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

An Overview of Mortality Cause Categories

This section describes broad cause-of-death categories, based on the ICD-10's classification chapters. Mortality is classified into one of the 17 categories listed in Box 1, shown with the corresponding ICD-10 codes.

The charts shown in this section and in the sections that follow detail U.S. mortality patterns over the period 1999–2019 variously by cause, RE group, sex, and age group. See the Notes on the Mortality Charts below for information on interpreting both the charts and the discussions that accompany them.

Chart 6 shows the number and percentage distribution of deaths by category for 1999 and 2019, with detail by RE group and age. Variation in the age distributions of the RE groups and in age-specific mortality rates account for differences in the relative shape of the death count profiles. For instance, deaths resulting from external causes appear much more prominent among the Hispanic population than for WNH individuals. However, the Hispanic community experiences a significantly lower age-adjusted mortality rate from external causes than does the WNH population. Thus, the difference in shape between the graphs is mostly determined by differing age distributions, in that the Hispanic population is substantially younger. In the area plots showing the percentage distribution of deaths by cause for each RE group by single year of age, the different age distributions between the groups are factored out.

Diseases of the circulatory system were the leading cause of death in each RE group across most ages, followed by neoplasms (cancers). At younger ages (0–24) and the midlife years (25–64), however, external causes of mortality, which include traffic-related and other accidents, assaults, suicides, and drug overdoses, were one of the primary causes of death. The share of deaths caused by respiratory diseases was generally greater among the WNH population than for other groups. In 1999, it was the third leading cause of death for all RE groups at ages 65 or older. Nevertheless, when combining all ages, external causes still accounted for a higher proportion of deaths than respiratory disorders among the Black, Hispanic, and API communities.

Driven in large part by the acquired immune deficiency syndrome (AIDS) epidemic, the percentage of deaths caused by infectious and parasitic diseases was significantly higher in 1999 than in 2019, particularly among the Black and Hispanic populations. For instance, in 1999, infectious and parasitic diseases accounted for more than 10 percent of deaths among Black people aged 25–64, compared with 3 percent among the WNH population in the midlife years. The percentage of deaths caused by diseases of the digestive system was higher for Hispanic people than any other RE group, while deaths related to endocrine, nutritional, and metabolic diseases (such as diabetes) accounted for a larger proportion of mortality among the Black and Hispanic populations than for the other RE groups. There were also substantial changes over time in the categorical distribution of causes of death. From 1999 to 2019, the percentage of deaths attributed to circulatory system diseases declined for all four RE groups. For instance, in 1999, 40.8 percent of deaths in the WNH population involved circulatory diseases, but the share had dropped to 30.7 percent by 2019. During this period, the percentage of deaths caused at older ages by mental and behavioral disorders (such as dementia) and diseases of the nervous system (such as Alzheimer's disease, Parkinson's disease, and other degenerative disorders) rose dramatically. In 1999, the two categories combined (mental disorders and diseases of the nervous system) constituted 5.7 percent of deaths among the WNH population. By 2019, that share had risen almost to 14 percent.

Chart 7 shows age-adjusted mortality rates by age group, RE group, and sex for 1999–2019. As noted earlier, all mortality rates discussed in this article are age-adjusted deaths per 100,000 population. Chart 7 covers all-cause mortality and mortality for each of 17 cause-of-death categories. The panel for each cause-of-death category (as well as the all-causes panel) includes one plot showing age-adjusted mortality rates for all ages combined and three additional plots, one each for age groups 0–24, 25–64, and 65 or older. Notice that age-adjusted mortality rates are irrelevant for certain causes and age groups but are included nonetheless for the sake of completeness. For example, mortality rate plots at ages 0–24 for many causes appear quite “noisy” because the numbers of deaths from those causes (such as diseases of the skin and subcutaneous tissue or mental and behavioral disorders) are negligible. Conversely, almost 99 percent of deaths caused by conditions originating in the perinatal period occur before age 1 (Panel O), rendering the plots for ages 25–64 and 65 or older virtually meaningless. In addition, mortality caused by complications of pregnancy, childbirth, and the puerperium is negligible for women aged 65 or older and nonexistent for males (Panel R).¹⁴

