Differences in Death Rates due to Injury Among Blacks and Whites, 1984

Jama A. Gulaid, Ph.D., M.P.H. E. Chukwudi Onwuachi-Saunders, M.B.B.S., M.P.H. Jeffrey J. Sacks, M.D., M.P.H. Diane R. Roberts Division of Injury Epidemiology and Control Center for Environmental Health and Injury Control

INTRODUCTION

A 1985 report to Congress on "Injury in America" underscored the public health importance of injuries in the United States and indicated that the injury burden rests disproportionately among the poor (1), many of whom belong to minority groups. In a special report on minority health, the U.S. Department of Health and Human Services identified injuries as one of six problem areas that cause "excess deaths"* among blacks compared with whites (2). The other areas were cancer, heart disease and stroke, chemical dependency, diabetes, and infant mortality and low birth weight.

This summary describes the epidemiology of four causes of injuries with the largest disparities in black-white deaths in 1984 and discusses opportunities for intervention. It focuses on deaths from homicides, residential fires, drownings, and pedestrian mishaps--each of which accounted for over 1,000 deaths and showed a ratio of mortality rates between blacks and whites that exceeded 1.5. Other injuries, such as those caused by motor vehicles, accounted for many deaths but did not show statistically significant black-white differences in death rates; therefore, they are not included in this report. METHODS

The numbers of deaths from the four injury categories selected for study were obtained from the mortality tapes of the National Center for Health Statistics (NCHS) for 1984, the latest year for which these data were available when this study was begun. Each death caused by injury was coded according to the Ninth Revision of the International Classification of Diseases, as shown in Table 1. Information on the NCHS tapes included the decedent's age, sex, race, and date of death. Death rates per 100,000 persons by race (blacks and whites only), sex, and age were calculated with the use of population estimates for 1984 from the U.S. Department of Commerce, Bureau of the Census (3). RESULTS

In 1984, although blacks represented 12.0% of the U.S. population, they accounted for 15.3% of all deaths due to injury. Among the four causes studied for both blacks and whites, homicides accounted for the most deaths from injury (Table 1). For blacks, homicides were followed by pedestrian mishaps, residential fires, and drownings. For whites, homicides were followed by pedestrian mishaps, drownings, and residential fires.

The rate ratios of black-white deaths were highest for homicides (5.2:1), followed by residential fires (3.2:1), drownings (1.8:1), and pedestrian mishaps (1.6:1) (Table 1). Among the four race-sex groups, black males had the highest death rates from these causes; white females had the lowest death rates. Black females had death rates similar to those of white females except for homicides and residential fires; in those two categories, black females had higher death rates than both white females and white males.

Homicides accounted for the greatest disparity in injury mortality rates between blacks and whites. In 1984, the homicide rate for blacks was 29.0 per 100,000. This rate was just over five times higher than the homicide rate for whites of 5.5 per 100,000 (Table 1). For both blacks and whites, the age-specific homicide rates decreased from infancy to ages 5-9 years and then began to increase (Figure 1). For blacks, the rates peaked at ages 25-29 years, declined markedly to ages 65-69, and then declined slightly. In contrast, the rates for whites peaked at ages 20-24, declined gradually to ages 65-69, and then slightly increased.

For both males and females in 1984, homicide rates were highest among young adults ages 20-39. Rates for black males peaked at 99.6 for the 25- through 29-year-old age group. Although rates were higher for black males than for any other race-sex group, black females also were at high risk of homicide. Their rate also peaked in the 25- through 29-year-old age group at 21.9. Rates for black males were four to five times greater than those for black females in all age groups above 15 years of age. A similar pattern was seen among whites--that is, young adults were at highest risk, and males had consistently higher rates than females in each age group. The ratio of male-to-female rates, however, was less for whites, with the rate for white males generally ranging from two to three times higher than that for white females. Among blacks, 61.7% of homicides were committed with firearms, compared with 58.6% among whites.

For residential fires, black males had almost twice the death rate of black females, over three times the rate of white males, and over five times the rate of white females (Table 1). The distributions of age-specific death rates between the races, however, were similar (Figure 2). Black and white children (0-4 years) and elderly persons (greater than 65 years) had the highest death rates due to residential fires. The rates for blacks and whites declined after ages 0-4 years, but after ages 40-44 years the rates increased more rapidly for blacks than for whites. Although blacks consistently had higher death rates due to residential fires than whites, the smallest rate differences were at ages 10-29 years, and the greatest were at ages 0-4 and 70+ years (Figure 2).

