Little Improvement Seen Over Two Decades in US Racial Health Disparities

Black adults continue to have significantly higher rates of death due to diabetes, hypertension, heart disease, and stroke compared with white adults, and these disparities are magnified in rural areas of the United States, a contemporary analysis shows.

Death related to hypertension and diabetes were found to be two to three times higher among Black adults compared with white adults in rural parts of the US, senior author Rishi Wadhera, MD (Beth Israel Deaconess Medical Center, Boston, MA), told TCTMD. “What's really concerning is our finding that those striking racial disparities have not meaningfully improved over the last two decades,” he added.

In a research letter published in the Journal of the American College of Cardiology, Wadhera and colleagues led by Rahul Aggarwal, MD (Beth Israel Deaconess Medical Center), observed that between 1999 and 2018 there was a more-rapid narrowing of the diabetes- and hypertension-related mortality gap between Black and white adults living in urban areas as opposed to rural areas. On a positive note, while the racial gap in deaths from cardiovascular disease declined at a similar rate in urban and rural dwellers, a sharper decline was seen for stroke deaths among Black adults living in rural versus urban areas (-0.80 vs. -1.35; P = 0.02).

“I think that probably reflects several concerted public health and policy efforts, including the expansion of health system referral networks and regional systems of care that have enabled rural hospitals to efficiently send patients with heart attacks and strokes to more-specialized centers for treatment, as well as the medical and technological advancements that we all know about that have occurred for the treatment of these conditions,” Wadhera told TCTMD.

Understanding and Addressing Gaps

For the analysis, the researchers examined data from the CDC Wonder Database on age-adjusted mortality for Black and white adults age 25 years and over, stratified by whether they lived in rural or urban areas from 1999 to 2018.

While deaths related to hypertension increased across all populations during the time period, the sharpest increase was found to be among Black adults in rural areas. For diabetes mortality, Black adults in urban areas experienced more of decline than those in rural areas. Aggarwal and colleagues say the “striking” and “persistent” disparities between rural Black and white adults in death from diabetes and hypertension “may reflect structural inequities that impede access to primary, preventive, and specialist care.”

Wadhera said before the health-related gaps can be addressed, “we probably need to take a step back and think about why these disparities exist in the first place.” Black communities disproportionately face structural and systemic inequities that lead to a higher burden of common comorbid conditions. Those factors, including things like poverty, living in a disadvantaged area with limited access to filling prescriptions—so-called pharmacy deserts—and less access to healthy foods, as well as poor access to primary and preventative care result in reduced disease-related awareness, treatment and control, he added.

“We need public health and policy initiatives on the state and federal level levels to intensify their focus on addressing the root causes of these racial health inequities, including income inequality, disparate access to healthcare services, and structural racism,” Wadhera said.

Improving health and access to healthcare among individuals living in rural areas was highlighted by the American Heart Association and the American Stroke Association as a “call to action” item in early 2020, prior to the start of the COVID-19 pandemic. Wadhera said there’s real concern that the last year has only made things worse.

“We know that Americans that live in rural communities have a higher burden of comorbid conditions, which leads to their higher death rates. It's hard to imagine that the COVID pandemic is going to make that better,” he noted. “We also already know that the COVID-19 pandemic has disproportionately affected Black Americans in terms of the direct toll of the disease. I suspect that as we, hopefully, exit this pandemic phase, we're going to see that the indirect effects of the pandemic have also disproportionately affected racial and ethnic minority communities, and specific Black Americans and Latinx Americans.”