Trends in Cause-Specific Mortality by Race and Hispanic Origin, 1999–2019

Summary

Mortality differentials by RE group and sex affect Social Security retirement and disability program-participation outcomes. This article summarizes and compares recent trends (1999–2019) in cause-specific mortality among four major RE groups in the increasingly diverse U.S. population. From 1999 to 2019, the WNH population increased by about 3.8 million. By contrast, the Hispanic, Black, and API populations respectively increased by 26.6 million, 10.4 million, and 10.5 million. The Hispanic community is the youngest RE group, as 42.2 percent of its population was younger than 25 in 2019, compared with only 27.3 percent of the WNH population. Immigration has influenced faster growth in the API and Hispanic populations than in the other groups and since about 2010, newly arrived API immigrants have been outnumbering Hispanic arrivals. The public's evolving perceptions about racial and ethnic identity and the rising share of ethnoracially mixed families pose a challenge to the future collection of data on race and ethnicity, and to their comparability with earlier data, as larger numbers of Americans will straddle multiple backgrounds and have many options for defining their RE identity.

U.S. mortality patterns vary geographically. The highest age-adjusted all-cause mortality rates are observed in most of the South along with some areas of the Midwest, Great Lakes, and Ohio Valley regions. The states with the highest percentages of Black residents are mostly in the South. The Hispanic population concentrates heavily along the Southern border, the West coast, and South Florida. Many API communities are located on the West coast and in portions of the Northeast Corridor. Nationwide, within a given RE group, males have higher all-cause mortality rates than females. For either sex, the Black community has the highest mortality rate, followed by the WNH population. The Hispanic population has a lower all-cause mortality rate than WNH people, a phenomenon often referred to as the Hispanic mortality paradox, given the WNH community's advantages in socioeconomic status. The API population enjoys the lowest all-cause age-adjusted death rates.

Much of the all-cause mortality rate improvement between 1999 and 2019 occurred during the first half of the period. By 2010, mortality rates began to decline at a substantially slower pace for all RE groups. Americans in the midlife years (ages 25–64) began experiencing a surge in deaths driven by the effects of drug overdoses, alcohol abuse, and suicides, often referred to as deaths of despair. All-cause age-adjusted death rates at ages 25–64 were higher in 2019 than in 2010 in most subpopulations, as the opioid epidemic, which initially affected primarily the WNH community, began to spread across all demographic groups. Over the entire 1999–2019 period, all-cause mortality rates within a given RE group improved faster for males than for females, narrowing the gender gap. In addition, mortality rates improved at a slower rate among the WNH population than for other RE groups, reducing the WNH-Black mortality gap. Nevertheless, in 2019, Black females had higher all-cause mortality rates than both API and Hispanic males, while WNH females had higher mortality rates than API males.

Diseases of the circulatory system are the most common all-ages cause-of-death category. The proportion of all deaths that are caused by circulatory system diseases has steadily declined over time, yet in 2019 the proportion still ranged, across RE groups, from 27.6 percent among the Hispanic population to 32.2 percent among Black individuals. From 1999 to 2019, all-ages circulatory system disease mortality rates for all RE/sex groups declined by more than one-third, and most of the improvement occurred during the first decade of the period and at a faster pace for the aged than for those in the midlife years. By 2010, circulatory system disease mortality rates either had begun to decline at a slower rate, outright flattened, or increased among those in the midlife ages. The pause in the decline of circulatory system disease mortality rates contributed to the rise in all-cause mortality in the midlife ages seen in the second decade of the observation period. Black males had the highest all-ages circulatory system disease mortality rates, followed by WNH males and Black females. Ischemic and cerebrovascular diseases accounted for more than half of circulatory system disease–related deaths among Black and WNH individuals and almost two-thirds of those in the Hispanic and API populations in 2019. The substantial decline in mortality caused by ischemic and cerebrovascular diseases throughout the 2000s more than offset the increased mortality in other circulatory system–related causes, such as hypertensive disease and heart failure, that began in 2010. Among all RE/sex groups in 2019, Black females had the highest age-adjusted death rate from pulmonary heart disease; they also had the second highest mortality rate, following Black males, for cerebrovascular disease, hypertensive disease, and cardiac arrest; and they had the third highest mortality rate, after Black and WNH males, from heart failure, cardiomyopathy, other cardiac arrhythmias, and diseases of the arteries, arterioles, and capillaries.

