Significant impacts of the COVID-19 pandemic on race/ethnic differences in US mortality.

The coronavirus 2019 (COVID-19) pandemic triggered global declines in life expectancy. The United States was hit particularly hard among high-income countries. Early data from the United States showed that these losses varied greatly by race/ethnicity in 2020, with Hispanic and Black Americans suffering much larger losses in life expectancy compared with White people. We add to this research by examining trends in lifespan inequality, average years of life lost, and the contribution of specific causes of death and ages to race/ethnic life-expectancy disparities in the United States from 2010 to 2020. We find that life expectancy in 2020 fell more for Hispanic and Black males (4.5 and 3.6 y, respectively) compared with White males (1.5 y). These drops nearly eliminated the previous life-expectancy advantage for the Hispanic compared with the White population, while dramatically increasing the already large gap in life expectancy between Black and White people. While the drops in life expectancy for the Hispanic population were largely attributable to official COVID-19 deaths, Black Americans saw increases in cardiovascular diseases and "deaths of despair" over this period. In 2020, lifespan inequality increased slightly for Hispanic and White populations but decreased for Black people, reflecting the younger age pattern of COVID-19 deaths for Hispanic people. Overall, the mortality burden of the COVID-19 pandemic hit race/ethnic minorities particularly hard in the United States, underscoring the importance of the social determinants of health during a public health crisis.

Invited Commentary: Stop Analyzing Suicides, Drug-Related Deaths, and Alcohol-Related Deaths Together.

In the accompanying article, Spark et al. (Am J Epidemiol. 2023;192(5):720-731) estimate the undercounting of deaths due to suicide, drug use, and alcohol use in a Colorado veteran population and argue for a standardized case definition for the 3 causes of mortality. Use of a case definition for these 3 causes of death combined implies that they should be analyzed together. This is problematic, given the disparate trends in and historical contexts behind these 3 different causes of death.

"Outside the Skin": The Persistence of Black-White Disparities in U.S. Early-Life Mortality.

Research on Black-White disparities in mortality emphasizes the cumulative pathways through which racism gets "under the skin" to affect health. Yet this framing is less applicable in early life, when death is primarily attributable to external causes rather than cumulative, biological processes. We use mortality data from the National Vital Statistics System Multiple Cause of Death files and population counts from the Surveillance, Epidemiology, and End Result Program to analyze 705,801 deaths among Black and White males and females, ages 15-24. We estimate age-standardized death rates and single-decrement life tables to show how all-cause and cause-specific mortality changed from 1990 to 2016 by race and sex. Despite overall declines in early-life mortality, Black-White disparities remain unchanged across several causes-especially homicide, for which mortality is nearly 20 times as high among Black as among White males. Suicide and drug-related deaths are higher among White youth during this period, yet their impact on life expectancy at birth is less than half that of homicide among Black youth. Critically, early-life disparities are driven by preventable causes of death whose impact occurs "outside the skin," reflecting racial differences in social exposures and experiences that prove harmful for both Black and White adolescents and young adults.

Twin epidemics: the effects of HIV and systolic blood pressure on mortality risk in rural South Africa, 2010-2019.

