Increased Black–White Disparities in Mortality After the Introduction of Lifesaving Innovations: A Possible Consequence of US Federal Laws

Abstract

Objectives We explored whether the introduction of 3 lifesaving innovations introduced between 1989 and 1996 increased, decreased, or had no effect on disparities in Black-White mortality in the United States through 2006. Methods Centers for Disease Control and Prevention data were used to assess disease-, age-, gender-, and race-specific changes in mortality after the introduction of highly active anti-retroviral therapy (HAART) for treatment of HIV, surfactants for neonatal respiratory distress syndrome, and Medicare reimbursement of mammography screening for breast cancer. Results Disparities in Black-White mortality from HIV significantly increased after the introduction of HAART, surfactant therapy, and reimbursement for screening mammography. Between 1989 and 2006, these circumstances may have accounted for an estimated 22441 potentially avoidable deaths among Blacks. Conclusions These descriptive data contribute to the formulation of the hypothesis that federal laws promote increased disparities in Black-White mortality by inadvertently favoring Whites with respect to access to lifesaving innovations. Failure of legislation to address known social factors is a plausible explanation, at least in part, for the observed findings. Further research is necessary to test this hypothesis, including analytic epidemiological studies designed a priori to do so.

Clinical Care and Health Disparities

“…Levine et al (51) conducted an analysis of disease-, age-, gender-, and race-specific changes in mortality after three life-saving interventions were introduced between 1989 and 1996: active antiretroviral therapy (HAART), surfactants for neonatal respiratory distress syndrome, and Medicare reimbursement of mammography screening for breast cancer. These interventions resulted in increasing black-white disparities in mortality, but with marked variability across U.S. counties (51). Many other interventions that might be considered universally useful are inequitably applied.…”

Trends in Racial and Ethnic Disparities in Infant Mortality Rates in the United States, 1989–2006

“…Pairwise comparisons have suggested that, at least in relative terms, the Black-White disparity in infant mortality has widened over the past several decades. 10,11 However, pairwise comparisons such as relative risk ratios (RRs) or risk differences (RDs) do not allow for assessment of the overall degree of disparity in the entire population comprising more than 2 groups, and are not weighted by population size to account for demographic distributions and changes in population size over time. 12-14 The choice of disparity metric (e.g., absolute vs relative, population-weighted vs equally weighted, pairwise vs multigroup) reflects various value judgments that are often not explicated; it is important to note that different metrics can lead to different conclusions about whether disparities are increasing or decreasing.…”

Black:White Disparities in HIV Mortality in the United States: 1990–2009

“…Some portion of the racial difference in the percent prescribed ART may be accounted for by guidelines at the time which recommended ART based on disease severity [42]. And some portion of the racial difference in the percent achieving viral suppression may be accounted for by differences in either response or adherence to ART [9,13,23,40,[43][44][45][46][47][48][49][50].…”