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ABSTRACT: Current US surveillance data provide estimates of diabetes using laboratory tests at the national level as well as self-reported data at the state level. Self-reported diabetes prevalence may be biased because respondents may not be aware of their risk status. Our objective was to estimate the prevalence of diagnosed and undiagnosed diabetes by state.
We estimated undiagnosed diabetes prevalence as a function of a set of health system and sociodemographic variables using a logistic regression in the National Health and Nutrition Examination Survey (2003-2006). We applied this relationship to identical variables from the Behavioral Risk Factor Surveillance System (2003-2007) to estimate state-level prevalence of undiagnosed diabetes by age group and sex. We assumed that those who report being diagnosed with diabetes in both surveys are truly diabetic.
The prevalence of diabetes in the U.S. was 13.7% among men and 11.7% among women >/= 30 years. Age-standardized diabetes prevalence was highest in Mississippi, West Virginia, Louisiana, Texas, South Carolina, Alabama, and Georgia (15.8 to 16.6% for men and 12.4 to 14.8% for women). Vermont, Minnesota, Montana, and Colorado had the lowest prevalence (11.0 to 12.2% for men and 7.3 to 8.4% for women). Men in all states had higher diabetes prevalence than women. The absolute prevalence of undiagnosed diabetes, as a percent of total population, was highest in New Mexico, Texas, Florida, and California (3.5 to 3.7 percentage points) and lowest in Montana, Oklahoma, Oregon, Alaska, Vermont, Utah, Washington, and Hawaii (2.1 to 3 percentage points). Among those with no established diabetes diagnosis, being obese, being Hispanic, not having insurance and being >/= 60 years old were significantly associated with a higher risk of having undiagnosed diabetes.
Diabetes prevalence is highest in the Southern and Appalachian states and lowest in the Midwest and the Northeast. Better diabetes diagnosis is needed in a number of states.
Population Health Metrics 09/2009; 7:16. · 2.11 Impact Factor
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ABSTRACT: RATIONALE: Since 2001, Mexico has designed and implemented a comprehensive health reform, an essential component of which is called Seguro Popular (SP). This program aims to provide medical care, preventative services, and financial protection to the approximately 50 million Mexicans without health coverage by 2010. The program intends to focus enrollment on the most vulnerable families - poor, rural, indigenous and female-headed households. Indeed, it mandates free insurance to all families in the poorest two income deciles, but requires contributions from enrollees with higher income. To encourage enrollment and improve service quality, Mexico's state ministries of health receive reimbursement for each affiliated family, along with separate funds to improve infrastructure in underserved areas. OBJECTIVES: This study evaluates each Mexican state's enrollment performance based on the ratio of actual versus expected affiliation. We also verify whether states fulfill their SP enrollment goals by corroborating official enrollment reports with household surveys and define the discrepancy between these data sources as effective affiliation. In addition, we calculate each state's payment gap, the number of families in the third income decile or above that receive coverage without having to pay. Finally, we investigate the household characteristics of families that forgo enrollment, even though they are eligible for free coverage. METHODS: Mexico's states differ markedly in socio-demographic variables and the timing of their association to the SP program. To compare each state's affiliation performance, we predict a family's probability of affiliation given household covariates. Multiple surveys are used to generate an expected number of affiliates: the Mexican 2005 Census, a state-representative health survey called ENSANut 2005-2006, and the 1-year follow-up survey in 7 states with especially intensive affiliation efforts. Then, we aggregate each family's probability of affiliation to generate a state's expected number of enrollees and calculate performance: the ratio of observed to expected affiliates. At the state level, we control for time associated to SP and already existing health infrastructure using SINERHAIS, a national database of health infrastructure. Data on official affiliation comes from the Padron del Seguro Popular 2002-2006, a registry of all affiliated individuals. RESULTS: By the beginning of 2006, Mexico had enrolled 2.3 million families in SP, about 10% of the nation. Nevertheless, affiliation performance differed significantly between states. The observed versus expected affiliation ratio was lowest for states that recently began enrollment. In addition, we found that effective affiliation remains significantly lower than official statistics, meaning that families are not taking full advantage of their SP benefits. Moreover, the payment gap was widest for the wealthiest states and those that began affiliation earliest. CONCLUSIONS: Mexico's recent initiative represents one of the largest health reforms in decades and has already improved social protection for many. However, these successes must not distract from continued enrollment of Mexico's most vulnerable citizens and improved data collection. The conclusions from this analysis can recommend changes both in Mexico and other nations seeking to improve health-system equity, efficiency, and population health.