Cancers (neoplasms) were the second most common cause-of-death category after circulatory system diseases, accounting for more than one-fifth of all deaths in 2019. Unlike the pattern for circulatory diseases, cancer death rates generally declined steadily throughout the 1999–2019 period. Black males had the highest all-ages mortality rate, followed by WNH males, Black females, and WNH females. Black and WNH females both had a higher cancer-related mortality rate in 2019 than Hispanic and API males. However, the mortality rates of Black males and females improved more rapidly than those of any other RE/sex group, narrowing substantially the mortality gap with the WNH population. In addition, the gender gap in cancer death rates narrowed over the observation period for every RE group.

Among males in 2019, the Black RE group had the highest mortality rates in six cancer subcategories: neoplasms of the respiratory and intrathoracic organs (lung cancer); of the genital organs; of the pancreas; of the colon; of other digestive system organs (esophagus, stomach, small intestine, and rectum); and of ill-defined, other secondary, and unspecified sites.²⁶ The WNH RE group had the highest death rates in six other subcategories: neoplasms of the lymphoid, hematopoietic, and related tissue (such as leukemia and lymphoma); of the urinary tract (primarily kidney and bladder cancers); of the eye, brain, and other parts of the central nervous system; of the lip, oral cavity, and pharynx; of the skin (such as melanoma); and in the residual “all other cancers” subcategory.

Of the specific cancer subcategories, for females in 2019, the Black RE group had the highest death rates associated with neoplasms of the lymphoid, hematopoietic, and related tissue (leukemia and lymphoma); of the breast; of the genital organs (cervical, uterine, and ovarian cancers); of the pancreas; of the colon; of other digestive system organs (esophagus, stomach, small intestine, and rectum); and of ill-defined, other secondary, and unspecified sites. The WNH group had the highest mortality rates in six neoplasm subcategories (lung, urinary tract, eye/brain/nervous system, oral, and skin cancers, as well as the “all other cancers” subcategory). The death rates associated with most cause-specific cancers declined throughout the 1999–2019 period, resulting in substantial cancer mortality-rate improvement for all RE/sex groups. Neoplasms of the liver and intrahepatic bile ducts are an exception, in that mortality rates declined only for the API population but increased significantly for the other RE groups, regardless of sex. Until about 2013, however, the API community had a higher mortality rate in this subcategory than did any other RE group. Rising liver cancer rates in the Hispanic, WNH, and Black populations have generally been attributed to the spread of hepatitis C, while the disproportionately high rate of liver cancer incidence in the API community is linked to the high prevalence of chronic hepatitis B in the API population, whether U.S.- or foreign-born.

Depending on the RE group, about 7–10 percent of all deaths in 2019 were caused by diseases of the respiratory system. This category represents an unusual exception, in that age-adjusted mortality rates are higher among WNH males and females than their Black counterparts. The disparity is driven by mortality at ages 65 or older, because Black people in the midlife years and younger ages experience higher death rates than any other RE group of the same sex. The leading specific cause of death among respiratory disorders is chronic lower respiratory disease (primarily COPD but also emphysema and asthma), followed by influenza/pneumonia. Over the 1999–2019 period, respiratory system disease mortality declined substantially, particularly among the non-WNH population. Nevertheless, mortality in the midlife ages was higher in 2019 than in 2010 in every RE/sex group. In 2019, WNH males and females had the highest and second highest all-ages mortality rates associated with chronic lower respiratory disease, while Black people experienced higher death rates from influenza/pneumonia than any other RE group of the same sex. On the other hand, the Hispanic community had a disproportionately large percentage of respiratory disorder–related deaths attributed to interstitial respiratory diseases (such as pulmonary fibrosis). In 2019, among RE/sex groups, Hispanic males and females experienced the second and third highest all-ages mortality rates from interstitial respiratory disease, after WNH males.

