- Email: [email protected]
Black-white differences in injury race or social class?
Black-White
Differences in Injury
Race or Social Class? CHUKWUDI ONWUACHI-SAUNDERS,
MD,
MPH,
AND DARNELL F. HAWKINS,
PHD,
JD
In the United States injuries are the leading cause of years of potential life lost and the leading cause of death for persons less than 4.5 years of age. Minority groups, particularly African-Americans, are disproportionately represented among those persons who die as a result of injury. Homicides uccount for much of this racial disparity; howewer, other forms of injury also contribute signijicuntly to the differential. This paper examines death rates due to four types of injuries that contribute most to the black/white mortality gap. Our examination of death rates from 1984 to 1988 reveals no major reduction in the racial gap during the period, despite the initiation of some prevention efforts. We suggest that socioeconomic status rather than ruce is perhaps the major correlate of the social conditions and lifestyle choices which contribute to these injuries. We propose that injuy prevention efforts must target both the causes and the consequences of socioeconomic inequality. Ann Epidemiol I993;3: 150-153. KEY
WORDS:
Injury,
socioeconomic
status, racial differences, mortality,
INTRODUCTION Public health problems are prioritized according to their impact on the health of those affected and their impact on the larger society. In the United States, injuries are the leading cause of premature death before the age of 65, as measured by years of potential life lost (YPLL) (1). They are also the leading cause of death for all persons in the United States less than 45 years old (1, 2). Injuries can be divided into two categories: unintentional and intentional. Unintentional injuries are traditionally referred to as “accidents,” and it is often assumed that little can be done to prevent them. However, most injuries, including those labeled as unintentional, are predictable and therefore preventable. Much research on both unintentional and intentional injuries suggests that scientific interventions are possible (3). During an average year, over one-third of injury-related deaths in the United States are intentional. Most of these injuries result from acts that can be described as violent or aggressive. Such violence may be self-directed (suicide) or directed toward someone else (assaultive injury, homicide). The social and economic costs of injuries are enormous.
From the Centers for Disease Control, National Centers for Injury Prevention and Control, Atlanta, GA (C. O.-S.), and the Departments of African-American Studies and Sociology, University ofIllinois at Chicago, Chicago, IL (D. F. H.). Address reprint requests to: Chukwudi Owuachi-Saunders, MD, MPH, National Center for Injury Prevention and Control (MSF44), Centers for Disease Control and Prevention, 1600 Clifton Road NE, Atlanta GA 30333. Received July 17, 1992; September 23, 1992. Elsevier SciencePublishing Co., Inc.
prevention.
In 1985, the lifetime cost of injuries was estimated to be $158 billion (2). The estimated lifetime cost for 1988 was $180 billion (2). Injuries, indeed, are one of the leading public health problems facing the nation, based on their impact on health today (1, 2). The costs of many health problems are disproportionately borne by those segments of the American population defined as minority groups. “Minority groups” in the United States include blacks, Hispanics, Native Americans, Alaskan Natives, Asians, and Pacific Islanders (4). The Report of the Secretary’s Task Force on Black and Minority Health, published in 1985, identified injuries as a major cause of “excess deaths” among blacks and other nonwhites in the United States (4). Homicides account for much of the disparity in injury mortality rates between blacks and whites (5). Less attention has been paid to the fact that other injuries also contribute to this differential. In a recent epidemiologic study by Gulaid and colleagues, four categories of injury- homicide, residential fire, drowning, and pedestrian mishap-accounted for much of the difference in mortality rates between blacks and whites (5). Both intentional and unintentional injuries contribute to the disproportionate burden from injuries experienced by blacks in the United States. This article examines the death rates due to the four major types of injuries that contribute most to the blackwhite mortality gap in the United States. We report mortality rates for residential fire, drowning, pedestrian mishaps, and homicide from 1984 to 1988. Our data are presented to illustrate the magnitude of the problem that injuries pose for blacks. We also seek to determine whether injury data 1047-2797/93/$06.00
AEP Vol. 3, No. 2 March 1993: 150-l 53
Onwuachi-Saunders and Hawkins BLACK-WHITE DIFFERENCES IN INJURY
151
TABLE 1. Residential fires’: US age-adjusted death rates, 1984-198Sb 1984
1988
1987
1986
1985
NO.
