Race, Class, and Place Modify Mortality Rates for the Leading Causes of Death in the United States, 1999–2021

Abstract

Background: Race and ethnicity, socioeconomic class, and geographic location are well-known social determinants of health in the US. Studies of population mortality often consider two, but not all three of these risk factors. Objectives: To disarticulate the associations of race (whiteness), class (socioeconomic status), and place (county) with risk of cause-specific death in the US. Design: We conducted a retrospective analysis of death certificate data. Bayesian regression models, adjusted for age and race/ethnicity from the American Community Survey and the county Area Deprivation Index, were used for inference. Main Measures: County-level mortality for 11 leading causes of death (1999–2019) and COVID-19 (2020–2021). Key Results: County “whiteness” and socioeconomic status modified death rates; geospatial effects differed by cause of death. Other factors equal, a 20% increase in county whiteness was associated with 5–8% increase in death from three causes and 4–15% reduction in death from others, including COVID-19. Other factors equal, advantaged counties had significantly lower death rates, even when juxtaposed with disadvantaged ones. Patterns of residual risk, measured by spatial county effects, varied by cause of death; for example: cancer and heart disease death rates were better explained by age, socioeconomic status, and county whiteness than were COVID-19 and suicide deaths. Conclusions: There are important independent contributions from race, class, and geography to risk of death in the US.