The proportion of deaths attributed to external causes, such as injuries resulting from accidents and assaults, was substantially higher in the younger and midlife age groups than for those aged 65 or older. Across RE groups in 2019, the share of all deaths attributed to external causes ranged from 7.6 percent among API people to 12.9 percent in the Hispanic population. External causes were the third leading cause-of-death category for Hispanic and Black males at all ages, following only circulatory system diseases and neoplasms. All-ages external-cause mortality rates were significantly higher among males than females. For WNH males and females, the rates rose steadily throughout the 1999–2019 period. For the other RE/sex groups, the rates rose after about 2013. For males, the Black RE group had the highest external-cause mortality rate, followed by the WNH and Hispanic groups. Among females, the WNH group had the highest all-ages external-cause mortality rate from 2002 to 2019. No other cause-of-death category exhibited greater heterogeneity by RE group or such compositional variation over the two decades. Assaults constituted disproportionately larger shares of external-cause deaths for the Black and Hispanic communities, while suicides accounted for greater shares of such deaths in the WNH and API populations. In addition, the percentage of external-cause deaths attributed to accidental poisonings (largely from drug and alcohol overdoses), as well as to falls at older ages, rose dramatically over the 1999–2019 period. Increasing mortality from falls is likely associated with the rising prevalence of dementia and degenerative disorders of the nervous system and to the increasing use of medications that raise the risk of falling.

In 1999, transportation accidents were the leading external cause of death for every RE/sex group other than Black males. By 2019, however, transportation accidents were the leading external cause of death only among Hispanic females. Each year during 1999–2019, more Black males died as a result of assault than from any other external cause. In 2019, the all-ages assault-related mortality rate for Black males was more than 10 times that of WNH males. By contrast, mortality rates from suicide among WNH males and females were double those of their Black counterparts. Suicide was also the leading external cause of death for API males in 2019. Furthermore, the rate of mortality caused by falls increased significantly among the aged in all RE/sex groups from 1999 to 2019, becoming the leading external cause of death over all ages combined for API females. Finally, the opioid epidemic drove an increase in poisoning-related mortality, such that it had become the leading external cause of death for WNH and Black females and for WNH and Hispanic males by 2019. Among females, the poisoning-related mortality was highest for the WNH RE group, for whom the all-ages death rate rose more than six-fold during the 1999–2019 period. Among males, the WNH group had the highest accidental poisoning mortality rate from 2003 until 2019, when the rate for the Black group surpassed it. The growth in opioid-involved overdose deaths among Black people now outpaces that of any other RE group, as fentanyl and other synthetic opioids disproportionately affect overdose death rates among older people in the Black community.

The shares of deaths that are caused by diseases of the nervous system and by mental and behavioral disorders rapidly expanded in the observation period, driven primarily by rising mortality at older ages associated with Alzheimer's and Parkinson's diseases, other degenerative diseases of the nervous system not elsewhere classified (including senile degeneration of the brain and degeneration of the nervous system because of alcohol), and unspecified dementia and other organic mental disorders. Also driving the rising shares of deaths attributable to the mental/behavioral and nervous system categories were increases in mortality at younger ages from mental and behavioral disorders caused by psychoactive substance use (which overwhelmingly involves alcohol). The percentage of all deaths attributed to the combination of mental/behavioral disorders and diseases of the nervous system rose in the WNH population from 5.7 percent in 1999 to 13.9 percent in 2019. WNH males and females had the highest all-ages mortality rates associated with diseases of the nervous system, followed by Black males and females. In each RE group, the age-adjusted nervous system disease mortality rates were similar between males and females, despite significant gender differences in mortality by specific cause. For example, Alzheimer's disease mortality rates were substantially higher for women than men. Conversely, mortality associated with Parkinson's disease in men was at least twice that of women. Among mental and behavioral disorders, WNH and Black women had the highest death rates caused by unspecified dementia, followed by Black and WNH men. In addition, death rates from mental and behavioral disorders caused by psychoactive substance use began to rise among all RE/sex groups around 2010, exhibiting developments associated with increasing numbers of deaths of despair.

