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NIH Collaboration Seeks to Help Understand U.S. Burden of Health Disparities: Why Your County Matters
Posted on by Eliseo J. Pérez-Stable, M.D., National Institute on Minority Health and Health Disparities
Since the early 1990s, federal support of research has increased to understand minority health and identify and address health disparities. Research in these areas has evolved from a starting point of developing a basic descriptive understanding of health disparities and who is most affected. Now, it is discovering the underlying complexity of factors involved in health outcomes to inform interventions and reduce these disparities.
One of these many factors is where we live, learn, work, and play and how that affects different people. A group of NIH scientists and their colleagues recently published a study in the journal The Lancet that they hope is a step toward better understanding geographic disparities and their role in health equity [1].
As Director of NIH’s National Institute on Minority Health and Health Disparities (NIMHD), I worked with NIMHD’s Scientific Director, Anna María Nápoles, to conceive the study and establish the Global Burden of Disease (GBD) U.S. Health Disparities Collaborators at NIH with five NIH Institutes and two Offices. Through this collaboration, NIH funded the Institute for Health Metrics and Evaluation (IHME), University of Washington to conduct the analysis. The IHME has worked for 30 years on the GBD project in over 200 countries.
The Lancet paper offered the first comprehensive U.S. county-level life expectancy estimates to highlight the significant gaps that persist among racial and ethnic populations across the nation. The analysis revealed that despite overall life expectancy gains of 2.3 years from 2000–2019, Black populations experienced shorter life expectancy than White populations.
In addition, American Indian and Alaska Native populations’ life expectancy did not improve and, in fact, decreased in most counties. We found national-level life expectancy advantages for Hispanic/Latino and Asian populations ranging from three to seven years, respectively, compared to White populations. But there were notable exceptions for Hispanic/Latino populations in selected counties in the Southwest.
Certainly the most-alarming trend identified in the paper was that during the study’s last 10 years (2010–2019), life expectancy growth was stagnant across all races and ethnicities. Moreover, 60 percent of U.S. counties experienced a decrease in life expectancy.
While these findings provide an important frame for how disparities exist along many dimensions—by race, ethnicity, and geographic region—they also highlight these differences within our local communities. This level of detail offers an unprecedented opportunity for researchers and public health leaders to focus on where these differences are the most prominent, and possibly give us a clearer picture on what can be done about it.
These data raise many important questions, too. What can we learn from places that are doing well in caring for their most disadvantaged populations? How can these factors be sustained, replicated, and transferred to other places? Are there current policies and/or community services that contribute to or inhibit gaining access to appropriate clinical care, healthy and affordable food, good schools, and/or economic opportunities?
To help answer these questions, the GBD U.S. Health Disparities Collaborators at NIH, in partnership with IHME, have developed a comprehensive database and interactive data visualization tool that provides life expectancy and all-cause mortality by race and ethnicity for 3,110 U.S. counties from 2000-2019. Efforts are underway to expand the database to include causes of death and risk factors by race/ethnicity and education, as well as to disaggregate some of the major racial-ethnic groups.
Using IHME’s established model of comprehensive and replicable data collection, the joint effort aims to improve access to health data resources, bolster analytic approaches, and deliver user-friendly estimates to the wider research and health policy community. The collection’s standardized, comprehensive, historical, and real-time data can be the cornerstone for efforts to address disparities and advance health equity.
It is important to note that the Lancet study only included data from before the COVID-19 pandemic. The pandemic’s disproportionate effect on overall mortality and life expectancy has exacerbated existing health disparities. Disaggregated data are essential in helping to understand the underlying mechanisms of health disparities and guiding the development and implementation of interventions that address local needs.
As a clinician scientist, I have made a personal commitment at NIMHD to foster and encourage data collection with standardized measures, harmonization, and efficient data sharing to help us explore the nuances within all populations and their communities. Without these guiding principles for managing data, inequities remain unseen and unaddressed. Scientists, clinicians, and policymakers can all potentially benefit from this work if we use the data to inform our actions. It is an opportunity to implement real change in our NIH-wide combined efforts to reduce health disparities and improve quality of life and longevity for all populations.