Rate
NO.
Rate
NO.
Rate
NO.
Rate
No.
Rate
Black male White male Black female
818 1832 550
7.03 1.91 3.83
744 1822 545
6.29 1.88 3.65
799 1778 553
6.62 1.82 3.61
810 1668 536
6.55 1.69 3.52
901 1739 558
7.31 1.73 3.58
White female
1165
1.05
1205
1.07
1152
1.01
1170
1.01
1197
1.02
’ICD-9 codes, E890-E899. b Age-adjusted death rates per 100,000 persons by sex and race. Rates were standardized to the age distribution
for this 5-year period reveal any downward trend or narrowing of the racial gap, since many injury prevention initiatives were begun this period.
METHODS Data on deaths were obtained from the National Center for Health Statistics. We analyzed the data tapes on the underlying causes of death from 1984 through 1988, the latest year for which data were available. The four types of injury-related deaths were identified according to the Ninth Revision of the International Classification of Diseases (ICD-9) External Codes as drownings (E830, E832, E910), residential fires (E890 to E899), homicides (E960 to E969), and pedestrian mishaps (E810 to E825(.7)) (5). Age-adjusted death rates per 100,000 persons by sex and race are reported in this article. These rates were standardized to the age distribution of the 1980 US population.
RESULTS Residential Fire Deaths As shown in Table 1, more than 6800 blacks died as a result of residential fires between 1984 and 1988. The rates were highest for black males. Black male death rates from residential fires increased by 4% in 1988, while the rates for white males decreased by 9.4%. Death rates for both female groups decreased. But black female death rates from residential fires were higher than those for white males.
of the 1980 US population
Drowning Deaths More than 5200 blacks lost their lives to drownings during the 5-year period (Table 2). Black males had the highest rate of deaths from drownings, although their rates decreased by 16.9% from 1984 to 1988. Rates for black females increased by 2.2%. Males of both races were more likely than females to die from drowning. Pedestrian Deaths Rates for pedestrian deaths for males were similar to those for drownings (Table 3). During the period, pedestrian death rates decreased for all four groups. The greatest decrease was for white males, at 9.3%. Although black male rates decreased by 7.8%, they maintained the highest overall rate. Homicides More than 45,000 blacks and 55,000 whites died from homicides from 1984 to 1988 (Table 4). Homicide death rates for both black males and females increased between 1984 and 1988, by 15.3% and 17.4%, respectively. Homicide rates for white males and white females remained basically the same. Although white male rates decreased by 4.4%, white female rates increased minimally by 0.7%.
DISCUSSION In comparison to their share of the nation’s overall population, blacks continue to experience disproportionate rates of
TABLE 2. Drowning”: US age-adjusted death rates, 1984-1988” 1984
1987
1986
1985
No.
Rate
No.
Rate
No.
Rate
Black male White male Black female
911 3347 137
4.56 3.41 0.89
891 3359 138
6.31 3.39 0.89
959 3543 177
6.68 3.55 1.10
White female
790
0.76
724
0.69
782
0.74
No. 928 3104 149 707
1988 Rate
No.
Rate
6.45 3.08 0.91 0.67
794 3074 151 721
5.45 3.04 0.91 0.67
a ICD-9 codes, E830, E832, E910. b Age-adjusted death rates per 100,000 persons by sex and race. Rates were standardized to the age distribution of the 1980 US population.
152
Onwuachi-Saunders and Hawkins BLACK-WHITE DIFFERENCES IN INJURY
TABLE
3. Pedestrian
mishaps”: US age-adjusted 1984
Black White Black White
male male female female
AEP Vol. 3, No. 2 March 1993: 150-153
death rates, 1984-1988b 1985
1986
1987
1988
NO.
Rate
NO.
Rate
NO.
Rate
NO.
