than $400 billion. The number revises upward previous estimates of the cost of health disparities from $309 billion in 2006 and $320 billion in 2014. Seventy percent of that cost was borne by Black Americans, the study found, with two-thirds of the burden attributable to premature death, and the rest due to medical care costs and lost labor productivity.
“These findings provide a clear and important message,” wrote Harvard School of Public Health scholars Rishi Wadhera and Issa Dahabreh in an accompanying editorial arguing there may be an economic, as well as a moral, imperative to invest in curbing the nation’s massive racial and ethnic health disparities.
The new analysis on excess deaths rebuts those who dismiss the heavy loss of life in Black communities as being due predominantly to crime, accidents, or firearm injury. “A lot of it is traditional causes like heart disease and cancer,” Krumholz said.
The authors said their work also makes clear there is no underlying biological mechanism to explain racial differences in life expectancy. They said the early deaths were due to other factors linked to race, such as access to healthy food, stable housing, quality health care, and economic opportunity. Investing in these “is simply a smart strategy to improve the health of all residents,” Marcella Nunez-Smith, a physician, associate dean of health equity research at the Yale School of Medicine, and study co-author, told STAT. “We do fundamentally know what communities need to be healthy.”
Krumholz said investments in tackling structural racism in medicine were as critical as those made in the fight against cancer. “It’s an enormous opportunity to save lives,” he said.
The study found nearly a million excess deaths occurred in Black males between 1999-2020 while more than 600,000 occurred in Black females. The excess mortality rate among the Black males declined from 404 to 211 deaths per 100,000 people between 1999-2011, plateaued between 2011-2019, and jumped to 395 in 2020 during the coronavirus pandemic. For Black females, excess death rates declined from 224 deaths per 100,000 people in 1999 to 87 in 2015, and then rose in 2020 to 192 deaths.
While it is clear why excess deaths increased during the pandemic, the study did not provide specific reasons for the improvements seen in Black populations starting around 1999 or explain why that progress stalled after 2011. Some authors suggested that health improvements may have been tied to a stronger overall economy, but said more analysis was needed. The authors did not analyze excess death rates in other hard-hit populations such as Hispanics or Native Americans, but hope to do so in the future, Krumholz said.
The analysis found the brunt of excess deaths in Black communities was due to the loss of infants and older Americans, and that a leading cause of excess mortality, in addition to heart disease and cancer, was infant mortality.
Clyde Yancy, a study co-author, professor of medicine and the vice dean of diversity and inclusion at Northwestern University’s Feinberg School of Medicine, called the findings “both sobering and disheartening.”
“Now is the time to address health equity and to especially consider candidate root causes including the intersection of health and the community and the pernicious burden of bias,” he told STAT.
Yancy said it was “particularly onerous” to see the loss of modest progress made some two decades ago and to see life expectancy differences of decades between Black and white Americans existing in the same city.
He also lamented the fact that, as STAT has reported, so little progress has occurred in the 20 years following release of the National Institute of Medicine’s landmark “Unequal Treatment” report on the root causes of health disparities.
Lisa Cooper, a professor of medicine at Johns Hopkins University who leads the university’s Center for Health Equity and has worked in the field since the mid-1990s, has written numerous commentaries on the staggering death toll in Black communities, due to Covid-19 and health disparities.
“It’s so sobering and alarming that we had improvement and it just ebbed away,” she said of the findings. “It’s one thing to know in a general sense things are bad, but to see how bad it is over time, in such specific ways, is important.”
She said tracking excess deaths on an annual or quarterly basis as the new study did could provide a powerful tool to track progress — or the lack of it — in ending health disparities and said she hoped scholars would look to the new work to determine if there were specific programs, regions, events, or economic circumstances that had led to improvements that could be replicated.
Cooper said much research, including her own, has shown that various interventions, including programs that offer nutritional coaching and access to better food, can prevent hypertension and curb deaths from heart disease, which is largely preventable. “We know something like that can work,” she said. “We have interventions. The question is, how do we scale those up? And who’s going to pay for it?”
Despite the distressing numbers and the fact that earlier progress was “fleeting and fragile,” Nunez-Smith said she remained optimistic that change could occur and that the distressing death toll among Black Americans would be seen as unacceptable to society at large. “We have lost artists, scientists, spiritual leaders, teachers, friends,” she said. “This should be a call to action for us as a nation.”
This story was updated to clarify a comment made by Krumholz.