McCord C, Freeman HP. Excess mortality in Harlem. New England Journal of Medicine 1990; 322: 173-7

A striking finding of this paper was that males in Harlem, New York City, were less likely to reach the age of 65, than men in Bangladesh, one of the poorest countries in the world! Most deaths were from cardiovascular disease. They conclude that Harlem and probably other inner-city areas with largely black populations have extremely high mortality rates that justify special consideration analogous to that given to natural-disaster areas. This lends strong support to the income inequality health relationship by suggesting that it is not the inequalities in Harlem that result in poor health, but its deprivation in relative to the rest of the US outside Harlem.

Abstract

In recent decades mortality rates have declined for both white and nonwhite Americans, but national averages obscure the extremely high mortality rates in many inner-city communities. Using data from the 1980 census and from death certificates in 1979, 1980, and 1981, we examined mortality rates in New York City's Central Harlem health district, where 96 percent of the inhabitants are black and 41 percent live below the poverty line. For Harlem, the age-adjusted rate of mortality from all causes was the highest in New York City, more than double that of U.S. whites and 50 percent higher than that of U.S. blacks. Almost all the excess mortality was among those less than 65 years old. With rates for the white population as the basis for comparison, the standardized (adjusted for age) mortality ratios (SMRs) for deaths under the age of 65 in Harlem were 2.91 for male residents and 2.70 for female residents. The highest ratios were for women 25 to 34 years old (SMR, 6.13) and men 35 to 44 years old (SMR, 5.98). The chief causes of this excess mortality were cardiovascular disease (23.5 percent of the excess deaths; SMR, 2.23), cirrhosis (17.9 percent; SMR, 10.5), homicide (14.9 percent; SMR, 14.2), and neoplasms (12.6 percent; SMR, 1.77). Survival analysis showed that black men in Harlem were less likely to reach the age of 65 than men in Bangladesh. Of the 353 health areas in New York, 54 (with a total population of 650,000) had mortality rates for persons under 65 years old that were at lest twice the expected rate. All but one of these areas of high mortality were predominantly black or Hispanic. We conclude that Harlem and probably other inner-city areas with largely black populations have extremely high mortality rates that justify special consideration analogous to that given to natural-disaster areas.

Keywords

• behavioral factors
• cause specific mortality
• city
• community
• education
• health inequalities
• homicide
• income
• international
• life expectancy
• medical care
• mortality
• neighborhoods
• poverty
• psychosocial factors
• race
• regional
• relative deprivation
• smoking
• socioeconomic status
• stress
• violence
• violent crime
• women