Health Care Law & Policy eJournal. 06/2007;
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ABSTRACT: Rationale: Ambitious targets have been set to reduce the burden of disease caused by malaria, and funding to do so has increased. In spite of the large increase in funding, many countries are still far from meeting targets. The Roll Back Malaria global partnership was founded in 1998 with the ambitious goals to halve malaria-associated mortality by 2010 and again by 2015. Core targets of RBM include having at least 60% of all children and pregnant women sleeping under an insecticide treated net (ITN); ensuring that 60% of all children with malaria symptoms are treated with a nationally approved antimalarial within 24 hours of onset of symptoms; and providing at least 60% of all pregnant women with intermittent preventive treatment (IPT). Financial resources to support these goals increased significantly following the creation of the Global Fund for Aids, Tuberculosis and Malaria (GFATM) in 2001. The GFATM had committed almost $2 billion by early November 2006 to scale up targeted interventions to fight malaria in Africa and other malarious countries There is a growing interest in examining the extent to which GFATM resources are impacting on the variables of interest, which are health service coverage and population outcomes. Objectives. This study seeks to achieve three specific objectives: assess the progress made towards meeting the global malaria targets contained in RBM and MDG goals; test the effect of GFATM on access to treatment and prevention in Africa; and identify factors for success Methods. The study uses data from multiple household-based surveys principally demographic and health surveys (DHS), the multiple indicator cluster survey (MICS) and malaria indicator survey available for the period 1999-2006. We examine trends in coverage in the data. Further, several regression analyses are performed to test the effects of GFATM and country-level characteristics on coverage of ITN, prompt treatment and IPT. The dependent variable in these regression models was coverage of ITNs, ACT and IPT for pregnant women. Finally, a literature search was conducted to learn about some specific factors that may have been responsible for success or failure in a sample of national programs. Results. Overall, the study reports that some progress towards meeting some of the RBM targets has been made in a few countries. However, only a few countries have reached the one of the Abuja targets of 60% coverage of ITNs. Progress by intervention has not been uniform as in many cases while ITN coverage has increased we note that coverage of access to treatment especially with ACTs has been sluggish. Clearly, more external funding is required to bring many countries closer to the targets. Country-level factors have also been found to affect progress. Finally, the study discusses the limitations and difficulties associated with current monitoring frameworks for tracking progress.