BACKGROUND: Sub-Saharan African settings are experiencing dual epidemics of HIV and hypertension. We investigate effects of each condition on mortality and examine whether HIV and hypertension interact in determining mortality. METHODS: Data come from the 2010 Ha Nakekela population-based survey of individuals ages 40 and older (1,802 women; 1,107 men) nested in the Agincourt Health and socio-Demographic Surveillance System in rural South Africa, which provides mortality follow-up from population surveillance until mid-2019. Using discrete-time event history models stratified by sex, we assessed differential mortality risks according to baseline measures of HIV infection, HIV-1 RNA viral load, and systolic blood pressure. RESULTS: During the 8-year follow-up period, mortality was high (477 deaths). Survey weighted estimates are that 37% of men (mortality rate 987.53/100,000, 95% CI: 986.26 to 988.79) and 25% of women (mortality rate 937.28/100,000, 95% CI: 899.7 to 974.88) died. Over a quarter of participants were living with HIV (PLWH) at baseline, over 50% of whom had unsuppressed viral loads. The share of the population with a systolic blood pressure of 140mm Hg or higher increased from 24% at ages 40-59 to 50% at ages 75-plus and was generally higher for those not living with HIV compared to PLWH. Men and women with unsuppressed viral load had elevated mortality risks (men: adjusted odds ratio (aOR) 3.23, 95% CI: 2.21 to 4.71, women: aOR 2.05, 95% CI: 1.27 to 3.30). There was a weak, non-linear relationship between systolic blood pressure and higher mortality risk. We found no significant interaction between systolic blood pressure and HIV status for either men or women (p>0.05). CONCLUSIONS: Our results indicate that HIV and elevated blood pressure are acting as separate, non-interacting epidemics affecting high proportions of the older adult population. PLWH with unsuppressed viral load were at higher mortality risk compared to those uninfected. Systolic blood pressure was a mortality risk factor independent of HIV status. As antiretroviral therapy becomes more widespread, further longitudinal follow-up is needed to understand how the dynamics of increased longevity and multimorbidity among people living with both HIV and high blood pressure, as well as the emergence of COVID-19, may alter these patterns.

Trends in "Deaths of Despair" Among Working-Aged White and Black Americans, 1990-2017.

Life expectancy for US White men and women declined between 2013 and 2017. Initial explanations for the decline focused on increases in "deaths of despair" (i.e., deaths from suicide, drug use, and alcohol use), which have been interpreted as a cohort-based phenomenon afflicting middle-aged White Americans. There has been less attention on Black mortality trends from these same causes, and whether the trends are similar or different by cohort and period. We complement existing research and contend that recent mortality trends in both the US Black and White populations most likely reflect period-based exposures to 1) the US opioid epidemic and 2) the Great Recession. We analyzed cause-specific mortality trends in the United States for deaths from suicide, drug use, and alcohol use among non-Hispanic Black and non-Hispanic White Americans, aged 20-64 years, over 1990-2017. We employed sex-, race-, and cause-of-death-stratified Poisson rate models and age-period-cohort models to compare mortality trends. Results indicate that rising "deaths of despair" for both Black and White Americans are overwhelmingly driven by period-based increases in drug-related deaths since the late 1990s. Further, deaths related to alcohol use and suicide among both White and Black Americans changed during the Great Recession, despite some racial differences across cohorts.

Worth the Weight? Recent Trends in Obstetric Practices, Gestational Age, and Birth Weight in the United States.

Birth weight in the United States declined substantially during the 1990s and 2000s. We suggest that the declines were likely due to shifts in gestational age resulting from changes in obstetric practices. Using restricted National Vital Statistics System data linked birth/infant death data for 1990-2013, we analyze trends in obstetric practices, gestational age distributions, and birth weights among first-birth singletons born to U.S. non-Hispanic White, non-Hispanic Black, and Latina women. We use life table techniques to analyze the joint probabilities of gestational age-specific birth and gestational age-specific obstetric intervention (i.e., induced cesarean delivery, induced vaginal delivery, not-induced cesarean delivery, and not-induced vaginal delivery) to fully document trends in obstetric practices by gestational age. We use simulation techniques to estimate counterfactual changes in birth weight distributions if obstetric practices did not change between 1990 and 2013. Results show that between 1990 and 2013, the likelihood of induced labors and cesarean deliveries increased at all gestational ages, and the gestational age distribution of U.S. births significantly shifted. Births became much less likely to occur beyond gestational week 40 and much more likely to occur during weeks 37-39. Overall, nearly 18% of births from not-induced labor and vaginal delivery at later gestational ages were replaced with births occurring at earlier gestational ages from obstetric interventions. Results suggest that if rates of obstetric practices had not changed between 1990 and 2013, then the average U.S. birth weight would have increased over this time. Findings strongly indicate that recent declines in U.S. birth weight were due to increases in induced labor and cesarean delivery at select gestational ages.

Family Socioeconomic Status and Early Life Mortality Risk in the United States.