All-Cause Mortality

Panel A presents all-cause mortality rates. For all RE groups, males had higher rates than females. For either sex, Black individuals had the highest mortality rates, followed by the WNH population. Hispanic people had lower all-cause mortality rates than WNH people, a phenomenon often referred to as the Hispanic mortality paradox because their lower mortality belies a socioeconomic disadvantage relative to the WNH population.¹⁵ The API community experienced the lowest all-cause mortality rate. For all ages combined, mortality rates improved (that is, declined) more slowly for WNH males and females than for all other RE/sex groups. As a result, the mortality gap between the Black and the WNH populations narrowed substantially over the period. For instance, in 1999, mortality rates were 1,433.7 and 1,045.6 for Black and WNH males, respectively. By 2019, the respective rates had dropped to 1,041.0 and 864.9. Put differently, in 1999, 388 more Black males than WNH males died per 100,000, but the gap declined to 176 more deaths per 100,000 by 2019. Over the entire 1999–2019 period, mortality rates within a given RE group improved at a higher rate for males than for females, narrowing the gender gap.

In 2019, Black females had a higher all-cause mortality rate than both API and Hispanic males, while WNH females had a higher mortality rate than API males. Much of the all-cause mortality rate improvement in each RE/sex group occurred during the first decade of the 1999–2019 period and was more pronounced among those aged 65 or older than at other ages. In fact, all-cause mortality rates in the midlife ages were higher in 2019 than in 1999 for both WNH males (446.3 versus 428.8) and WNH females (263.6 versus 251.5). By about 2014, all-cause mortality rates in the 25–64 age group began to increase for almost every RE/sex group. Specifically, the mortality rate among those aged 25–64 was higher in 2019 than in 2010 for every RE/sex group except Black and API women.

Long-term increases in U.S. life expectancy at birth plateaued in 2010 and expectancy declined in 2015, 2016, and 2017 (Woolf and Schoomaker 2019). This reversal was the culmination of a trend beginning in the 1990s, when mortality at ages 25–64 began to rise, especially for certain causes. Americans in the midlife ages experienced a surge in deaths driven by the near-term effects of drug overdoses, alcohol abuse, and suicides, often referred to as “deaths of despair” (Case and Deaton 2020). Initially, the rising rate in deaths of despair was offset by concurrent declines in other leading causes of death, such as traffic accidents, ischemic heart disease, cancer, and HIV infection. However, by 2010, all-cause mortality at ages 25–64 began to rise, and by 2014, it was increasing across all RE groups (Woolf and Schoomaker 2019).

Diseases of the Circulatory System

Circulatory system diseases were the leading all-ages cause of death among the four RE groups in 2019, accounting for 27–32 percent of deaths in each group and totaling 874,613 deaths overall.¹⁶ However, the proportion of deaths caused by circulatory system diseases has steadily declined over time (Chart 6). For instance, in 1999, diseases of the circulatory system respectively caused 40.8 percent and 32.7 percent of deaths among WNH and Hispanic people. However, by 2019, the corresponding percentages were 30.7 percent for the WNH population and 27.6 percent for the Hispanic community. Typically, circulatory system diseases account for a small percentage of deaths at younger ages (less than 4 percent for those aged 0–24), but the share increases steadily with age. By the midlife years, diseases of the circulatory system in 2019 accounted for 20.6 percent and 29.1 percent of deaths among Hispanic and Black individuals, respectively. However, for those aged 65 or older, circulatory system diseases caused at least one-third of all deaths in 2019, irrespective of RE group.

Chart 7, Panel B shows that from 1999 to 2019, the all-ages circulatory system disease mortality rates for both males and females in every RE group declined by more than one-third, and most of the improvement occurred during the first decade of the period. Circulatory system disease mortality rates also dropped more rapidly for the aged than for those in the midlife years. By 2010, mortality rates had begun either to decline at a slower rate, to flatten, or to increase among those in the midlife years or younger ages. For example, from 2010 to 2019, the circulatory system disease mortality rate among WNH men aged 25–64 dropped only from 103.9 to 103.0, while the rate for WNH women in the same age group increased from 44.1 to 46.3. This pause in the improvement over time in the circulatory system disease mortality rate is one factor contributing to the increase in all-cause mortality in the midlife ages exhibited in the last decade (Woolf and Schoomaker 2019; Case and Deaton 2020). Black males had the highest all-ages circulatory disease mortality rate in 2019 (341.8), followed by WNH males (262.4) and Black females (228.6). By contrast, API and Hispanic females had the lowest all-ages circulatory system disease mortality rates, at 102.2 and 128.4, respectively. Note that at ages 65 or older, WNH women and Hispanic men had relatively similar mortality rates in 2019 (1,211.3 and 1,222.4, respectively). However, at ages 25–64, WNH women experienced lower circulatory system disease mortality rates than both Hispanic and API men.