Public Health Law & Policy eJournal. 06/2007;
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ABSTRACT: Rationale: New global funding mechanisms for HIV/AIDS have arisen in the wake of a concerted global effort to mobilize support for the fight against HIV/AIDS - namely, the Global Fund for AIDS, Tuberculosis and Malaria (GFATM) in 2001 and the Presidents Emergency Plan for AIDS Relief (PEPFAR) in 2003. In 2003, WHO initiated "3 by 5", a campaign to place 3 million individuals, or roughly 50% of those in need, on ART by December 2005. Although the targets set by 3 by 5 have not been achieved, the demonstrated efficacy of ART in rich countries and in resource-poor setting provides a strong rationale for continued emphasis on expanding coverage. External funding to support the rapid scale-up of ART has signifcantly increased. However, questions remain regarding the actual increase in treatment coverage of the population in need that has been achieved, and the possible overestimation of the numbe of people receiving treatment, claimed by different programs. Objective: In this analysis, we will analyze the impact of spending on HIV/AIDS on targets set by global health organizations. Specifically, we will assess the relative contributions and overall impact of Global Fund and PEPFAR spending on observed trends in ART coverage. Methods: To quantify the impact of Global Fund and PEPFAR spending on scaling up ART coverage, we use ART coverage - the ratio of treatment utilization to estimated need for ART - as the outcome variable in analysis. We obtain these variables separately from UNAIDS country-specific epidemiological fact sheets and from online databases available from the WHO. The consistency of estimates across sources is investigated. Disbursement information for HIV/AIDS was obtained from the Global Fund and PEPFAR websites. Additional covariates - GDP per capita and indicators of government effectiveness - were included in the model to investigate the influence of other country-level determinants. Results: Our preliminary findings suggest that countries receiving concurrent assistance from the Global Fund and PEPFAR are experiencing increases in rates of ART coverage. Conclusion: We find that Global Fund and PEPFAR spending are having a positive impact on the expansion of ART coverage. These results must be interpreted with caution due to data quality issues such as cross-country discrepancies in how coverage data was collected and reported. Because the organizations function differently in ways that might influence spending outcomes, future work to disentangle the relative contributions of Global Fund and PEPFAR to these outcomes is especially important.
HEN: Financing & Budgeting (Topic). 06/2007;
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ABSTRACT: Rationale: In spite of the fact that a cost-effective cure for tuberculosis (TB) was developed more than fifty years ago, about two billion people - comprising one third of the world's population - are infected with the mycobacteria that cause TB. Of those infected two million die of this air-borne infectious disease each year. At the same time, we are facing two new challenges: the rising incidence of drug-resistant TB disease and the growth of the HIV/AIDS pandemic. The Millennium Development Goals proposed that, by 2005, the detection rate of new smear-positive cases should be raised to 70% and successful treatment of these detected case should reach 85%. Unfortunately, we have failed to achieve these goals. The Global Fund was created in 2002 to combat AIDS, TB and Malaria by raising and disbursing funds to countries. To date, the Global Fund has approved 81 grants in 69 countries for TB and TB/HIV co-infection programs and has disbursed about 426 million dollars to recipients. Objective: In this study, we want to investigate, after several years of implementation, whether or not the Global Fund has contributed to achieving the targets set by the MDGs. Methods: To assess the performance of Global Fund spending against the MDG goals for TB control, we use data till 2005 from various sources. The outcome variables - case notification rates with new smear positive and treatment success of smear positives - are from WHO's Global TB Database. Disbursement information was obtained from the Global Fund and other independent variables such as GDP per capita and indicators of government effectiveness were obtained from UN, World Bank and IMF online databases. Various estimation methods and model specifications are tested. A panel analysis using the fixed-effects model is finally adopted for this study. We also assume different timing of the effect to examine the sensitivity of our findings. Results: We find that the Global Fund has a positive effect on case notification rates and estimates are significant. The results are robust to various model specifications and timing of effect. The preliminary results also show that there is a positive impact of Global Fund spending on countries with high-TB burden or low income countries. Conclusion: With the data observed, we find that Global Fund spending is helping recipient countries to improve case notification rates.
HEN: Other Specific Diseases or Therapies (Sub-Topic). 06/2007;
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The Lancet 06/2007; 369(9575):1768-9. · 38.28 Impact Factor
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Catherine Michaud,
Matthew McKenna,
Stephen Begg,
Niels Tomijima,
Meghna Majmudar,
Maria Bulzacchelli,
Shahul Ebrahim,
Majid Ezzati,
Joshua Salomon,
Gaber Kreiser Jessica,
Mollie Hogan, Christopher Murray
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ABSTRACT: Abstract
Background
Burden of disease studies have been implemented in many countries using the Disability-Adjusted Life Year (DALY) to assess major health problems. Important objectives of the study were to quantify intra-country differentials in health outcomes and to place the United States situation in the international context.
