PRB

Wildfire. Drought. Lead Exposure. Oil spill.

Environmental events and changes can have profound effects on our health and jobs and help shape our decisions on where we live.

A new, special issue of the journal, Population and Environment, explores the ways that environmental forces shape people’s lives and behaviors, and identifies policy approaches community leaders can use to plan, adapt, and mitigate risks in specific settings worldwide.

The featured studies draw on the expanding availability of environmental data, which reflects growing interest in the human implications of climate change and the increasing frequency of extreme weather events, report Katherine Curtis, Marcy Carlson, and Malia Jones of the University of Wisconsin-Madison, editors of this special issue.

Much of the research in this journal issue grapples with the impact of dynamic forces in the natural environment on child health and migration:

• U.S. children exposed to air pollution and household lead face a higher risk of incarceration and lower incomes in adulthood.¹ The study also linked high levels of air pollution—disproportionately found in Black and Latino neighborhoods—to a greater likelihood of teen childbearing. White children were much less likely to be exposed to either air pollution or household lead, suggesting that efforts to clean up neighborhood toxins could increase social mobility and decrease inequality. Policy Summary.
• Children whose families lost income or jobs related to the BP Deepwater Horizon oil spill were more likely to have persistent health problems.² Children affected by the oil spill had poorer health compared with their peers, whether they had physical contact with toxins or their household lost jobs or income because of the disaster. While the effects of physical exposure to the oil spill dissipated over time, the effects of related job or income loss persisted. These findings underscore the need for policies and programming that better support the long-term health of children who have experienced a disaster. Policy Summary.
• Climate change-related declines in water availability impact child health and growth in West Africa’s Sahel region.³ Child health and growth suffer in Burkina Faso, Mali, and Senegal when the quality and quantity of surface water (waterholes) declines, analysis shows. These countries are already experiencing chronic food insecurity and childhood malnutrition, and their rapidly growing populations are dependent on livestock and crops in a region predicted to experience hotter and drier conditions. Research results highlight the potential importance of monitoring waterholes and ensuring clean drinking water is available locally for the health of people—especially children—and livestock. Policy Summary.
• Better rainfall linked to more time farming and less time breastfeeding among Ethiopian mothers.⁴ More favorable rainfall conditions for crop production may impact mothers’ time use, possibly reducing the time they have available to breastfeed their babies, the study finds. This information can help policymakers develop targeted interventions that reflect the dynamic needs of farming households, such as suppling technologies that make planting and harvesting more efficient. Policy Summary.
• Climate change-induced extreme heat and wildfire dampen migration in U.S. regions high in natural amenities.⁵Rural counties with outdoor recreation and environmental features such as ample sunshine, dramatic topography, warm and dry climates, and forests are most affected by these migration shifts, researchers find. Policymakers and planners have relied on migration models that predict more people moving to U.S. counties rich in amenities, but climate change is likely to alter migration trends, impacting economic development. Policy Summary.
• Repeated droughts in rural Thailand and Vietnam trap poorer households, reducing migration.⁶ Both household assets and consumption shrink in rural areas that have experienced two years of drought, analysis shows. Particularly among poorer households, this decrease creates an obstacle to those who would migrate for income-earning opportunities. As extreme weather events like drought become more frequent and severe, the need for safety nets and social protection programs, such as cash transfer and insurance programs, becomes crucial, especially when targeted to poorer households. Policy Summary.

Extreme Weather Hits Under-Resourced People Hardest; Research to Support Climate Adaptation Crucial

“Environmental shocks and stressors expose and often exacerbate existing inequalities, taking the greatest toll on the most disadvantaged people,” note Curtis, Carlson, and Jones. They point to the tsunami in Southeast Asia (2004) and Hurricane Katrina in New Orleans (2005) as examples.

The resources and infrastructure needed to plan and adapt to climate events are unevenly distributed around the globe, underscoring the importance of linking scholars with policymakers, they argue.

Recent technological advancements mean that the data and tools needed to identify ways to mitigate climate-related risks are available, notes Barbara Entwisle of the University of North Carolina at Chapel Hill in a piece in the special issue.⁷ Demographers are poised to “contribute significantly to a larger and deeper understanding of environmental change and its consequences, locally, regionally, and globally,” she writes.