Rate
No.
Rate
1044 4237 325 1834
8.57 4.41 2.20 1.70
1002 4054 361 1893
8.07 4.17 2.40 1.73
1034 3954 359 1755
8.11 4.02 2.32 1.59
1027 4012 342 1786
7.93 4.04 2.19 1.59
1041 4024 353 1908
7.90 4.00 2.19 1.67
a 1’3-9 codes, EBIO-E825(.7). b Age-adjusted death rates per 100,000 persons by sex and race. Rates were standardized m the age distribution of the 1980 US population.
death from the four categories of injuries that we analyzed. During the years between 1984 and 1988, little progress was made toward substantially reducing these rates or lessening the racial gap. Black males were especially overrepresented among injury victims. They showed consistently higher levels of injury than did black females and their white counterparts. This is true for both intentional injury-related deaths (homicides) and for the three forms of unintentional injuries analyzed in this study. Black males have the highest death rates for all four of the injury categories. Black females also showed higher rates of death due to homicides and residential fires than did white males, and consistently had much higher rates than did white females. Blacks of all ages appear to be more exposed than whites to the specific risk factors that are associated with fatal outcomes from these four injuries (5, 6). To what can one attribute the racial differences observed in this study and documented in numerous studies during the last decase? What are the causes of the elevated risk of injury among blacks as compared to whites in the United States? What interventions are needed to narrow the blackwhite gap? Previous studies have shown that blacks have higher death rates than whites from residential fires (5,6). Residential fires still continue to exert an enormous toll on black males. Their death rates continue to climb. Risk factors for residential fire-related death include residing in substandard housing that is more prone to rapid destruction by fire, lack of smoke detectors as early warnings in instances of fire, and residency in poverty-stricken rural areas without adequate access to modern fire-fighting equip ment and personnel (3, 5-7).
TABLE
4. Homicides”: US age-adjusted
death rates, 1984-1988b
1984
Black White Black White
male male female female
A greater percentage of blacks live below the poverty line as compared to whites (8). Thus, more blacks live in substandard housing coupled with no smoke detectors. In our view, since most people throughout the country have little knowledge of the laws governing the installation and retrofitting of smoke detectors in residential housing or the enforcement of proper building codes, many are forced to continue to live in these unsafe environments. These risk factors appear to be related to socioeconomic status of the victim to a greater extent than one’s race. Rates of death due to drownings are decreasing for all groups, but blacks continue to have much higher rates than whites. Like deaths from fires, drownings are more common among the poor (6). Risk factors for drowning are clearly related to income and access. Risk factors include, but are not limited to the lack of formal or informal swimming lessons and the absence of safe swimming areas in inner cities and in rural areas (5,6,9). There has been no conclusive evidence presented that links these risk factors to race per se. Rather they seem to be related to race through the effects of economic circumstances. Thus, because blacks are disproportionately represented among the poor and have limited access to water safety measures, they are at greater risk for drowning. White children between the ages of 1 and 4 have a higher risk of drowning than do black children the same age (5). This increased rate is due largely to increased access to residential swimming pools (10). In this instance, the effects of race are associated with a higher income status instead of poverty. The effects of economic disadvantage may also be evident in the figures for pedestrian deaths. Because of the income
1985
No.
Rate
No.
6460 8000 1675 2952
49.50 7.89 10.94 2.83
6527 7963 1662 3040
1986
1987
1988
Race
No.
Rate
No.
Rate
No.
