Correspondence

Mortality from Cardiovascular Causes among Blacks and Whites in New York City

N Engl J Med 1997; 336:1321-1322May 1, 1997

Article

To the Editor:

Fang et al.,1 Geronimus et al.,2 and Gillum3 (Nov. 21 issue) address interracial and intraracial disparities in cardiovascular and other causes of mortality among blacks and whites. Similar patterns in reproductive-health outcomes have long been noted. Our own analysis of New York City data on vital statistics a decade ago showed that the black:white gap in maternal and infant mortality rates persisted across class lines yet varied according to national origin, with African Americans faring worse than Caribbean blacks.4 Differences in birth outcomes have also been demonstrated among low-income Hispanics, Asians, and Native Americans in the United States, according to national or tribal descent groupings.5-7

The implication of these analyses is that neither biologic nor social-class explanations suffice to explain disparities in health, but rather that race, culture, poverty, and environment are interactive. One question therefore is, What are the mechanisms by which these different social experiences are translated into this wide range of biologic outcomes? Sometimes we can intervene successfully, even without fully understanding these mechanisms. The legalization of abortion is a case in point, as it has been one of the few interventions to narrow a black:white mortality differential significantly.8

The impending devolution of governmental responsibility for welfare and Medicaid to the local level could provide an opportunity to address these heterogeneous profiles of risk with programs tailored to meet the health needs of specific communities. However, the attendant reductions in funding may well exacerbate the vulnerability of populations already in need.

Wendy Chavkin, M.D., M.P.H.
Deborah Elman, M.P.H.
Columbia University School of Public Health, New York, NY 10032

8 References

1. 1

   Fang J, Madhavan S, Alderman MH. The association between birthplace and mortality from cardiovascular causes among black and white residents of New York City. N Engl J Med 1996;335:1545-1551
   Full Text | Web of Science | Medline

2. 2

   Geronimus AT, Bound J, Waidmann TA, Hillemeier MM, Burns PB. Excess mortality among blacks and whites in the United States. N Engl J Med 1996;335:1552-1558
   Full Text | Web of Science | Medline

3. 3

   Gillum RF. The epidemiology of cardiovascular disease in black Americans. N Engl J Med 1996;335:1597-1598
   Full Text | Web of Science | Medline

4. 4

   Chavkin W, Busner C, McLaughlin M. Reproductive health: Caribbean women in New York City, 1980-1984. Int Migr Rev 1987;21:609-625
   CrossRef | Web of Science | Medline

5. 5

   Becerra JE, Atrash HK, Perez N, Saliceti JA. Low birthweight and infant mortality in Puerto Rico. Am J Public Health 1993;83:1572-1576
   CrossRef | Web of Science | Medline

6. 6

   Morrow HW, Chavez GF, Giannoni PP, Shah RS. Infant mortality and related risk factors among Asian Americans. Am J Public Health 1994;84:1497-1500
   CrossRef | Web of Science | Medline

7. 7

   Indian Health Service. Regional differences in Indian health, 1995. Rockville, Md.: Department of Health and Human Services, 1995.
   

8. 8

   Binkin N, Gold J, Cates W Jr. Illegal-abortion deaths in the United States: why are they still occurring? Fam Plann Perspect 1982;14:163-167
   CrossRef | Medline

Author/Editor Response

Dr. Geronimus replies:

To the Editor: Our article and that of Fang et al. document substantial variation among U.S. blacks in rates of mortality due to cardiovascular diseases and other causes. This variation and the intraracial variation documented for additional outcomes, as Chavkin and Elman note, should generate hypotheses about how socially defined background characteristics translate into differential morbidity. Because Fang et al. find differences in cardiovascular mortality according to birthplace among black residents of New York City, simple concepts of “culture” or “ethnicity” suggesting dietary or perhaps even genetic differences have been raised by scholars and highlighted in the media as being among the potentially important factors contributing to this variation. However, if one reads the two articles together, some findings appear inconsistent with this interpretation. Fang et al. find that southern-born blacks fare worse than those born in the Northeast, but our poor southern black population fared substantially better than any of our poor northern or urban black populations, including the one in New York City. Fang et al. find that Caribbean-born blacks fare better than blacks born in the Northeast, yet we find that native-born blacks living in the same New York communities as the Caribbean-born fare no worse than their Caribbean-born neighbors.

Both studies are descriptive, leaving evidence of causality for future research. But it is important to avoid reducing the set of hypotheses to be tested to ones that assume birthplace differences in themselves, since the populations studied by Fang et al. differ in other potentially important respects that are not controlled in their analysis. For example, in their Table 1, Fang et al. show systematic socioeconomic differences among their three populations. These appear to favor the Caribbean-born while suggesting that the southern-born migrants are, on average, more disadvantaged than other black residents of New York City. Variation in mortality rates among our impoverished study populations is inconsistent with the view that economic characteristics alone determine mortality rates, but the two sets of findings together do suggest it is plausible that when U.S.-born or Caribbean-born blacks enjoy socioeconomic advantages, writ large, they enjoy favorable mortality profiles. For less advantaged blacks, if unhealthful behavior contributes to the staggering excess mortality rates we described for central-city residents, it may be derivative of stressful circumstances rather than the sign of an invariant cultural heritage.

Arline T. Geronimus, Sc.D.
University of Michigan School of Public Health, Ann Arbor, MI 48109-2029

Citing Articles (3)

Citing Articles

1. 1

   Richard G. Roetzheim, Eduardo C. Gonzalez, Jeanne M. Ferrante, Naazneen Pal, Daniel J. Van Durme, Jeffrey P. Krischer. (2000) Effects of health insurance and race on breast carcinoma treatments and outcomes. Cancer 89:11, 2202-2213
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2. 2

   R. G. Roetzheim, N. Pal, E. C. Gonzalez, J. M. Ferrante, D. J. Van Durme, J. P. Krischer. (2000) Effects of health insurance and race on colorectal cancer treatments and outcomes. American Journal of Public Health 90:11, 1746-1754
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3. 3

   Robert L. Satcher. (1999) African Americans and Orthopaedic Surgery. Clinical Orthopaedics and Related Research 362, 114???116
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