Neoplasms

In 2019, cancers (neoplasms) were the second most common cause of death after circulatory system diseases, accounting for at least one-fifth of deaths for all ages combined, ranging across the RE groups from 20.7 percent of deaths in the Black population to 25.3 percent among API people.¹⁷ At ages 0–24, the shares of deaths attributable to this category ranged from 2.9 percent for Black individuals to 7.2 percent in the API community. As illustrated in Chart 6, the share of deaths from neoplasms typically peaks between ages 50 and 75 and then progressively declines at older ages, as other groups of impairments account for relatively larger proportions of deaths. In 2019, cancer caused 615,191 deaths. As a percentage of all deaths, cancer ranks higher in the API population than for the other RE groups; yet for either sex, cancer-related mortality rates are lower for the API community than for any other RE group (Chart 7, Panel C).

Unlike the death rates for circulatory system diseases, those for cancer generally declined steadily throughout 1999–2019. The cancer mortality rates of Black males and females improved more rapidly than those of any other RE/sex group, substantially narrowing the mortality gap with their WNH counterparts. For example, in 1999, over all ages combined, Black males and females respectively experienced 94.8 and 27.8 more deaths per 100,000 than their WNH counterparts. By 2019, the gaps had narrowed to 23.8 and 11.6, respectively. At ages 65 or older, Hispanic men had a higher cancer mortality rate than both Black and WNH women. During the midlife ages, however, Black women had the second highest cancer mortality rate (after Black men), followed in turn by WNH men and WNH women. The gender gap in cancer death rates also narrowed over time for every RE group. For instance, in 1999, the cancer mortality rate for Black men aged 65 or older (1,994.2) was almost twice that of Black women (1,019.6). By 2019, the gender ratio in mortality rates for that age group had declined from 2.0 to 1.6.

Diseases of the Respiratory System

In 2019, respiratory system diseases accounted for 6.6 percent of deaths in both the Black and Hispanic groups, 7.4 percent of deaths for API individuals, and 10.3 percent of deaths among WNH people. In total, 271,026 deaths were caused by respiratory system diseases. The share of all deaths attributed to this category was higher for the WNH population than the other RE groups (Chart 6). Chart 7, Panel D shows that WNH males had the highest all-ages respiratory disease death rates, followed by Black males and WNH females, making this one of the few ICD-10 chapter-level categories in which mortality was higher among WNH males and females than their Black counterparts. For instance, in 2019, the respiratory system disease death rates were 81.3 and 70.5 among WNH and Black males, respectively, and the rate for WNH females (66.1) was 1.4 times higher than that of Black females. This disparity was driven by mortality at ages 65 or older. At ages 0–24 and 25–64, Black people had higher death rates than members of the same sex in the other RE groups.

Over the 1999–2019 period, mortality caused by diseases of the respiratory system declined substantially, particularly among the non-WNH RE groups. Nevertheless, respiratory system disease mortality at ages 25–64 was higher in 2019 than in 2010 for every RE/sex group. The all-ages death rate improved at a faster pace among males than females, narrowing the gender gap. Hence, from 1999 to 2019, the male-to-female respiratory disease mortality ratio dropped from 1.5 to 1.2 among WNH individuals, from 1.9 to 1.5 among Black people, from 1.6 to 1.5 among the Hispanic community, and from 2.0 to 1.7 for the API population.

External Causes of Mortality

External causes of mortality comprise transportation accidents, assaults, suicides, and any other accidental causes of death, including drug and alcohol overdoses. External causes of mortality account for larger shares of deaths among men than women, and for Hispanic and Black individuals than for the WNH and API populations. In 2019, roughly 8 percent of deaths at all ages combined among the WNH and API populations were due to external causes, compared with 10.8 percent of deaths among Black people and 12.9 percent of deaths among Hispanic individuals. For Hispanic and Black males, the percentages of 2019 deaths caused by external factors were 17.7 percent and 15.5 percent, respectively, representing the third leading cause-of-death category after circulatory system diseases and neoplasms. At ages 0–24, external causes overwhelmingly accounted for the most deaths (Chart 6), representing in 2019 more than half of deaths among WNH people, about 45 percent of deaths among Black and Hispanic individuals, and about 40 percent of deaths in the API community. At ages 25–64, external causes of mortality in 2019 exceeded all other causes among Hispanic and WNH men (29.9 percent and 25.3 percent, respectively), were the second leading cause of death among Black men (25.4 percent), and were the third leading cause of death among API men and among women of all RE groups. On the other hand, the shares of deaths caused by external factors at ages 65 or older were low, ranging from 2.6 percent among the Black population to 3.7 percent for the WNH population. Overall, 251,350 deaths in 2019 were attributed to external causes.