For drownings, black males had twice the death rate of white males, over seven times the rate of black females, and over eight times the rate of white females (Table 1). Blacks in the age groups 0-4 and 70+ years had lower rates than whites of the same age. In all other age groups, blacks had higher rates (Figure 3). For both races, the death rates peaked at ages 15-19 years and then declined with increasing age. By ages 70-74 years, the death rate among blacks fell to a level below that of whites.

For pedestrian mishaps, black males had nearly twice the death rate of white males, more than three times the death rate of black females, and over four times the rate of white females (Table 1). Blacks ages 15-19 years had a lower rate than whites of the same age (1.9 versus 3.0) (Figure 4). At all other ages, blacks had higher rates than whites. The rates for blacks and whites declined from infancy to ages 10-14 years. This decline began at an older age group for black children (5-9 years) than for white children (0-4 years) and ended at an older age for blacks (15-19 years) than for whites (10-14 years). DISCUSSION

Overall, death rates resulting from homicides, residential fires, drownings, and pedestrian mishaps were higher among blacks than among whites. With few exceptions, this increased risk among blacks occurred over the entire age range. Black females generally had higher death rates than white females, and black males generally had the highest death rates. Of the four types of injuries studied for both blacks and whites, homicide was the leading cause of death; residential fires ranked second for blacks and fourth for whites.

Reasons are unclear as to why blacks have higher death rates from these injuries than whites, because little information is available on race-specific risk factors. Previous studies have shown that deaths from homicides, residential fires, drownings, and pedestrian mishaps have common risk factors such as low socioeconomic status (SES) and alcohol consumption (1,2,4-7). Each cause, however, also has unique risk factors associated with death.

Clearly, blacks have had dramatically higher homicide rates than whites. Various explanations for this racial difference have been considered. Poverty has been suggested as an underlying factor in homicide (5,6), and indeed poverty is more prevalent among blacks than among whites in this country (8). Supporting the suggestion that poverty increases the risk of homicide, research has shown that racial differences in homicide rates all but disappear when SES status is taken into account (9,10). These studies suggest that interventions should not be targeted to blacks as a race but rather to the impoverished. Even if low SES were found unequivocally to increase the risk of homicide, however, the mechanism by which it increases that risk would need to be identified.

Other data show a commonality in homicide patterns among blacks and whites which suggests that, despite dramatic differences in the risk of victimization, the fundamental causes of homicide may be much the same regardless of race. For both races, males were at higher risk of death from homicide than females, perhaps because of the way males are taught to respond to conflicts. Accordingly, intervention efforts might focus on teaching appropriate methods for resolving conflicts. Profound questions remain to be answered concerning risk factors related to homicide, such as drug and alcohol abuse and ready accessibility of firearms. A multidisciplinary approach will be needed to define these risk factors and to develop and implement successful intervention strategies.

For residential fires, the risk factors for a fatal outcome include a lack of smoke detectors, physical conditions that prevent escape from a fire, inappropriate heating devices, residence in poor housing, smoking in bed, and decreased availability and slower response of fire department services (4,11-13). Blacks are less likely to own smoke detectors than whites (11). Moreover, since blacks are disproportionately poorer than whites (31.1% of blacks were below the poverty level in 1986, compared with 10.2% of whites) (8), they may have greater exposure to other risk factors, such as living in poor housing and using inappropriate heating devices more frequently than whites. Aside from these factors, no conclusive evidence links risk factors specifically to race.

For drowning, the risk factors include living in a warm climate, swimming in undesignated areas, inability to swim, not using or misusing personal flotation devices, and using open boats (4,14,15). The distribution of these risk factors among blacks is not clearly understood, because specific research has not been done. Because of income disparity among whites and blacks, however, fewer blacks than whites may own swimming pools. Consequently, the relatively lower drowning rate among black children compared with white children may result from less exposure to swimming pools. The higher risk among blacks 15-19 years of age may be related to lack of instruction in swimming and to recreation at less guarded bodies of water, such as lakes, rivers, and ponds (16).

For pedestrian mishaps, specific reasons for the higher death rate among blacks have not been identified; however, epidemiologic studies have suggested that fatal pedestrian mishaps are associated with vehicle size and design, speed of impact, contact point, and behavior of the pedestrian and driver (4,17). One hypothesis is that blacks may walk more often than whites because a smaller percentage of them own motor vehicles. Death rates from pedestrian mishaps reportedly have been highest in the Southeast and Southwest regions of the United States, and--in contrast to the death rate for whites--the highest death rates for blacks have occurred in rural areas (4,17). By one estimate, the ratio of death to injury in rural areas was three times that in urban areas (4). More blacks may live in rural areas, where driving rules may be less strictly enforced than in urban areas. Thus, impact speeds between vehicles and pedestrians may be greater, increasing the likelihood of a fatal outcome. Delayed or inadequate emergency medical services in rural areas may also play a role.