Methods
We applied methods developed for the Global Burden of Disease (GBD) to data specific to the United States to compute Disability-Adjusted Life Years. Estimates are provided by age and gender for the general population of the United States and for each of the four official race groups: White; Black; American Indian or Alaskan Native; and Asian or Pacific Islander. Several adjustments of GBD methods were made: the inclusion of race; a revised list of causes; and a revised algorithm to allocate cardiovascular disease garbage codes to ischaemic heart disease. We compared the results of this analysis to international estimates published by the World Health Organization for developed and developing regions of the world.
Results
In the mid-1990s the leading sources of premature death and disability in the United States, as measured by DALYs, were: cardiovascular conditions, breast and lung cancers, depression, osteoarthritis, diabetes mellitus, and alcohol use and abuse. In addition, motor vehicle-related injuries and the HIV epidemic exacted a substantial toll on the health status of the US population, particularly among racial minorities. The major sources of death and disability in these latter populations were more similar to patterns of burden in developing rather than developed countries.
Conclusion
Estimating DALYs specifically for the United States provides a comprehensive assessment of health problems for this country compared to what is available using mortality data alone.
Population Health Metrics. 01/2006;
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ABSTRACT: BACKGROUND: Sub-national figures providing information about the wealth of the population are useful in defining the spatial distribution of both economic activity and poverty within any given country. Furthermore, since several health indicators such as life expectancy are highly correlated with household welfare, sub-national figures allow for the estimation of the distribution of these health indicators within countries when direct measurement is difficult.We have developed methods that utilize spatially distributed information, including night-time light imagery and population to model the distribution of income per capita, as a proxy for wealth, at the country and sub-national level to support the estimation of the distribution of correlated health indicators. RESULTS: A first set of analysis are performed in order to propose a new global model for the prediction of income per capita at the country level. A second set of analysis is then confirming the possibility to transfer the country level approach to the sub-national level on a country by country basis before underlining the difficulties to create a global or regional models for the extrapolation of sub-national figures when no country data set exists. CONCLUSIONS: The methods described provide promising results for the extrapolation of national and sub-national income per capita figures. These results are then discussed in order to evaluate if the proposed methods could not represent an alternative approach for the generation of consistent country specific and/or global poverty maps disaggregated to some sub-national level.
International Journal of Health Geographics 03/2005; 4(1):5. · 2.62 Impact Factor
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ABSTRACT: Abstract
Background
In 2002, the World Health Organization published a health system performance ranking for 191 member countries. The ranking was based on five indicators, with fixed weights common to all countries.
Methods
We investigate the feasibility and desirability of using mathematical programming techniques that allow weights to vary across countries to reflect their varying circumstances and objectives.
Results
By global distributional measures, scores and ranks are found to be not very sensitive to changes in weights, although differences can be large for individual countries.
Conclusions
Building the flexibility of variable weights into calculation of the performance index is a useful way to respond to the debates and criticisms appearing since publication of the ranking.
BMC Health Services Research. 01/2004;
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ABSTRACT: Abstract
Background
Healthy life expectancy – sometimes called health-adjusted life expectancy (HALE) – is a form of health expectancy indicator that extends measures of life expectancy to account for the distribution of health states in the population. The World Health Organization reports on healthy life expectancy for 192 WHO Member States. This paper describes variation in average levels of population health across these countries and by sex for the year 2002.
Methods
Mortality was analysed for 192 countries and disability from 135 causes assessed for 17 regions of the world. Health surveys in 61 countries were analyzed using new methods to improve the comparability of self-report data.
Results
Healthy life expectancy at birth ranged from 40 years for males in Africa to over 70 years for females in developed countries in 2002. The equivalent "lost" healthy years ranged from 15% of total life expectancy at birth in Africa to 8–9% in developed countries.
Conclusion
People living in poor countries not only face lower life expectancies than those in richer countries but also live a higher proportion of their lives in poor health.