Across RE groups, the shares of all deaths that were caused by endocrine, nutritional, and metabolic diseases ranged in 2019 from 4.5 percent in the WNH population to 6.5 percent for Black and Hispanic people. Age-adjusted endocrine, nutritional, and metabolic disease mortality rates declined for all RE/sex groups between 1999 and 2010, but increased thereafter for most groups. As a result, mortality rates were higher in 2019 than in 1999 for WNH, Black, and API males. The gender gap in mortality widened considerably in all RE groups over the 1999–2019 period, with males experiencing disproportionately higher mortality rates than females. In 2019, Black males had the highest all-ages endocrine, nutritional, and metabolic disease mortality rate, followed by Black females and Hispanic males. Hispanic females had higher all-ages endocrine, nutritional, and metabolic disease mortality rates than WNH males until 2007. Hispanic males and females experienced higher all-ages endocrine, nutritional, and metabolic disease mortality rates than their WNH counterparts, although the gap narrowed considerably over the observation period. Diabetes is by far the most common cause of death among endocrine, nutritional, and metabolic diseases, accounting in 2019 for two-thirds to three-quarters of deaths in this category, depending on the RE group. During the 21-year period, diabetes mortality rates improved for all RE/sex groups other than API males. However, death rates associated with metabolic disorders, obesity, and malnutrition rose in every RE/sex group. Malnutrition is a serious health issue among the aged, for whom decreased appetite, poor dental health, loneliness, failing health, lack of mobility, depression, and cognitive disorders affecting memory and behavior are contributing risk factors.

Across RE groups, the shares of all deaths caused by diseases of the digestive system ranged in 2019 from 3.0 percent in the Black community to 5.7 percent among Hispanic individuals. Alcoholic liver disease and other disorders of the liver accounted for 70 percent of digestive system disease–related deaths for the Hispanic population and almost half of those in the WNH community. In 2019, Hispanic males had the highest all-ages alcoholic liver disease death rate, followed by WNH males. Among females, the WNH group had the highest all-ages alcoholic liver disease mortality rate, followed by the Hispanic group. Regardless of sex, Black individuals in 2019 had lower alcoholic liver disease mortality rates than their Hispanic and WNH counterparts. From 1999 to 2019, age-adjusted mortality rates in the midlife years for diseases of the digestive system rose significantly for WNH men and women but declined for the Black, Hispanic, and API populations. This development is in part the result of the rise in deaths of despair, as suggested by the significant increase in mortality from alcoholic and other liver diseases among WNH men and women.

The shares of deaths that were caused by diseases of the genitourinary system ranged in 2019 from 2.4 percent in the WNH community to 3.5 percent among the Black population. Renal failure accounted for at least two thirds of the deaths in this category, followed by other disorders of the urinary system (primarily involving urinary tract infections of unspecified site). Black males and females respectively had the highest and second highest all-ages genitourinary system–related mortality rates, which in 2019 were close to twice those of their WNH counterparts.

Across RE groups, the share of all deaths attributable to infectious and parasitic diseases ranged in 2019 from 2.0 percent for WNH people to 3.3 percent for Black people. Those shares declined over the 1999–2019 period, as HIV mortality rates dropped dramatically. In 1999, HIV accounted for more than half of infectious and parasitic disease deaths among Black and Hispanic males, while sepsis (infection caused by large amounts of bacteria entering the bloodstream) was the leading specific cause of infectious and parasitic disease death in all other RE/sex groups. By 2019, the all-ages HIV death rate was less than one-fourth the 1999 rate among Black males and Hispanic males and females, and less than one-third the 1999 rate among Black and API females and WNH males. Nevertheless, enormous RE-group disparity remained in 2019, when HIV mortality rates among Black males, Black females, and Hispanic males exceeded that of WNH males by factors of 7.4, 3.2, and 2.0, respectively. From 1999 to 2019, infectious and parasitic disease mortality declined in all RE/sex groups and for major specific causes (except intestinal infectious diseases), with Black males and females experiencing higher all-ages death rates than any other RE/sex group. By the second half of the period, Hispanic males and females had lower infectious and parasitic disease mortality rates than their WNH counterparts.

Finally, the United States has the highest maternal and infant mortality rates among comparable developed countries. Black mothers and their infants experience death rates several times higher than those of their peers in other RE groups. Age-adjusted mortality rates from complications of pregnancy, childbirth, and the puerperium increased over the 1999–2019 period. The maternal mortality rate in 2019 for Black women was 2.5 times the rate for WNH women and 3.5 times the rate for Hispanic women (Hoyert 2021). Similarly, deaths caused by conditions originating in the perinatal period (which include disorders related to the length of gestation and fetal growth; complications of pregnancy, labor, and delivery; and any other medical conditions related to the perinatal period) were substantially higher for Black infants. Another major cause of death shortly after birth is congenital malformations, deformations, and chromosomal abnormalities, for which mortality is significantly higher in the Black community than for any other RE group. The death rate for Black infants in 2018 was twice that of infants born to WNH mothers.