Premature Death Racial Disparity in Tennessee

Tennessee

Rates of disease and mortality are often higher among historically marginalized racial and ethnic groups. Counties that are majority non-Hispanic Black or majority American Indian/Alaska Native have higher rates of premature death than counties that are majority non-Hispanic white.

Studies show that poverty, low education, inadequate social support and racial segregation contribute to premature death. These social factors often converge in minority communities. Structural racism further limits the resources available to racial/ethnic minority communities, where need is highest: Chronic stress due to racial discrimination can set off physiological and psychological chain reactions, manifesting in earlier onset and higher prevalence of high blood pressure, cardiovascular disease and stroke. 

Eliminating racial disparities in premature death would save the United States an estimated $135 billion a year in lost productivity and excess health costs. 

According to America’s Health Rankings data, the racial/ethnic groups with the largest disparities in premature death include:

• The American Indian/Alaska Native population, which has the highest premature death rate. It is 3.8 times higher than that of the Asian/Pacific Islander population and 1.6 times higher than that of the white population. Among the American Indian/Alaska Native population, the top four leading causes of premature death in 2021 were COVID-19, unintentional injuries, heart disease and cancer.
  • Risk factors contributing to a higher rate of unintentional injuries include rural environments, lack of traffic safety and higher rates of alcohol-related accidents.
  • Higher prevalences of smoking, alcohol abuse and diabetes contribute to elevated rates of premature death from heart disease and cancer. 
  • Another source of racial disparities in premature death are gaps in birth outcomes. The infant mortality rate is almost twice as high among infants born to American Indian/Alaska Native mothers compared with infants born to white mothers.
• The Black population, which has a premature death rate 3.4 times higher than that of the Asian/Pacific Islander population and 1.4 times higher than that of the white population. Data from 1960 through 2009 showed the premature mortality rate for the Black population was consistently twice that of the white population. Among the Black population, the top four leading causes of premature death in 2021 were heart disease, cancer, COVID-19 and unintentional injuries. 
  • Racial disparities in cardiovascular disease and homicide are leading drivers of disparities in premature mortality.
  • Staggering and persistent gaps in birth outcomes are also contributors to early death rates. The non-Hispanic Black population has the highest infant mortality rate in the U.S. — more than twice that of non-Hispanic white and Asian populations.

Racial disparities in health endure in the U.S. because of the inequitable systems of power that affect nearly every aspect of life, from the individual, interpersonal and internal level to the institutions where policy, law and resource allocation are determined. The resulting inequalities in the social determinants of health, such as income and wealth, access to quality health care, education and employment, are deeply entangled with one another. According to Healthy People 2030, promoting healthy choices is not enough to eliminate health disparities. They suggest that public health organizations collaborate with other sectors such as education, transportation and housing to improve the conditions in people's social, economic and physical environments. 

The health disparities that minority populations experience are different from community to community and local solutions are needed. The Centers for Disease Control and Prevention (CDC) has documented several strategies for reducing health disparities, including:

• The Traditional Foods Project, aimed at reducing rates of Type 2 diabetes in American Indian/Alaska Native populations.
• The Boston Children’s Hospital’s Community Asthma Initiative, an intervention for Black and Hispanic children at risk of asthma complications.
• Programs funded by the CDC’s Colorectal Cancer Control Program (CRCCP) that implemented multicomponent interventions to increase colorectal cancer screening among racial and ethnic minority populations.

Increasing access to mental health and primary care for currently underserved minority populations is also critical for decreasing premature death rates. Currently, there is insufficient research to determine the most effective methods of increasing access to behavioral health and primary care for racial and ethnic minority populations.

One of the overarching goals of Healthy People 2030 is to “attain healthy, thriving lives and well-being free of preventable disease, disability, injury and premature death.” While Healthy People 2030 does not have a specific goal for reducing premature death, it does set goals for many contributors to premature death, including:

• Reducing cancer-related illness and death. 
• Preventing unintentional injuries. 
• Reducing deaths related to smoking. 
• Preventing obesity. 
• Reducing deaths from heart disease and stroke. 
• Reducing maternal deaths.
• Reducing the rate of infant deaths. 
• Reducing the rate of child and adolescent deaths. 

Alegría, Margarita, Kiara Alvarez, Rachel Zack Ishikawa, Karissa DiMarzio, and Samantha McPeck. “Removing Obstacles to Eliminating Racial and Ethnic Disparities in Behavioral Health Care.” Health Affairs 35, no. 6 (June 1, 2016): 991–99. https://doi.org/10.1377/hlthaff.2016.0029.

Alhusen, Jeanne L., Kelly M. Bower, Elizabeth Epstein, and Phyllis Sharps. “Racial Discrimination and Adverse Birth Outcomes: An Integrative Review.” Journal of Midwifery & Women’s Health 61, no. 6 (November 2016): 707–20. https://doi.org/10.1111/jmwh.12490.

Bruner, Charles. “ACE, Place, Race, and Poverty: Building Hope for Children.” Academic Pediatrics 17, no. 7S (September 1, 2017): S123–29. https://doi.org/10.1016/j.acap.2017.05.009.

Calvin, Rosie, Karen Winters, Sharon B. Wyatt, David R. Williams, Frances C. Henderson, and Evelyn R. Walker. “Racism and Cardiovascular Disease in African Americans.” The American Journal of the Medical Sciences 325, no. 6 (June 2003): 315–31. https://doi.org/10.1097/00000441-200306000-00003.

