The country’s pervasive health inequities were evidenced by a tragic tally of 74,402 excess deaths, on average, among Black people compared with white people each year between 2016 and 2018, according to an analysis of all-cause mortality rates in the 30 largest U.S. cities.

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But rates vary widely. In Chicago, for example, racial inequities in mortality rates resulted 3,804 excess Black deaths annually, compared to just six excess deaths a year in El Paso, Texas.

“Inequities in mortality are not inevitable,” said Fernando De Maio, PhD, with DePaul University’s department of sociology, and a co-author of the study published in JAMA Network Open.

“If health equity can be achieved in some cities, why not all?” said De Maio, director of research and data use for the AMA Center for Health Equity. “Our results are an indication of the toll of structural racism in U.S. society, but they also give us hope that better, and more equitable, patterns of population health are possible.”

Another study that found a link between high levels of income inequality in a community and higher levels of COVID-19 cases and deaths was co-written by De Maio and sociologist Tim F. Liao, PhD, with the University of Illinois at Urbana-Champaign, and published the same day in JAMA Network Open.

Learn more with the AMA about how, when put in context, data can help expose and fix health inequities.


De Maio and researchers at the Sinai Urban Health Institute (SUHI) examined almost 26.3 million death records between 2009 and 2018. They determined the national all-cause mortality rate among Blacks was 24% higher than among whites.

With only 537 deaths per 100,000 population, San Francisco had the lowest all-cause mortality rate between 2016 and 2018 among the cities studied. And, with 1,342 deaths per 100,000 population, Las Vegas had the highest all-cause mortality. But, in San Francisco, the all-cause mortality rate for Blacks was 92% higher than among whites. In Las Vegas, it was 18% higher.

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Except for in El Paso, the mortality rates among Black people were significantly higher than for whites in the 29 other cities studied. During the period examined, the gap between Blacks and whites closed in Memphis and Philadelphia, while inequities rose in Chicago, Las Vegas, Portland, Oregon, San Francisco, Seattle and Washington. Statistically significant changes in racial equity were not seen in the other 22 cities studied.

That finding “is remarkably disappointing, given national and local efforts focused on health equity,” De Maio and colleagues wrote. “Simultaneously, these results may serve to reinforce the need for systems-level change, shifting community health improvement efforts from behavioral to structural interventions.”

Fourteen of the cities saw significant declines in overall mortality between 2009 and 2018, 13 were described as “stable,” and three—Houston, Indianapolis and Louisville—saw mortality significantly go up, according to the study.

“It is plausible that city-level variability in racial inequities in mortality reflects differential exposures to policies and systems that create and reinforce this wide range of social drivers of health inequities,” the study says.

National all-cause mortality has long been a primary measure of population health, one that has been documented in the U.S. since the 1800s.

This information should be helpful to physicians also, De Maio said, noting that more reports are coming related to the cause-specific mortality research conducted by SUHI, which is part of Sinai Chicago, the largest private safety-net health care system in Illinois.

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These will include studies on cancer, heart disease, infant mortality, and kidney disease as well as homicide, suicide and fatal drug overdoses.

The researchers are talking with physicians to get their interpretation of the statistics, because the goal is to not just generate more data, De Maio said, but to make the research more meaningful, practical and actionable for physicians and health systems.

Coming in September will be Unequal Cities, Structural Racism and the Death Gap in America’s 30 Largest Cities, a book published by Johns Hopkins University Press and co-edited by De Maio and SUHI senior research fellow Maureen Benjamins, PhD, that will examine the reasons behind the 13-year gap in life expectancy between the healthiest and unhealthiest U.S. cities.

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