BMC Public Health. 01/2004;
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ABSTRACT: Population Health Metrics is an open-access online electronic journal published by BioMed Central - it is universally and freely available online to everyone, its authors retain copyright, and it is archived in at least one internationally recognised free repository. To fund this, from November 1 2003, authors of articles accepted for publication will be asked to pay an article-processing charge of US$500. This editorial outlines the reasons for the introduction of article-processing charges and the way in which this policy will work.Waiver requests will be considered on a case-by-case basis, by the Editor-in-Chief. Article-processing charges will not apply to authors whose institutions are 'members' of BioMed Central. Current members include NHS England, the World Health Organization, the US National Institutes of Health, Harvard, Princeton and Yale universities, and all UK universities. No charge is made for articles that are rejected after peer review. Many funding agencies have also realized the importance of open access publishing and have specified that their grants may be used directly to pay APCs.
Population Health Metrics 12/2003; 1(1):8. · 2.11 Impact Factor
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ABSTRACT: Valid, reliable and comparable measures of the health states of individuals and of the health status of populations are critical components of the evidence base for health policy. We need to develop population health measurement strategies that coherently address the relationships between epidemiological measures (such as risk exposures, incidence, and mortality rates) and multi-domain measures of population health status, while ensuring validity and cross-population comparability.Studies reporting on descriptive epidemiology of major diseases, injuries and risk factors, and on the measurement of health at the population level - either for monitoring trends in health levels or inequalities or for measuring broad outcomes of health systems and social interventions - are not well-represented in traditional epidemiology journals, which tend to concentrate on causal studies and on quasi-experimental design. In particular, key methodological issues relating to the clear conceptualisation of, and the validity and comparability of measures of population health are currently not addressed coherently by any discipline, and cross-disciplinary debate is fragmented and often conducted in mutually incomprehensible language or paradigms. Population health measurement potentially bridges a range of currently disjoint fields of inquiry relating to health: biology, demography, epidemiology, health economics, and broader social science disciplines relevant to assessment of health determinants, health state valuations and health inequalities.This new journal will focus on the importance of a population based approach to measurement as a way to characterize the complexity of people's health, the diseases and risks that affect it, its distribution, and its valuation, and will attempt to provide a forum for innovative work and debate that bridge the many fields of inquiry relevant to population health in order to contribute to the development of valid and comparable methods for the measurement of population health and its determinants.
Population Health Metrics 05/2003; 1(1):6. · 2.11 Impact Factor
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ABSTRACT: Reliable and comparable analysis of risks to health is key for preventing disease and injury. Causal attribution of morbidity and mortality to risk factors has traditionally been conducted in the context of methodological traditions of individual risk factors, often in a limited number of settings, restricting comparability.In this paper, we discuss the conceptual and methodological issues for quantifying the population health effects of individual or groups of risk factors in various levels of causality using knowledge from different scientific disciplines. The issues include: comparing the burden of disease due to the observed exposure distribution in a population with the burden from a hypothetical distribution or series of distributions, rather than a single reference level such as non-exposed; considering the multiple stages in the causal network of interactions among risk factor(s) and disease outcome to allow making inferences about some combinations of risk factors for which epidemiological studies have not been conducted, including the joint effects of multiple risk factors; calculating the health loss due to risk factor(s) as a time-indexed "stream" of disease burden due to a time-indexed "stream" of exposure, including consideration of discounting; and the sources of uncertainty.