Centers for Disease Control and Prevention. “Strategies for Reducing Health Disparities — Selected CDC-Sponsored Interventions, United States, 2016.” MMWR. Morbidity and Mortality Weekly Report, Supplement, 65, no. 1 (February 12, 2016). https://stacks.cdc.gov/view/cdc/37922.

Ely, Danielle M., and Anne K. Driscoll. “Infant Mortality in the United States, 2020: Data From the Period Linked Birth/Infant Death File.” National Vital Statistics Reports 71, no. 5 (September 29, 2022). https://doi.org/10.15620/cdc:120700.

Espey, David K., Melissa A. Jim, Nathaniel Cobb, Michael Bartholomew, Tom Becker, Don Haverkamp, and Marcus Plescia. “Leading Causes of Death and All-Cause Mortality in American Indians and Alaska Natives.” American Journal of Public Health 104, no. S3 (June 2014): S303–11. https://doi.org/10.2105/AJPH.2013.301798.

Galea, Sandro, Melissa Tracy, Katherine J. Hoggatt, Charles DiMaggio, and Adam Karpati. “Estimated Deaths Attributable to Social Factors in the United States.” American Journal of Public Health 101, no. 8 (August 2011): 1456–65. https://doi.org/10.2105/AJPH.2010.300086.

Henning-Smith, Carrie, Ashley M. Hernandez, Marizen Ramirez, Rachel Hardeman, and Katy Kozhimannil. “Dying Too Soon: County-Level Disparities in Premature Death by Rurality, Race, and Ethnicity.” Policy Brief. Minneapolis, MN: University of Minnesota Rural Health Research Center, March 2019. http://rhrc.umn.edu/wp-content/files_mf/1552267547UMNpolicybriefPrematureDeath.pdf.

Joseph, Djenaba A. “Use of Evidence-Based Interventions to Address Disparities in Colorectal Cancer Screening.” MMWR Supplements 65, no. 1 (2016). https://doi.org/10.15585/mmwr.su6501a5.

Krieger, Nancy. “Discrimination and Health Inequities.” In Social Epidemiology, 2nd ed., 17–62. Oxford, New York: Oxford University Press, 2014. https://doi.org/10.1093/med/9780195377903.003.0003.

Krieger, Nancy, Jarvis T. Chen, Brent A. Coull, Jason Beckfield, Mathew V. Kiang, and Pamela D. Waterman. “Jim Crow and Premature Mortality Among the US Black and White Population, 1960–2009: An Age–Period–Cohort Analysis.” Epidemiology 25, no. 4 (July 2014): 494–504. https://doi.org/10.1097/EDE.0000000000000104.

National Academies of Sciences, Engineering, and Medicine, Health and Medicine Division, Board on Population Health and Public Health Practice, and Committee on Community-Based Solutions to Promote Health Equity in the United States. Communities in Action: Pathways to Health Equity. Edited by Alina Baciu, Yamrot Negussie, Amy Geller, and James N. Weinstein. Washington, D.C.: National Academies Press, 2017. http://www.ncbi.nlm.nih.gov/books/NBK425848/.

Phelan, Jo C., and Bruce G. Link. “Is Racism a Fundamental Cause of Inequalities in Health?” Annual Review of Sociology 41, no. 1 (2015): 311–30. https://doi.org/10.1146/annurev-soc-073014-112305.

Quiñones, Ana R., Maya O’Neil, Somnath Saha, Michele Freeman, Stephen R. Henry, and Devan Kansagara. Interventions to Improve Minority Health Care and Reduce Racial and Ethnic Disparities. VA Evidence-Based Synthesis Program Reports. Washington, D.C.: Department of Veterans Affairs, 2011. http://www.ncbi.nlm.nih.gov/books/NBK82564/.

Satterfield, Dawn, Lemyra DeBruyn, Marjorie Santos, Larry Alonso, and Melinda Frank. “Health Promotion and Diabetes Prevention in American Indian and Alaska Native Communities — Traditional Foods Project, 2008–2014.” MMWR Supplements 65, no. 1 (February 12, 2016): 4–10. https://doi.org/10.15585/mmwr.su6501a3.

Turner, Ani. “The Business Case for Racial Equity: A Strategy for Growth.” Battle Creek, MI: W.K. Kellogg Foundation & Altarum, 2018. https://altarum.org/sites/default/files/uploaded-publication-files/WKKellogg_Business-Case-Racial-Equity_National-Report_2018.pdf.

Williams, David R., Jourdyn A. Lawrence, and Brigette A. Davis. “Racism and Health: Evidence and Needed Research.” Annual Review of Public Health 40, no. 1 (April 1, 2019): 105–25. https://doi.org/10.1146/annurev-publhealth-040218-043750.

Woods, Elizabeth R., Urmi Bhaumik, Susan J. Sommer, Elaine Chan, Lindsay Tsopelas, Eric W. Fleegler, Margarita Lorenzi, et al. “Community Asthma Initiative to Improve Health Outcomes and Reduce Disparities Among Children with Asthma.” MMWR Supplements 65, no. 1 (February 12, 2016): 11–20. https://doi.org/10.15585/mmwr.su6501a4.