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

External Causes of Mortality

In 2019, external causes were the overwhelming leading cause of death among people aged 0–24. For those aged 25–64, this category was the leading cause of death among Hispanic and WNH men, the second leading cause of death among Black men (after circulatory system diseases), and the third leading cause of death among API men and among women of all RE groups. This section provides a closer look at the seven external cause-of-death subcategories listed in Box 5.

Chart 20 shows the number and percentage distribution of external-cause deaths by subcategory for 1999 and 2019, with detail by RE group and age. The distribution of deaths by type of external cause varies widely across RE groups. Assaults constituted a disproportionately large share of external-cause deaths for the Black and Hispanic populations, while suicides represented a greater share of deaths among WNH and API individuals. In 1999, assault was the leading external cause of death for Black people (32.1 percent) and the second leading external cause of death in the Hispanic community (20.9 percent), while it accounted for only 13.4 percent and 5.2 percent of external-cause deaths among API and WNH people, respectively. Conversely, suicide in 1999 accounted for almost one-quarter of external-cause deaths among the WNH and API populations, but for only 12.5 percent and 8.2 percent of deaths, respectively, among Hispanic and Black people.

The composition of external-cause deaths by subcategory has also changed dramatically over time. In 1999, the most common type of external-cause death, transportation accidents, accounted for about one-third of such deaths for all RE/sex groups except Black men, for whom assault accounted for more external-cause deaths (35.2 percent, versus 23.5 percent for transportation accidents). By 2019, the shares of external-cause deaths attributed to transportation accidents had declined, ranging from 14.9 percent among WNH individuals to 23.5 percent among the Hispanic population. On the other hand, the proportion of external-cause deaths that were due to accidental poisoning rose sharply during this period, fueled by an epidemic of opioid overdoses. Relative to 1999, the percentage of all external-cause deaths attributed to accidental poisonings in 2019 had increased by 2.5 times among Hispanic people (to 27.6 percent), had more than tripled for the Black and WNH populations (to 26.7 percent and 26.2 percent, respectively), and had more than quadrupled in the API community (from 3.5 percent to 14.1 percent). At all ages, accidental poisoning was the leading external cause of death in 2019 among all RE groups except API individuals, for whom suicide represented the largest subcategory (26.7 percent).

Another notable external cause of death in Chart 20 is falls, which are infrequent among the young and those in the midlife years (less than 2 percent for those aged 0–24 and less than 5 percent for those aged 25–64) but represent a significant external cause of death at older ages. The share of deaths caused by falls has increased substantially over time, becoming the leading external cause of death among those aged 65 or older in every RE group. In 2019, falls accounted for half of external-cause deaths among Black people aged 85 or older and more than 66 percent of deaths in that age group for the other RE groups. Note that although deaths caused by falls cluster at the oldest ages (when external causes of death represent a small fraction of all-cause mortality), the number of deaths is significant. The share of external-cause deaths attributable to falls at all ages was substantially higher among the WNH and API populations (about 19 percent in 2019), exceeding the share attributable to transportation accidents for these two RE groups.

As noted earlier, for each RE group, mortality rates from external causes are higher for males than females. The distribution of external-cause deaths by subcategory also varies significantly by sex. In 2019, over all ages combined, falls were the leading cause of death for both WNH and API females, while poisonings and suicides were the most commonly occurring subcategories among WNH and API males, respectively. More Black males died because of assault than from any other external cause, while poisoning was the leading external cause of death among Black females. Likewise for Hispanic males, poisoning was the leading external cause of death in 2019. However, among external-cause deaths, more Hispanic females died from transportation accidents (24.9 percent) than poisonings (23.2 percent) in 2019.

Chart 21 shows age-adjusted death rates for 1999–2019 by RE group, sex, and age group. Panel A shows the rates for external causes of mortality overall.