Reference:
[1] Life expectancy by county, race, and ethnicity in the USA, 2000-19: a systematic analysis of health disparities. GBD US Health Disparities Collaborators. Lancet. 2022 Jul 2;400(10345):25-38.
Links:
Understand Health Disparities Series (National Institute on Minority Health and Health Disparities/NIH)
HD Pulse (NIMHD)
PhenX Social Determinants of Health Toolkit (NIMHD)
Institute for Health Metrics (University of Washington, Seattle)
NIH Support: The members of the GBD U.S. Health Disparities Collaborators at NIH include: National Heart, Lung, and Blood Institute; National Cancer Institute; National Institute on Aging; National Institute of Arthritis and Musculoskeletal and Skin Diseases; NIH Office of Disease Prevention; NIH Office of Behavioral and Social Science Research
Note: Dr. Lawrence Tabak, who performs the duties of the NIH Director, has asked the heads of NIH’s Institutes and Centers (ICs) to contribute occasional guest posts to the blog to highlight some of the interesting science that they support and conduct. This is the 17th in the series of NIH IC guest posts that will run until a new permanent NIH director is in place.
Analysis of Death Records Shows Growing Disparities in Opioid Epidemic
Posted on by Lawrence Tabak, D.D.S., Ph.D.
Based on the most recent data, about 100,000 people now die in the United States from drug overdoses over the course of a year, about half of them from synthetic opioids and primarily fentanyl [1,2]. That’s more than a 30 percent increase over 2019 levels, and a reminder that the exact causes of these tragic overdoses continue to evolve over time, including from changes in how people use drugs.
Now, an NIH-funded study provides a detailed look at one shift in drug use: overdose deaths involving some combination of opioids and stimulant drugs, including cocaine and methamphetamine. These latest findings on the nation’s opioid epidemic, from a thorough analysis of death certificate data over a decade and up to the start of the pandemic, showed an alarming rise in overdose deaths from combined opioids and stimulants in all parts of the country.
The data also reveal extremely troubling racial disparities. Opioid/stimulant deaths among Black Americans have risen at more than three times the rate seen among non-Hispanic white people, especially in Eastern states. In other parts of the country, there’s also been a disproportionate increase in these combination overdose deaths among Hispanic and Asian Americans.
The findings, published in the American Journal of Epidemiology, suggest that efforts to prevent opioid overdoses, including wide distribution of naloxone, should target not only people who primarily use opioids but those who primarily use crack cocaine or other street drugs [3].
The new study comes from a team led by Tarlise Townsend, NYU Langone Center for Opioid Epidemiology and Policy, New York, and David Kline, Wake Forest University School of Medicine, Winston-Salem, NC. They wanted to dig deeper into the increase in combined stimulant/opioid overdose deaths observed over the last decade.
To do so, the researchers analyzed individual death certificate data for overdoses from the 2007-2019 National Center for Health Statistics. They grouped them by state as well as by race and ethnicity (non-Hispanic white, non-Hispanic Black, Hispanic, and non-Hispanic Asian American/Pacific Islander). They also analyzed separately deaths from opioids in combination with cocaine and those involving methamphetamine and other stimulants (MOS).
These national data showed that cocaine/opioid mortality increased 575 percent among Black people compared to 184 percent in white people. The pattern for methamphetamines and other stimulants combined with opioids showed an even starker and truly terrible pattern. MOS/opioid mortality rose by 16,200 percent in Black people versus 3,200 percent in white people.
The study uncovered some other noteworthy regional trends from 2007-2019, including:
• By 2019, rates of cocaine/opioid mortality in Black Americans were considerably higher than among white Americans in 47 of the 50 states.
• The largest disparity between Black Americans and white Americans was found in MOS/opioid mortality in the Midwest.
• MOS/opioid death rates among Black Americans increased 66 percent per year in the Northeast, 72 percent per year in the Midwest, and 57 percent in the South.
