Health Equity Matters
In this Newsletter
Fall 2014 ~ Vol.3, #4
A quarterly e-newsletter in which the Centers for Disease Control and Prevention's (CDC)
Office of Minority Health and Health Equity (OMHHE)
shares news, perspectives and progress in the science and practice of health equity.
Leandris C. Liburd, PhD, MPH, MA
Associate Director for Minority Health and Health Equity, CDC/ATSDR
to Health Equity Matters,
an electronic newsletter intended to promote awareness of minority health and health
equity issues that affect our work at CDC and in the broader public health community, support the achievement of our goal to eliminate health disparities, and foster ongoing communication and collaboration.
As we approach the holiday season, I want to extend my gratitude and appreciation to our readership, my colleagues at CDC, and our partners for their tireless efforts to promote and protect the health of our nation and globally. In particular, I want to thank the Office of Minority Health and Health Equity for rallying to accomplish our strategic priorities, and rising to every occasion with passion and excellence. Events highlighted in this issue of Health Equity Matters reflect some of our most significant collaborations and achievements this quarter. We hosted the second cohort of Millennial Health Leaders representing 18 universities from across the country, and heard a compelling talk by Dr. David Williams on the relationship between a diverse public health workforce and reducing health disparities. We celebrated Hispanic Heritage Month and learned more about the historic and contemporary contributions of Hispanic researchers and practitioners who have contributed to the social and economic uplift of the U.S. We introduce another federal Office of Minority Health in this issue –the Office of Minority Health at the Centers for Medicare and Medicaid Services (CMS) led by Dr. Cara James, and we honor Mr. William F. Benson as a Health Equity Champion for his career long commitment to protecting our elders and promoting healthy aging. These and other stories and scientific resources demonstrate how we’re continuing to advance the science and practice of health equity at CDC.
Over the past several months, CDC has been involved in responding to the largest Ebola epidemic in history. Over 800 staff members have been deployed to CDC’s Emergency Operations Center, locations around the country, as well as in West Africa to stop the spread of the virus. The Office of Minority Health and Health Equity salutes our colleagues for their 24/7 dedication to combatting the spread of the Ebola virus.
We wish all who receive this issue of Health Equity Matters good health and much cheer throughout the holidays and in the New Year!
Leandris C. Liburd, PhD, MPH, MA
Associate Director for Minority Health and Health Equity, CDC/ATSDR
Office of Minority Health & Health Equity (OMHHE)
As always, we hope you will enjoy this issue, and your comments are always welcome!
Our readership continues to grow. We now have over 17,000 subscribers,
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News You Can Use!
More than 50 graduate students selected through nominations by 18 schools of public health and medical schools across the country convened at the second assembly of the Millennial Health Leaders Summit. The Summit brought together a cadre of public health, medical, nursing and public policy students on October 3-4, 2014 to discuss complex issues facing communities disproportionately affected by health disparities. Students were selected based on their outstanding achievements and promise as future leaders in addressing health disparities across the nation. The 2014 Summit provided opportunities for students to consider issues and effective models for addressing health disparities in diverse populations.
“We have accepted a wonderful and enthusiastic cohort of students, all of whom have a strong interest in addressing health equity and the social determinants of health,” said Dr. Leandris Liburd. Carmen Villar, MSW, Chief of Staff of the CDC, was the keynote speaker at the inauguration. “Delivering key simple public health messages are important. I always think what I would tell my grandmother,” said Villar. She also highlighted the importance of partnerships between diverse cultures and backgrounds. “Bringing those perspectives is critical to what we do.”
Throughout the two-day Summit, students participated in interactive workshops and case study discussions given by health disparities researchers, program experts and policymakers within CDC. Workshop topics included multi-sector collaboration; working with tribes; social medicine and health disparities; and global health emergencies. Case study sessions allowed students to apply their knowledge to addressing health disparities related to environmental justice, intimate partner violence, tobacco use, and the intersection of health and transportation. “One of the key takeaways of the Summit was the importance of understanding how to implement evaluation-informed policies by analyzing political, economic, and justice aspects in addition to epidemiological evidence,” said Cassie Boles, a Master of Public Policy student at the Johns Hopkins Bloomberg School of Public Health. “My experience at the Summit solidified my desire to continue pursing a career in public health policy working with multiple stakeholders to attain health equity,” said Ms. Boles.
