The reversal of fortunes: trends in county mortality and cross-county mortality disparities in the United States

Background

Counties are the smallest unit for which mortality data are routinely available, allowing consistent and comparable long-term analysis of trends in health disparities. Average life expectancy has steadily increased in the United States but there is limited information on long-term mortality trends in the US counties This study aimed to investigate trends in county mortality and cross-county mortality disparities, including the contributions of specific diseases to county level mortality trends.

Methods and Findings

We used mortality statistics (from the National Center for Health Statistics [NCHS]) and population (from the US Census) to estimate sex-specific life expectancy for US counties for every year between 1961 and 1999. Data for analyses in subsequent years were not provided to us by the NCHS. We calculated different metrics of cross-county mortality disparity, and also grouped counties on the basis of whether their mortality changed favorably or unfavorably relative to the national average. We estimated the probability of death from specific diseases for counties with above- or below-average mortality performance. We simulated the effect of cross-county migration on each county''s life expectancy using a time-based simulation model. Between 1961 and 1999, the standard deviation (SD) of life expectancy across US counties was at its lowest in 1983, at 1.9 and 1.4 y for men and women, respectively. Cross-county life expectancy SD increased to 2.3 and 1.7 y in 1999. Between 1961 and 1983 no counties had a statistically significant increase in mortality; the major cause of mortality decline for both sexes was reduction in cardiovascular mortality. From 1983 to 1999, life expectancy declined significantly in 11 counties for men (by 1.3 y) and in 180 counties for women (by 1.3 y); another 48 (men) and 783 (women) counties had nonsignificant life expectancy decline. Life expectancy decline in both sexes was caused by increased mortality from lung cancer, chronic obstructive pulmonary disease (COPD), diabetes, and a range of other noncommunicable diseases, which were no longer compensated for by the decline in cardiovascular mortality. Higher HIV/AIDS and homicide deaths also contributed substantially to life expectancy decline for men, but not for women. Alternative specifications of the effects of migration showed that the rise in cross-county life expectancy SD was unlikely to be caused by migration.

Conclusions

There was a steady increase in mortality inequality across the US counties between 1983 and 1999, resulting from stagnation or increase in mortality among the worst-off segment of the population. Female mortality increased in a large number of counties, primarily because of chronic diseases related to smoking, overweight and obesity, and high blood pressure.     

Increasing Black:White disparities in breast cancer mortality in the 50 largest cities in the United States

Introduction: This paper presents race-specific breast cancer mortality rates and the corresponding rate ratios for the 50 largest U.S. cities for each of the 5-year intervals between 1990 and 2009. Methods: The 50 largest cities in the U.S. were the units of analysis. Numerator data were abstracted from national death files where the cause was malignant neoplasm of the breast (ICD-9 = 174 and ICD-10 = C50) for women. Population-based denominators were obtained from the U.S. Census Bureau for 1990, 2000, and 2010. To measure the racial disparity, we calculated non-Hispanic Black:non-Hispanic White rate ratios (RRs) and confidence intervals for each 5-year period. Results: At the final time point (2005–2009), two RRs were less than 1, but neither significantly so, while 39 RRs were >1, 23 of them significantly so. Of the 41 cities included in the analysis, 35 saw an increase in the Black:White RR between 1990–1994 and 2005–2009. In many of the cities, the increase in the disparity occurred because White rates improved substantially over the 20-year study period, while Black rates did not. There were 1710 excess Black deaths annually due to this disparity in breast cancer mortality, for an average of about 5 each day. Conclusion: This analysis revealed large and growing disparities in Black:White breast cancer mortality in the U.S. and many of its largest cities during the period 1990–2009. Much work remains to achieve equality in breast cancer mortality outcomes.     

Survival and cause-specific mortality of male wild turkeys across the southeastern United States

Estimating survival and cause-specific mortality of male eastern wild turkeys (Meleagris gallopavo silvestris) is important for understanding population dynamics and implementing appropriate harvest management. To better understand age-specific estimates of annual survival and harvest rates, we captured and marked male wild turkeys with leg bands (n = 311) or bands and transmitters (n = 549) in Georgia, Louisiana, North Carolina, and South Carolina, USA, during 2014–2022. We fitted time to event models to data from radio-marked birds to estimate cause-specific mortality and annual survival. We used band recovery models incorporating both band recovery and telemetry data to further investigate harvest rates and survival. Annual survival from known-fate models in hunted populations was 0.54 (95% CI = 0.49–0.59) for adults and 0.86 (95% CI = 0.81–0.92) for juveniles. Cause-specific mortality analysis produced an annual harvest estimate of 0.29 (95% CI = 0.24–0.33) for adults and 0.02 (95% CI = 0.01–0.03) for juveniles, whereas predation was 0.15 (95% CI = 0.10–0.20) and 0.12 (95% CI = 0.08–0.17), respectively. Annual survival for adult males in a non-hunted population was 0.83 (95% CI = 0.72–0.97). Survival rate was negatively correlated with harvest rate, indicating harvest was an additive mortality source. Annual survival from band recovery models was 0.40 (95% CI = 0.37–0.44) for adults and 0.88 (95% CI = 0.81– 0.93) for juveniles, whereas annual harvest estimates were 0.24 (95% CI = 0.23–0.25) for adults and 0.04 (95% CI = 0.03–0.05) for juveniles. Both models suggested no differences in annual survival across years or among study areas, which included privately owned and public properties. Harvest was an additive mortality source for male wild turkeys, suggesting that managers interested in increasing annual survival of adult males could consider ways of reducing harvest rates.     