But as researchers work with data linked to specific geographic locations, they must strike a balance between privacy and accuracy so that confidentiality is not breached, Lori Hunter of the University of Colorado, Boulder and colleagues assert in another article in the journal.⁸ The authors compare unaltered data from surveys and vegetation information from rural South Africa with similar data generated by a series of geomasking techniques designed to reduce the likelihood that individual respondents can be identified. They find that geomasking approaches that use buffers and account for population density produce the most accurate results. But they also show that higher levels of accuracy increase the likelihood that potential respondents can be identified.

Yet the challenges of this research should not be an obstacle, argue Curtis, Carlson, and Jones. “Environmental change is happening. Environmental events are occurring,” they write. “These environmental forces have demonstrable consequences for human lives and livelihoods and, by extension, for the welfare” of the entire human family.

The special issue of Population and Environment is based on a conference supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) (Grant HD 096853).

Prior to the COVID-19 pandemic, Appalachia’s median household income was on the rise, residents of nearly all ages were more likely to have health insurance than other Americans, and unemployment rates were on par with national levels.

But longstanding vulnerabilities suggest that some groups in the Region risk greater hardship related to the pandemic, including low-income young adults, disabled older adults, students without internet access, and residents of the Region’s rural counties (that is, counties not part of or adjacent to a metropolitan area).

The Appalachian Region: A Data Overview From the 2015-2019 American Community Survey, a new PRB report for the Appalachian Regional Commission, provides a comprehensive picture of social and economic conditions in Appalachia immediately before the onset of the COVID-19 pandemic. Because detailed data for the pandemic period (2016-2020) will not be available until the end of 2021, this report can help program planners and policymakers pinpoint areas and population subgroups most at risk and target assistance.

Many Appalachian Young Adults Were Not Doing Well Before the Pandemic

Before the pandemic began, many young adults ages 18 to 34 were already at a disadvantage in Appalachia. Nearly one in four of those ages 18 to 24 were poor, with income below $25,926 for a family of two adults and two children. This poverty rate is higher than for any other age group in Appalachia. While some individuals in this age group may have low incomes because they are in training programs or college, the high poverty rate also reflects a lack of employment opportunities for young adults in the Region—particularly in rural counties where nearly one in three young people is poor.

One-sixth of adults ages 26 to 34 in the Region lacked health insurance, and this share exceeded 25% among young adults in 79 Appalachian counties—predominately in South Central and Southern Appalachia (see Figure 1). In fact, 26-to-34-year-olds were the only Appalachian age group less likely to have health insurance than their peers living elsewhere in the United States.

Figure 1. Percent of Appalachian Residents Ages 26 to 34 Without Health Insurance, 2015-2019

“Some young adults in Appalachia were struggling before the pandemic began,” says co-author Linda A. Jacobsen, PRB’s vice president for U.S. Programs. “We know that workers without college degrees were hit hardest with income and job losses because of the pandemic and are now having the hardest time getting hired. Many young adults in Appalachia are parents so the economic hardships they face are affecting their children too.”

The Pandemic May Have Heightened Isolation Among Disabled Adults

Among all age groups, the share of Appalachian residents who reported a disability (difficulty with hearing, vision, cognition, walking or climbing, self-care, or independent living) in 2015-2019 was above the national average—with the widest gap among 35-to-64-year-olds (more than four percentage points: 17% in Appalachia versus 12.6% nationwide). In Appalachia’s rural counties, nearly one in four adults ages 35 to 64 and two in five ages 65 and older reported having at least one disability.

In Central Appalachia (counties in eastern Kentucky, southwestern West Virginia, and parts of southwestern Virginia and northeastern Tennessee), nearly half of adults ages 65 and older were disabled, considerably higher than the national average of 34.5% (see Figure 2).

Figure 2. Percent of Appalachian Residents Ages 65 and Older With a Disability, 2015-2019

“Isolation related to stay-at-home orders during the pandemic may have been especially difficult in the Region for disabled residents, particularly those ages 65 and older,” Jacobsen points out. “They may have not been able to get the assistance they needed from agencies because of pandemic shutdowns, and family and friends may have reduced contact to protect them from exposure.”

Appalachia’s Digital Divide Is Most Acute in Rural Counties

Just over 86% of Appalachian households had access to a computer device, more than four percentage points below the national average. The share of households with broadband internet access, at 78%, was nearly five points below the national average. The report found that the digital divide was particularly acute in Appalachia’s rural communities: One in four rural Appalachian households lacked internet access compared with one in five households in rural counties outside the Region. (See Figure 3).

Figure 3. The Digital Divide Is Wider in Rural Appalachia Than in the Rest of Rural America

Source: U.S. Census Bureau, 2015-2019 American Community Survey.