Opportunities exist to reduce the death toll from homicides, residential fires, drownings, and pedestrian mishaps, although a complete knowledge of race- and cause-specific risk factors is lacking. Interventions may be aimed either at known risk factors common to these injuries or at high-risk groups. Although these approaches are not mutually exclusive, those aimed at common risk factors may be preferable. If successful, such approaches may bring about gains in several areas. For example, an intervention aimed at improving SES in a population might also decrease the number of deaths from homicides, residential fires, and pedestrian mishaps. A drawback to this approach, however, is that no one knows what specific aspects of low SES are associated with excess deaths. On the other hand, interventions aimed at high-risk groups are more focused because the control efforts are applied more selectively. For example, a program that promotes the installation and maintenance of smoke detectors may target children and the elderly, the highest risk groups for deaths in residential fires. Another program offering swimming instructions and water safety skills may target black males 15-19 years of age, the highest risk group for drownings.

In conclusion, fatal injuries exact a disproportionate burden on blacks compared with whites. Homicides, residential fires, drownings, and pedestrian mishaps account for most of this difference. To reduce the higher death rates due to injury among blacks, investigators must define the race- and cause-specific risk factors that can be used to guide intervention strategies. These findings then must be integrated into public health programs designed to reduce the injury burden on blacks in this country.

References

1. Committee on Trauma Research, Commission on Life Sciences, National Research Council, Institute on Medicine. Injury in America: a continuing public health problem. Washington, DC: National Academy Press, 1985.

2. US Department of Health and Human Services. Report of the Secretary's Task Force on Black and Minority Health. Washington, DC: US Department of Health and Human Services, August 1985.

3. US Department of Commerce, Bureau of the Census. Current population reports. Estimates of the population of the United States, by age, sex, and race: 1980-1986. Washington, DC: US Government Printing Office, 1987. (Series P-25, no. 1000.)

4. Baker SP, O'Neill B, Karpf RS. The injury fact book. Lexington, Massachusetts: Lexington Books, DC Heath and Company, 1984.

5. Wolfgang ME, Zahn MA. Criminal homicide. In: Kadish SH, ed. Encyclopedia of crime and justice. New York: Free Press, 1979.

6. Flango VE, Sherbenou EL. Poverty, urbanization, and crime. Criminology 1976;14:331-46.

7. Mercy JA, Goodman RA, Rosenberg ML, et al. Patterns of homicide victimization in the city of Los Angeles, 1970-79. Bull NY Acad Med 1986;62:427-45.

8. US Department of Commerce, Bureau of the Census. Current population reports. Money income and poverty status of families and persons in the United States, 1986. (Advanced data from the March 1987 current population survey). Washington DC: US Department of Commerce, 1987. (Series P-60, no. 157.)

9. Loftin C, Hill RH. Regional subculture and homicide. Am Soc Rev 1974;39:714-24.

10. Williams KR. Economic sources of homicide: reestimating the effects of poverty and inequality. Am Soc Rev 1984;49:283-9.

11. Hall JR Jr, Groeneman S. Two homes in three have detectors. Fire Services Today 1983;50:18-20.

12. Mierley MC, Baker SP. Fatal house fires in an urban population. JAMA 1983;249:1466-8.

13. Centers for Disease Control. Regional distribution of deaths from residential fires--United States, 1978-1984. MMWR 1987;36:645-9.

14. US Coast Guard. Boating statistics 1985. Technical Report COMDITINST M16754.1G. Washington, DC: US Department of Transportation, 1986.

15. Centers for Disease Control. Drownings--Georgia, 1981-1983. MMWR 1985;34:281-3.

16. Waller JA. Injury control: a guide to the causes and prevention of trauma. Lexington, Massachusetts: Lexington Books, 1985:372-3.

17. Fell JC, Hazzard BG. The role of alcohol involvement in fatal pedestrian collisions. 29th Proceedings of the American Association for Automotive Medicine. Des Plaines, Illinois: American Association of Automotive Medicine, 1985:105-25. *"Excess deaths" refers to the difference between the number of deaths actually observed among blacks and the number of deaths that would have occurred if blacks had died at the same rate, for each age and sex, as whites (2).

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