All-ages external-cause mortality rates were higher in 2019 than in 1999 for all RE/sex groups except API females (Chart 7, Panel E). The all-ages death rates increased steadily among adult WNH males and females after 1999. For the other RE/sex groups, however, mortality rates generally declined throughout the first decade of the period, but they increased after about 2010. Among males, all-ages mortality rates from external causes were highest for those who were Black, followed in order by those who were WNH and Hispanic. In 1999, for instance, all-ages mortality rates for Black and WNH males were 112.2 and 76.4, respectively. By 2014, the mortality-rate gap between those two populations had almost disappeared (93.7 and 92.9, respectively), but it widened thereafter. Conversely, the gap in all-ages mortality between Hispanic and WNH males widened considerably from 1999 to 2019, rising from 4.3 to 34.8 additional deaths per 100,000 among WNH males. Among females, those who are WNH had the highest age-adjusted external-cause mortality rate after 2002.

At ages 0–24, Black individuals had the highest external-cause mortality rates among both males and females. At ages 65 or older, however, men and women who were WNH had higher mortality rates than those of other RE groups. In the midlife ages, Black people had the highest mortality rate among men, while WNH individuals had the highest mortality among women. Furthermore, external-cause mortality typically increased at a much higher rate in the midlife years than at ages 65 or older. For instance, from 1999 to 2019, the external-cause mortality rate of WNH women aged 25–64 almost doubled, from 27.6 to 54.3 deaths; yet at ages 65 or older, the rate increased more gradually, from 88.6 to 115.9. Mortality caused by external factors differed widely by sex. Specifically, the male-to-female ratio in mortality rates was higher for external causes than for any other ICD-10 chapter-level category. All-ages male external-cause mortality rates exceeded those of females in 2019 by a factor of 2.3 for the WNH population, 2.4 for the API population, 3.1 among Hispanic people, and 3.3 for the Black community.

Diseases of the Nervous System

The share of deaths that are caused by nervous system diseases increased rapidly from 1999 to 2019 (Chart 6), driven by higher incidence of Alzheimer's and Parkinson's diseases and other degenerative disorders at older ages. In each RE group, nervous system diseases accounted for a higher share of deaths among women than men. In addition, this category's share of all deaths was higher in the WNH population than for the other RE groups. For instance, in 1999, diseases of the nervous system at all ages accounted for 3.8 percent of deaths among WNH individuals and 2.1 percent of deaths among Black people. By 2019, those shares had risen to 8.8 percent and 5.5 percent, respectively. At ages 65 or older, more than 12 percent of WNH and Hispanic women, 10.6 of API women, and 9.0 percent of Black women died of nervous system diseases. In 2019, 233,715 Americans of all ages died of nervous system diseases.

Chart 7, Panel F shows that from 1999 to 2019, nervous system disease mortality rates increased substantially for every RE/sex group. Further, within each RE group, mortality rates by sex converged. WNH males and females had the highest mortality rates, followed by Black males and females. The all-ages nervous system disease mortality rate rose from 34.9 to 60.9 for WNH males during the period, and from 30.4 to 61.3 for WNH females. All-ages mortality rates rose faster for females than males, more than doubling in every female RE group over the 1999–2019 period. Nervous system disease mortality rates also increased during the observation period for people in the midlife ages, although at a far slower pace than at older ages, with the Black population experiencing the highest death rates in the 25–64 age group.