“With most schools closed throughout 2020 due to the COVID-19 pandemic, this rural digital divide has likely made online education and maintaining learning virtually impossible for a large share of children in rural Appalachian counties,” says Kelvin Pollard, PRB senior demographer and report coauthor.

“With high-speed internet access being credited as enhancing economic growth and development, these are signs that many communities in the Region may be at risk of being left behind,” argues Pollard. “The wide use of remote work, online shopping, and telemedicine during the COVID-19 pandemic has put a spotlight on these discrepancies.”

Rural Appalachia Is at a Disadvantage Compared to Elsewhere in Rural America

The report also compares Appalachia’s 107 rural counties to the 840 rural counties outside the Region. It shows that rural Appalachia lagged behind the rest of rural America on a variety of measures such as educational attainment, household income, and population growth.

Labor force participation rates are lower in rural counties within the Region than in rural counties elsewhere in the United States (see Figure 4). Workers in rural Appalachia are also much more likely to work outside their county of residence and have commutes of 30 minutes or more. Levels of disability and poverty are higher across all age groups in rural Appalachia than in rural counties outside the Region.

Figure 4. Rural Appalachia Has Lower Labor Force Participation Rates, Longer Commutes Than the Rest of Rural America

Source: U.S. Census Bureau, 2015-2019 American Community Survey.

“These comparisons suggest that conditions were already more challenging in rural counties within Appalachia than in rural counties outside the Region even before the pandemic brought job and income losses,” says Jacobsen.

The Appalachian Region encompasses 205,000 square miles along the Appalachian Mountains from southern New York to northern Mississippi, including portions of 12 states and all of West Virginia. The Appalachian Regional Commission report uses data from the 2015-2019 American Community Survey and the Census Bureau’s vintage 2019 population estimates—the most recent data available for the characteristics studied. It includes detailed tables and county-level maps covering state- and county-level data on population, age, race and ethnicity, housing occupancy and tenure, housing type, education, computer ownership and internet access, labor force participation, employment and unemployment, transportation and commuting, income and poverty, health insurance coverage, disability status, migration patterns, and veteran status. It also includes a detailed comparison of characteristics in rural Appalachian counties with those outside the Region.

ABOUT THE APPALACHIAN REGIONAL COMMISSION

The Appalachian Regional Commission is an economic development agency of the federal government and 13 state governments focusing on 420 counties across the Appalachian Region. ARC’s mission is to innovate, partner, and invest to build community capacity and strengthen economic growth in Appalachia to help the Region achieve socioeconomic parity with the nation.

An enabling policy environment is a critical step to ensuring that women and girls have access to comprehensive health care, including safe abortion and postabortion care, but too often conversations around abortion are ideological and divisive. The SAFE ENGAGE project supports constructive, data-driven policy dialogue, works with partners to co-create compelling, evidence-based materials, and offers training and technical support to enhance partners’ policy communication skills to reduce unsafe abortion and expand access to safe abortion.

A growing body of research suggests that experiencing racism damages a person’s health by triggering the release of stress hormones and a chain of biological events that cause premature aging, thereby increasing the risk of chronic disease.

April D. Thames and colleagues focus on Black and white adults with similar socioeconomic backgrounds and stress levels, examining their experiences of racial discrimination and blood markers for stress and inflammation.¹

Chronic inflammation can cause premature aging and organ damage, raising the risk of diabetes, heart disease, and high blood pressure. Genes that promote chronic inflammation—activated by the body’s fight-or-flight stress response—are expressed more often in Black adults than in white adults, particularly Black adults who perceive greater levels of racial discrimination.

Thames and colleagues find that exposure to racism and discrimination could potentially account for more than 50% of the difference in the activity of inflammation-triggering genes between Black and white adults. The researchers suggest that racial discrimination should be perceived as a health risk factor on par with smoking, obesity, high blood pressure, and substance abuse.

Black men may be especially vulnerable to racism-related stressors. “Black men have some of the worst health profiles and shortest life expectancies of all race-gender groups in the United States,” write Tyson H. Brown and Taylor W. Hargrove.² Using Health and Retirement Study data, they examine participants’ perceptions of daily challenges associated with unfair treatment and of significant discrimination related to work, housing, lending, and the criminal justice and health care systems.

Brown and Hargrove argue that many traditional research tools developed for the white population do not capture the stressors “most salient for older Black men’s health.” Black men’s disproportionately high risk of contact with the criminal justice system likely shapes their health, they suggest. Also, Black men often experience distress associated with trying to provide economically for their families despite “constrained economic opportunities and racial discrimination in many areas of life.”