OBJECTIVES: We examine the association between several dimensions of parental socioeconomic status (SES) and all-cause and cause-specific mortality among children and youth (ages 1-24) in the United States. METHODS: We use Cox proportional hazard models to estimate all-cause and cause-specific mortality risk based on data from the 1998 to 2015 National Health Interview Survey-Linked Mortality Files (NHIS-LMFs), restricted to children and youth ages 1-17 at the time of survey followed through age 24, or the end of the follow-up period in 2015 (N = 377,252). RESULTS: Children and youth in families with lower levels of mother's education, father's education, and/or family income-to-needs ratio exhibit significantly higher all-cause mortality risk compared with children and youth living in higher SES families. For example, compared to children and youth living with mothers who earned college degrees, those living with mothers who have not graduated high school experience 40% higher risk of early life mortality over the follow-up period, due in part to higher mortality risks of unintentional injuries and homicides. Similarly, children/youth whose fathers did not graduate high school experience a 41% higher risk of dying before age 25 compared to those with fathers who completed college. CONCLUSIONS: Today's children and youth experience clear disparities in mortality risk across several dimensions of parental SES. As the U.S. continues to lag behind other high-income countries in health and mortality, more attention and resources should be devoted to improving children's health and well-being, including the family and household contexts in which American children live.

The impact of early death on birth counts in the United States, 1950 to 2019.

In a previous issue of PNAS Nexus, Bor et al. quantified the number of "missing Americans"-the deaths that would have been averted if the United States had experienced the mortality conditions of other wealthy nations. In 2019 alone, their estimates indicate that more than 100,000 individuals in reproductive ages (15-49 years) would have survived. The concept of the "missing Americans" is a valuable one, but here we argue that it is incomplete because it does not include children that would have been born to those who died an early death. We examine 3 indicators to assess the strength of the mortality-fertility nexus at the population level, showing that mortality more negatively affects birth counts in the United States than in other wealthy nations. Using the mortality conditions in other wealthy nations as a reference, we estimate that between 2010 and 2019 alone, approximately 200,000 children were not born in the United States due to the premature death of their potential mothers. Our findings highlight that improving morbidity and mortality among people of reproductive age-without compromising their reproductive autonomy-is critical in the United States.

US exceptionalism? International trends in midlife mortality.

BACKGROUND: Rising midlife mortality in the USA has raised concerns, particularly the increase in 'deaths of despair' (due to drugs, alcohol and suicide). Life expectancy is also stalling in other countries such as the UK, but how trends in midlife mortality are evolving outside the USA is less understood. We provide a synthesis of cause-specific mortality trends in midlife (25-64 years of age) for the USA and the UK as well as other high-income and Central and Eastern European (CEE) countries. METHODS: We document trends in midlife mortality in the USA, UK and a group of 13 high-income countries in Western Europe, Australia, Canada and Japan, as well as seven CEE countries from 1990 to 2019. We use annual mortality data from the World Health Organization Mortality Database to analyse sex- and age-specific (25-44, 45-54 and 55-64 years) age-standardized death rates across 15 major cause-of-death categories. RESULTS: US midlife mortality rates have worsened since 1990 for several causes of death including drug-related, alcohol-related, suicide, metabolic diseases, nervous system diseases, respiratory diseases and infectious/parasitic diseases. Deaths due to homicide, transport accidents and cardiovascular diseases have declined since 1990 but saw recent increases or stalling of improvements. Midlife mortality also increased in the UK for people aged 45-54 year and in Canada, Poland and Sweden among for those aged 25-44 years. CONCLUSIONS: The USA is increasingly falling behind not only high-income, but also CEE countries, some of which were heavily impacted by the post-socialist mortality crisis of the 1990s. Although levels of midlife mortality in the UK are substantially lower than those in the USA overall, there are signs that UK midlife mortality is worsening relative to that in Western Europe.

Inequalities in healthcare use during the COVID-19 pandemic.

