City-level economic distress, race, and avoidable mortality

The disparity between US blacks and whites in avoidable mortality (AM, usually operationalized as mortality before age 65) has been well documented, but little is known about the associations of AM with geography, urbanicity, or city-level economic distress. We investigated rates of all-cause AM, and differences in AM rates, for blacks and whites in the 70 largest U.S. cities. In these cities, blacks had 94% higher AM rates than whites (IRR 95% CI = 1.78 – 2.12). This disparity was especially pronounced among women, where the AM rate was 3 times higher among blacks than whites (IRR 95% CI = 2.76 – 3.32). City-level economic distress (defined by poverty, labor force participation, income distribution, and other economic variables) was also significantly related to AM. Controlling for race and gender, AM rates were 29% higher in distressed than in non-distressed cities (IRR 95% CI = 1.07-1.55). When components of economic distress were disaggregated and interacted with race, we found that blacks and whites did not benefit equally from the economic health of cities. As labor force participation and the proportion of households earning greater than $75k/year each increased, AM rates decreased for whites, but remained the same for blacks. These associations were not mediated by access to care (operationalized as the proportion of city residents without health insurance), which was not significantly associated with AM rates in any of our models. Distressed cities face a higher burden of AM overall, but black/white disparities in AM are higher in economically better off cities.