Ryon J. Cobb and colleagues focus on allostatic load—the wear and tear on the body caused by chronic stress.³ High allostatic load signals physical dysregulation and premature aging, which contribute to chronic conditions such as diabetes and heart disease. Drawing on a locally representative sample of around 1,200 Black and white adults in the Nashville Stress and Health Study, the researchers find Black adults have significantly higher allostatic loads.

Health disparities related to skin tone also underscore the insidious nature of racism. Cobb and colleagues show that levels of allostatic load vary by Black adults’ skin tone, even after accounting for social and economic differences. The health disparities are largest between white and darker-skinned Black adults and smallest between white and lighter-skinned Black adults.

Because the interviewers identified participants’ skin tone for this study, the findings can “more closely capture the degree to which individuals’ experiences within racialized social interactions vary by how they are racially categorized based on color by others,” the researchers write. The study uncovers the way racism stigmatizes and disadvantages those with the darkest skin the most.

Older Black adults are less likely than their white peers to have private insurance and more likely to rely on Medicaid or Medicare as their only health insurance. Black adults under age 65 who do not qualify for Medicare are also less likely than their white peers to have employer-provided health insurance, creating barriers to care. Black adults who are beneficiaries of Medicare are also more likely than their white peers to receive care in emergency rooms and nursing homes and report fewer doctor’s office visits.¹

Although disparities in health care access persist, the quality of hospitals treating mainly Black patients for heart attacks has improved over the past 20 years. Amitabh Chandra, Pragya Kakani, and Adam Sacarny examined data on Black and white Medicare patients treated for heart attacks.² Black patients received care at lower-performing hospitals more often than did white patients, even when they live in the same ZIP code or hospital service area, they report.

Although the performance gap between hospitals treating mainly Black patients and those treating mainly white patients shrank by more than two-thirds over the past two decades, these gains are a result of performance improvement at the hospitals treating mainly Black patients rather than reallocation of Black patients to better hospitals. Chandra, Kakani, and Sacarny find that improved hospital performance is linked to hospitals adopting use of beta-blocker medications. They suggest that the diffusion of similar low-cost but high-impact technologies may help further reduce disparities.

Many older Black adults mistrust the health care system because of a history of mistreatment and exploitation by health care providers and more recent experiences of family and friends. For 40 years, the Tuskegee Syphilis Study monitored but did not treat hundreds of unsuspecting Black men suffering with syphilis.³ Calling the study an “egregious example of medical exploitation,” Marcella Alsan and Marianne Wanamaker document that the study’s health toll extended far beyond the test subjects. They find evidence that the 1972 public disclosure of the study led to heightened medical mistrust, decreased health care use, and increased mortality before age 75 among Black men, particularly among those living in areas near the study’s subjects.

Alsan and Wanamaker estimate that life expectancy at age 45 for Black men fell by up to 1.4 years in direct response to the study’s 1972 disclosure. This decline in longevity could explain approximately 35% of the life expectancy gap between Black and white men and 25% of the gap between Black men and women in 1980. They argue the disclosure of the Tuskegee study may have stalled, or even reversed, pre-1972 gains in narrowing the racial gap in health care use and mortality.

More diversity in the physician workforce may help close racial health gaps by encouraging use of preventive health services. Older Black male patients assigned to a Black doctor have a much higher take-up of screening services than those assigned to a non-Black doctor.⁴ Alsan, Owen Garrick, and Grant Graziani estimate that having more Black doctors could reduce the Black-white gap in men’s cardiovascular mortality by 19% and in male life expectancy by 8%.

The research team points to examples of past abuse and neglect such as the Tuskegee Syphilis Study to help explain why Black men have higher levels of mistrust of the medical establishment. Whereas older Black adults represent 9% of the population ages 65 and older, Black doctors make up only 4% of U.S. physicians. “Given the current supply of Black doctors, a more diverse physician workforce might be necessary to realize these gains,” they conclude.

