Shrinking Poor White Life Spans: Class, Race, and Health Justice

The Role of Race in Deaths of Despair in Brazil: Is it a White People Problem?

BACKGROUND

A new paradigm has been discussed regarding the impact of economic cycles on the mortality pattern from specific causes. These causes are called deaths of despair, and they selectively impact specific demographic groups. Also, low- and middle-income countries are most affected due to their economic and social instability. In this sense, the objective of study was to compare the magnitude of disparity in deaths from despair according to sex, age, and race in Brazil.

METHODS

We performed Poisson regression modeling to estimate the magnitude of the association between sex, age group, race, and deaths from despair. Also, we estimated the relationship of time as a proxy of economic crisis phase and deaths of despair.

RESULTS

We found an association between mortality from despair and male sex (PR = 6.15, 95%CI 6.09-6.22); emphasis on the age groups from 40 to 49 years old (PR = 2.45, 95% CI 2.41-2.48) and 50 to 59 years old (PR = 2.39, 95% CI 2.36-2.43); and brown (PR = 1.21, 95% CI 1.20-1.22) and black race (PR = 1.36, 95% CI 1.34-1.37).

CONCLUSIONS

The present study preliminarily presents the effect of the economic crisis and mortality in the population, with demographic differences. Association with race was opposite to that verified in the original study in the USA, which suggests that this variable should be analyzed in the light of structural context.

Discriminatory Healthcare Experiences and Medical Mistrust in Patients With Serious Illness

CONTEXT

Though discrimination in healthcare settings is increasingly recognized, the discriminatory experiences of patients with serious illness has not been well studied.

OBJECTIVES

Describe racial differences in patient-reported experiences with discrimination in the healthcare setting and examine its association with mistrust.

METHODS

We used surveys containing patient-reported frequency of discrimination using the Discrimination in Medical Setting (DMS) and Microaggressions in Health Care Settings (MHCS) scales, mistrust using the Group Based Medical Mistrust (GBMM) scale, and patient characteristics including patient-reported race, income, wealth, insurance status, and educational attainment. Univariable and multivariable linear regression models as well as risk ratios were used to examine associations between patient characteristics including self-reported race, and DMS, MHCS, and GBMM scores.

RESULTS

In 174 participants with serious illness, racially minoritized patients were more likely to report experiencing discrimination and microaggressions. In adjusted analyses, DMS scores were associated with elements of class and not with race. Black, Native American/Alaskan Native (NA/AN), and multiracial participants had higher MHCS scores compared to White participants with similar levels of income and education. Higher income was associated with lower GBMM scores in participants with similar DMS or MHCS scores, but Black and NA/AN participants still reported higher levels of mistrust.

CONCLUSION

In this cross-sectional study of patients with serious illness, discriminatory experiences were associated with worse mistrust in the medical system, particularly for Black and NA/AN participants. These findings suggest that race-conscious approaches are needed to address discrimination and mistrust in marginalized patients with serious illness and their families.

White Privilege, White Poverty: Reckoning with Class and Race in America

This essay argues that a failure to think and talk critically and candidly about White privilege and White poverty is a key threat to the United States of America's precarious democracy. Whiteness frames one of America's most pressing collective challenges-the poor state of the nation's health, which lags behind other wealthy nations and is marred by deep and entrenched class- and race-based inequities. The broadscale remedies experts recommend demand what is in short supply: trust in evidence, experts, government, and one another. The authors' prescription is threefold, beginning with a call for intersectional health studies and reports that avoid one-dimensional misrepresentations of widespread health problems as simply Black or White problems. Second, there is the need for a "critical consciousness" about race and class. Lastly, the essay calls for widescale opportunities for Americans to engage in cross-racial and cross-class democratic conversations about their struggles and aspirations in search of common ground.

Life Expectancy and Mortality Rates in the United States, 1959-2017

Importance

US life expectancy has not kept pace with that of other wealthy countries and is now decreasing.

Objective

To examine vital statistics and review the history of changes in US life expectancy and increasing mortality rates; and to identify potential contributing factors, drawing insights from current literature and an analysis of state-level trends.

Evidence

Life expectancy data for 1959-2016 and cause-specific mortality rates for 1999-2017 were obtained from the US Mortality Database and CDC WONDER, respectively. The analysis focused on midlife deaths (ages 25-64 years), stratified by sex, race/ethnicity, socioeconomic status, and geography (including the 50 states). Published research from January 1990 through August 2019 that examined relevant mortality trends and potential contributory factors was examined.

Findings

Between 1959 and 2016, US life expectancy increased from 69.9 years to 78.9 years but declined for 3 consecutive years after 2014. The recent decrease in US life expectancy culminated a period of increasing cause-specific mortality among adults aged 25 to 64 years that began in the 1990s, ultimately producing an increase in all-cause mortality that began in 2010. During 2010-2017, midlife all-cause mortality rates increased from 328.5 deaths/100 000 to 348.2 deaths/100 000. By 2014, midlife mortality was increasing across all racial groups, caused by drug overdoses, alcohol abuse, suicides, and a diverse list of organ system diseases. The largest relative increases in midlife mortality rates occurred in New England (New Hampshire, 23.3%; Maine, 20.7%; Vermont, 19.9%) and the Ohio Valley (West Virginia, 23.0%; Ohio, 21.6%; Indiana, 14.8%; Kentucky, 14.7%). The increase in midlife mortality during 2010-2017 was associated with an estimated 33 307 excess US deaths, 32.8% of which occurred in 4 Ohio Valley states.

Conclusions and Relevance

US life expectancy increased for most of the past 60 years, but the rate of increase slowed over time and life expectancy decreased after 2014. A major contributor has been an increase in mortality from specific causes (eg, drug overdoses, suicides, organ system diseases) among young and middle-aged adults of all racial groups, with an onset as early as the 1990s and with the largest relative increases occurring in the Ohio Valley and New England. The implications for public health and the economy are substantial, making it vital to understand the underlying causes.