Rate
48.57 7.77 10.74 2.86
7536 8409 1859 3119
54.57 8.14 11.08 2.93
7418 7804 1965 3146
52.87 7.53 12.32 2.91
8239 7837 2088 3065
57.38 7.54 12.84 2.85
e ICD-9 codes, E960-E969.
bAge-adjusted death rates
per 100,000 persons by sex and race. Rates were standardized
to the age distribution
of the 1980 US population
153
Onwuachi-Saunders and Hawkins BLACK-WHITE DIFFERENCES IN INJURY
AEP Vol. 3, No. 2 March 1993: 150-153
disparity between blacks and whites, fewer blacks live in areas where there are safe play areas for children. Many
argue that absent such policies and strategies, the nation
blacks also live where there are no pedestrian crossing signs
will continue to experience “excess deaths” among blacks and other minorities that are attributable to residential fires,
in hazardous locations
drownings, pedestrian mishaps, and homicide. We believe
and in areas where there is inade-
quate street lighting. All of these environmental
modifica-
that the racial gap evident for these forms of injury may
tions have proved to be effective in increasing pedestrian
largely reflect the effects of social class. Hence, prevention
safety (3). Blacks have a much higher rate of death from homicide
efforts must target both the causes and the consequences socioeconomic
inequality
of
in the United States.
than do whites. The effects of social class are also evident for risk of death by homicide. racial differences
In fact, a previous study of
in homicides
controlling
for social class
found no significant differences between rates for blacks and
Presented in part at the Tenth Annual Scientific Meeting of the American College of Epidemiology, Atlanta, GA, November 1991.
whites (11). Unfortunately,
most of the reasons for higher rates of
death to blacks caused by residential fires, drownings, pedestrian mishaps, and homicides are still unclear. Blacks consistently have the highest rates over time. Low socioeconomic status has been shown to increase the risk of injury, and to lead to a greater likelihood of death once injured (5,6). But, there is still a need for more research
to identify cause-
specific risk factors or life-style patterns that contribute
to
injury and death. Blacks in this country may also have a higher risk of injury based on their life-styles, living conditions, and their economic
inability to change them. Consequently,
socio-
economic status becomes a confounder for life-style choices and circumstances, and not necessarily a direct risk factor for injury.
REFERENCES 1. Committee on Trauma Research, Commission on Life Sciences, National Research Council Institute on Medicine, Injury In America. A Continuing Public Health Problem. Washington, DC: National Academy Press; 1985. 2. Rice DP, MacKenzie EJ, et al. Cost of Injury in the United States: A Report to Congress. San Francisco, CA: Institute for Health and Aging, University of California; and Baltimore, MD: Injury Prevention Center, The Johns Hopkins University; 1989. 3. National Committee for Injury Prevention and Control (US). Injury prevention: meeting the challenge, Am J Prev Med. 1989;5(Suppl). 4. US Department of Health and Human Services. Report of the Secretary’s Task Force on Black and Minority Health. Washington, DC: US Department of Health and Human Services; August 1985. EC, Sacks J, Roberts D. Differences in 5. G&id J, Onwuachi-Saunders death rates due to injury among blacks and whites, 1984, MMWR. 1988;37(NOSS-3):25-31. 6. Baker SP, O’Neill B, Ginsburg M, Guohua L. The Injury Fact Book. 2nd ed. New York: Oxford University Press; 1992.
CONCLUSIONS
7. Hall JR. A decade of detectors: 37-43.
Numerous studies, including those cited in this article, have
8. US Department of Commerce, Bureau of the Census. Current Population Reports. Series P-60, no. 157. Money, Income and Poverty: Status of Families and Persons in the United States, 1986. (Advances data from the March 1987 current population survey.) Washington, DC: US Department of Commerce; 1987.
noted the need to devise public policies and intervention strategies aimed at the reduction unintentional
of both intentional
injuries among American
minority
and
groups.
To the extent that they have been devised, our data suggest that these efforts led to little change in racial disparities during the late 1980s. There remains a need for would-be interveners
to develop, implement,
programmatic
interventions
monitor,
and evaluate
that may reduce the level of
injury found among blacks and other racial minorities.