Endocrine, Nutritional, and Metabolic Diseases

In 2019, endocrine, nutritional, and metabolic diseases such as diabetes constituted roughly 1 in 20 deaths overall, ranging from 4.5 percent of deaths among WNH people to 6.5 percent of deaths among Hispanic and Black individuals. The share of deaths from these diseases has increased moderately over time among all RE groups but is disproportionately higher for the Black and Hispanic communities (Chart 6). In 2019, 140,107 deaths were attributed to these diseases. Chart 7, Panel G shows that Black males had the highest all-ages endocrine, nutritional, and metabolic disease mortality rate in 2019 (64.7), followed by Black females (47.2) and Hispanic males (41.5). Hispanic females had higher endocrine, nutritional, and metabolic disease mortality rates than WNH males until 2007, after which the gap reversed and widened, reaching 39.6 for WNH males and 29.1 for Hispanic females in 2019. API females had the lowest all-ages endocrine, nutritional, and metabolic disease mortality rate, at 19.3. In addition, although Hispanic males and females experienced higher all-ages endocrine, nutritional, and metabolic disease mortality rates than their WNH counterparts (a rare departure from the Hispanic paradox), that gap narrowed considerably over the observation period.

All-ages endocrine, nutritional, and metabolic disease mortality rates declined among all RE groups from 1999 to 2010, but then they increased (except among Black females, for whom the 2011 and 2019 mortality rates were the same). As a result, the all-ages death rate was higher in 2019 than in 1999 for WNH, Black, and API males. Chart 7, Panel G shows the 1999–2019 trends that resulted in the male-to-female endocrine, nutritional, and metabolic disease mortality ratio increasing from 1.2 to 1.5 among WNH people, from 1.0 to 1.4 for the Black population, from 1.1 to 1.4 among the Hispanic community, and from 1.2 to 1.3 in the API population. This divergence occurred among both aged adults and those in the midlife years. At ages 65 or older, Hispanic men and women experienced higher endocrine, nutritional, and metabolic disease mortality rates than WNH men and women, while at ages 25–64, rates were higher among WNH individuals than in the Hispanic population.

Mental and Behavioral Disorders

Like the pattern for diseases of the nervous system, the share of deaths caused by mental and behavioral disorders rose over the observation period (Chart 6), fueled by both a higher incidence of “unspecified dementia and other organic disorders” among people aged 65 or older and a rise in mental and behavioral disorders resulting from psychoactive substance use at ages 25–64 beginning around 2010. At all ages combined, the percentage of deaths caused by mental and behavioral disorders is higher among females than males, and higher in the WNH population than for the other RE groups. For instance, in 1999, 1.8 percent of WNH individuals died of mental and behavioral disorders. By 2019, that share had risen to 5.1 percent. Overall, 133,959 people died of mental and behavioral disorders in 2019. That year, 10.7 percent of WNH women aged 85 or older died from causes in this category.

Chart 7, Panel H shows that for every RE group, mental and behavioral disorder death rates rose sharply until 2013, then declined. The all-ages death rate from mental and behavioral disorders was highest for Black males until 2011, when their mortality rate was surpassed by that of WNH women. In 2019, the all-ages mental and behavioral disorder mortality rate was 36.6 for WNH females, 36.0 for Black males, 33.4 for WNH males, and 30.5 for Black females. Hispanic people experienced substantially lower mortality rates from mental and behavioral disorders (19.5 for males and 17.3 for females), while API males had the lowest mortality rate, at 13.5. At ages 65 or older, mortality rates roughly tripled from 1999 to 2019 for Black and API women and more than doubled for all other RE/sex groups except Hispanic men.

Diseases of the Digestive System

In 2019, the shares of deaths caused by digestive system diseases ranged from 3.0 percent in the Black population to 5.7 percent for the Hispanic community. The incidence of these deaths peaked in the midlife ages. For instance, in 2019, the percentage of deaths attributed to diseases of the digestive system among individuals aged 25–64 was 8.7 percent for Hispanic people, 6.8 percent for WNH individuals, 4.1 percent among the API population, and 3.8 percent for the Black community. Digestive system diseases caused 112,894 deaths in 2019. Chart 7, Panel I shows that Hispanic and Black males had the highest all-ages digestive system disease death rates from 1999 to 2005, and although the rates for both groups continued to decline, the mortality rate for Black males dropped more sharply until 2011, when it was first surpassed by the mortality rate for WNH males. Similarly, among females, those who are Black had the highest digestive system disease mortality rate in 1999. By 2019, however, Black males and females both had lower mortality rates than their counterparts in the WNH and Hispanic communities. On the other hand, the all-ages mortality rates from digestive system diseases for API males and females were half those of their Black counterparts.

