A Difference-in-Differences Approach to Assess the Effect of a Heat Action Plan on Heat-Related Mortality, and Differences in Effectiveness According to Sex, Age, and Socioeconomic Status (Montreal, Quebec).

BackgroundThe impact of heat waves on mortality and health inequalities is well documented. Very few studies have assessed the effectiveness of heat action plans (HAPs) on health, and none has used quasi-experimental methods to estimate causal effects of such programs.ObjectivesWe developed a quasi-experimental method to estimate the causal effects associated with HAPs that allows the identification of heterogeneity across subpopulations, and to apply this method specifically to the case of the Montreal (Quebec, Canada) HAP.MethodsA difference-in-differences approach was undertaken using Montreal death registry data for the summers of 2000-2007 to assess the effectiveness of the Montreal HAP, implemented in 2004, on mortality. To study equity in the effect of HAP implementation, we assessed whether the program effects were heterogeneous across sex (male vs. female), age (≥ 65 years vs. < 65 years), and neighborhood education levels (first vs. third tertile). We conducted sensitivity analyses to assess the validity of the estimated causal effect of the HAP program.ResultsWe found evidence that the HAP contributed to reducing mortality on hot days, and that the mortality reduction attributable to the program was greater for elderly people and people living in low-education neighborhoods.ConclusionThese findings show promise for programs aimed at reducing the impact of extreme temperatures and health inequities. We propose a new quasi-experimental approach that can be easily applied to evaluate the impact of any program or intervention triggered when daily thresholds are reached. Citation: Benmarhnia T, Bailey Z, Kaiser D, Auger N, King N, Kaufman J. 2016. A difference-in-differences approach to assess the effect of a heat action plan on heat-related mortality, and differences in effectiveness according to sex, age, and socioeconomic status (Montreal, Quebec). Environ Health Perspect 124:1694-1699; http://dx.doi.org/10.1289/EHP203

Racism and the Political Economy of COVID-19: Will We Continue to Resurrect the Past?

COVID-19 is not spreading over a level playing field; structural racism is embedded within the fabric of American culture, infrastructure investments, and public policy, and fundamentally drives inequities. The same racism that has driven the systematic dismantling of the American social safety-net has also created the policy recipe for American structural vulnerability to the impacts of this and other pandemics. The Bronx provides an important case study for investigating the historical roots of structural inequities showcased by this pandemic; current lived experiences of Bronx residents are rooted in the racialized dismantling of New York City’s public infrastructure and systematic disinvestment. The story of the Bronx is repeating itself, only this time with a novel virus. In order to address the root causes of inequities in cases and deaths due to COVID-19, we need to focus not just on restarting the economy, but on reimagining the economy, divesting of systems rooted in racism and the devaluation of Black and Brown lives

Structural Racism and Severe Maternal Morbidity in New York State

ABSTRACT Objective: We examined the association between county-level structural racism indicators and the odds of severe maternal morbidity (SMM) in New York State. Design: We merged individual-level hospitalization data from the New York State Department of Health Statewide Planning and Research Cooperative System (SPARCS) with county-level data from the American Community Survey and the Vera Institute of Justice from 2011 to 2013 (n = 244 854). Structural racism in each county included in our sample was constructed as the racial inequity (ratio of black to white population) in female educational attainment, female employment, and incarceration.ReSulT S: Multilevel logistic regression analysis estimated the association between each of these structural racism indicators and SMM, accounting for individual- and hospital-level characteristics and clustering in facilities. In the models adjusted for individual- and hospital-level factors, county-level racial inequity in female educational attainment was associated with small but statistically significant higher odds of SMM (odds ratio [OR] = 1.17, 95% confidence interval [CI] = 1.47, 1.85). County-level structural racism indicators of female employment inequity and incarceration inequity were not statistically significant. Interaction terms examining potential effect measure modification by race with each structural racism indicator also indicated no statistical difference. Conclusions: Studies of maternal disparities should consider multiple dimensions of structural racism as a contributing cause to SMM and as an additional area for potential intervention

Housing stability and diabetes among people living in New York city public housing

Public housing provides affordable housing and, potentially, housing stability for low-income families. Housing stability may be associated with lower incidence or prevalence and better management of a range of health conditions through many mechanisms. We aimed to test the hypotheses that public housing residency is associated with both housing stability and reduced risk of diabetes incidence, and the relationship between public housing and diabetes risk varies by levels of housing stability. Using 2004-16 World Trade Center Health Registry data, we compared outcomes (housing stability measured by sequence analysis of addresses, self-reported diabetes diagnoses) between 730 New York City public housing residents without prevalent diabetes at baseline and 730 propensity score-matched non-public housing residents. Sequence analysis found 3 mobility patterns among all 1460 enrollees, including stable housing (65%), limited mobility (27%), and unstable housing patterns (8%). Public housing residency was associated with stable housing over 12 years. Diabetes risk was not associated with public housing residency; however, among those experiencing housing instability, a higher risk of diabetes was found among public housing versus non-public housing residents. Of those stably housed, the association remained insignificant. These findings provide important evidence for a health benefit of public housing via housing stability among people living in public housing

Carceral epidemiology: mass incarceration and structural racism during the COVID-19 pandemic

