Understanding Health Inequities in Boston

Barbara Ferrer, PH.D., MPH, M.ED

Executive Director

Boston Public Health Commission

Health Indicator Black WhiteAsthma (< 5, hosp) 11.4 per 1000 3.4Birth Weight (Less than 3.3lbs) 3.0% of births 1.6%Body Weight (Overweight or Obese) 68% 41%Breast Cancer (Morality) 29.7 per 100,000 25.9Cervical Cancer (Mortality) 5.6 per 100,000 2.3Death Rate (Mortality) 1116.8 per 100,000 919.6Diabetes (Mortality) 41.8 per 100,000 16.6Drug Related Mortality 15.7 per 100,000 19Heart Disease (Mortality) 239.6 per 100,000 238.1High Blood Pressure 30.4% 17.2%HIV / AIDS (Mortality) 28.1 per 100,000 6.8Homicide 27.2 per 100,000 2.2Hospitalization 163.8 per 1000 108.9Infant Mortality (Mortality) 8.7 per 1000 4.1Lung Cancer (Mortality) 61.6 per 100,000 66.2Prostate Cancer (Mortality) 68.3 per 100,000 31.2Smoking during pregnancy 6.3% 5.1%Suicide (Mortality) 3.6 6.2Teen Birth Rate (15 - 17) 14.1 per 1,000 6Uninsured 9.2% 6.5%

Racial Disparities in Boston

Life Expectancy of Black and White Boston Residents, 2004-2006

74.881.1

69.6

77.475.581.6

0

10

20

30

40

50

60

70

80

90

100

Males Female

Life

Exp

ect

an

cy in

Ye

ars

Boston

Black

White

DATA SOURCE: Boston resident deaths and live births, Massachusetts Department of Public HealthData ANALYSIS: Boston Public Health Commission Research Office

Infant Mortality Rates by Race/Ethnicity and Year, Boston, 1993-2005

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

Dea

ths

per

1,00

0 Li

ve B

irths

W

ithin

Rac

e/E

thni

city

Black 15.0 12.5 11.9 9.9 12.8 12.0 13.5 13.6 13.5 12.4 14.2 12.1 8.7

Latino 8.9 8.2 3.0 5.2 3.6 4.5 4.1 5.1 5.6 6.5 4.0 9.4 3.1

White 5.9 7.2 4.7 6.7 9.5 4.0 5.6 2.8 5.1 4.6 3.1 4.1

Boston 9.8 9.2 6.8 7.0 8.4 6.3 7.4 6.7 7.4 7.0 6.3 6.0 5.2

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

NOTE: Rates for Asians and Others are not presented because each group had less than 5 deaths per year for most of the years shown.DATA SOURCE: Boston resident deaths, Massachusetts Department of Public HealthDATA ANALYSIS: Boston Public Health Commission Research Office

n<5

Cumulative Birthweight Distribution by Race/Ethnicity, Boston: 2000-2005

<500g <750g <1,000g <1,500g <2,000g <2,500g 2,500g+

Asian 0.08% 0.19% 0.49% 0.90% 2.04% 6.69% 93.31%

Black 0.54% 1.41% 2.02% 3.46% 5.97% 13.25% 86.75%

Latino 0.18% 0.51% 0.80% 1.54% 3.05% 7.94% 92.06%

White 0.09% 0.28% 0.58% 1.26% 2.79% 6.93% 93.07%

Other 0.23% 0.77% 1.17% 2.03% 4.06% 9.15% 90.85%

DATA SOURCE: Boston Resident live births, Massachusetts Department of Public HealthDATA ANALYSIS: Boston Public Health Commission Research Office

Birthweight-Specific Infant Mortality Rates by Race/Ethnicity, Boston, 2002-2004

0.0

150.0

300.0

450.0

600.0

750.0

900.0

Dea

ths

per

1,00

0 Li

ve B

irths

in B

irthw

eigh

t C

ateg

ory

White 714.3 90.9 0.7

Black 780.5 131.6 2.2

Latino 923.1 149.3 14.9 1.7

ELBW VLBW LBW NBW

* Count is 0; therefore rate not calculated.NOTE: ELBW is <500g, VLBW is <1,500g, LBW is <2,500g, NBW is 2,500g+.DATA SOURCE: Boston resident live births and infant deaths, Massachusetts Department of Public HealthDATA ANALYSIS: Boston Public Health Commission Research Office

n<5*

IS IT ABOUT EDUCATION OR INCOME?

Racial & Ethnic DisparitiesInfant Mortality & Education

African Americans

16+ years of

schooling

White Americans <9

years of schooling

Per 1,000 Live BirthsNCHS 2002

10.2

6.8

Racial & Ethnic DisparitiesInfant Mortality & Household Income

African Americans

with Household

Income $35,000+

White Americans

with Household

Income <$10,000

Per 1,000 Live Births

16.6

11.2

IS IT ABOUT HEALTH BEHAVIOR?