The COVID-19 pandemic led to reductions in non-COVID related healthcare use, but little is known whether this burden is shared equally. This study investigates whether reductions in administered care disproportionately affected certain sociodemographic strata, in particular marginalised groups. Using detailed medical claims data from the Dutch universal health care system and rich full population registry data, we predict expected healthcare use based on pre-pandemic trends (2017 - Feb 2020) and compare these expectations with observed healthcare use in 2020 and 2021. Our findings reveal a 10% decline in the number of weekly treated patients in 2020 and a 3% decline in 2021 relative to prior years. These declines are unequally distributed and are more pronounced for individuals below the poverty line, females, older people, and individuals with a migrant background, particularly during the initial wave of COVID-19 hospitalisations and for middle and low urgency procedures. While reductions in non-COVID related healthcare decreased following the initial shock of the pandemic, inequalities persist throughout 2020 and 2021. Our results demonstrate that the pandemic has not only had an unequal toll in terms of the direct health burden of the pandemic, but has also had a differential impact on the use of non-COVID healthcare.

Projecting the long-term effects of the COVID-19 pandemic on U.S. population structure.

The immediate, direct effects of the COVID-19 pandemic on the United States population are substantial. Millions of people were affected by the pandemic: many died, others did not give birth, and still others could not migrate. Research that has examined these individual phenomena is important, but fragmented. The disruption of mortality, fertility, and migration jointly affected U.S. population counts and, consequently, future population structure. We use data from the United Nations World Population Prospects and the cohort component projection method to isolate the effect of the pandemic on U.S. population estimates until 2060. If the pandemic had not occurred, we project that the population of the U.S. would have 2.1 million (0.63%) more people in 2025, and 1.7 million (0.44%) more people in 2060. Pandemic-induced migration changes are projected to have a larger long-term effect on future population size than mortality, despite comparable short-term effects.

Increases in Obstetric Interventions and Changes in Gestational Age Distributions of U.S. Births.

Objective: To examine how changes in induction of labor (IOL) and cesarean deliveries between 1990 and 2017 affected gestational age distributions of births in the United States. Materials and Methods: Singleton first births were drawn from the National Vital Statistics System Birth Data for years 1990-2017. Separate analytic samples were created (1) by maternal race/ethnicity (Hispanic, non-Hispanic Black, non-Hispanic Asian, and non-Hispanic white), (2) by maternal age (15-19, 20-24, 25-29, 30-34, 35-39, 40-49), (3) by U.S. states, and (4) for women at low risk for obstetric interventions (e.g., age 20-34, no hypertension, no diabetes, no tobacco use). Gestational age was measured in weeks, and obstetric intervention status was measured as: (1) no IOL, vaginal delivery; (2) no IOL, cesarean delivery; and (3) IOL, all deliveries. The joint probabilities of birth at each gestational week by obstetric intervention status for years 1990-1991, 1998-1999, 2007-2008, and 2016-2017 were estimated. Results: Between 1990 and 2017, the percent of singleton first births occurring between 37 and 39 weeks of gestation increased from 38.5% to 49.5%. The changes were driven by increases in IOL and a shift in the use of cesarean deliveries toward earlier gestations. The changes were observed among all racial/ethnic groups and all maternal ages, and across all U.S. states. The same changes were also observed among U.S. women at low risk for interventions. Conclusion: Changes in gestational age distributions of U.S. births and their underlying causes are likely national-level phenomena and do not appear to be responding to increases in maternal risk for interventions.

Comparing trends in mid-life 'deaths of despair' in the USA, Canada and UK, 2001-2019: is the USA an anomaly?