Demographers have referred to an “accidental mortality hump,” the spike in mortality among young adults that deviates from the normal pace of senescence (Remund, Camarda, and Riffe 2018). As an example, in 1999, transportation accidents were the leading external cause of death for every non-Black RE group aged 0–24 and 25–64. In that year, traffic accidents led to 52 percent of external-cause deaths among WNH people aged 0–24, and to 41 percent of those among young Hispanic and API individuals. Chart 21, Panel B shows that, from 1999 to 2010, transportation accident mortality rates declined for every RE/sex group, especially among females. However, during the 2011–2019 period, the transportation accident mortality rates declined much more slowly among the WNH and API communities, and they increased among the Black and Hispanic populations.

In 2014, the transportation accident mortality rate among Black males began to diverge from that of WNH males overall and at ages 25–64, opening a gap. Among those aged 65 or older, API and Black women had the lowest transportation accident mortality rates in 2019 (8.0 and 8.3, respectively), followed by Hispanic women (8.7) and WNH women (10.6), while Black men had the highest mortality rate (27.4). In 2019, API females had the lowest transportation accident mortality rate in every age group. In addition, Black men and women were the only two groups in 2019 experiencing higher transportation accident mortality rates at ages 25–64 than at ages 65 or older. In 2019, the all-ages transportation accident mortality rates for Black and Hispanic males were about three times higher than those of their female counterparts. For WNH males, the rate was about 2.5 times higher than that of WNH females, and the rate for API males was double that of API females.

In 2019, deaths caused by assault respectively accounted for 3.0 percent and 6.5 percent of external-cause deaths among the WNH and API populations. For Hispanic and Black individuals, however, assaults led to 11.3 percent and 26.3 percent, respectively, of external-cause deaths. Assaults accounted for a disproportionate share of external-cause deaths in the Black community, particularly among males, for whom it was the leading external cause of deaths over all ages combined in both 1999 and 2019.

Chart 21, Panel C shows that Black males had the highest all-ages assault death rate in all years, followed by Hispanic males and Black females. Assault death rates are inconsistent with the Hispanic paradox, as both Hispanic males and females had higher all-ages mortality rates than their WNH counterparts in all but 3 years. In 2019, the all-ages assault-related mortality rate for Black males (37.2) was more than 10 times that of WNH males (3.6). From 1999 to 2019, the all-ages death rate from assault declined for every RE/sex group other than Black males. Despite dropping by almost half among Black men aged 65 or older (from 13.2 to 6.7), the rate nonetheless increased significantly for those aged 25–64, from 37.7 to 47.4.

Assault-related mortality is typically highest at ages 25–64 and lowest for the aged, except that API and WNH women aged 65 or older had slightly higher rates than their counterparts aged 0–24. The assault mortality rate for API females is the lowest of any RE group in the midlife and younger ages but at ages 65 or older, it is higher than those of WNH and Hispanic women. Assault also carries interesting gender dynamics. The share of external-cause deaths that are due to assault is similar between males and females among the WNH and API populations but is substantially higher for males than females among the Hispanic and Black communities. In 2019, the all-ages assault mortality rates of API and WNH males were twice those of their female counterparts. By contrast, the all-ages assault mortality rate for Hispanic males was almost four times that of Hispanic females, and the rate for Black males was 6.5 times higher than the rate for Black females.

For all ages combined, intentional self-harm (suicide) was in 2019 the leading subcategory of external-cause deaths among API individuals (26.7 percent), the second leading subcategory for the WNH population (21.3 percent), the third leading cause in the Hispanic community (15.8 percent) and the fifth leading subcategory among the Black population (8.6 percent), following poisonings, assaults, transportation accidents, and all other accidents.

Chart 21, Panel D shows that WNH males had substantially higher all-ages death rates from suicide than those of any other RE/sex group. In 2019, the rates were 27.8 for WNH males, 11.8 for Black males, 11.6 for Hispanic males, and 10.7 for API males. From 1999 to 2019, the all-ages suicide mortality rate increased for every RE/sex group. Among females in 2019, the all-ages suicide mortality rates from highest to lowest were those for the WNH, API, Hispanic, and Black populations. At ages 0–24 and 25–64, mortality rates from suicide increased significantly across the board, but they declined at ages 65 or older, except among WNH men and women. In addition, Black men aged 65 or older had lower suicide mortality rates than men of that age in any other RE group. Suicide deaths typically accounted for a higher share of external-cause deaths among men than for women. For example, in 2019, suicides constituted 25.3 percent of all-ages external-cause deaths among WNH males, but only 13.6 percent of those for WNH females.