• In the South, deaths from cocaine and opioids grew 26 percent per year in Black Americans, 27 percent per year in Hispanic people, and 12 percent per year in non-Hispanic white people.
• MOS/opioid death rates among Asian Americans and Pacific Islanders increased faster than in white people in the West and Northeast.
• MOS/opioid death rates also grew faster among Hispanic people than among white people in the West, Northeast, and upper Midwest.
The results show that the nature of overdose deaths vary considerably from state to state and even within the same region of the country. More study, however, is needed to understand fully the observed trends and their causes.
For instance, it’s not clear how often such opioid/stimulant deaths stem from intentional use of these drugs in combination versus growing contamination of stimulant drugs, such as cocaine, with synthetic fentanyl, which is the extremely potent and dangerous opioid that’s largely responsible for the recent uptick in stimulant/opioid overdose deaths.
As researchers work to get these answers, this study comes as a reminder that successfully tackling the opioid epidemic through NIH’s Helping to End Addiction Long-term (HEAL) Initiative and other efforts will require a multi-pronged approach, including concerted efforts to improve prevention and treatment for opioid misuse and addiction. It also will be essential to ensure that such advances will reach those who are being hit hardest by the opioid epidemic, including minority and marginalized communities.
References:
[1] 12 month-ending provisional number of drug overdose deaths. Centers for Disease Control and Prevention. January 1, 2022.
[2] Drug overdose deaths. Centers for Disease Control and Prevention. March 3, 2021.
[3] Racial/ethnic and geographic trends in combined stimulant/opioid overdoses, 2007-2019. Townsend T, Kline D, Rivera-Aguirre A, Bunting AM, Mauro PM, Marshall BDL, Martins SS, Cerda M. American Journal of Epidemiology. 7 Feb 2022.
Links:
Drug Topics (National Institute on Drug Abuse/NIH)
Opioid Overdose Crisis (NIDA)
Helping to End Addiction Long-term (HEAL) Initiative (NIH)
Tarlise Townsend (NYU Langone, New York)
David Kline (Wake Forest University School of Medicine, Winston-Salem, NC)
NIH Support: National Institute on Drug Abuse
Most Vaccine-Hesitant People Remain Willing to Change Their Minds
Posted on by Dr. Francis Collins
As long and difficult as this pandemic has been, I remain overwhelmingly grateful for the remarkable progress being made, including the hard work of so many people to develop rapidly and then deploy multiple life-saving vaccines. And yet, grave concerns remain that vaccine hesitancy—the reluctance of certain individuals and groups to get themselves and their children vaccinated—could cause this pandemic to go on much longer than it should.
We’re seeing the results of such hesitancy in the news every day, highlighting the rampant spread of COVID-19 that’s stretching our healthcare systems and resources dangerously thin in many places. The vast majority of those currently hospitalized with COVID-19 are unvaccinated, and most of those tragic 2,000 deaths each day could have been prevented. The stories of children and adults who realized too late the importance of getting vaccinated are heartbreaking.
With these troubling realities in mind, I was encouraged to see a new study in the journal JAMA Network Open that tracked vaccine hesitancy over time in a random sample of more than 4,600 Americans. This national study shows that vaccine hesitancy isn’t set in stone. Over the course of this pandemic, hesitancy has decreased, and many who initially said no are now getting their shots. Many others who remain unvaccinated lean toward making an appointment.
The findings come from Aaron Siegler and colleagues, Emory University, Atlanta. They were interested in studying how entrenched vaccine hesitancy would be over time. The researchers also wanted to see how often those who were initially hesitant went on to get their shots.
To find out, they recruited a diverse, random, national sampling of individuals from August to December 2020, just before the first vaccines were granted Emergency Use Approval and became widely available. They wanted to get a baseline, or starting characterization, on vaccine hesitancy. Participants were asked two straightforward questions, “Have you received the COVID-19 vaccine?” and “How likely are you to get it in the future?” From March to April 2021, the researchers followed up by asking participants the same questions again when vaccines were more readily available to many (although still not all) adults.