Racial & Ethnic DisparitiesInfant Mortality & Cigarette Smoking

African American

Non-Smokers

White American

Smokers

Per 1,000 Live Births NCHS 2002

13.2

9.2

Low Birthweight by Smoking Status and Race/Ethnicity, Boston, 2005

17.9%

13.4%

17.9%

25.5%

9.3%

6.8%

7.9%

13.7%

5.7%

0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0%

BOSTON

White

Latino

Black

Asian Nonsmoker

Smoker

Percentage of Births Within Race/Ethnicity and Smoking Group

NOTE: LBW for Asian smokers not shown because n<5DATA SOURCE: Boston resident live births, Massachusetts Department of Public HealthDATA ANALYSIS: Boston Public Health Commission

Racial & Ethnic DisparitiesInfant Mortality & Prenatal Care

African Americans

First Trimester

Prenatal Care

White Americans

Prenatal Care

After 1st

Trimester or None

Per 1,000 Live Births NCHS 2002

12.7

7.1

0%

5%

10%

15%

20%

25%

30%

Per

cent

age

of B

irth

s W

ithin

R

ace/

Eth

nici

ty a

nd P

NC

Ade

uqac

y G

roup

Adequate-Intensive 9% 26% 18% 25% 15% 19%

Adequate-Basic 4% 6% 3% 4% 2% 3%

Intermediate 8% 4% 3% 3% 5%

Inadequate/None 10% 16% 9% 13% 8% 12%

Asian Black Latino Other White Boston

NOTE: LBW percentage are not shown where n<5. PNC adequacy was assessed by the Kotelchuck Index (APNCU Index).DATA SOURCE: Boston resident live births, Massachusetts Department of Public HealthDATA ANALYSIS: Boston Public Health Commission Research Office

Low Birthweight by Adequacy of Prenatal Care and Race/Ethnicity,

Boston, 2005

n<5

Is It About Race?

Race has no clear biologic or genetic basis…”there are no characteristics, no traits, not even one gene that turns up in all members of one so-called race, yet is absent from others” (L. Adelman. Race and Gene Studies)

The meanings of racial designations- White, Black, Asian- are subject to historical, cultural and political forces; “race justified social inequalities as natural”.

Racial & Ethnic DisparitiesInfant Mortality & Nativity

0

2

4

6

8

10

12

14

16

Foreign Born United States Born

Black Women

9.2

14.2

Per 1,000 Live Births

NCHS 2002

Low Birthweight by Maternal Birthplace, Boston, 2004

8.1% 7.3%

4.9%

12.5%

10.0%

12.3%

6.8%

15.1%

10.5%

13.8%

7.2%8.1%

0.0%

4.0%

8.0%

12.0%

16.0%

20.0%

China

Domin

ican

Rep.

El Sal

vado

rHai

ti

Jam

aica

Puerto

Rico

US - Asia

n

US - Bla

ck

US - L

atin

o

US - O

ther

US - W

hite

Vietn

am

Pe

rce

nta

ge

of B

irth

s W

ithin

Birt

hp

lace

SOURCE: Boston resident live births, Massachusetts Department of Public HealthANALYSIS: Boston Public Health Commission Research Office

WHAT ABOUT RACISM ?

How Can Racism Affect Health Status?

Differences in socio-economic status and environmental conditions

Differences in exposure to “stress” Differences in access to health care services Differences in diagnostic testing, treatment, and the

quality of care received within the health care system Differences in health behaviors

Socio-Economic Conditions

Legacy of slavery, segregation and discrimination created social and economic inequities

Institutional structures and social relations can serve to maintain these disparities

Model of Social Determinants of Health Disparities

Racism

SocioeconomicStatus

EnvironmentalExposure

Stress

Access To HealthServices

Access to Testingand Screening

HealthOutcomesHealth Behaviors

24%

5% 4% 4% 3%8%

39%

14%

84%

44%

2%

14%

53%

3%

48%

15%

6%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

BOSTON

Allsto

n/Brig

hton

Back

Bay

Charle

stown

East B

osto

n

Fenway

Hyde

Park

Jam

aica

Plain

Mat

tapa

n

North

Dor

ches

ter

North

End

Roslin

dale

Roxbu

ry

South

Bos

ton

South

Dor

ches

ter

South

End

Wes

t Rox

bury

Pe

rce

nta

ge

of

To

tal P

op

ula

tion

Of

Ne

igh

bo

rho

od

DATA SOURCE: US Department of Commerce, Bureau of the Census, American Fact Finder, Census 2000DATA ANALYSIS: Boston Public Health Commission, Research Office

