Ancel Keys Lecture: Adventures (and misadventures) in understanding (and reducing) disparities in stroke mortality.

O ne of the 2 key goals of the Healthy People 2010 statement , the guiding document for the United States Department of Health and Human Services, is to " eliminate health disparities among different segments of the population " by the year 2010. 1 The US Congress has by law directed National Institutes of Health (NIH) to specifically define health disparities to include the components: • Minority health research and related activities. • Rural health research and related activities. • Research and other activities related to the socioeconomically disadvantaged in the urban setting. 2 For brevity, we focus on a review of the magnitude of the disparities in stroke of only the first 2 of these disparities: review progress in reducing these disparities, and assess barriers and opportunities to reduce these disparities. Racial differences in stroke mortality are the most well-known and well documented of the stroke disparities. 3–5 Among non-Hispanics aged between 45 and 64 years, in 2009, there were 4359 deaths from stroke and an age-adjusted death rate of 48.9 per 100 000 in blacks, whereas there were 9994 deaths and a death rate of 16.3 per 100 000 in whites; this represents a 3-fold difference in death rates. 6 There would have been ≈3000 fewer deaths for blacks in this 20-year age range if they had the mortality rate of whites (4359×(16.3/48.9)=1424 projected deaths for a reduction of 2935 deaths). If the case-fatality rate is 20%, then these 3000 deaths would have arisen from ≈15 000 extra stroke events (3000/0.2=15 000), and a public health burden of the racial disparity in stroke is ≈$2.1 billion dollars annually (assuming a $140 000 cost of stroke). 7 The racial disparity in stroke mortality has been remarkably persistent, where between 1949 and 1951 the nonwhite (primarily blacks)/white stroke mortality ratio was 1.63 for men and 1.92 for women (reported in the very first volume of Stroke!). 8 Using CDC WONDER, 6 for ages ≥45 years, we observed a remarkable 37% decline in the age-adjusted cerebrovascular disease mortality between 1999 and 2009 there was a decline for each race/ethnic group, the cerebro-vascular disease death rates (International Classification of Diseases-Tenth Revision: I60–I69) are strikingly higher for blacks than for whites and marginally lower for Hispanics, Native Americans, and Asians than for whites (Figure 1 Left). Although the cerebrovascular death rates are falling for both whites and blacks, it is falling consistently …