Population Health Metrics 05/2003; 1(1):1. · 2.11 Impact Factor
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ABSTRACT: Information on the unit cost of inpatient and outpatient care is an essential element for costing, budgeting and economic-evaluation exercises. Many countries lack reliable estimates, however. WHO has recently undertaken an extensive effort to collect and collate data on the unit cost of hospitals and health centres from as many countries as possible; so far, data have been assembled from 49 countries, for various years during the period 1973-2000. The database covers a total of 2173 country-years of observations. Large gaps remain, however, particularly for developing countries. Although the long-term solution is that all countries perform their own costing studies, the question arises whether it is possible to predict unit costs for different countries in a standardized way for short-term use. The purpose of the work described in this paper, a modelling exercise, was to use the data collected across countries to predict unit costs in countries for which data are not yet available, with the appropriate uncertainty intervals.The model presented here forms part of a series of models used to estimate unit costs for the WHO-CHOICE project. The methods and the results of the model, however, may be used to predict a number of different types of country-specific unit costs, depending on the purpose of the exercise. They may be used, for instance, to estimate the costs per bed-day at different capacity levels; the "hotel" component of cost per bed-day; or unit costs net of particular components such as drugs.In addition to reporting estimates for selected countries, the paper shows that unit costs of hospitals vary within countries, sometimes by an order of magnitude. Basing cost-effectiveness studies or budgeting exercises on the results of a study of a single facility, or even a small group of facilities, is likely to be misleading.
Cost Effectiveness and Resource Allocation 03/2003; 1(1):3. · 0.87 Impact Factor
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ABSTRACT: This article provides a description of the population model PopMod, which is designed to simulate the health and mortality experience of an arbitrary population subjected to two interacting disease conditions as well as all other "background" causes of death and disability. Among population models with a longitudinal dimension, PopMod is unique in modelling two interacting disease conditions; among the life-table family of population models, PopMod is unique in not assuming statistical independence of the diseases of interest, as well as in modelling age and time independently. Like other multi-state models, however, PopMod takes account of "competing risk" among diseases and causes of death.PopMod represents a new level of complexity among both generic population models and the family of multi-state life tables. While one of its intended uses is to describe the time evolution of population health for standard demographic purposes (e.g. estimates of healthy life expectancy), another prominent aim is to provide a standard measure of effectiveness for intervention and cost-effectiveness analysis. PopMod, and a set of related standard approaches to disease modelling and cost-effectiveness analysis, will facilitate disease modelling and cost-effectiveness analysis in diverse settings and help make results more comparable.
Cost Effectiveness and Resource Allocation 03/2003; 1(1):6. · 0.87 Impact Factor
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ABSTRACT: Abstract
Background
The Global Burden of Disease 2000 (GBD 2000) study starts from an analysis of the overall mortality envelope in order to ensure that the cause-specific estimates add to the total all cause mortality by age and sex. For regions where information on the distribution of cancer deaths is not available, a site-specific survival model was developed to estimate the distribution of cancer deaths by site.
Methods
An age-period-cohort model of cancer survival was developed based on data from the Surveillance, Epidemiology, and End Results (SEER). The model was further adjusted for the level of economic development in each region. Combined with the available incidence data, cancer death distributions were estimated and the model estimates were validated against vital registration data from regions other than the United States.
Results
Comparison with cancer mortality distribution from vital registration confirmed the validity of this approach. The model also yielded the cancer mortality distribution which is consistent with the estimates based on regional cancer registries. There was a significant variation in relative interval survival across regions, in particular for cancers of bladder, breast, melanoma of the skin, prostate and haematological malignancies. Moderate variations were observed among cancers of colon, rectum, and uterus. Cancers with very poor prognosis such as liver, lung, and pancreas cancers showed very small variations across the regions.
Conclusions
The survival model presented here offers a new approach to the calculation of the distribution of deaths for areas where mortality data are either scarce or unavailable.
BMC Cancer. 01/2002;
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ABSTRACT: Abstract
Background
Mortality estimates alone are not sufficient to understand the true magnitude of cancer burden. We present the detailed estimates of mortality and incidence by site as the basis for the future estimation of cancer burden for the Global Burden of Disease 2000 study.