Students also had the opportunity to meet others with similar research and program interests, and to engage one-on-one with CDC experts conducting health equity work. “The opportunity to learn from CDC experts and engage with fellow students from across the country was valuable for connecting my interests in public health and social justice with practice and policy,” said Laura Harker, a Master of Public Health student at Emory University who is also interning with OMHHE to help evaluate the Summit.
The Summit was organized by CDC’s Office of Minority Health and Health Equity, the Harvard School of Public Health, Brown University, and the University of North Carolina, Chapel Hill Gillings School of Global Public Health.
Recent high-profile incidents of intimate partner violence have captured the attention of the public and increased awareness that this is a serious problem impacting individuals, families, communities and society. The Millennial Health Leaders Summit provided an opportunity for a group of future leaders to explore this issue in depth. At the Summit, Dr. Kirsten Rambo and Sara Patterson from CDC’s National Center for Injury Prevention and Control led a case study on the relationship between intimate partner violence and health, with a focus on achieving health equity.
Intimate partner violence is a significant public health problem, affecting 24% of women and 14% of men in their lifetimes. While all people are at risk of intimate partner violence, all people do not have the same risk: intimate partner violence disproportionately affects women, people of color, and people with low incomes.(1)
The case study, in which ten graduate students participated, focused on examining two communities. In the case study scenario, both communities were experiencing calls to their domestic violence hotline, but the communities differed in terms of composition based on race/ethnicity or socioeconomic status, neighborhood characteristics, and differential arrest rates. The case study provided participants with a framework for examining health inequities developed by the World Health Organization’s Commission on the Social Determinants of Health, which examines a variety of social conditions and processes that contribute to health inequities. Using this framework to examine differential risk for intimate partner violence, the group developed a plan that included short-term programmatic solutions, such as training law enforcement on how to respond to domestic violence calls. Importantly, the group’s plan also included long-term policy and structural solutions, such as increasing access to affordable child care so women could become economically independent. The case study examined the intersection of race, class, and gender in addressing intimate partner violence, and the group was able to identify solutions informed by these complex issues.
This case study was an exciting opportunity to examine a societal problem that many are just now beginning to understand as a public health issue. By exploring both individually-focused approaches as well as broader, more challenging, structural approaches, case study participants were able to develop creative and meaningful short- and long-term solutions to this significant public health problem.
(1) National Intimate Partner and Sexual Violence Survey.
An Overview of Intimate Partner Violence in the United States — 2010 Findings.
Health Disparities and Diversity: Two Peas in the Same Pod?
Dr. David R. Williams, Professor at Harvard University, offered a lecture at CDC’s Chamblee Campus, September 30, 2014, in an event co-sponsored by CDC’s National Center for Injury Prevention and Control, OMHHE, and the Office of Equal Employment Opportunity Committee on Diversity.
An expert on issues of social influences on health, Dr. Williams examined the challenges of health disparities and the benefits of diversity in the workplace, as well as barriers to diversity, steps to take to initiate and sustain diversity, and the value that can be obtained by implementing the features of diversity across multiple social and work environments.
“It is not enough just to open the gates of opportunity. Everyone, irrespective of social group and background, must have the ability to walk through those gates. But communities of color continue to face longstanding barriers with regards to economic, educational, and social opportunities,” said Williams. He cited studies proving that greater diversity enriches workplaces; leads to creativity and innovation, and even greater profitability. He added that initiatives that embed accountability, authority and expertise, such as affirmative action plans, diversity committees and taskforces, and diversity managers, are most effective in increasing proportions of women and minorities. Speaking of the high cost of inaction, Dr. Williams stated, “Racial disparities in health are really costly to our society –disparities in health cost $309 billion dollars a year, more than the GDP of India. People need to be aware of the benefits of diversity”, said Williams, adding that people are hungry for solutions, and success stories are important to raise awareness of racism and health.
Celebration of National Hispanic Heritage Month at CDC
CDC held a series of events in observation of the National Hispanic Heritage Month (September 15- October 15). This year’s theme was “Hispanics: A Legacy of History, a Present of Action and a Future of Success.” The main event included a lecture by Aida L. Giachello, PhD, Professor, Department of Preventive Medicine/Feinberg School of Medicine, on September 16, at CDC’s Chamblee Campus in Atlanta, Georgia.