A February 2021 survey by the Pew Research Center shows that a majority of Black Americans (61%) plan to get a COVID-19 vaccine or have already received one, a sharp rise from November 2020, when 42% told interviewers that they planned to get vaccinated. Over the three-month period, differences in vaccination plans shrank among Black, white, Hispanic, and Asian American adults.⁵ In January 2021, about 37% of non-Hispanic Black participants reported in a U.S. Census Bureau survey that they will “probably” or “definitely” not get a vaccine, a higher share than among Hispanic, non-Hispanic white, or Asian participants.⁶

Older Americans with dementia, functional limitations, or other disabilities rely on unpaid family caregivers who enable them to live independently or in settings other than nursing facilities. Compared with their white peers, older Black care recipients are more likely to have dementia and incomes below the federal poverty line, report Chanee D. Fabius, Jennifer L. Wolff, and Judith D. Kasper.⁷

Using data from the National Study of Caregiving of the National Health and Aging Trends Study, Fabius, Wolff, and Kasper show that older Black care recipients are more likely than their white counterparts to receive care from an adult child or other relative rather than a spouse. Black caregivers are more likely than white caregivers to report financial strain and receive help from community organizations but less likely to report emotional difficulty related to caregiving. These findings underscore the importance of paid family leave and expanding faith- and community-based programs to better support older Black adults and their unpaid caregivers, the researchers suggest.

Risk of diabetes, heart disease, and stroke increase among Black adults as they age because of poor blood pressure control and diabetes prevention, Uchechi A. Mitchell, Jennifer A. Ailshire, and Eileen M. Crimmins show.¹ Using Health and Retirement Study data, they examine changes in health risks for diabetes, heart disease, and stroke measured by multiple cardiovascular and metabolic biomarkers. The researchers find that older Black adults began the study with a higher number of risk factors than older white and Hispanic adults, and their risk increased over four years, driven by increases in pulse pressure (a measure of stiffening arteries) and blood glucose (an indicator of diabetes).

As they age, Black adults experience more rapid physiological dysregulation, a decline in the body’s ability to recover from stress or damage. Lifestyle and health care factors only explain a fraction of this difference, the researchers note. They point to a variety of potential explanations, including:

• Economic hardship. A larger proportion of Black adults reported inconsistent medication use due to costs.
• Shortcomings in primary disease prevention. Among individuals considered healthy at the beginning of the study, older Black adults were four times more likely to develop high blood glucose levels.
• Structural factors. Maintaining ideal biomarker levels is more difficult for populations that have encountered systemic discrimination and barriers to quality health care.
• Difficulty managing chronic disease over time. A difference in the onset of high-risk pulse pressure was observed between older Black and white adults who, at baseline, had successfully controlled their blood pressure.
• The effects of discrimination-related stress. The adverse effects of discrimination on blood pressure and other physiological outcomes are well documented and may explain why older Black adults, a population disproportionately exposed to discrimination, are less likely to maintain blood pressure and glucose control.

Older Black adults also have persistently higher rates of disability relative to white adults. Between 1980 and 2000, older white adults experienced consistent declines in disability levels, but older Black adults saw little improvement and possibly an increase in disability.² Miles G. Taylor, Scott M. Lynch, and Stephanie Ureña focus on disability related to inability to perform the basic activities of daily living, such as bathing and dressing, using the National Long-Term Care Survey. They identify three health factors strongly linked to disability among Black adults: stroke, diabetes, and heart attack. These factors also are related to obesity, which is implicated in increases in disability among the general U.S. population.

“Although we find no consistent improvements among older Black adults, and link these to particularly disabling conditions, it is possible that white older adults were simply more advantaged in terms of resources needed to carry out these tasks independently,” they write.

Black adults may be less likely to have accessible home environments. For example, a decline in the share of white adults who have trouble bathing may reflect better physical function or an increase in the availability of walk-in showers in white households.

“Increased accessibility to medications and treatments for heart attack, stroke, and diabetes among older African Americans may reduce the severity of disablement,” Taylor, Lynch, and Ureña write. Greater access to assistive devices (such as walkers and wheelchairs) and changes to living environments (such as grab bars and ramps) may contribute to better physical function among older Black adults.

There is also some good news. Improved diagnosis and treatment of high blood pressure and high cholesterol reduced racial disparities in cardiovascular disease (CVD) risk between 1990 and 2010, Mitchell and colleagues show.³ The racial gap in CVD risk narrowed for women because of improved blood pressure and lipid profiles among Black women and increasing obesity prevalence among white women.

Whether these trends will continue or translate into further declines in disparities in deaths from CVD is unclear, they write. Recent increases in obesity may offset some of the improvements seen in the 1990s to 2010s and “may lead to a slowing or reversal of trends in racial disparities in total cardiovascular risk.”