Black Resident Population by NeighborhoodBoston, 2000

Environmental Exposures

Exposure to waste disposal sites Exposure to air pollutants Exposure to “unregulated” job sites (housecleaning,

sweat shops, farms) Exposure to sub-standard housing (quality, density,

location) Exposure to alcohol and tobacco products

Low Birthweight by Neighborhood Boston, 2005

5.7%

8.5%

7.0%

5.5%

7.2%

11.5%

13.4%

7.8%

12.8%

8.0%

11.5%

9.3%

6.1%

9.5%9.0%

7.6%

9.6%

0%

5%

10%

15%

BOSTON

Allsto

n/Brig

hton

Back B

ay**

Charle

stown

East B

osto

n

Fenway

Hyde

Park

Jam

aica

Plain

Mat

tapa

n

North

Dorch

este

r

North

End

Roslin

dale

Roxbu

ry

South

Bos

ton

South

Dor

ches

ter

South

End

Wes

t Rox

bury

Pe

rce

nta

ge

of B

irth

s W

ithin

Ne

igh

bo

rho

od

NOTE: Back Bay includes the North End/DATA SOURCE: Boston resident live births, Massachusetts Department of Public HealthDATA ANALYSIS: Boston Public Health Commission Research Office

Asthma Hospitalizations of Children Under Age 5 by Neighborhood, Boston, 2004-2006

3.7

7.4

9.7

7.9

12.9

5.8

11.511.6

7.86.9

7.8

5.04.03.7

2.5

8.1

0.0

3.0

6.0

9.0

12.0

15.0

BOSTON

Allsto

n/Brig

hton

Back

Bay*

Charle

stown

East B

osto

n

Fenway

Hyde

Park

Jam

aica

Plain

Mat

tapa

n

North

Dor

ches

ter

Roslin

dale

Roxbu

ry

South

Bos

ton

South

Dor

ches

ter

South

End

Wes

t Rox

bury

Hos

pita

lizat

ions

per

1,0

00 P

opul

atio

n

*Includes the North EndDATA SOURCE: Acute Care Hospital Case Mix files, Massachusetts Division of Health Care Finance and PolicyDATA ANALYSIS: Boston Public Health Commission Research Office

Health Behaviors

Individual behavior exists within a social context

Internalized racism can affect health behavior Health behavior alone does not account for

unequal burden of disease and death

48 6283 88 88 103 107 117 126

158 175

230

347

050

100150200250300350400

Charle

stow

n

South

Bos

ton

Allsto

n/Brig

hton

Jam

aica P

lain

Wes

t Rox

bury

Combi

ned

Centra

l Are

a*

Hyde

Park

Roxbur

y

East B

osto

n

South

Dor

ches

ter

Mat

tapa

n

Roslinda

le

North D

orch

este

r

Yo

uth

Pe

r F

aci

lity

Number of Youth Per Facility Across Boston Neighborhoods 1999-2000

* Combined Central Area includes Beacon Hill/Back Bay, Central, Fenway/Kenmore, and South End.

DATA SOURCE: Play Across Boston: Summary Report, December 2002

The Contextual Effect of the Local Food Environment on Residents’ Diets

Study by Moreland et al. AJPH. 11/2002

Findings: Only 8% of Black Americans lived in a census tract

with at least one supermarket compared to 31% of White respondents

Presence of supermarkets was associated with meeting dietary recommendations among Black Americans

Stress

Understanding the biologic impacts of social stress (Wadhwa et al. 2001., Culhane et al. 2001., Kramer et al. 2001 )

Theory of allostatic load (Michael Lu. 2002, Rich-Edwards. 2001)

“ ..a woman’s chronic exposure to racism creates an allostatic load ..altering the endocrine milieu in which the placenta is established….” (Rich-Edwards. 2001)

Racial and Ethnic Disparities Stress & Preterm Birth

Mother Placenta FetusStress

Hypothalamus

Pituitary

Adrenal

CRH

CRH

ACTH

CortisolNorepineprhine

++

Hypothalamus

Pituitary

Adrenal

Liver

CRH

ACTH

CortisolDS

16 alpha OH DS

Estriol

+

+

Adapted from Hobel 1998

Racial & Ethnic DisparitiesLow Birth Weight & Racism

0

2

4

6

8

10

12

14

16

18

20

Per

cent

Wom

en R

epor

ting

D

iscr

imin

atio

n

<1,500 g > 2,500 g

Birthweight

Collins 2000

12%

20%

P < 0.01

The Provision of Health Care

Differences in access to and types of health insurance/health plans

Differences in access to pharmaceutical drugs

Differences in provision of diagnostic tests, therapeutic procedures, transplants, and preventive services

Evidence of Racial and Ethnic Disparities in Healthcare

Disparities consistently found across a wide range of disease areas and clinical services

Disparities are found even when clinical factors, such as stage of disease presentation, co-morbidities, age, and severity of disease are taken into account

Disparities are found across a range of clinical settings, including public and private hospitals, teaching and non-teaching hospitals, etc.

Disparities in care are associated with higher mortality among minorities (e.g., Bach et al., 1999; Peterson et al., 1997; Bennett et al., 1995)

“If racism was constructed, it can be undone.

It can be undone if people understand when it was constructed, why it was constructed, how it functions, and how it is maintained.”

---People’s Institute For Survival and Beyond

What Next?

Need for Institutional ResponsibilityUnderstanding the nature of the

problemIdentifying opportunities for alternativeroles

Need for Institutional ResponseChanging policies and proceduresMobilizing for action