Location, race and income affect life spans in U.S.

WASHINGTON — Where people live, combined with their race and income, plays a huge role in the nation's health disparities, differences so stark that a report issued Monday contends it's as if there are eight separate Americas instead of one.

Millions of the worst-off Americans have life expectancies typical of developing countries, concluded Dr. Christopher Murray of the Harvard School of Public Health.

Murray said the longevity gap has persisted for two decades "despite the efforts made by public-health programs."

The reason, he said, is that many programs have been aimed at addressing infant mortality, violence and HIV/AIDS, while the real problems unearthed by the study are diseases of the heart, lung and liver, including cancer, taking a toll on people between 15 and 65.

"This is a surprise," Murray said. "Despite a decade or longer of programs to reduce disparities in the U.S., the longevity gap is not getting any smaller, and in fact may be getting worse for males." These findings are "a pretty strong indictment on these efforts. We are clearly not doing enough."

At one end of the scale are Asian-American women living in Bergen County, N.J., who have an average life expectancy of 91 years, according to the report published in the journal PLoS Medicine.

At the other extreme are American Indians in South Dakota, whose average life expectancy is only 58 years. "That's comparable to the life expectancy in Southeast Asia and in sub-Saharan Africa," said Dr. Richard Suzman, associate director of the National Institute on Aging, which partially funded the study.

According to the state data, Hawaii is the healthiest, with an average life span for men and women of 80 years.

Washington state ranked 13th, at 78.2 years.

The District of Columbia had the lowest life expectancy, 72 years. It is followed by Mississippi, 73.6; Louisiana, 74.2; Alabama, 74.4; and South Carolina, 74.8.

A black man living in a high-crime American city can expect to live 21 fewer years than a woman of Asian descent in the United States.

Inhabitants of what the report calls "Black Middle America" — African Americans who live outside inner cities and the rural South — have a life expectancy five years shorter than those in "Middle America," which encompasses the vast majority of urban and suburban whites.

Even among groups that appear quite similar, there are wide differences in the risk of early death. A farmer from a Great Plains state such as North Dakota is likely to live four years longer than a farmer living in Appalachia or the Mississippi Valley.

Murray and his colleagues looked at life expectancy in 2,000 geographical units — counties or groups of counties. They then divided them into eight groupings based on ethnicity, race and income.

The Eight Americas were:

• Asians, scattered throughout the country

• Rural whites in the Northern Plains and Dakotas

• White Middle America, consisting of 214 million people not assigned to other categories

• Low-income whites in Appalachia and the Mississippi Valley

• Western Indians (the smallest group, with 1 million people)

• Black Middle America

• Low-income rural Southern blacks

• High-risk urban blacks (those living in places where a person has a 1 percent or greater risk of being killed between ages 15 and 74)

As previous studies have shown, Asians have by far the longest life expectancy: 87.4 years for women and 82.1 for men. Black urban men have the shortest, at 66.7, followed by Southern rural black men, at 67.7. Indian men in the West are next, at 69.4.

Curiously, Asian women in the United States — many of whom are second-generation and have spent their whole lives here — have a life expectancy that is three years longer than Japanese women, who, as a national group, are the longest-living in the world. Previous research suggested that Asians lose their "survival advantage" after they are in the United States for a long time and have adopted an American diet and habits, but the new study suggests that is not happening with Asian women.

Among the more interesting comparisons, however, are those among whites.

Northern Plains whites have a per-capita income below that of Middle America whites (about $18,000 versus $25,000), and essentially the same percentage who are high-school graduates (83 versus 84). But they live longer: 79 years versus 77.9 years.

The comparison is even more dramatic with the Appalachian and Mississippi Valley group. The latter has a per-capita income only $1,400 less than the Northern Plains group, but a markedly lower high-school graduation rate, at 72 percent.

The gap in life expectancy between those groups in 2001 was 4.2 years for men and 3.8 years for women. This is not far off the overall gap of 6.4 years between black men and white men, and the 4.6-year gap between white women and black women.

The paper did not examine the causes of death among the groups. However, the researchers note that high mortality in urban black men persists even when homicide and AIDS are removed. Heart attack, stroke, diabetes, cirrhosis and fatal injuries are the major causes of reduced life expectancy in that group.

The huge strides in cutting infant mortality in the past 50 years are clearly evident in the findings. The risk of dying between birth and age 4 is extremely similar among all Eight Americas — much more similar than at any other age.

While black inner-city men have a mortality risk similar to that of West Africans, that is true only once they reach their 40s. West Africans have more than 10 times the risk of dying in childhood as even the most disadvantaged African Americans.

Interestingly, there was less variation among the Eight Americas in the rate of health-insurance coverage and the frequency of routine medical appointments than there was in life expectancy. That finding suggests that access to care does not explain most of the differences in mortality.

Richard Cooper, chairman of preventive medicine at Loyola University School of Medicine, said "the problem with these sorts of analyses is that they don't tell you anything very illuminating about the underlying social process" that leads to differences in life expectancy.

Compiled from The Washington Post, The Associated Press, Newsday and Los Angeles Times