In 2020, COVID-19 deaths appear to have eliminated many of the gains made since 2006 in closing the Black-white life expectancy gap.¹ Theresa Andrasfay and Noreen Goldman projected the gap in life expectancy at birth between Black and white Americans would widen by nearly 40% in 2020—from 3.6 years to more than 5 years—reflecting how the pandemic has “laid bare the risks associated with social and economic disadvantage.” They estimated COVID-19 deaths would reduce average years remaining at age 65 by 1.7 years for Black people and 0.6 years for white people. As Andrasfay and Goldman point out, Black Americans’ higher rates of chronic conditions and disease such as obesity and diabetes may underlie these life expectancy differences as these factors are linked to fatal COVID-19 infections.

Differences in obesity, smoking, and education levels help explain the Black-white disparity in premature death.² Using data on Americans ages 40 to 79 from the National Health and Nutrition Examination Survey, Irma T. Elo, Neil Mehta, and Samuel Preston explore what would happen to the Black-white mortality gap if Black Americans had the same obesity rate, smoking prevalence, and educational distribution as their white peers.

Elo, Mehta, and Preston find that key risk factors for premature death are obesity among Black women and smoking among Black men (see table). Lower educational attainment among both Black men and women also contributes to the Black-white mortality gap. Low educational attainment is associated not only with smoking and obesity but also with lifelong economic hardship, inferior access to health care, and a range of other factors pertinent to health, the researchers report. Smoking may be a way of coping with stressful life conditions, they suggest.

TABLE. Smoking, Obesity, and Education Levels Explain a Large Share of Black-White Differences in Premature Death

Key Risk Factors Contributing to Black-White Differences in Mortality Among Men and Women Ages 40-79 (in Percentages)

Source: Irma T. Elo, Neil Mehta, and Samuel Preston, “The Contribution of Weight Status to Black-White Differences in Mortality,” Biodemography and Social Biology 63, no. 3 (2017): 206-20, https://doi.org/10.1080/19485565.2017.1300519.

In 2010, diabetes was responsible for reducing life expectancy by slightly more than one year among Black women at age 30 and by an average of about 10 months among all Americans, Preston and colleagues show in another study.³ Given that life expectancy grew by only 0.1 years between 2011 and 2015, they argue that diabetes plays a major role in reducing U.S. longevity, particularly among Black women.

By age 50, Black parents are up to twice as likely as white parents to have experienced the stressful and traumatic death of a child, Rachel Donnelly and colleagues report.⁴ Using data from the nationally representative Health and Retirement Study, they show that losing a child is related to heightened mortality risk among both aging Black and white parents.

“Black Americans already face higher mortality rates compared to white Americans, and the unequal burden of child death adds to their mortality risk,” the research team writes. To reduce racial disparities in health and mortality, they argue for policies and programs designed to address “the unequal burden of family loss experienced in black communities.”

As the novel coronavirus has spread across the United States, Black Americans have been disproportionately affected by infections and deaths. Among Black Americans ages 65 and older, death rates from COVID-19, the disease caused by the coronavirus, appear to be three times that of their white peers.¹

The pandemic has shone a spotlight on well-documented and long-standing health disparities between Black and white Americans. Compared with their white counterparts, Black men and women have lower life expectancies and a higher prevalence of health conditions such as hypertension, diabetes, dementia, stroke, and cancer.

Growing evidence suggests that a variety of social factors, not genetics, drive this health inequality—including lower levels of education and income, less access to and lower quality health care, and the toll that racism-related stress takes on the body’s defenses. These factors combine with a higher risk of exposure at work and in multigenerational households to help explain why older Black adults have been especially vulnerable to COVID-19 (download the full issue in the left sidebar, or see more content from this issue under “In Six Parts” below. )

This brief summarizes what we know about Black-white health inequality at older ages, focusing on the recent work of researchers supported by the National Institute on Aging. It explores trends and examines the underlying structural forces shaping racial health disparities. These findings can help lawmakers design policies to address these inequalities and help improve health and prevent early death among Black Americans.

Racial Health Disparities Have Policy Implications

The COVID-19 pandemic laid bare long-standing racial health disparities woven deeply into U.S. social structures. Older Black adults have been disproportionately burdened by the pandemic—reflecting more limited health care access, greater job and household exposure to the coronavirus, and higher rates of underlying health conditions, all of which increase vulnerability to severe illness and death.

Trends summarized in this report show that Black-white health disparities related to cardiovascular disease narrowed somewhat related to improvements in diabetes and blood pressure control. Better prevention and treatment of chronic disease and obesity could help shrink the racial gaps in life expectancy and chronic disease.