Linking remotely sensed ecosystem resilience with forest mortality across the continental United States

Episodes of forest mortality have been observed worldwide associated with climate change, impacting species composition and ecosystem services such as water resources and carbon sequestration. Yet our ability to predict forest mortality remains limited, especially across large scales. Time series of satellite imagery has been used to document ecosystem resilience globally, but it is not clear how well remotely sensed resilience can inform the prediction of forest mortality across continental, multi-biome scales. Here, we leverage forest inventories across the continental United States to systematically assess the potential of ecosystem resilience derived using different data sets and methods to predict forest mortality. We found high resilience was associated with low mortality in eastern forests but was associated with high mortality in western regions. The unexpected resilience–mortality relation in western United States may be due to several factors including plant trait acclimation, insect population dynamics, or resource competition. Overall, our results not only supported the opportunity to use remotely sensed ecosystem resilience to predict forest mortality but also highlighted that ecological factors may have crucial influences because they can reverse the sign of the resilience–mortality relationships.     

Association between disparities in intergenerational economic mobility and cause-specific mortality among Black and White persons in the United States

BackgroundEvidence about the association between structural racism and mortality in the United States is limited. We examined the association between ongoing structural racism, measured as inequalities in adulthood income between White and Black children with similar parental household income (economic mobility gap) in a recent birth cohort, and Black-White disparities in death rates (mortality gap) overall and for major causes.MethodsSex-, race/ethnicity-, and county-specific data were used to examine sex-specific associations between economic mobility and mortality gaps for all causes combined, heart diseases, cerebrovascular diseases, chronic obstructive pulmonary disease (COPD), injury/violence, all malignant cancers, and 14 cancer types. Economic mobility data for 1978–1983 birth cohorts and death rates during 2011–2018 were obtained from the Opportunity Atlas and National Center for Health Statistics, respectively. Data from 471 counties were included in analyses of all-cause mortality at ages 30−39 years during 2011–2018 (corresponding to partially overlapping 1978–1983 birth cohorts); and from 1,572 and 1,248 counties in analyses of all-cause and cause-specific mortality in all ages combined, respectively.ResultsIn ages 30−39 years, a one percentile increase in the economic mobility gap was associated with a 6.8 % (95 % confidence interval 1.8 %–11.8 %) increase in the Black-White mortality gap among males and a 13.5 % (8.9 %–18.1 %) increase among females, based on data from 471 counties. In all ages combined, the corresponding percentages based on data from 1,572 counties were 10.2 % (7.2 %–13.2 %) among males and 14.8 % (11.4 %–18.2 %) among females, equivalent to an increase of 18.4 and 14.0 deaths per 100,000 in the mortality gap, respectively. Similarly, strong associations between economic mobility gap and mortality gap in all ages were found for major causes of death, notably for potentially preventable conditions, including COPD, injury/violence, and cancers of the lung, liver, and cervix.ConclusionsEconomic mobility gap conditional on parental income in a recent birth cohort as a marker of ongoing structural racism is strongly associated with Black-White disparities in all-cause mortality and mortality from several causes.     

Obesity and early mortality in the United States

Objective:

Although obesity is a serious public health problem, there are few reliable measures of its health hazards in the United States. The objective of this study was to estimate how much earlier mortality is likely to occur for Americans who are obese (body mass index [BMI], ≥ 30).

Design and Methods:

Data from the National Health and Nutrition Examination Survey (NHANES) I (1971–1975), NHANES II (1976–1980), and NHANES III (1988–1994) for 37,632 participants who experienced 8,791 deaths during 15 years of follow‐up were prospectively analyzed. The relative risk of death from all causes and its advancement period, adjusted for covariates, were calculated. Stratification was used to investigate the effects of pre‐existing illness, smoking, and older age on the advancement period.