Methods
Age- and sex- specific mortality envelope for all malignancies by region was derived from the analysis of country life-tables and cause of death. We estimated the site-specific cancer mortality distributions from vital records and cancer survival model. The regional cancer mortality by site is estimated by disaggregating the regional cancer mortality envelope based on the mortality distribution. Estimated incidence-to-mortality rate ratios were used to back calculate the final cancer incidence estimates by site.
Results
In 2000, cancer accounted for over 7 million deaths (13% of total mortality) and there were more than 10 million new cancer cases world wide in 2000. More than 60% of cancer deaths and approximately half of new cases occurred in developing regions. Lung cancer was the most common cancers in the world, followed by cancers of stomach, liver, colon and rectum, and breast. There was a significant variations in the distribution of site-specific cancer mortality and incidence by region.
Conclusions
Despite a regional variation, the most common cancers are potentially preventable. Cancer burden estimation by taking into account both mortality and morbidity is an essential step to set research priorities and policy formulation. Also it can used for setting priorities when combined with data on costs of interventions against cancers.
BMC Cancer. 01/2002;
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ABSTRACT: Population Health Metrics is an open-access online electronic journal published by BioMed Central – it is universally and freely available online to everyone, its authors retain copyright, and it is archived in at least one internationally recognised free repository. To fund this, from November 1 2003, authors of articles accepted for publication will be asked to pay an article-processing charge of US$500. This editorial outlines the reasons for the introduction of article-processing charges and the way in which this policy will work. Waiver requests will be considered on a case-by-case basis, by the Editor-in-Chief. Article-processing charges will not apply to authors whose institutions are 'members' of BioMed Central. Current members include NHS England, the World Health Organization, the US National Institutes of Health, Harvard, Princeton and Yale universities, and all UK universities. No charge is made for articles that are rejected after peer review. Many funding agencies have also realized the importance of open access publishing and have specified that their grants may be used directly to pay APCs.
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Zulfiqar Bhutta,
Julio Frenk,
Richard Horton,
Alan Lopez,
Fatima Marinho de Souza,
Anne Mills,
Peter Piot, Christopher Murray,
Osman Sankoh,
Kenji Shibuya,
Debrework Zewdie
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ABSTRACT: Background: The gap between the highest and lowest life expectancies for race-county combinations in the United States is over 35 y. We divided the race-county combinations of the US population into eight distinct groups, referred to as the "eight Americas," to explore the causes of the disparities that can inform specific public health intervention policies and programs. Methods and Findings: The eight Americas were defined based on race, location of the county of residence, population density, race-specific county-level per capita income, and cumulative homicide rate. Data sources for population and mortality figures were the Bureau of the Census and the National Center for Health Statistics. We estimated life expectancy, the risk of mortality from specific diseases, health insurance, and health-care utilization for the eight Americas. The life expectancy gap between the 3.4 million high-risk urban black males and the 5.6 million Asian females was 20.7 y in 2001. Within the sexes, the life expectancy gap between the best-off and the worst-off groups was 15.4 y for males (Asians versus high-risk urban blacks) and 12.8 y for females (Asians versus low-income southern rural blacks). Mortality disparities among the eight Americas were largest for young (15–44 y) and middle-aged (45–59 y) adults, especially for men. The disparities were caused primarily by a number of chronic diseases and injuries with well-established risk factors. Between 1982 and 2001, the ordering of life expectancy among the eight Americas and the absolute difference between the advantaged and disadvantaged groups remained largely unchanged. Self-reported health plan coverage was lowest for western Native Americans and low-income southern rural blacks. Crude self-reported healthcare utilization, however, was slightly higher for the more disadvantaged populations. Conclusions: Disparities in mortality across the eight Americas, each consisting of millions or tens of millions of Americans, are enormous by all international standards. The observed disparities in life expectancy cannot be explained by race, income, or basic health-care access and utilization alone. Because policies aimed at reducing fundamental socioeconomic inequalities are currently practically absent in the US, health disparities will have to be at least partly addressed through public health strategies that reduce risk factors for chronic diseases and injuries.