Age-adjusted digestive system disease mortality rates in the midlife ages rose significantly for WNH men and women from 1999 to 2019 (from 23.7 to 29.3 among men and from 11.6 to 18.7 among women). By contrast, mortality rates at ages 25–64 declined throughout this period for the Black and Hispanic populations. This trend reflects a significant rise in alcoholic and other liver diseases among WNH men and women, part of the increase in deaths of despair. As is further discussed later, from 1999 to 2019, the share of digestive system disease deaths that is attributed to alcoholic and other liver diseases rose from 37.8 percent to 49.1 percent among the WNH population and from 64.1 percent to 69.5 percent in the Hispanic community.

Diseases of the Genitourinary System

In 2019, the shares of deaths at all ages that were caused by genitourinary system diseases ranged from 2.4 percent for WNH people to 3.5 percent for Black individuals. The genitourinary disease share of deaths increased slightly from 1999 to 2019 in all RE groups and tended to be higher among females than males and among Black and Hispanic individuals than API and WNH people. In 2019, 72,871 people died of causes in this category, and roughly 70 percent of these deaths involved renal failure. Chart 7, Panel J shows that Black males had the highest all-ages genitourinary disease mortality rates throughout the observation period, followed by Black females. In 1999, the mortality rates for Black males and females (44.6 and 34.2, respectively) more than doubled those of their WNH counterparts (20.7 and 16.0, respectively). Hispanic males and females had lower all-ages genitourinary disease mortality rates than their WNH counterparts, and API females experienced the lowest genitourinary disease mortality rate (12.1). By 2019, the all-ages death rates from this category of causes had declined in every RE group—modestly so in the WNH community, and with much greater improvement for Black and API people. However, the mortality rate at ages 25–64 increased from 3.6 to 5.3 for WNH men and from 3.1 to 4.3 for WNH women in the period 1999–2019.

Infectious and Parasitic Diseases

In 2019, the percentage of all deaths that were caused by infectious and parasitic diseases ranged from 2.0 percent for WNH people to 3.3 percent among Black people (Chart 6). For men in the midlife ages, particularly those who are Black and Hispanic, the percentages tended to be slightly higher. In 2019, 64,706 deaths were caused by infectious and parasitic diseases. The share of deaths attributable to infectious and parasitic diseases, however, has declined significantly since 1999, when they accounted for 9.2 percent of deaths of Hispanic males and 11.2 percent of deaths of Black males. More than 65 percent of those deaths were attributed to HIV. Chart 7, Panel K shows that in 1999, the all-ages death rate from infectious and parasitic diseases for Black males (75.9) was more than 3.5 times that of WNH males (20.8), and the rate for Black females (42.0) was more than twice the rate for WNH males. All-ages infectious and parasitic disease mortality rates were higher for females who are Hispanic than for those who are WNH until 2008 and the rates were higher for Hispanic males than for their WNH counterparts until 2016. By 2019, the infectious and parasitic disease mortality rate of Black males at all ages had declined by more than half, while Black females and Hispanic and API males experienced a mortality-rate improvement of more than 40 percent.

Black males and females had the highest infectious and parasitic disease mortality rate in every age group but also experienced faster mortality-rate improvement. Among those aged 65 or older, for whom bacterial infection of the bloodstream (sepsis) was the leading cause of death within this category, mortality rates declined from 229.2 in 1999 to 149.6 in 2019 for Black men and from 165.8 to 104.9 among Black women. Hispanic men and women aged 65 or older had lower infectious and parasitic disease mortality rates than their WNH counterparts. At ages 25–64, mortality rate improvement was to a large extent driven by the widespread use of highly active antiretroviral therapy, an effective HIV treatment that emerged in the mid-1990s. In 1999, Hispanic men aged 25–64 had a substantially higher mortality rate from infectious and parasitic diseases than WNH men (31.3 versus 15.3). However, by 2019, the gap had largely vanished (10.9 versus 9.8). Likewise, by 2013, Hispanic women aged 25–64 had lower infectious and parasitic disease mortality rates than WNH women.