“It was a moving experience for me to reflect on the work of some of the past and present Latino leaders and unsung heroes who have pursued an agenda of social justice to improve not only the health, social, economic and political conditions of Hispanics/Latinos, but to make the U.S. a fair and just society for all. I commend CDC for its commitment to improve Latino health and to develop public health initiatives to address the needs of individuals, families and to improve the built environments (eg., work, schools, community) and to promote system change,” said Dr. Giachello.
Dr. Giachello was featured as Health Equity Champion in our previous issue, and she received a certificate from Dr. Liburd honoring her contributions.
CDC Discusses Strategies to Reduce Health Disparities
OMHHE participated in a panel presentation about strategies to reduce health disparities during the Multicultural Health Marketing Conference held in Atlanta, October 15–17, 2014. The event featured presentations from experts in multicultural health marketing and focused on strategies and initiatives for reaching the key multicultural populations in the United States including African Americans, Hispanic Americans, LGBT Americans, and Asian Americans. OMHHE panelists were Leandris C. Liburd, PhD, MPH, MA, OMHHE Director, Ana Penman-Aguilar, PhD, MPH, Associate Director for Science, OMHHE; Julio Dicent Taillepierre, MS, Team Leader, Initiatives and Partnerships Unit, and Yvonne Green, RN, CNM, MSN, CAPT, US Public Health Service, Director, Office of Women’s Health.
CDC presenters on the panel described key health disparities by race/ethnicity and sex, provided examples of CDC’s education campaigns aimed at reducing and eliminating health disparities in women of color; described some of CDC’s efforts to diversify the public health workforce to promote health equity; and discussed the importance of partnerships in these efforts.
Inaugural Taste of Culture Event at CDC
On September 24, 2014, CDC’s National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) hosted its inaugural “Taste of Culture” event to celebrate the richness and diversity of NCHHSTP’s workforce. Guest speakers included NCHHSTP’s Deputy Director, Dr. Hazel D. Dean, and OMHHE’s Director, Dr. Leandris C. Liburd. Over 200 people attended the event who enjoyed meeting other colleagues and sampling foods from the varied cultures that represent NCHHSTP.
New Journal Supplement on Veteran’s Health Equity Issues
The Department of Veterans Affairs (VA) joined with the American Journal of Public Health (AJPH) to bring focus to the health equity issues specific to our nation’s Veterans through the release of the VA Health Equity Supplement. VA’s Office of Health Equity Executive Director, Uche S. Uchendu, MD, presented the supplement during the webinar “Partnership in Pursuit of Health Equity: Focus on Minority Veterans,” on September 24, 2014. The session included a discussion of the VA journey and crucial partnerships towards eliminating health care disparities. It also highlighted collaborations with examples from Veteran’s Health Administration (VHA) Office of Health Equity, Center for Health Equity Research and Promotion, and Health Equity and Rural Outreach Innovation Center. The webinar was also part of the VA Center for Minority Veterans 20th anniversary events.
“Minority veteran challenges, noted by the VA Center for Minority Veterans, are related to health, some more directly and others indirectly as we consider the socioeconomic determinants of health, which in turn impact health equity and health disparities. There are challenges of over representation among chronic diseases, health disparities, lower patient satisfaction, greater than 48% of the homeless population, education gap, unemployment, and incarceration,” said Dr. Uchendu, whose office was fully stablished in February of 2013.
“The pursuit of health equity should be everyone’s business. It is a journey that takes time and effort. What can you do today in your area of influence to improve health equity? I personally recommend—at a minimum—in all your actions, do not increase the disparity.” Dr. Uchendu urged everyone.
The AJPH Supplement focuses on improving the understanding of the root causes of health and health care disparities and on reducing/eliminating such disparities among vulnerable Veteran populations. For more information about this special Supplement dedicated to Veterans,
Amercian Journal of Public Health, September 2014, Vol. 104, No. S4..
Meet the Federal Offices of Minority Health
We continue with our series featuring the six Offices of Minority Health (OMH) established within the Department of Health and Human Services in 2010.