We
Measuring
9. Dietz PE, Baker SP. Drowning-epidemiology Public Health. 1974;64:303-12.
the effect, Fire J. 1985;79:
and prevention,
Am J
10. Wintemute GJ, Kraus JF, Tenet SP, Wright M. Drowning in childhood and adolescents: A population-based study, Am J Public Health. 1987; 77:830-2. 11. Centerwall BS. Race, socioeconomic status and domestic Atlanta 1971-72, Am J Public Health. 1984;74:813-5.
violence,
Differences in Injury
Race or Social Class? CHUKWUDI ONWUACHI-SAUNDERS,
MD,
MPH,
AND DARNELL F. HAWKINS,
PHD,
JD
In the United States injuries are the leading cause of years of potential life lost and the leading cause of death for persons less than 4.5 years of age. Minority groups, particularly African-Americans, are disproportionately represented among those persons who die as a result of injury. Homicides uccount for much of this racial disparity; howewer, other forms of injury also contribute signijicuntly to the differential. This paper examines death rates due to four types of injuries that contribute most to the black/white mortality gap. Our examination of death rates from 1984 to 1988 reveals no major reduction in the racial gap during the period, despite the initiation of some prevention efforts. We suggest that socioeconomic status rather than ruce is perhaps the major correlate of the social conditions and lifestyle choices which contribute to these injuries. We propose that injuy prevention efforts must target both the causes and the consequences of socioeconomic inequality. Ann Epidemiol I993;3: 150-153. KEY
WORDS:
Injury,
socioeconomic
status, racial differences, mortality,
INTRODUCTION Public health problems are prioritized according to their impact on the health of those affected and their impact on the larger society. In the United States, injuries are the leading cause of premature death before the age of 65, as measured by years of potential life lost (YPLL) (1). They are also the leading cause of death for all persons in the United States less than 45 years old (1, 2). Injuries can be divided into two categories: unintentional and intentional. Unintentional injuries are traditionally referred to as “accidents,” and it is often assumed that little can be done to prevent them. However, most injuries, including those labeled as unintentional, are predictable and therefore preventable. Much research on both unintentional and intentional injuries suggests that scientific interventions are possible (3). During an average year, over one-third of injury-related deaths in the United States are intentional. Most of these injuries result from acts that can be described as violent or aggressive. Such violence may be self-directed (suicide) or directed toward someone else (assaultive injury, homicide). The social and economic costs of injuries are enormous.
From the Centers for Disease Control, National Centers for Injury Prevention and Control, Atlanta, GA (C. O.-S.), and the Departments of African-American Studies and Sociology, University ofIllinois at Chicago, Chicago, IL (D. F. H.). Address reprint requests to: Chukwudi Owuachi-Saunders, MD, MPH, National Center for Injury Prevention and Control (MSF44), Centers for Disease Control and Prevention, 1600 Clifton Road NE, Atlanta GA 30333. Received July 17, 1992; September 23, 1992. Elsevier SciencePublishing Co., Inc.
prevention.
In 1985, the lifetime cost of injuries was estimated to be $158 billion (2). The estimated lifetime cost for 1988 was $180 billion (2). Injuries, indeed, are one of the leading public health problems facing the nation, based on their impact on health today (1, 2). The costs of many health problems are disproportionately borne by those segments of the American population defined as minority groups. “Minority groups” in the United States include blacks, Hispanics, Native Americans, Alaskan Natives, Asians, and Pacific Islanders (4). The Report of the Secretary’s Task Force on Black and Minority Health, published in 1985, identified injuries as a major cause of “excess deaths” among blacks and other nonwhites in the United States (4). Homicides account for much of the disparity in injury mortality rates between blacks and whites (5). Less attention has been paid to the fact that other injuries also contribute to this differential. In a recent epidemiologic study by Gulaid and colleagues, four categories of injury- homicide, residential fire, drowning, and pedestrian mishap-accounted for much of the difference in mortality rates between blacks and whites (5). Both intentional and unintentional injuries contribute to the disproportionate burden from injuries experienced by blacks in the United States. This article examines the death rates due to the four major types of injuries that contribute most to the blackwhite mortality gap in the United States. We report mortality rates for residential fire, drowning, pedestrian mishaps, and homicide from 1984 to 1988. Our data are presented to illustrate the magnitude of the problem that injuries pose for blacks. We also seek to determine whether injury data 1047-2797/93/$06.00
AEP Vol. 3, No. 2 March 1993: 150-l 53
Onwuachi-Saunders and Hawkins BLACK-WHITE DIFFERENCES IN INJURY
151
TABLE 1. Residential fires’: US age-adjusted death rates, 1984-198Sb 1984
1988
1987
1986
1985
NO.