Other Causes of Death

In 2019, 14,553 deaths were caused by diseases of the musculoskeletal system and connective tissue, representing about 0.5 percent of all deaths. For a given RE group, musculoskeletal disorders accounted for a higher share of deaths among females than males and skewed toward older ages. Systemic connective tissue disorders accounted for 25.3 percent of the deaths in this category, followed by diseases of the bone and cartilage (23.3 percent), arthropathies or joint disease (22.0 percent), soft tissue disorders (18.1 percent), and all other musculoskeletal/connective tissue disorders (11.3 percent). Chart 7, Panel M shows that females in all RE groups experienced higher musculoskeletal system/connective tissue–related mortality rates than males. Black females had the highest all-ages mortality rate throughout the study period, followed by WNH females until about 2016, when their mortality rate was surpassed by that of Black males. API males consistently had the lowest musculoskeletal system/connective tissue–related mortality rate. At ages 65 or older, however, WNH women experienced the highest mortality rates of any RE/sex group in every year except 2018. In general, females have a higher prevalence of musculoskeletal disorders than males, caused in part by hormonal and anatomical differences between the sexes (Wolf and others 2015).

Another cause-of-death category combines diseases of the blood and blood-forming organs with certain disorders involving the immune mechanism; this category accounted for 10,815 deaths in 2019. About 37 percent of these deaths involved aplastic and other types of anemias, while another 25 percent were related to coagulation defects, purpura, and other hemorrhagic conditions. This category accounted for 0.3 percent of deaths among WNH people and 0.7 percent of deaths among Black people. Chart 7, Panel N shows that in 1999, the all-ages mortality rates for Black males and females were about 2.5 times the rates for their WNH counterparts. Although the mortality rate for this cause has declined significantly for the Black population since 1999, it remained in 2019 more than twice that of any other RE group. The racial mortality gap in 1999 was wider still at ages 25–64: Compared with those of their WNH counterparts, the mortality rates were 6.5 times higher among Black men and 7.1 times higher for Black women. Beyond socioeconomic and other structural factors that might partially explain the observed disparities, individuals of African ancestry are known to have much higher prevalence of certain genetic conditions such as sickle cell and other anemias (Neel 1997).

In 2019, deaths caused by conditions originating in the perinatal period numbered 10,412, and 99 percent of them occurred before age 1. Conditions in this category include disorders related to the length of gestation and fetal growth, complications occurring in utero or during labor or delivery, and other medical conditions related to the perinatal period. At all ages, perinatal condition–related deaths accounted for more than 0.2 percent of deaths among WNH people, 0.6 percent of deaths among API individuals, and 1.0 percent of deaths among Black and Hispanic people. This cause of death represented 45.1 percent of deaths occurring before age 1 in the WNH group, 49.4 percent of those in the Hispanic community, and more than half of those for the Black and API populations. Chart 7, Panel O highlights enormous disparity by RE group in perinatal condition mortality rates. In 1999, the mortality rate for this category of causes was about three times higher for Black males and females than for their counterparts in the other RE groups. Although mortality rates for Black males and females later improved, disparities by factors of 2.4 to 2.8 remained in 2019. Consistent with findings in Ely and Driscoll (2020), the death rate for Black infants was twice that of WNH infants. In 2018, the infant death rates per 1,000 live births among the WNH and Black populations were 4.6 and 10.8, respectively.

In 2019, 9,713 deaths were caused by congenital malformations, deformations, and chromosomal abnormalities. Across RE groups, these deaths constituted from 0.3 percent of deaths among WNH individuals to 0.8 percent of deaths in the Hispanic community. Notice, however, that about 44 percent of these deaths occurred before age 1. Congenital causes accounted for many deaths occurring shortly after birth (almost one-quarter of those that occur before age 1) and represented about 10 percent of deaths among individuals aged 0–24 (Chart 6). Chart 7, Panel P shows that all-ages congenital/chromosomal abnormality–related mortality rates generally declined from 1999 to 2019 among all RE/sex groups. For those aged 0–24, Black males and females had the highest mortality rates, while API males and females had the lowest mortality rates over the observation period. However, the all-ages mortality rates for Black females and WNH males were similar.

Diseases of the skin and subcutaneous tissue accounted for 5,229 deaths in 2019 (0.2 percent of all deaths). One-fifth of these deaths involved decubitus ulcers (bed sores) and infections accounted for another three-fifths. Chart 7, Panel Q shows that Black females had the highest all-ages skin/subcutaneous tissue disease mortality rates, followed by Black males, although the mortality rates for both declined substantially over the observation period. For instance, in 1999, the skin/subcutaneous tissue disease mortality rate for Black women aged 65 or older (28.6) was almost four times that of aged WNH women (7.7). By 2019, the mortality rates for those same groups were 12.3 and 7.4, respectively.