Results:

Compared to the participants of reference weight (BMI, 23 to <25 kg/m2), mortality was likely to occur 9.44 years (95% confidence interval [CI]: 0.72, 18.16) earlier for those who were obese (BMI, ≥ 30). For overweight (25 to <30 kg/m2), grade 1 obesity (BMI, 30 to <35) and grades 2–3 obesity (BMI, ≥ 35.0), the mortality was likely to occur earlier by 4.40 (?3.90, 12.70), 6.69 (?2.06, 15.43), and 14.16 (3.35, 24.97) years, respectively. These estimates apply to healthy nonsmoker young‐ and middle‐aged (21–55 years) adults, who constituted an estimated 32.8% of Americans with age of >21 years between 1988 and 1994. Without stratifying simultaneously for preexisting illness, smoking, and age, values of the advancement period for obesity were markedly smaller than those observed for healthy nonsmoker young and middle‐aged adults.

Conclusions:

For healthy nonsmokers young‐ and middle‐aged adults who constitute about one‐third of American adults, being obese is likely to hasten mortality by 9.44 years.

     

Aboriginal mortality in Canada, the United States and New Zealand

Indigenous populations in New World nations share the common experience of culture contact with outsiders and a prolonged history of prejudice and discrimination. This historical reality continues to have profound effects on their well-being, as demonstrated by their relative disadvantages in socioeconomic status on the one hand, and in their delayed demographic and epidemiological transitions on the other. In this study one aspect of aboriginals' epidemiological situation is examined: their mortality experience between the early 1980s and early 1990s. The groups studied are the Canadian Indians, the American Indians and the New Zealand Maori (data for Australian Aboriginals could not be obtained). Cause-specific death rates of these three minority groups are compared with those of their respective non-indigenous populations using multivariate log-linear competing risks models. The empirical results are consistent with the proposition that the contemporary mortality conditions of these three minorities reflect, in varying degrees, problems associated with poverty, marginalization and social disorganization. Of the three minority groups, the Canadian Indians appear to suffer more from these types of conditions, and the Maori the least.     

Genetic variation among apple and hawthorn host races of Rhagoletis pomonella across an ecological transition zone in the Mid-Western United States

In previous studies, we have shown that apple and hawthorn populations of Rhagoletis pomonella (Diptera: Tephritidae) represent partially reproductively isolated and genetically differentiated host races; a result consistent with predictions of sympatric speciation models. The geographic pattern of allozyme variation for these flies is complex, however, as inter-host differences are superimposed on latitudinal allele frequency clines within the races. In addition, pronounced allele frequency shifts exist among R. pomonella populations across three major ecological transition zones in the mid-western United States. This suggests that selection related to environmental heterogeneity is responsible for the allele frequency shifts, but does not rule out secondary contact as an alternative possibility. Resolution of this issue is important, because if secondary contact is involved, then we would have to reassess the relationship host race formation has with speciation in the R. pomonella group.Here, we present results from a detailed genetic analysis of fly populations spanning the deciduous/prairie transition zone near the border between the states of Wisconsin and Illinois. Allele frequencies for hawthorn populations within the zone formed spikes, rather than the expected steps, and these frequency peaks correlated with variation in local ambient temperature conditions. Ambient temperature, and not secondary contact, therefore appears to be an important determinant of the shape of R. pomonella allele frequency clines. Allele frequency heterogeneity was also observed among apple populations, but was less pronounced compared to that for hawthorn flies. This suggests that ambient temperature differentially affects the host races, possibly through differences in the fruiting phenologies of apple and hawthorn trees. Several pairs of linked loci displayed concordant allele frequency changes and were in disequilibrium among both apple and hawthorn populations along the Wisconsin/Illinois transect. Although we do not know the reason for the observed pattern of disequilibrium, site to site variation in levels of inter-host migration, coupled with selection, seem the most likely explanations. We conclude by discussing how host specific adaptations, such as those associated with ambient temperature, may interact with host recognition traits to drive the sympatric speciation process for R. pomonella group flies.     

Congenital cytomegalovirus mortality in the United States, 1990-2006

Background

Congenital cytomegalovirus (CMV) infection is the most common intrauterine infection in the United States disproportionately affecting minority races and those of lower socio-economic class. Despite its importance there is little information on the burden of congenital CMV-related mortality in the US. To measure congenital CMV-associated mortality in the US and assess possible racial/ethnic disparities, we reviewed national death certificate data for a 17-year period.

Methods

Congenital CMV-associated deaths from 1990 through 2006 were identified from multiple-cause-coded death records and were combined with US census data to calculate mortality rates.