Rate
NO.
Rate
NO.
Rate
NO.
Rate
No.
Rate
Black male White male Black female
818 1832 550
7.03 1.91 3.83
744 1822 545
6.29 1.88 3.65
799 1778 553
6.62 1.82 3.61
810 1668 536
6.55 1.69 3.52
901 1739 558
7.31 1.73 3.58
White female
1165
1.05
1205
1.07
1152
1.01
1170
1.01
1197
1.02
’ICD-9 codes, E890-E899. b Age-adjusted death rates per 100,000 persons by sex and race. Rates were standardized to the age distribution
for this 5-year period reveal any downward trend or narrowing of the racial gap, since many injury prevention initiatives were begun this period.
METHODS Data on deaths were obtained from the National Center for Health Statistics. We analyzed the data tapes on the underlying causes of death from 1984 through 1988, the latest year for which data were available. The four types of injury-related deaths were identified according to the Ninth Revision of the International Classification of Diseases (ICD-9) External Codes as drownings (E830, E832, E910), residential fires (E890 to E899), homicides (E960 to E969), and pedestrian mishaps (E810 to E825(.7)) (5). Age-adjusted death rates per 100,000 persons by sex and race are reported in this article. These rates were standardized to the age distribution of the 1980 US population.
RESULTS Residential Fire Deaths As shown in Table 1, more than 6800 blacks died as a result of residential fires between 1984 and 1988. The rates were highest for black males. Black male death rates from residential fires increased by 4% in 1988, while the rates for white males decreased by 9.4%. Death rates for both female groups decreased. But black female death rates from residential fires were higher than those for white males.
of the 1980 US population
Drowning Deaths More than 5200 blacks lost their lives to drownings during the 5-year period (Table 2). Black males had the highest rate of deaths from drownings, although their rates decreased by 16.9% from 1984 to 1988. Rates for black females increased by 2.2%. Males of both races were more likely than females to die from drowning. Pedestrian Deaths Rates for pedestrian deaths for males were similar to those for drownings (Table 3). During the period, pedestrian death rates decreased for all four groups. The greatest decrease was for white males, at 9.3%. Although black male rates decreased by 7.8%, they maintained the highest overall rate. Homicides More than 45,000 blacks and 55,000 whites died from homicides from 1984 to 1988 (Table 4). Homicide death rates for both black males and females increased between 1984 and 1988, by 15.3% and 17.4%, respectively. Homicide rates for white males and white females remained basically the same. Although white male rates decreased by 4.4%, white female rates increased minimally by 0.7%.
DISCUSSION In comparison to their share of the nation’s overall population, blacks continue to experience disproportionate rates of
TABLE 2. Drowning”: US age-adjusted death rates, 1984-1988” 1984
1987
1986
1985
No.
Rate
No.
Rate
No.
Rate
Black male White male Black female
911 3347 137
4.56 3.41 0.89
891 3359 138
6.31 3.39 0.89
959 3543 177
6.68 3.55 1.10
White female
790
0.76
724
0.69
782
0.74
No. 928 3104 149 707
1988 Rate
No.
Rate
6.45 3.08 0.91 0.67
794 3074 151 721
5.45 3.04 0.91 0.67
a ICD-9 codes, E830, E832, E910. b Age-adjusted death rates per 100,000 persons by sex and race. Rates were standardized to the age distribution of the 1980 US population.
152
Onwuachi-Saunders and Hawkins BLACK-WHITE DIFFERENCES IN INJURY
TABLE
3. Pedestrian
mishaps”: US age-adjusted 1984
Black White Black White
male male female female
AEP Vol. 3, No. 2 March 1993: 150-153
death rates, 1984-1988b 1985
1986
1987
1988
NO.
Rate
NO.
Rate
NO.
Rate
NO.
Rate
No.