OBJECTIVES: In recent years, 'deaths of despair' due to drugs, alcohol and suicide have contributed to rising mid-life mortality in the USA. We examine whether despair-related deaths and mid-life mortality trends are also changing in peer countries, the UK and Canada. DESIGN: Descriptive analysis of population mortality rates. SETTING: The USA, UK (and constituent nations England and Wales, Northern Ireland and Scotland) and Canada, 2001-2019. PARTICIPANTS: Full population aged 35-64 years. OUTCOME MEASURES: We compared all-cause and 'despair'-related mortality trends at mid-life across countries using publicly available mortality data, stratified by three age groups (35-44, 45-54 and 55-64 years) and by sex. We examined trends in all-cause mortality and mortality by causes categorised as (1) suicides, (2) alcohol-specific deaths and (3) drug-related deaths. We employ several descriptive approaches to visually inspect age, period and cohort trends in these causes of death. RESULTS: The USA and Scotland both saw large relative increases and high absolute levels of drug-related deaths. The rest of the UK and Canada saw relative increases but much lower absolute levels in comparison. Alcohol-specific deaths showed less consistent trends that did not track other 'despair' causes, with older groups in Scotland seeing steep declines over time. Suicide deaths trended slowly upward in most countries. CONCLUSIONS: In the UK, Scotland has suffered increases in drug-related mortality comparable with the USA, while Canada and other UK constituent nations did not see dramatic increases. Alcohol-specific and suicide mortalities generally follow different patterns to drug-related deaths across countries and over time, questioning the utility of a cohesive 'deaths of despair' narrative.

Differences in Determinants: Racialized Obstetric Care and Increases in U.S. State Labor Induction Rates.

Induction of labor (IOL) rates in the United States have nearly tripled since 1990. We examine official U.S. birth records to document increases in states' IOL rates among pregnancies to Black, Latina, and White women. We test if the increases are associated with changes in demographic characteristics and risk factors among states' racial-ethnic childbearing populations. Among pregnancies to White women, increases in state IOL rates are strongly associated with changes in risk factors among White childbearing populations. However, the rising IOL rates among pregnancies to Black and Latina women are not due to changing factors in their own populations but are instead driven by changing factors among states' White childbearing populations. The results suggest systemic racism may be shaping U.S. obstetric care whereby care is not "centered at the margins" but is instead responsive to characteristics in states' White populations.

The effects of HIV and systolic blood pressure on mortality risk in rural South Africa, 2010-2019: a data note.

OBJECTIVES: South Africa is experiencing both HIV and hypertension epidemics. Data were compiled for a study to identify effects of HIV and high systolic blood pressure on mortality risk among people aged 40-plus in a rural South African area experiencing high prevalence of both conditions. We aim to release the replication data set for this study. DATA DESCRIPTION: The research data comes from the 2010-11 Ha Nakekela (We Care) population-based survey nested in the Agincourt Health and socio-Demographic Surveillance System (AHDSS) located in the northeast region of South Africa. An age-sex-stratified probability sample was drawn from the AHDSS. The public data set includes information on individual socioeconomic characteristics and measures of HIV status and blood pressure for participants aged 40-plus by 2019. The AHDSS, through its annual surveillance, provided mortality data for nine years subsequent to the survey. These data were converted to person-year observations and linked to the individual-level survey data using participants' AHDSS census identifier. The data can be used to replicate Houle et al. (2022) - which used discrete-time event history models stratified by sex to assess differential mortality risks according to Ha Nakekela measures of HIV-infection, HIV-1 RNA viral load, and systolic blood pressure.

Midlife Health in Britain and the US: A comparison of Two Nationally Representative Cohorts.

Background: Older adults in the United States (US) have worse health and wider socioeconomic inequalities in health compared to Britain. Less is known about how health in the two countries compares in midlife, a time of emerging health decline, including inequalities in health. Methods: We compare measures of smoking status, alcohol consumption, obesity, self-rated health, cholesterol, blood pressure, and glycated haemoglobin using population-weighted modified Poisson regression in the 1970 British Cohort Study (BCS70) in Britain (N= 9,665) and the National Longitudinal Study of Adolescent to Adult Health (Add Health) in the US (N=12,297), when cohort members were aged 34-46 and 33-43, respectively. We test whether associations vary by early- and mid-life socioeconomic position. Findings: US adults had higher levels of obesity, high blood pressure and high cholesterol. Prevalence of poor self-rated health, heavy drinking, and smoking was worse in Britain. We found smaller socioeconomic inequalities in midlife health in Britain compared to the US. For some outcomes (e.g., smoking), the most socioeconomically advantaged group in the US was healthier than the equivalent group in Britain. For other outcomes (hypertension and cholesterol), the most advantaged US group fared equal to or worse than the most disadvantaged groups in Britain. Interpretation: US adults have worse cardiometabolic health than British counterparts, even in early midlife. The smaller socioeconomic inequalities and better overall health in Britain may reflect differences in access to health care, welfare systems, or other environmental risk factors. Funding: ESRC, UKRI, MRC, NIH, European Research Council, Leverhulme Trust.

