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‘Structural racism’ reflected in regional cardiovascular death rates

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A recent study investigates regional disparities in cardiovascular disease outcomes. sudok1/Getty Images
  • Deaths due to cardiovascular disease (CVD) in the United States have steadily declined over the last four decades.
  • However, the authors of a recent study argue that systemic racism underpins persistent health inequality across U.S. counties.
  • Their research stresses the urgency of addressing behavior-based and social risk factors to close the gap on cardiovascular health outcomes.

The U.S. has experienced a decrease in CVD-related death rates over the past 40 years. However, scientists from the University of Texas (UT) Southwestern Medical Center in Dallas have discovered glaring disparities between areas with high and low mortalities.

The team presented their preliminary research at the American Heart Association’s (AHA) Epidemiology, Prevention, Lifestyle & Cardiometabolic Health conference on May 20, 2021.

The researchers reviewed data gathered between 1980 and 2014 from all 3,133 U.S. counties. CVD-related deaths included all deaths attributed to cardiovascular causes on the death certificates.

They targeted county-level data because that is where many decision-makers devise public health policies.

Using a ClustMixType algorithm approach yielded three distinct clusters of counties based on the CVD-mortality trajectories over the study’s timeline.

“High mortality” counties had a baseline of approximately 60 CVD deaths per 10,000 population. “Intermediate mortality” and “low mortality” clusters had a baseline of 50 and 40 CVD deaths per 10,000 population, respectively.

The researchers compared these statistics with county-level demographic, environmental, and health markers. These data included crime rates, housing vacancies, smoking, diabetes, obesity, and food scarcity.

The analysis revealed parallel declines in CVD deaths among all groups.

However, Dr. Shreya Rao, the study’s lead author and research fellow at the UT Southwestern Medical Center in Dallas, recounted:

“We were surprised to find that even though CVD death rates improved across the country, including in areas where rates had been among the highest and the lowest, relative differences across county groups and existing disparities among counties did not change. Counties that started with the highest rates of death continued to perform worse than other counties, and those with the lowest rates of death stayed the lowest during the study period.”

The regions with the lowest CVD mortality included counties in the Northwest, Great Plains, Midwest, Northeast, and Florida.

Areas in the South Atlantic states, Deep South, and portions of Appalachia saw the highest mortality rates.

Dr. Rao notes: “High-mortality counties were much more clustered and centered in areas known to have high rates of chronic health conditions, such as heart disease, stroke, high blood pressure, type 2 diabetes, and obesity.”

The study found that the highest-mortality counties had higher nonwhite populations. These areas also saw low high school completion rates, higher violent crime, and higher housing vacancies.

It concluded that education status, violent crime rates, and smoking were the strongest predictors of being in the high-mortality subgroup.

The UT researchers note that public health agencies do not normally consider social issues as controllable risk factors for CVD. Nonetheless, the study’s authors believe that these problems impact long-term health outcomes.

Dr. Rao observed an “inextricable” correlation between social and economic distress and poor health metrics.

The study’s senior author, Dr. Ambarish Pandey, an assistant professor of internal medicine at UT Southwestern Medical Center in Dallas, commented:

“For clinicians, it is very natural to focus on the modifiable risk factors for our patients… [H]owever, it is important to understand that some of an individual’s risk factors are not necessarily under their control. And some factors may be modifiable through public policy and health systems changes and programs.”

A 2020 AHA presidential advisory calls out structural racism as a “fundamental cause of persistent health disparities in the U.S.”

Racism impacts individual and population health through “redlining and racialized residential segregation, mass incarceration, police violence, and unequal medical care,” according to an article in The New England Journal of Medicine.

“We observed that counties with high mortality trajectory had a higher proportion of Black adults and worse measures of social distress, including higher housing vacancy rates and violent crime rates and low levels of high school education,” explains Dr. Rao.

“This isn’t a coincidence. It is important to understand that structural and environmental characteristics are not randomly distributed. These patterns are reflective of historical patterns of structural racism, and much of what we found are the long-term, downstream effects of these types of systems and policies that created and maintained inequities, whether openly stated or not.”

Medical News Today spoke with Dr. Rocco Perla, co-founder of The Health Initiative. “This study reaffirms what physicians know: that access to healthcare intersects with access to the basics people need to be healthy to produce health outcomes,” Dr. Perla commented. “What is so striking about these results is that counties with the highest cardiovascular mortality risk map almost identically to counties with the highest rates of food insecurity.”

“It is crucial that the next wave of health reform directly addresses these basic drivers of health, especially as the economic consequences of COVID-19 only exacerbate healthcare outcomes and increase costs,” he continues.

“It is for this reason that a recent Physicians Foundation survey found that 70% of physicians support insurance companies including patients’ challenges in accessing nutritious food and safe housing into risk scoring formulas that determine patient complexity.”

It is worth noting that the study does have certain limitations. For instance, the authors realize that using data on counties does not allow for drawing conclusions on an individual level.

Also, the study cannot establish causality between the risk factors and health outcomes that the researchers analyzed.

Every year, racial inequalities cost the economy $93 billion in avoidable medical care expenses and $42 billion in untapped productivity. However, the true cost is far higher, considering premature deaths and other economic losses.

As the nation’s demographic diversity increases, addressing disparities is a crucial step toward improving the country’s overall social and economic well-being.

The UT research team maintains the importance of educating patients on controllable risk factors. Ultimately, though, they hope to enlighten decision-makers “to the need to address public health at the community, state, and national level.”

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