Black mortality improves greatly during the 20th century in the face of persistent institutional racism
By Robert Hahn
In 1900, white female newborns lived 15.2 years more than Black female newborns and white male newborns lived 14.1 years more than Black male newborns. By 2010, black life expectancy had more than doubled, and the gap between Black and white people had decreased to 3.3 years among females and 4.7 years among males. Reductions in Black age-adjusted mortality were greatest among the youngest, lowest among older adults. Deaths from infectious diseases showed the greatest decrease—largely preceding the advent of immunization and antibiotics. Heart disease mortality among Black people increased substantially from 1920 to 1950, then decreased. Cancer mortality rose to a peak in 1990, then declined. The rise in heart disease and cancer mortality early in the century is probably associated with the rapid increase in cigarette smoking among Black people (as among white people).
Given the pervasive structural racism during the 20th century and beyond, relative improvement of Black compared with white mortality may be surprising. Despite considerable resistance to the dismantling of systemic racism, it is likely that the gains in Black mortality from 1900 to 2010 are associated with gains in multiple social determinants of health. Health care facilities were legally segregated until the Civil Rights Act of 1964, following which, for example, Black infant mortality rates plummeted. In 1900, 22.1% of Black people lived in their own homes, compared with 49.2% of white people; by 2010, Black home ownership had doubled to 45.4%. In 1900, 37.8% of Black boys and 41.9% of Black girls attended school, compared with 72.2% of white boys and 71.9% of white girls; by 1990, the percentages of Black and white people attending school in the U.S. were comparable. By 2010, the high school graduation rate for Black students was approximately 90%. However, these statistics mask the overall lower quality of housing and schooling available for black people compared with white people. Black access to professional occupations with higher income increased, income increased, poverty declined. Housing, education, employment, and income are powerful determinants of long-term health. Nevertheless, the white-Black gap in household wealth is large and has grown in recent decades. Black communities themselves were a powerful source of progress in the Black community during the 20th century and before, for example by developing educational opportunities such as the training of Black nurses not available elsewhere and the founding of the National Medical Association.
It is likely that the gains by the Black population in education, housing, employment, rights, and income account for a large portion of the reduction in mortality in the Black population from 1900 to 2010. Since 1900, the dismantling of structural racism—the system that underlay inequitable access to societal resources for Black people—has been slow, halting, and intensely resisted. Critical steps were the Brown vs. Board of Education decision of 1954 that declared “separate but equal” unconstitutional and the Civil Rights Act of 1964 that began to promise equal access to societal resources for diverse segments of the population. But laws can be effective only when enforced, and enforcement of anti-segregation and civil rights laws for education, employment, accommodation, and health care access have been inconsistent. Enforcement of anti-discrimination regulations in housing have not eliminated racial and ethnic residential segregation, a major cause of poor health among Blacks. As we are reminded today by the racial differences in the spread of COVID 19 and by the police murder of George Floyd and others, substantial gains in the assurance of equitable access to societal resources remain to be made. There is no health equity without societal equity.
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