Since 1999, U.S. opioid overdose deaths have occurred in three compounding waves (Ciccarone 2019). The first wave is tied to natural and semisynthetic opioids, reflecting a steep increase in opioid prescriptions. The second wave is tied to heroin, to which many addicts transitioned from prescription opioids. The third wave is tied to synthetic opioids such as illicitly manufactured fentanyl. Chart 21, Panel E plots mortality rates from accidental poisoning by and exposure to noxious substances. In 2019, Black males had the highest all-ages poisoning mortality rate (33.9), followed by WNH and Hispanic males (32.8 and 20.3, respectively). However, from 2003 to 2018, the poisoning-related mortality rate was higher for WNH males than for Black males. From 1999 to 2010, the all-ages poisoning-related mortality rate for WNH males increased by 183 percent, but it remained relatively flat for Black and Hispanic males. However, during the 2011–2019 period, the death rates rose substantially for every population group except API women aged 65 or older. In 2019, the WNH and Black RE groups had the highest poisoning-related mortality rates among females.²³

From 1999 to 2019, the increase in poisoning-related mortality for all population groups (except API women aged 65 or older) can only be described as explosive. The all-ages poisoning death rate more than doubled for API females and Hispanic males, it more than tripled for Hispanic females and for Black males and females, and it more than quintupled for API and WNH males. WNH females experienced the worst increase. In 2019 their age-adjusted mortality rate (15.1) was more than 6.5 times higher than it had been in 1999 (2.3). By 2019, poisoning became the leading external cause of death at all ages for WNH and Hispanic males and for WNH and Black females and the second leading cause of death among Black males and Hispanic females. In the midlife ages, poisoning was by far the subcategory responsible for most external-cause deaths among all RE/sex groups other than API men and women. Mortality rates rose among almost all age groups. In 2019, the poisoning-related mortality rates at ages 0–24 and 25–64 were higher for WNH males than for any other RE/sex group, but for the 65 or older age group, Black men had the highest death rate. According to the Substance Abuse and Mental Health Services Administration (2020), fentanyl and other synthetic opioids are especially affecting the overdose death rates among older Black Americans. From 1999 to 2012, the mortality rate among Black men aged 65 or older doubled from 4.1 to 8.5. Then, in the 7-year span from 2013 to 2019, it nearly tripled, from 10.0 to 28.6. The increase in opioid-involved overdose deaths in the Black community now outpaces that of any other RE group.

Chart 21, Panel F shows the mortality rates from falls. From 1999 to 2019, all-ages fall mortality rates increased significantly for all RE/sex groups, especially for WNH males and females and API females, for whom the rates more than doubled. In 2019, the all-ages mortality rate from falls was highest among WNH males, second highest among WNH females, and lowest among Black females. For either sex, Black people had lower all-ages mortality rates from falls than API, WNH, and Hispanic individuals. In 2019, the fall-related mortality rate for WNH men aged 65 or older (86.5) was more than twice that for aged Black men (37.8). Likewise, the mortality rate from falls among aged WNH women almost tripled that of aged Black women (65.7 versus 22.4).

It is unclear why the mortality rates associated with falls at older ages have increased over time to such an extent, but the finding is consistent with the mortality trends observed in other developed countries (Hartholt and others 2019). Plausible explanations include the higher prevalence of dementia and degenerative disorders of the nervous system and the role of medications that increase the risk of falling. Shaver and others (2021) document the concurrent rise in mortality from falls and the increasing use of medications classified as “fall risk increasing drugs.” These medications include anticonvulsants, antidepressants, antihypertensives, antipsychotics, benzodiazepines, opioids, sedative hypnotics, and nonprescription medications such as antihistamines. The authors found that women were more likely than men to be prescribed drugs that raised the risk of falls, particularly Black women. This appears consistent with the fact that women have experienced a higher rate of increase in mortality from falls than men but seems at odds with the substantially lower Black female mortality rate.

