Black people in America experienced an excess 1.6 million deaths compared with white people during the past two decades, a staggering loss that comes at a cost of hundreds of billions of dollars, according to two new studies that build on a generation of research into health disparities and inequity.
In one study, researchers conclude that the gap in health outcomes translated into 80 million years of potential life lost — years of life that could have been preserved if the gap between Black and White mortality rates had been eliminated. The second report determined the price society pays for failing to achieve health equity and allowing Black people to die prematurely: $238 billion in 2018 alone.
“This is our collective challenge as a country because it hurts all of us deeply,” said Marcella Nunez-Smith, associate dean for health equity research at Yale University and co-author of the study on excess deaths and years of life lost. “All of the potential. Which one of those people whose life was cut short was on the way to some scientific discovery that would transform all of our lives or create beautiful art and music? Who among them was going to be a spiritual or religious leader? Not to mention the economic impact.”
The reasons for the excess deaths and resulting economic toll are many, including mass incarceration, but the root is the same, according to the reports published Tuesday in the influential medical journal JAMA: the unequal nature of how American society is structured.
That includes access to quality schools, jobs with a living wage, housing in safe neighborhoods, health insurance and medical care — all of which affect health and well-being. For centuries, Black people were legally deprived of these benefits, and researchers said we have yet to fully ameliorate the effects.
"Just to illustrate the issue, one of the clearest examples of structural racism was in 1935 when the Social Security Act was passed," said Thomas LaVeist, dean of the Tulane University School of Public Health and Tropical Medicine and lead author of the study on the economic implications of health disparities. "They intentionally left out domestic workers and farmworkers, who were disproportionately Black. That hasn't been fully unraveled."
And the shorter life expectancy of Black Americans means they do not derive what they have invested in Social Security. People born in 1960 can start receiving their full Social Security benefits at age 67, but according to the Centers for Disease Control and Prevention, Black men born that year had an average life expectancy of just 61 years.
Not only is that person paying into a system they are not fully benefiting from but society is also losing "because that person isn't there as part of the economy," LaVeist said. "We've paid for schooling for this person, who gets a job and pays taxes and dies prematurely. The investment in that person is never recovered by society."
That comes at a significant cost in military readiness, in workforce fitness, in dollars and cents.
Researchers explored the economic burden caused by health inequities when someone dies prematurely or must pay out-of-pocket costs and third-party payments to health-care providers for emergency room visits, ambulance services, or vision and dental care.
They also calculated the economic toll when people can't work because they or a relative are sick, or when employees show up to work but are less productive because they're not well.
Expanding their analysis to a broader population, the researchers concluded that the failure to achieve health equity in 2018 cost the nation $1.03 trillion. That price tag includes the burden experienced by U.S. adults older than 25 who do not have a college degree and by Native American, Asian, Black, Latino and Pacific Islander people.
More than two-thirds of the economic burden experienced by people of color was attributed to premature deaths, with most of those untimely deaths coming from the Black community. Meanwhile, “adults with a 4-year-college degree had zero premature death costs,” the report said.
For nearly 40 years, study after study examining disparate health outcomes in the Black community have started by referencing a landmark study on Black and minority health that came to be known as the "Heckler Report," so named because it was written when Margaret Heckler was President Ronald Reagan's health secretary. The two studies released Tuesday are no exception in citing that report, which attributed 60,000 excess deaths a year to health disparities as it became a clarion call to the nation.
"It's not just the '85 report, it's going back to 'The Philadelphia Negro' with W.E.B. Du Bois," which was published 124 years ago and was the first ethnography to outline problems faced by the Black community, said Darrell Hudson, who researches health disparities at Washington University in St. Louis. "The outcome is not new. Our understanding of the mechanisms, policies and practices have evolved."
In the decades since, modern medicine has witnessed major scientific discoveries and technological breakthroughs, but those advances haven’t benefited everyone equally. When taken together, researchers say, the reports released Tuesday dispel several myths about how society has — and has not — responded to the alarm sounded more than a generation ago.
"We tend to have this idea as we move through time, we're constantly improving," said Jessica Owens-Young, an assistant professor in the Department of Health Studies at American University, where she researches health equity. But, she said, "we can't always assume that as we continue to innovate that is going to promote and protect people's health."
Nunez-Smith, who was chair of President Biden's Covid-19 Health Equity Task Force, said the report on excess deaths dispenses with the notion that the root causes of racial health disparities reflect "some deterministic factor that race is biological."