Rate
1044 4237 325 1834
8.57 4.41 2.20 1.70
1002 4054 361 1893
8.07 4.17 2.40 1.73
1034 3954 359 1755
8.11 4.02 2.32 1.59
1027 4012 342 1786
7.93 4.04 2.19 1.59
1041 4024 353 1908
7.90 4.00 2.19 1.67
a 1’3-9 codes, EBIO-E825(.7). b Age-adjusted death rates per 100,000 persons by sex and race. Rates were standardized m the age distribution of the 1980 US population.
death from the four categories of injuries that we analyzed. During the years between 1984 and 1988, little progress was made toward substantially reducing these rates or lessening the racial gap. Black males were especially overrepresented among injury victims. They showed consistently higher levels of injury than did black females and their white counterparts. This is true for both intentional injury-related deaths (homicides) and for the three forms of unintentional injuries analyzed in this study. Black males have the highest death rates for all four of the injury categories. Black females also showed higher rates of death due to homicides and residential fires than did white males, and consistently had much higher rates than did white females. Blacks of all ages appear to be more exposed than whites to the specific risk factors that are associated with fatal outcomes from these four injuries (5, 6). To what can one attribute the racial differences observed in this study and documented in numerous studies during the last decase? What are the causes of the elevated risk of injury among blacks as compared to whites in the United States? What interventions are needed to narrow the blackwhite gap? Previous studies have shown that blacks have higher death rates than whites from residential fires (5,6). Residential fires still continue to exert an enormous toll on black males. Their death rates continue to climb. Risk factors for residential fire-related death include residing in substandard housing that is more prone to rapid destruction by fire, lack of smoke detectors as early warnings in instances of fire, and residency in poverty-stricken rural areas without adequate access to modern fire-fighting equip ment and personnel (3, 5-7).
TABLE
4. Homicides”: US age-adjusted
death rates, 1984-1988b
1984
Black White Black White
male male female female
A greater percentage of blacks live below the poverty line as compared to whites (8). Thus, more blacks live in substandard housing coupled with no smoke detectors. In our view, since most people throughout the country have little knowledge of the laws governing the installation and retrofitting of smoke detectors in residential housing or the enforcement of proper building codes, many are forced to continue to live in these unsafe environments. These risk factors appear to be related to socioeconomic status of the victim to a greater extent than one’s race. Rates of death due to drownings are decreasing for all groups, but blacks continue to have much higher rates than whites. Like deaths from fires, drownings are more common among the poor (6). Risk factors for drowning are clearly related to income and access. Risk factors include, but are not limited to the lack of formal or informal swimming lessons and the absence of safe swimming areas in inner cities and in rural areas (5,6,9). There has been no conclusive evidence presented that links these risk factors to race per se. Rather they seem to be related to race through the effects of economic circumstances. Thus, because blacks are disproportionately represented among the poor and have limited access to water safety measures, they are at greater risk for drowning. White children between the ages of 1 and 4 have a higher risk of drowning than do black children the same age (5). This increased rate is due largely to increased access to residential swimming pools (10). In this instance, the effects of race are associated with a higher income status instead of poverty. The effects of economic disadvantage may also be evident in the figures for pedestrian deaths. Because of the income
1985
No.
Rate
No.
6460 8000 1675 2952
49.50 7.89 10.94 2.83
6527 7963 1662 3040
1986
1987
1988
Race
No.
Rate
No.
Rate
No.
Rate
48.57 7.77 10.74 2.86
7536 8409 1859 3119
54.57 8.14 11.08 2.93
7418 7804 1965 3146
52.87 7.53 12.32 2.91
8239 7837 2088 3065
57.38 7.54 12.84 2.85
e ICD-9 codes, E960-E969.