The subcategory named “all other accidental causes” includes death from fire, smoke, drowning, electric current, extreme temperatures, and other factors. It represents a declining percentage of external-cause deaths, with shares ranging in 2019 from 8.4 percent of all-ages external causes of death among Hispanic people to 11.0 percent among API individuals. Nevertheless, all other accidental causes account for larger shares of external-cause deaths among the oldest and youngest individuals, involving, for example, 31.2 percent of external-cause deaths among Black people aged 85 or older in 2019.

Chart 21, Panel G shows that from 1999 to 2019, mortality rates from all other accidents declined substantially for every RE/sex group, with most of the improvement occurring in the first decade. In 2019, Black males had the highest death rate in every age group, followed by WNH males. The gap between these two populations narrowed over the period. At ages 65 or older, the mortality rate for Black men declined by more than half, from 69.1 in 1999 to 34.2 in 2019. Among the RE/sex groups, Hispanic men had the third highest all-ages mortality rate from other accidental causes. However, at ages 65 or older, Black and WNH women both had higher mortality rates than Hispanic men. Among those aged 0–24, Black females had the third highest mortality rate, after Black and WNH males.

The final subcategory comprises all external causes of death that are excluded from the previous subcategories. Examples include complications of medical and surgical care, sequelae of external causes of morbidity and mortality, events of undetermined intent, and legal interventions and operations of war. Depending on the RE group, these causes account for about 4 percent to 7 percent of external-cause deaths. Chart 21, Panel H shows that all-ages mortality rates in this subcategory increased for every RE/sex group from 2014 to 2019.

In summary, external causes of mortality represent a racially and ethnically heterogenous category that has exhibited some dramatic changes over time. From 1999 to 2019, the all-ages external-cause mortality rate increased for every RE/sex group except API females. This is evident in Chart 22, which shows the contribution of each external cause-of-death subcategory to the all-ages external-cause mortality rate by RE group and sex in 1999 and 2019.

Among males in 1999, those who were Black had the highest external-cause mortality rate. Although suicide mortality for WNH males was nearly twice that of Black males, the death rate for Black males from assault alone exceeded the rate for WNH males caused by assault, transportation accidents, and poisoning combined. By contrast, for Hispanic males, the higher assault-related mortality rate in 1999 than that of WNH males was more than offset by a much lower suicide death rate. All-ages mortality rates for API males were substantially lower than those for any other male RE group in transportation accidents, poisoning, and all other accidents. As a result, the mortality rate from external factors for Black males in 1999 was more than triple that of API males, and for WNH and Hispanic males it was roughly double that of API males. Chart 22 does not capture the fact that by 2014, the gap in external-cause mortality rates between Black and WNH males had almost disappeared, as the latter group experienced rapid mortality rate increases driven by suicides, falls at older ages, and especially overdose and other poisonings. However, the gap widened thereafter; by 2019, Black men aged 25 or older had experienced increased transportation accident mortality and a steep rise in poisoning deaths.

Mortality patterns for females in 1999 largely mirrored those of males, generally exhibiting the same RE group rankings, but with some important differences. For instance, all-ages external-cause mortality rates for API and Hispanic females were much closer to one another (18.9 and 21.3, respectively). Similarly, the all-ages external-cause mortality rate for Black females (34.6) was much closer to that of WNH females (31.4). In 2019, the combined all-ages death rate from transportation accidents, suicides, and assaults was similar for Black and WNH females (both at about 16), as higher suicide mortality rates among WNH females were offset by a lower assault mortality rate. On the other hand, WNH female mortality rates from poisoning and falls were 1.3 and 2.7 times higher, respectively, than those of Black females. As a result, WNH females experienced a higher external-cause mortality rate than any other female RE group in 2019.

For every RE/sex group except API females, the rise in poisoning-related deaths was the primary factor contributing to higher external-cause mortality in 2019 than in 1999. If the poisoning mortality rate had stayed constant at its 1999 level, the all-ages external-cause death rate for WNH males and females would have risen nonetheless, as the decline in mortality from transportation and other accidents would have been more than offset by the rise in suicides and fall-related deaths. However, for all other RE/sex groups, external-cause mortality rates would have declined if not for the rise in poisoning-related deaths.