Conclusions and Comment

During 1999–2015, age-adjusted death rates decreased by 25% for blacks and 14% for whites, with 284 fewer age-adjusted deaths per 100,000 blacks and 120 fewer age-adjusted deaths per 100,000 whites during 2015 compared with 1999. Among persons aged ≥65 years, there was a black-white mortality crossover, whereby blacks had slightly lower age-adjusted deaths than whites beginning in 2010. In addition, during 1999–2015, blacks saw declines in the two leading causes of death, heart disease and cancer, across all age groups. However, despite substantive reductions in death rates among blacks in the United States, blacks continue to have higher death rates overall, higher prevalence of many chronic health conditions, and lower prevalence of some healthy behaviors. Blacks were less likely to participate in leisure-time physical activity and maintain a healthy weight. Blacks were more likely to report not being able to see a doctor because of cost, even though, across age groups, the percentages of blacks and whites who reported having a personal doctor or health care provider were approximately equal.

In addition, this analysis shows that blacks had significantly lower educational attainment and home ownership and almost twice the proportion of households living below the poverty level and unemployed than whites in all age groups. Such social factors are posited as “fundamental causes” because they influence chronic conditions, related behaviors, health-related quality of life, and health care utilization by constraining persons’ abilities to engage in prevention or treatment (7,8). These differences in “fundamental causes,” health behaviors, and access to health care contribute to the excess deaths and chronic conditions among younger black adults that are most common among persons aged ≥65 years. For example, blacks in age groups 18–34 and 35–49 were nearly twice as likely to die from heart disease, stroke, and diabetes as whites. These findings are generally consistent with previous reports that use the term “weathering” to suggest that blacks experience premature aging and earlier health decline than whites, and that this decline in health accumulates across the entire life span and potentially across generations, as a consequence of psychosocial, economic, and environmental stressors (9,10).

Taken in the context of other research, the substantial differences in mortality, health behaviors, access to health care, and social factors across the life span identified in this analysis highlight the importance of a dual strategy of universal and targeted interventions to address disparities in black health (11). Opportunities for interventions have been identified that decision-makers, public health programs, clinicians, and communities can use. The Community Preventive Services Task Force has recommendations for interventions with proven effectiveness for the prevention of obesity, physical inactivity, tobacco use, promotion of cancer screening, and medication adherence (https://www.thecommunityguide.org/External ). CDC has also released a series of violence prevention technical packages to help communities use the strategies with the best available evidence (https://www.cdc.gov/violenceprevention/pub/technical-packages.html). To ensure continued progress in improving health for all U.S. residents, targeted interventions for populations living in vulnerable social and economic conditions (e.g., poverty or racially segregated neighborhoods with fewer resources) also should be considered. The U.S. Department of Health and Human Services Action Plan to Reduce Racial and Ethnic Health Disparities promotes targeted interventions to reduce these disparities (https://www.minorityhealth.hhs.gov/npa/files/Plans/HHS/HHS_Plan_complete.pdfCdc-pdf External ). In addition, The Racial and Ethnic Approaches to Community Health (REACH) program, which supports targeted interventions through community-based, participatory approaches, identified strategies to address health disparities for blacks and other racial/ethnic populations (12–15).

The findings in this report are subject to at least six limitations. First, information about many characteristics were self-reported and subject to recall and social desirability biases, although this is unlikely to account for large disparities within the analyses (16). Second, this was a cross-sectional analysis, and data do not allow a comparison of rates for the same cohort as they aged (16). Third, the American Community Survey and BRFSS are household surveys and exclude persons living in institutions, long-term care facilities, and prisons. Fourth, there are technical and conceptual limitations associated with examining race in epidemiologic analyses because it is complex and generally represents other economic, psychosocial, and environmental factors (17–19). Fifth, although whites were considered as the benchmark (20), or referent in this analysis, blacks had lower death rates for unintentional injury and suicide in some age groups and lower prevalences of binge drinking. Finally, differences within blacks and whites by sex, socioeconomic characteristics, and Hispanic subgroups were not considered, yet might modulate some of the relationships seen overall.

Optimizing health for all U.S. residents while also eliminating disparities, remains an integral part of disease prevention and health promotion activities. Although significant strides have been made in the United States in the last 17 years, disparities still exist. To continue to improve the health of the black population, there is a continued need to translate research results into effective universal and targeted interventions across the lifespan to inform action.