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Research Article

Eight Americas: Investigating Mortality Disparities across Races, Counties, and Race-Counties in the United States

  • Christopher J. L Murray,

    Affiliations: Harvard School of Public Health, Boston, Massachusetts, United States of America, Harvard University Initiative for Global Health, Cambridge, Massachusetts, United States of America, Center for Population and Development Studies, Harvard University, Cambridge, Massachusetts, United States of America

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  • Sandeep C Kulkarni,

    Affiliations: Harvard University Initiative for Global Health, Cambridge, Massachusetts, United States of America, University of California San Francisco, San Francisco, California, United States of America

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  • Catherine Michaud,

    Affiliations: Harvard University Initiative for Global Health, Cambridge, Massachusetts, United States of America, Center for Population and Development Studies, Harvard University, Cambridge, Massachusetts, United States of America

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  • Niels Tomijima,

    Affiliation: Center for Population and Development Studies, Harvard University, Cambridge, Massachusetts, United States of America

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  • Maria T Bulzacchelli,

    Affiliation: Center for Population and Development Studies, Harvard University, Cambridge, Massachusetts, United States of America

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  • Terrell J Iandiorio,

    Affiliation: Center for Population and Development Studies, Harvard University, Cambridge, Massachusetts, United States of America

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  • Majid Ezzati mail

    To whom correspondence should be addressed. E-mail: mezzati@hsph.harvard.edu

    Affiliations: Harvard School of Public Health, Boston, Massachusetts, United States of America, Harvard University Initiative for Global Health, Cambridge, Massachusetts, United States of America

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  • Published: September 12, 2006
  • DOI: 10.1371/journal.pmed.0030260

Reader Comments (4)

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Differences in Asian Communities are Important

Posted by plosmedicine on 31 Mar 2009 at 00:01 GMT

Author: Linda Silka
Position: Professor
Institution: University of Massachusetts Lowell
E-mail: linda_silka@uml.edu
Additional Authors: Robin Toof, Dorcas Grigg-Saito
Submitted Date: November 14, 2006
Published Date: November 15, 2006
This comment was originally posted as a “Reader Response” on the publication date indicated above. All Reader Responses are now available as comments.

The article "Eight Americas: Investigating Mortality Disparities across Races, Counties, and Race-Counties in the United States" (Sept 2006, 3 (9)) reports on what the authors describe as racial differences in mortality. The authors analyze what they label the "eight Americas" (i.e., Asian; Northland low-income rural white; Middle America, low-income whites in Appalachia and the Mississippi Valley; Western Native American; Black Middle America; Southern low-income rural black; high risk urban black). In contrast to other races, "Asian" is treated as a single homogenous category. Income and geographical differences are not considered. The authors point out that they have likely collapsed across differences with the "Asian" category, but they go on to report their results as if such differences are inconsequential. They are not. With regard to health disparities, such differences are particularly important.

Consider recent findings that speak to health differences within the nominal category of "Asian". As a part of the CDC's Racial and Ethnic Approaches to Community Health (REACH) 2010 program (Koch-Weser, Grigg-Saito, Toof, Kreth, Pot, Foo, et. al, 2004)., a survey was conducted in 2001-2002 with a sample of Vietnamese in several counties in California and Cambodians in Lowell, Massachusetts (the second largest Cambodian community in the U.S.). Comparing the results to the national 2002 Behavior Risk Factor Surveillance System survey that aggregates all Asian responses, the Koch-Weser et al data indicate that the educational level and income of Cambodians and Vietnamese were substantially lower than all Asians, and that Cambodians and Vietnamese were three times more likely than other Asians to not have visited a doctor in the past year due to financial reasons. In addition, in comparison to all Asians or the general population, higher proportions of Cambodian and Vietnamese men reporting smoking (50.4% and 30.4% respectively compared to 14.7% of aggregated Asians), and Cambodian and Vietnamese of both genders reported eating fewer vegetables (16.4% and 11.1%) and Vietnamese were less or aggregated Asians). And in the case of important chronic health problems such as diabetes, only 47.7% of Cambodians surveyed reported having their cholesterol checked and 41.9% a hemoglobin A1c test conducted if they were diabetic.

A 2002 representative survey of Cambodian adults over age 25 in Lowell, MA (Cambodian Community Health 2010, Community Behavioral Risk Factor Survey Results, 2002) found that Cambodians were more likely to report poor health than other Massachusetts residents (9% compared to 2%). Cambodian women and elders were much more likely to have experienced days of poor physical health (6.5 days on average for women and 8 days those over 50). A quarter of the Cambodian elders were symptomatic for depression, with the rate rising to 43% among women 50 and over. Although only 6% reported being uninsured, 23% wanted to see a doctor in the last year but could not, and 44% did not because of transportation problems.

In short, existing findings indicate how diverse the health data can be within the overall category of "Asian". The authors are to be applauded for their recognition of how misleading it can be to treat the categories of "blackness" or "whiteness" in undifferentiated ways. Unfortunately they have failed to extend that same understanding to the analysis they select for the category of Asians. As researchers and policy makers use the "Eight Americas" study to guide their efforts, the result could well be misleading interpretations that do a disservice to those very groups within the "Asian" category who face daily struggles with significant health problems and poor access to health care.

References

Cambodian Community Health 2010: Community behavior risk factor survey results. (2002). Lowell, Massachusetts.

Koch-Weser, S.; Grigg-Saito, D.; Toof, R.; Kreth, N. N.; Pot, M.; Foo, M. A.; Foong, H. L.; Kagawa-Singer, M.; Lee, S.W.; Tran, J. H.; Nguyen, T. N.; Tanjasiri, S. P.; Nguyen, T. T.; McPhee, P.; Liao, Y.; Tucker, P.; & Giles, W. (2004). Health status of Cambodians and Vietnamese- Selected communities, Unites States, 2001-2002. MMWR, 53, 33, 760-765.

No competing interests declared.