Cara James, PhD, Director
Office of Minority Health
at the Centers for Medicare and Medicaid Services (CMS).
CMS OMH serves as the principal advisor to CMS on the special needs of minority and underserved populations and coordinates activities within CMS to improve minority health and eliminate health disparities. CMS OMH focuses on disparities experienced by racial and ethnic minorities, sexual and gender minorities and people with disabilities. The office is organized into two groups: the Data and Policy Analytics Group and the Program Alignment and Partner Engagement Group.
Prior to joining CMS OMH in 2012, Dr. James was the Director of the Disparities Policy Project and the Director of the Barbara Jordan Health Policy Scholars Program at the Henry J. Kaiser Family Foundation, where she was responsible for addressing a broad array of health and access to care issues for racial and ethnic minorities, including the potential impact of the Affordable Care Act, and analyzing state-level disparities in health and access to care.
Madeleine Shea, PhD is the Deputy Director of the CMS Office of Minority Health. Prior to joining the OMH at CMS in October 2014, Dr. Shea served as the Director of the Disparities National Coordinating Center for Medicare Quality Improvement Organizations.
The CMS OMH focuses on eliminating health disparities and promoting health equity by:
- Improving the quality of care;
- Increasing access to care;
- Collaborating with the health care workforce;
- Estimating the economic burden and building the business case for reducing health and health care disparities;
- Enhancing language access; and,
- Strengthening population health.
“This office has an opportunity to positively impact the lives of many underserved populations,” James believes.
Working collaboratively with other offices and centers at CMS, the office plans to design, implement, and evaluate, effective, culturally and linguistically appropriate, and/or innovative interventions to reduce disparities as well as develop tools and resources to support education and outreach to minority communities, “said Dr. James.
“We are working to improve the availability and the quality of CMS data on race, ethnicity, primary language, sex, and disability for use to help identify gaps in the agency’s knowledge and understanding of health disparities, and to monitor progress of efforts to reduce and eliminate them,” added, stressing that “Partnerships are important to our work, and the creation of strong partnerships and coalitions will be important building blocks from which we will launch our efforts to reduce health disparities for all CMS beneficiaries.”
For more information about the CMS OMH visit
Centers for Medicare & Medicaid Services, Office of Minority Health
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Addressing Disparities in the Hispanic/Latino Community
Betsy J. Rodríguez MSN, CDE
Deputy Director, National Diabetes Education Program, Division of Diabetes Translation, CDC
Diabetes is an urgent health problem in the Hispanic/Latino (H/L) community. Rates of diabetes among Hispanics/Latinos are almost double those of non-Latino Whites. Based on the urgency of this problem, CDC’s Division of Diabetes Translation has collaborated with H/L leaders and communities on a variety of initiatives to address the burden of diabetes in this population.
Early efforts involved community health workers (CHWs), who play an essential role in addressing health and wellness in H/L populations. CDC has provided leadership in elevating the importance of CHWs nationally, through research,
networking and bringing groups together, and developing resources. Now, CHW approaches are included as an integral part of funded programs working in communities. CDC’s National Center for Chronic Disease Prevention and Health Promotion has formed an internal CHW Work Group to coordinate and gather subject matter expertise and resources on CHWs.
To address a major gap, in 1999, CDC funded the
U.S. Mexico Border Diabetes Prevention and Control Project.
A variety of key partners, local and international, were instrumental in accomplishing this project. This effort documented, for the first time, the prevalence of diabetes among H/L people in the border area and increased the capacity of health care professionals, including CHWs, to manage and educate people with and at risk for diabetes.
More recently, the
National Diabetes Education Program (NDEP)
at CDC conducted an audience needs assessment,
Hispanic/Latino Migrant and Seasonal Farm Workers Audience Needs Assessment,
to identify available diabetes education resources and gaps in addressing diabetes in migrant and seasonal farmworkers. This is an underserved group that is getting increased attention. In February 2014 DDT participated in a CDC-wide seminar, “CDC Immigrant/Migrant/Foreign-born Health: Addressing Health Disparities,” to increase awareness about these health disparities and CDC’s activities addressing them.