Explaining recent mortality trends among younger and middle-aged White Americans.

Background: Recent research has suggested that increases in mortality among middle-aged US Whites are being driven by suicides and poisonings from alcohol and drug use. Increases in these 'despair' deaths have been argued to reflect a cohort-based epidemic of pain and distress among middle-aged US Whites. Methods: We examine trends in all-cause and cause-specific mortality rates among younger and middle-aged US White men and women between 1980 and 2014, using official US mortality data. We estimate trends in cause-specific mortality from suicides, alcohol-related deaths, drug-related deaths, 'metabolic diseases' (i.e. deaths from heart diseases, diabetes, obesity and/or hypertension), and residual deaths from extrinsic causes (i.e. causes external to the body). We examine variation in mortality trends by gender, age and cause of death, and decompose trends into period- and cohort-based variation. Results: Trends in middle-aged US White mortality vary considerably by cause and gender. The relative contribution to overall mortality rates from drug-related deaths has increased dramatically since the early 1990s, but the contributions from suicide and alcohol-related deaths have remained stable. Rising mortality from drug-related deaths exhibit strong period-based patterns. Declines in deaths from metabolic diseases have slowed for middle-aged White men and have stalled for middle-aged White women, and exhibit strong cohort-based patterns. Conclusions: We find little empirical support for the pain- and distress-based explanations for rising mortality in the US White population. Instead, recent mortality increases among younger and middle-aged US White men and women have likely been shaped by the US opiate epidemic and an expanding obesogenic environment.

Mortality from Suicide, Chronic Liver Disease, and Drug Poisonings among Middle-Aged U.S. White Men and Women, 1980-2013.

Recent increases in all-cause mortality rates among the middle-aged U.S. white population have been explained in terms of elevated levels of midlife distress. This brief report provides evidence against this explanation for recent mortality trends among U.S. white men and women. Official mortality rates for U.S. white men and women aged 45-54 from suicide, chronic liver disease, drug poisonings, and other "extrinsic" causes of death (i.e., causes external to the body) between 1980 and 2013 are examined. Results suggest that recent increases in extrinsic mortality among the middle-aged U.S. white population are overwhelmingly driven by rapid increases in drug-related mortality. The contributions of chronic liver disease and suicide to U.S. white men's and women's mortality levels have been fairly stable for the past 30 years. Further, large gender differences in extrinsic mortality trends are observed. These two findings are inconsistent with the explanation that distress among the middle-aged U.S. white population is a common cause driving trends in U.S. white mortality.

Racial/Ethnic Differences in Early-Life Mortality in the United States.

U.S. early-life (ages 1-24) deaths are tragic, far too common, and largely preventable. Yet demographers have focused scant attention on U.S. early-life mortality patterns, particularly as they vary across racial and ethnic groups. We employed the restricted-use 1999-2011 National Health Interview Survey-Linked Mortality Files and hazard models to examine racial/ethnic differences in early-life mortality. Our results reveal that these disparities are large, strongly related to differences in parental socioeconomic status, and expressed through different causes of death. Compared to non-Hispanic whites, non-Hispanic blacks experience 60 percent and Mexican Americans 32 percent higher risk of death over the follow-up period, with demographic controls. Our finding that Mexican Americans experience higher early-life mortality risk than non-Hispanic whites differs from much of the literature on adult mortality. We also show that these racial/ethnic differences attenuate with controls for family structure and especially with measures of socioeconomic status. For example, higher mortality risk among Mexican Americans than among non-Hispanic whites is no longer significant once we controlled for mother's education or family income. Our results strongly suggest that eliminating socioeconomic gaps across groups is the key to enhanced survival for children and adolescents in racial/ethnic minority groups.