The COVID-19 pandemic and the ongoing epidemic of mass incarceration are closely intertwined, as COVID-19 entered US prisons and jails at astounding rates. Although observers warned of the swiftness with which COVID-19 could devastate people who are held and work in prisons and jails, their warnings were not heeded quickly enough. Incarcerated populations were deprioritised, and COVID-19 infected and killed those in jails and prisons at rates that outpaced the rates among the general population. The COVID-19 pandemic highlighted what has been long-known: mass incarceration is a key component of structural racism that creates and exacerbates health inequities. It is imperative that the public health, particularly epidemiology, public policy, advocacy, and medical communities, are catalysed by the COVID-19 pandemic to drastically rethink the USA's criminal legal system and the public health emergency that it has created and to push for progressive reform

Racial discrimination in medical care settings and opioid pain reliever misuse in a U.S. cohort: 1992 to 2015

BACKGROUND: In the United States whites are more likely to misuse opioid pain relievers (OPRs) than blacks, and blacks are less likely to be prescribed OPRs than whites. Our objective is to determine whether racial discrimination in medical settings is protective for blacks against OPR misuse, thus mediating the black-white disparities in OPR misuse. METHODS: We used data from 3528 black and white adults in the Coronary Artery Risk Development in Young Adults (CARDIA) study, an ongoing multi-site cohort. We employ causal mediation methods, with race (black vs white) as the exposure, lifetime discrimination in medical settings prior to year 2000 as the mediator, and OPR misuse after 2000 as the outcome. RESULTS: We found black participants were more likely to report discrimination in a medical setting (20.3% vs 0.9%) and less likely to report OPR misuse (5.8% vs 8.0%, OR = 0.71, 95% CI = 0.55, 0.93, adjusted for covariates). Our mediation models suggest that when everyone is not discriminated against, the disparity is wider with black persons having even lower odds of reporting OPR misuse (OR = 0.63, 95% CI = 0.45, 0.89) compared to their white counterparts, suggesting racial discrimination in medical settings is a risk factor for OPR misuse rather than protective. CONCLUSIONS: These results suggest that racial discrimination in a medical setting is a risk factor for OPR misuse rather than being protective, and thus could not explain the seen black-white disparity in OPR misuse

Invited Commentary: What Social Epidemiology Brings to the Table-Reconciling Social Epidemiology and Causal Inference

In response to the Galea and Hernan article, "Win-Win: Reconciling Social Epidemiology and Causal Inference" (Am J Epidemiol. 2020;189(3):167-170), we offer a definition of social epidemiology. We then argue that methodological challenges most salient to social epidemiology have not been adequately addressed in quantitative causal inference, that identifying causes is a worthy scientific goal, and that quantitative causal inference can learn from social epidemiology's methodological innovations. Finally, we make 3 recommendations for quantitative causal inference

Abstract B076: Influence of residential segregation and women’s health provider density on advanced stage endometrial cancer diagnoses

Abstract Background. Endometrial cancer (EC) is the most common gynecologic malignancy in the US, with an increasing incidence. Non-Hispanic Black (NHB) women are disproportionately impacted by EC but the complex mechanisms by which this is occurring are not yet fully understood. Taking a social ecological approach to this issue, our objective was to determine if there are associations between county-level OB-GYN provider density and residential segregation as measured by the Index of Concentration at the Extremes (ICE) on late-stage EC diagnoses in Florida.  Methods. All malignant EC cases were identified from 2001 to 2016 in the Florida Cancer Database System (FCDS). Using 5-year estimates from the 2013-2017 American Community Survey, five county-level ICE variables were calculated: economic (high vs low), race and/or ethnicity (non-Hispanic white (NHW) vs. NHB and NHW vs. Hispanic), and racialized economic segregation (low-income NHB vs. high-income NHW and low-income Hispanic vs. high-income NHW). County-level provider density was calculated as the number of OB-GYN providers divided by the female population of each county multiplied by 100,000. Early stage was defined as local and late stage was defined as regional/distant. Multivariable-adjusted logistic regression models were specified to estimate the association between each ICE variable and provider density separately on late-stage diagnosis of EC. Results. There were a total of 50,363 EC cases in Florida from 2001 to 2016 with 44,678 (88.7%) having stage information. Of those with stage information, the mean age at diagnosis was 64.1 years (SD: 11.9), 71.8% were NHW, 11.5% were NHB, 14.0% were Hispanic, and 2.8% were other race. The majority of individuals had government insurance (50.6%). More NHB women (27.1%) were diagnosed with aggressive EC histologies relative to NHW (16.4%) and Hispanic women (15.5%) (p<0.001). 14,366 (32.2%) were diagnosed with late-stage EC. A larger proportion of NHB women were diagnosed with later-stage EC compared to NHW women and Hispanic women (43.7% vs. 30.3% and 32.4%, respectively, p<0.001). NHB and Hispanic women had significantly greater odds of being diagnosed with later-stage EC compared to NHW women, regardless of residential segregation (OR: 1.46, 95% CI: 1.36, 1.56 and OR: 1.09, 95% CI: 1.01, 1.17, respectively). Women living in more economically disadvantaged Hispanic segregated counties had a greater odds of being diagnosed with later-stage EC compared to those living in more NHW segregated areas (OR: 1.16, 95% CI: 1.00, 1.65). Provider density was not found to be associated with later-stage diagnosis. Discussion. Advanced stage EC at diagnosis among Black and Hispanic women in Florida seems to be largely independent of provider density and residential segregation, though NHB more commonly present with metastatic disease. Biologic drivers of oncogenesis and barriers to timely care in this group require further exploration. Given the diversity and representation from Afro-Caribbeans in Florida, community-level investigations are required. Citation Format: Ashly Westrick, Zinzi Bailey, Matthew Schlumbrecht. Influence of residential segregation and women’s health provider density on advanced stage endometrial cancer diagnoses [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr B076