But socioeconomic inequality and racism-related stress are at the root of Black-white health disparities, requiring policies and interventions targeting both economic inequality and exposure to high levels of stress. Comprehensive action is needed to close health gaps, including criminal justice reform, expanded health care access, job guarantees and desegregation of schools, jobs, and neighborhoods. There is no magic bullet to eliminate long-standing Black-white disparities in health and mortality, but understanding these gaps and their causes is an important first step toward achieving equity.

Expanded educational opportunities during the early part of the 20th century are related to recent declines in dementia prevalence among both older non-Hispanic Black and non-Hispanic white adults, Mark D. Hayward and colleagues show.¹ Their review of Health and Retirement Study (HRS) data from 2000 to 2014 documents significant declines in dementia prevalence for both older non-Hispanic Black and non-Hispanic white adults. Non-Hispanic Black adults ages 65 to 74 experienced the steepest decline. Analysis demonstrates that higher levels of educational attainment are related to the recent declines in dementia prevalence.

Findings by Hayward and colleagues echo numerous studies that link more schooling with a lower risk of dementia. Researchers theorize that education may directly affect brain development by creating a cognitive reserve (stronger connections among brain cells) that older adults can draw on if their memory or reasoning ability begins to decline with dementia. They also suspect that people with more education may be better able to compensate or adapt in the face of disrupted mental functions. In addition, education brings multiple advantages: people with more education tend to have healthier lifestyles, higher incomes, better health care, and more social opportunities—all associated with better brain health.

In a related study based on HRS data, Mateo P. Farina and colleagues use modeling techniques to simulate dementia prevalence among different racial and ethnic groups and find lower dementia prevalence in both Black and white Americans with more education, especially at older ages.²

However, they also find that Black adults who have not finished high school are at much greater risk of dementia than other groups, even white adults without a high school diploma (see figure). In fact, dementia prevalence for Black adults at age 65 without a high school diploma is similar to that of Black adults at age 75 with a high school education and white adults at age 85 with at least some college.

FIGURE. Older Black Americans Who Did Not Graduate From High School Face a Higher Risk of Dementia

Implied Dementia Prevalence Among Black and White Older Adults by Age and Education Levels, 2000-2014

Source: Mateo P. Farina et al., “Racial and Educational Disparities in Dementia and Dementia-Free Life Expectancy,” The Journals of Gerontology: Series B, Psychological Sciences and Social Sciences 75, no. 7 (2020): Figure 1.

These findings show the importance of intersectionality—the overlapping of social disadvantages, compounding the impact—in explaining health disparities (see below). “When race and socioeconomic status are combined in empirical research, they intersect in ways that typically exaggerate disparities because of the distinct racialized and class-based exposures that affect health outcomes,” Farina and colleagues conclude.

Vicki Freedman and colleagues identify large and growing disparities in dementia risk by race/ethnicity, which could slow progress in cutting dementia levels. Among those ages 70 and older, dementia prevalence in the non-Hispanic Black population is estimated at 12.7%, compared with 8.4% among non-Hispanic white adults.³

Closing gaps in educational attainment is one way to reduce this Black-white disparity in dementia prevalence. But more research is needed to “unpack the ‘black box’ of how early-life education decreases later-life dementia risk,” writes Kenneth M. Langa.⁴

Bereavement also may be contributing to racial disparities in dementia risk, Debra Umberson and colleagues show.⁵ Their analysis of HRS data provides evidence that experiencing the death of a child prior to midlife (before a parent reaches age 40)—a tragedy more common for Black parents than for white parents—is related to increased dementia risk. The researchers find links between child loss and a variety of factors that may raise dementia risk, including depression, diminished earnings, alcohol consumption and smoking, and cardiovascular disease.

Researchers also note the need for better methods to measure dementia prevalence across different groups. Estimates of the Black-white gap in dementia prevalence differ across data sources based on whether they determine dementia using cognitive tests (via those in the HRS) or physician diagnosis (via Medicare claims). Yi Chen and colleagues find that older Black adults and individuals with less than a high school education are more likely than older white adults and college-educated individuals, respectively, to be identified as having dementia based on cognitive tests only.⁶ In contrast, dementia ascertained by only physician diagnosis yields similar prevalence rates for older Black and white adults and among older adults with different levels of education.

Chen and colleagues show that in the years following cognitive decline in older adults, only a small portion (15%) never receive a dementia diagnosis. However, Black and Hispanic adults, and people with low levels of education, are at higher risk of having a delayed or no dementia diagnosis. Both cognitive tests and a physician diagnosis have limitations, the researchers conclude, yet methodological advances and policy changes may be improving identification and diagnosis of dementia among different groups.