Complications of pregnancy, childbirth, and the puerperium accounted for 1,103 deaths in 2019. Across RE groups, these causes represented from less than 0.1 percent of deaths among WNH females to 0.2 percent of deaths among Black females. Chart 7, Panel R shows increases in maternal mortality rates over the observation period, as well as substantial racial disparity. Of course, a more meaningful measure of mortality would focus on pregnant women rather than all women within a given age group. Hoyert (2021) reported the maternity- and postpartum-related mortality rate in 2019 for non-Hispanic Black women as 44 deaths per 100,000 live births, 2.5 times the rate for WNH women (17.9) and 3.5 times higher than the rate for Hispanic women (12.6). The United States has the highest maternal and infant mortality among comparable developed countries (GBD 2015 Maternal Mortality Collaborators 2016), and Black mothers and their infants experience death rates several times higher than those of their counterparts in other RE groups.

Deaths that are not attributed to any of the causes discussed above are categorized as those associated with “symptoms, signs, and abnormal clinical and laboratory findings, not elsewhere classified.” The count of deaths in this category peaked in 2012 at 42,050 before declining to 32,408 in 2019. The shares of all deaths attributed to this cause-of-death category ranged from 0.9 percent in the API population to 1.3 percent among Black individuals in 2019. Many (40.9 percent) of these deaths were attributed to a subcategory identified as “ill-defined and unknown causes of mortality” (ICD-10 codes R95–R99). Because unusually high death counts were coded R99 (“other ill-defined and unspecified causes of mortality”) in California in 2000–2001, in New Jersey in 2009, and in Georgia in 2008–2009, these data should be interpreted with caution. Chart 7, Panel L shows that regardless of age, Black males generally had the highest abnormal clinical findings mortality rates, followed by Black females. API males and females generally had the lowest abnormal clinical findings mortality rates.

In summary, cause-of-death category-specific mortality trends reveal an enormous racial disparity. Black males had the highest all-ages mortality rates of any RE/sex group for every nonmaternity-related cause-of-death category throughout the 1999–2019 period, with only these exceptions: For respiratory system diseases, rates were higher among WNH males; for diseases of the digestive system, rates were higher among Hispanic males (except in 2001, 2003, and 2004) and WNH males (from 2011 to 2019); for diseases of the nervous system, rates were higher for WNH males and females; for musculoskeletal system and skin diseases, rates were higher for Black females; and for mental and behavioral disorders, rates were higher for WNH females (from 2011 to 2019). All-ages mortality rates among females were higher for those who are Black than for those in any other RE group in most causes of death, including circulatory system diseases; cancer; endocrine, nutritional, and metabolic diseases; infectious and parasitic diseases; genitourinary system diseases; conditions originating in the perinatal period; congenital malformations, deformations, and chromosomal abnormalities; complications of pregnancy, childbirth, and the puerperium; diseases of the blood and blood-forming organs; diseases of the musculoskeletal system and connective tissue; diseases of the skin and subcutaneous tissue; and symptoms, signs, and abnormal clinical and laboratory findings not elsewhere classified. In 2019, the Hispanic mortality paradox (lower death rates among Hispanic individuals than for the WNH population) was substantiated for all cause-of-death categories except endocrine, nutritional, and metabolic diseases; conditions originating in the perinatal period; and diseases of the digestive system in particular, for which Hispanic males had the highest all-ages mortality rates.

Chart 8 shows all-ages mortality rates by cause-of-death category, RE group, and sex in 1999 and 2019. In 1999, the mortality rate from the combination of circulatory system diseases and neoplasms was higher for Black individuals than the all-cause mortality rate in both the API and Hispanic communities, regardless of sex. For Black males, the combination of four impairment groups (circulatory system diseases, neoplasms, respiratory system diseases, and external causes of mortality) resulted in an age-adjusted mortality rate (1,105.7) well above the all-cause mortality rate among WNH males (1,045.6). For Black females, combining the same four disorder categories with endocrine, nutritional, and metabolic diseases yielded a higher mortality rate (745.8) than the rate for all causes among WNH females (722.2). By 2019, all-cause mortality rates had declined significantly in all RE/sex groups, particularly among the non-WNH populations, but a sizable gap remained.¹⁸ Age-adjusted mortality rates declined from 1999 to 2019 for most cause-of-death categories and RE/sex groups. Notable exceptions were external causes, for which death rates increased among all groups other than API females; and nervous system diseases and mental and behavioral disorders, for which death rates increased in all RE/sex groups.