bAge-adjusted death rates
per 100,000 persons by sex and race. Rates were standardized
to the age distribution
of the 1980 US population
153
Onwuachi-Saunders and Hawkins BLACK-WHITE DIFFERENCES IN INJURY
AEP Vol. 3, No. 2 March 1993: 150-153
disparity between blacks and whites, fewer blacks live in areas where there are safe play areas for children. Many
argue that absent such policies and strategies, the nation
blacks also live where there are no pedestrian crossing signs
will continue to experience “excess deaths” among blacks and other minorities that are attributable to residential fires,
in hazardous locations
drownings, pedestrian mishaps, and homicide. We believe
and in areas where there is inade-
quate street lighting. All of these environmental
modifica-
that the racial gap evident for these forms of injury may
tions have proved to be effective in increasing pedestrian
largely reflect the effects of social class. Hence, prevention
safety (3). Blacks have a much higher rate of death from homicide
efforts must target both the causes and the consequences socioeconomic
inequality
of
in the United States.
than do whites. The effects of social class are also evident for risk of death by homicide. racial differences
In fact, a previous study of
in homicides
controlling
for social class
found no significant differences between rates for blacks and
Presented in part at the Tenth Annual Scientific Meeting of the American College of Epidemiology, Atlanta, GA, November 1991.
whites (11). Unfortunately,
most of the reasons for higher rates of
death to blacks caused by residential fires, drownings, pedestrian mishaps, and homicides are still unclear. Blacks consistently have the highest rates over time. Low socioeconomic status has been shown to increase the risk of injury, and to lead to a greater likelihood of death once injured (5,6). But, there is still a need for more research
to identify cause-
specific risk factors or life-style patterns that contribute
to
injury and death. Blacks in this country may also have a higher risk of injury based on their life-styles, living conditions, and their economic
inability to change them. Consequently,
socio-
economic status becomes a confounder for life-style choices and circumstances, and not necessarily a direct risk factor for injury.
REFERENCES 1. Committee on Trauma Research, Commission on Life Sciences, National Research Council Institute on Medicine, Injury In America. A Continuing Public Health Problem. Washington, DC: National Academy Press; 1985. 2. Rice DP, MacKenzie EJ, et al. Cost of Injury in the United States: A Report to Congress. San Francisco, CA: Institute for Health and Aging, University of California; and Baltimore, MD: Injury Prevention Center, The Johns Hopkins University; 1989. 3. National Committee for Injury Prevention and Control (US). Injury prevention: meeting the challenge, Am J Prev Med. 1989;5(Suppl). 4. US Department of Health and Human Services. Report of the Secretary’s Task Force on Black and Minority Health. Washington, DC: US Department of Health and Human Services; August 1985. EC, Sacks J, Roberts D. Differences in 5. G&id J, Onwuachi-Saunders death rates due to injury among blacks and whites, 1984, MMWR. 1988;37(NOSS-3):25-31. 6. Baker SP, O’Neill B, Ginsburg M, Guohua L. The Injury Fact Book. 2nd ed. New York: Oxford University Press; 1992.
CONCLUSIONS
7. Hall JR. A decade of detectors: 37-43.
Numerous studies, including those cited in this article, have
8. US Department of Commerce, Bureau of the Census. Current Population Reports. Series P-60, no. 157. Money, Income and Poverty: Status of Families and Persons in the United States, 1986. (Advances data from the March 1987 current population survey.) Washington, DC: US Department of Commerce; 1987.
noted the need to devise public policies and intervention strategies aimed at the reduction unintentional
of both intentional
injuries among American
minority
and
groups.
To the extent that they have been devised, our data suggest that these efforts led to little change in racial disparities during the late 1980s. There remains a need for would-be interveners
to develop, implement,
programmatic
interventions
monitor,
and evaluate
that may reduce the level of
injury found among blacks and other racial minorities.
We
Measuring
9. Dietz PE, Baker SP. Drowning-epidemiology Public Health. 1974;64:303-12.
the effect, Fire J. 1985;79:
and prevention,
Am J
10. Wintemute GJ, Kraus JF, Tenet SP, Wright M. Drowning in childhood and adolescents: A population-based study, Am J Public Health. 1987; 77:830-2. 11. Centerwall BS. Race, socioeconomic status and domestic Atlanta 1971-72, Am J Public Health. 1984;74:813-5.
violence,