Results

A total of 777 congenital CMV-associated deaths occurred over the 17-year study period resulting in 56,355 years of age-adjusted years of potential life lost. 71.7% (557) of congenital CMV-associated deaths occurred in infants (age less than 1 year). Age-adjusted mortality rates stratified by race/ethnicity revealed mortality disparities. Age-adjusted rate ratios were calculated for each racial/ethnic group using whites as the reference. Native Americans and African Americans were 2.34 (95% CI, 2.11–2.59) and 1.89 (95% CI, 1.70–2.11) times respectively, more likely to die from congenital CMV than whites. Asians and Hispanics were 0.54 (95% CI, 0.44–0.66) and 0.96 (95% CI, 0.83–1.10) times respectively, less likely to die from congenital CMV than whites.

Conclusions/Significance

Congenital CMV infection causes appreciable mortality in the US exacting a particular burden among African Americans and Native Americans. Enhanced surveillance and increased screening are necessary to better understand the epidemiology of congenital CMV infection in addition to acceleration of vaccine development efforts.     

Human echinococcosis mortality in the United States, 1990-2007

Background

Despite the endemic nature of Echinococcus granulosus and Echinococcus multilocularis infection in regions of the United States (US), there is a lack of data on echinococcosis-related mortality. To measure echinococcosis-associated mortality in the US and assess possible racial/ethnic disparities, we reviewed national-death certificate data for an 18-year period.

Methodology/Principal Findings

Echinococcosis-associated deaths from 1990 through 2007 were identified from multiple-cause-coded death records and were combined with US census data to calculate mortality rates. A total of 41 echinococcosis-associated deaths occurred over the 18-year study period. Mortality rates were highest in males, Native Americans, Asians/Pacific Islanders, Hispanics and persons 75 years of age and older. Almost a quarter of fatal echinococcosis-related cases occurred in residents of California. Foreign-born persons accounted for the majority of echinococcosis-related deaths; however, both of the fatalities in Native Americans and almost half of the deaths in whites were among US-born individuals.

Conclusions/Significance

Although uncommon, echinococcosis-related deaths occur in the US. Clinicians should be aware of the diagnosis, particularly in foreign-born patients from Echinococcus endemic areas, and should consider tropical infectious disease consultation early.     

Sex differentials in morbidity and mortality in the United States

Abstract

Life expectation of females in the United States exceeds that of males, but females’ health while living appears worse. Based on self‐reports of illness, females have higher incidence rates for acute conditions, and a higher percentage of them have a chronic condition. The paper examines sex differentials in mortality and morbidity for 1958–72, using national vital statistics and Health Interview Survey data. The reversal of mortality and morbidity sex differentials in the aggregate is due in part to a distribution effect, diseases with a male excess being weighted heavily in mortality, but those with a female excess dominating morbidity. For specific conditions, sex morbidity and sex mortality differentials are usually in the same direction, the sicker sex being more likely to die. For several conditions, however, females have higher morbidity but lower mortality than males. By incorporating diagnostic data, these reversals are attributed to females’ interviewing and illness behavior, rather than to higher physical morbidity.     

Widening educational disparities in premature death rates in twenty six States in the United States, 1993-2007

Background

Eliminating socioeconomic disparities in health is an overarching goal of the U.S. Healthy People decennial initiatives. We present recent trends in mortality by education among working-aged populations.

Methods and Findings

Age-standardized death rates and their average annual percent change for all-cause and five major causes (cancer, heart disease, stroke, diabetes, and accidents) were calculated from 1993 through 2007 for individuals aged 25–64 years by educational attainment as a marker of socioeconomic status, using national vital registration data for 26 states with consistent educational information on the death certificates. Rate ratios and rate differences were used to assess disparities (≤12 versus ≥16 years of education) for 1993 through 2007. From 1993 through 2007, relative educational disparities in all-cause mortality continued to increase among working-aged men and women in the U.S., due to larger decreases of mortality rates among the most educated coupled with smaller decreases or even worsening trends in the less educated. For example, the rate ratios of all-cause mortality increased from 2.5 (95% confidence interval (CI), 2.4–2.6) in 1993 to 3.6 (95% CI, 3.5–3.7) in 2007 in men and from 1.9 (95% CI, 1.8–2.0) to 3.0 (95% CI, 2.9–3.1) in women. Generally, the rate differences (per 100,000 persons) of all-cause mortality increased from 415.5 (95% CI, 399.1–431.9) in 1993 to 472.7 (95% CI, 460.2–485.2) in 2007 in men and from 165.4 (95% CI, 154.5–176.2) to 256.2 (95% CI, 248.3–264.2) in women. Disparity patterns varied largely across the five specific causes considered in this study, with the largest increases of relative disparities for accidents, especially in women.

Conclusions

Relative educational differentials in mortality continued to widen among men and women despite emphasis on reducing disparities in the U.S. Healthy People decennial initiatives.