Intersectionality: Disparities Compound to Increase Negative Health Impacts

Mounting evidence shows that health disparities related to race/ethnicity, gender, and socioeconomic status interact, increasing health disadvantages. The health risk of compounded disparities is not the sum of each but a multiple of all.

For instance, older Black females experience especially poor health, Tyson H. Brown and colleagues show based on data from the nationally representative HRS.⁷ The researchers focused on self-reported health, a measure that previous studies show is more closely related to a person’s actual health status.

Brown and colleagues demonstrate that the effects of racial/ethnic, gender, and socioeconomic inequality on health interact to produce inequalities in health among women. They show that Black and Mexican American women have elevated risks of poor health above and beyond what would have been predicted by simply examining race/ethnicity or gender alone. Having higher levels of education—an advantage—is more strongly related to better health among white men and women than among their Black and Mexican American peers.

Being a Black woman is associated with increased risk of having hypertension (high blood pressure) beyond that related to being Black or female separately, a study by Liana J. Richardson and Brown based on HRS data shows.⁸ They also find that Black women experience elevated rates of hypertension at younger ages than do other racial or ethnic groups.

“We interpret racial/ethnic and gender inequalities, not as effects of race/ethnicity and gender per se, but rather as a result of relations of domination and subordination stemming from racism, sexism, and their consequences for class inequality,” Richardson and Brown write.

They emphasize the importance of taking gender into account when focusing on racial/ethnic disparities so interventions can target groups at highest risk. Policies and interventions should recognize that age, racial/ethnic, and gender inequalities operate together to increase hypertension risk, they argue.

Adults ages 60 and older are at higher risk of severe illness and death from COVID-19, the disease caused by the novel coronavirus. However, older Black Americans are especially at risk. The latest provisional data from the Centers for Disease Control and Prevention show that while non-Hispanic Black adults make up 10% of the population ages 65 to 74, they account for 18% of COVID-19-related deaths in that age group.¹

The pandemic’s heavy toll on older Black Americans is linked to structural racism—larger systems of inequality embedded in major U.S. social institutions, Marc A. Garcia and colleagues argue.² These unequal structures limit Black Americans’ access to quality health care and increase their overall risk for chronic disease, premature aging, and COVID-19 infection.

Black Americans have less wealth than white Americans and are more likely to live in multigenerational and extended family households, making it hard to isolate and increasing their risk of contracting COVID-19, Garcia and colleagues point out. Black adults are also overrepresented in high-contact jobs, such as food service and retail, which cannot be done from home. These jobs tend to be lower paying and lack health benefits and paid sick leave.

The stress of living in a society with compounding, daily instances of discrimination, creates “weathering,” a process that increases stress hormones and inflammation, triggering premature aging, Garcia and colleagues explain. Weathering contributes to older Black adults’ higher rates of obesity, cardiovascular disease, diabetes, hypertension, and chronic lung disease relative to white adults. These underlying conditions put older Black adults at higher risk of complications from COVID-19, and when they become ill, they are less likely than older white adults to have access to quality medical care.

Garcia and colleagues argue that structural racism “drives weathering processes resulting in the greater chronic disease burden” among Black Americans “that elevates their risk of health complications and death from COVID-19.”

Linda M. Chatters, Henry Owen Taylor, and Robert Joseph Taylor point to several additional factors contributing to older Black adults’ higher risk for illness and death related to COVID-19:³

• Racial residential segregation. A growing body of research shows that because of discriminatory housing practices such as redlining, older Black adults are more likely to live in racially segregated neighborhoods characterized by higher rates of poverty, lack of health care services and amenities (such as grocery stores and parks), and poorly maintained housing and infrastructure. In addition to contributing to higher rates of stress, chronic disease, and functional impairments, these neighborhood conditions influence and heighten older Black adults’ coronavirus exposure and risk of severe infection.
• Racial disparities in long-term care facilities. The nursing homes and other group-living settings where older Black Americans live tend to be characterized by low levels of services, support, and oversight, jeopardizing residents’ health and putting them at high risk of COVID-19 exposure and severe infection and death.

Reducing racial disparities in COVID-related deaths will require addressing multiple aspects of structural racism, but Garcia and colleagues argue that important starting points include ensuring that testing and vaccines are available in African American communities, that low-wage workers have access to personal protective equipment and economic relief, and that health organizations’ practices do not have a disparate impact on low-income older Black adults.