Nunez-Smith and the other researchers analyzed death certificates from 1999 through 2020 to reach their conclusions about excess deaths — the observed number of deaths versus what would be expected if Black and White death rates were the same.
From 1999 to the early 2010s, the report found that the gap in excess deaths narrowed, dropping by about 48 percent for Black men and about 61 percent for Black women compared with their White counterparts. But then progress plateaued, the excess burden of death stubbornly persisting until it ballooned in 2020.
Excess mortality during the first year of the coronavirus pandemic, the report said, exceeded that of any previous year of the study.
Infants bore the brunt of excess deaths and years of life lost, along with adults older than 50. The death gap between men and women widened sharply, according to the report.
The leading causes of excess death and years of life lost, according to the study, include infant mortality, heart disease and cancer.
"These findings indicate that current efforts to curb or eliminate mortality disparities have been minimally effective, and progress, when made, has been fragile," the report concluded.
The numbers represent something else, said Harlan Krumholz, a cardiologist at the Yale School of Medicine and co-author of the excess death study: a greater need to recognize "where we're failing and the magnitude of the problem."
"Why don't we accept that this is really racism as cause of death?" Krumholz asked. "What other health problem has created that kind of loss?"
The study shows that, except for ages 1 to 10, Black males experienced the highest rates of excess death and years of life lost, a finding that Derek Griffith, director of Georgetown University's Center for Men's Health Equity in the Racial Justice Institute, said reinforces the need to consider the ways "anti-Black racism is gendered and use that as foundation for how we need to intervene."
Griffith said the report mentions "structural racism, but it's too blunt of an instrument. Anti-Black racism manifests in stereotypes and tropes. It's that cultural narrative that shapes why it makes it okay for us to have these patterns."
Many of those stereotypes are viewed through a gender lens, he said.
Research shows Black boys are often viewed as older, stronger and less innocent than their peers. Black men are seen as criminals, intellectually inferior, "deadbeat dads." Black women are reduced to racist caricatures of lasciviousness, aggressiveness, the "welfare queen."
"We don't tend to think about the structural drivers of racial inequity in a way that is precise enough," Griffith said. He noted that talking about Black men's poor health outcomes often "gets uncomfortable. We try to deal with this as a race pattern without dealing with the gender pattern."
Those differences are evident in how men are socialized to handle stress and their health. Also, researchers said, many government and health programs tend to be geared toward helping single mothers, but those same services aren't available for men and single fathers.
"Over time, we find that social-economic status doesn't protect in the same way it does for other people, especially for Black men who report more discrimination the more income and education they have," Hudson, of Washington University, said.
Often, to seek out upward mobility, Black people have to cross boundaries, navigating mostly White spaces to get an education, earn a living, take out a loan, raise a child. That can prove caustic, Hudson said, because if someone is constantly crossing boundaries, they are constantly experiencing stress — or anticipating it.
Stress is a physiological reaction, hard-wired. At the first sign of danger, the brain sounds an alarm, setting off a torrent of neurological and hormonal signals that flood the bloodstream. Overexposure to those hormones wears down the body, causing it to become sicker and age quicker, or to "weather."
While weathering isn't specific to race, it is believed to take a particular toll on Black people because of the unique, unrelenting stress caused by racism. Research shows Black people have much higher rates of hypertension, obesity, diabetes and strokes than White people do, and they develop those chronic conditions up to 10 years earlier.
"Our bodies are not sophisticated enough to discern that this is not a lion on the Savannah, but someone who just looked at you funny," said Hudson, who calls it "the cost of upward social mobility."
But there is reason for hope, and it can be found in the period during the coronavirus pandemic when the gap between Black and White death rates began to shrink and even flip. In 2021, White people had the second-biggest drop in life expectancy, losing a full year while Black people lost 0.7 years, according to the CDC.
"And why was that happening?" asked Reed Tuckson, co-founder of the Black Coalition Against Covid. There are two reasons, he said. "One, of course, was the destructive messaging that came from many White political leaders but also the impact of the mobilization of Black faith and community-based organizations and social and fraternal organizations."
Tuckson, an internist and former Washington, D.C., public health commissioner, said the herculean efforts by the Black community "to fight for our lives" despite having meager resources show that it is past time for the federal government "to find a way to create sustainable, predicable funding at scale to support the Black community and its institutions."
“We have shown that we can catch up despite running a race with an anvil on our backs,” he said.