The survey’s initial results showed that nearly 70 percent of respondents were willing to get vaccinated at the outset, with the other 30 percent expressing some hesitancy. The good news is among the nearly 3,500 individuals who answered the survey at follow-up, about a third who were initially vaccine hesitant already had received at least one shot. Another third also said that they’d now be willing to get the vaccine, even though they hadn’t just yet.
Among those who initially expressed a willingness to get vaccinated, about half had done so at follow up by spring 2021 (again, some still may not have been eligible). Forty percent said they were likely to get vaccinated. However, 7 percent of those who were initially willing said they were now less likely to get vaccinated than before.
There were some notable demographic differences. Folks over age 65, people who identified as non-Hispanic Asians, and those with graduate degrees were most likely to have changed their minds and rolled up their sleeves. Only about 15 percent in any one of these groups said they weren’t willing to be vaccinated. Most reluctant older people ultimately got their shots.
The picture was more static for people aged 45 to 54 and for those with a high school education or less. The majority of those remained unvaccinated, and about 40 percent still said they were unlikely to change their minds.
At the outset, people of Hispanic heritage were as willing as non-Hispanic whites to get vaccinated. At follow-up, however, fewer Hispanics than non-Hispanic whites said they’d gotten their shots. This finding suggests that, in addition to some hesitancy, there may be significant barriers still to overcome to make vaccination easier and more accessible to certain groups, including Hispanic communities from Central and South America.
Willingness among non-Hispanic Blacks was consistently lowest, but nearly half had gotten at least one dose of vaccine by the time they completed the second survey. That’s comparable to the vaccination rate in white study participants. For more recent data on vaccination rates by race/ethnicity, see this report from the Kaiser Family Foundation.
Overall, while a small number of respondents grew more reluctant over time, most people grew more comfortable with the vaccines and were more likely to say they’d get vaccinated, if they hadn’t already. In fact, by the end of the study, the hesitant group had shrunk from 31 to 15 percent. It’s worth noting that the researchers checked the validity of self-reported vaccination using antibody tests and the results matched up rather well.
This is all mostly good news, but there’s clearly more work to do. An estimated 70 million eligible Americans have yet to get their first shot, and remain highly vulnerable to infection and serious illness from the Delta variant. They are capable of spreading the virus to other vulnerable people around them (including children), and incubating the next variants that might provide more resistance to the vaccines and therapies. They are also at risk for Long COVID, even after a relatively mild acute illness.
The work ahead involves answering questions and addressing concerns from people who remain hesitant. It’s also incredibly important to reach out to those willing, but unvaccinated, individuals, to see what can be done to help them get their shots. If you happen to be one of those, it’s easy to find the places near you that have free vaccines ready to administer. Go to vaccines.gov, or punch 438829 on your cell phone and enter your zip code—in less than a minute you will get the location of vaccine sites nearby.
Nearly 400 million COVID-19 vaccine doses have been administered in communities all across the United States. More than 600,000 more are being administered on average each day. And yet, more than 80,000 new infections are still reported daily, and COVID-19 still steals the lives of about 2,000 mostly unvaccinated people each day.
These vaccines are key for protecting yourself and ultimately beating this pandemic. As these findings show, the vast majority of Americans understand this and either have been vaccinated or are willing to do so. Let’s keep up the good work, and see to it that even more minds will be changed—and more individuals protected before they may find it’s too late.
Reference:
[1] Trajectory of COVID-19 vaccine hesitancy over time and association of initial vaccine hesitancy with subsequent vaccination. Siegler AJ, Luisi N, Hall EW, Bradley H, Sanchez T, Lopman BA, Sullivan PS. JAMA Netw Open. 2021 Sep 1;4(9):e2126882.
Links:
COVID-19 Research (NIH)
COVID-19 Vaccinations in the United States (Centers for Disease Control and Prevention, Atlanta)
Aaron Siegler (Emory University, Atlanta)
NIH Support: National Institute for Allergy and Infectious Diseases