Since 1997, NDEP has collaborated with community, public health, business, and government stakeholders to address the unique language and cultural needs of a wide spectrum of H/L communities, especially for diabetes-related educational resources.
NDEP and its H/L partners have developed and disseminated a range of culturally-sensitive toolkits, messages and materials, available in English and Spanish.
NDEP’s publications are based on audience research, and provide information on topics ranging from cooking with a Latin flair, to being more physically active while dancing. Resources include:
Road to Health Toolkit (Kit El camino hacia la buena salud)
Developed for CHWs and educators working with H/L populations at risk for type 2 diabetes, this toolkit provides supporting resources that include online courses, a training video and guide, an evaluation guide, and
Campeones del Kit El camino hacia la buena salud, and an on-line Community of Practice for networking and technical assistance.
Tasty Recipes: It's more than food. It's life. (Ricas recetas: Más que comida, es vida)
Is a set of resources developed around a bilingual booklet, Tasty Recipes for People with Diabetes and Their Families (Recetario Ricas recetas para personas con diabetes y sus familiares).
Do it for them! But for you too. (¡Hazlo por ellos! Pero por ti también)
Is a bilingual (Spanish/English) fotonovela featuring stories of Latinas talking to Latinas about preventing or delaying type 2 diabetes and being healthy for their children and themselves.
Movimiento Por su Vida
Is a music CD/DVD that helps Hispanics and Latinos incorporate more movement into their lives. It is a fun way to show how movement can help prevent and manage diabetes.
To engage H/L populations, major resources need to be in Spanish. In response to user requests, the
CDC Diabetes Prevention Program curriculum,
used in evidence-based lifestyle change interventions, is available in Spanish and will be revised in 2015. Additionally, the consumer-oriented sections of the website are
and the NDEP site will have a Spanish section soon.
To address diabetes health disparities at the community level, DDT funds the cooperative agreement, The
National Program to Eliminate Diabetes-Related Disparities in Vulnerable Populations.
One of the awardees, the National Alliance for Hispanic Health, focuses on raising awareness, increasing diabetes knowledge and improving access to diabetes self-management education (DSME) among Hispanics in Phoenix, AZ; Rio Ranch, NM; and Watsonville, CA.
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Health Equity A Priority for the Community Preventive Services Task Force
Health disparities exist when social disadvantages such as poverty, lack of education, and racial or gender discrimination influence the health of individuals within a certain population. Health equity is present when all individuals within a population have equal, achievable opportunities to be healthy no matter their circumstances.
Community Preventive Services Task Force
(Task Force) — an independent, nonfederal, unpaid panel of public health and prevention experts—bases its findings on systematic reviews of the scientific literature.
After making a decision on an intervention’s effectiveness, the Task Force considers health disparities and health equity issues related to the intervention.
When deciding which topics to prioritize for review, the Task Force examines the topics’ potential to reduce health disparities, and therefore increase opportunities for health equity, across different populations. The Task Force also identifies areas related to the topic where more research is needed. This gives researchers and program evaluators an opportunity to help fill those evidence gaps and increase understanding about specific topics for which those gaps exist.
All Task Force findings
and the systematic reviews on which they are based are compiled in The Guide to Community Preventive Services
(The Community Guide).
Visitors to The Community Guide website can view Task Force findings by topic; get email notifications about updates to topics; view What Works fact sheets, which are short, easy-to-read summaries of Task Force findings by topic; and read Community Guide in Action stories, which highlight how public health professionals have used Task Force findings.
The Community Guide
for the full recommendations, intervention definitions, systematic reviews, and peer-reviewed publications on these and other Task Force findings specific to health equity.
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Sonja S. Hutchins, MD, MPH, DrPH, FACPM, Captain, USPHS, Senior Medical Advisor, Office of Minority Health and Health Equity,
gave a presentation titled “Reducing Health Disparities and Achieving Health Equity through Preventive Care”
before the Accreditation Council for Continuing Medical Education (ACCME).
Dr. Hutchins discussed racial and ethnic differences in health status and patient use of preventive services among adults such as seasonal influenza vaccination, colorectal screening, and hypertension control.
She concluded by emphasizing that medical providers can close practice gaps in preventive care with several available tools and resources, such as
Standards for Adult Immunization Practice,
The National Culturally and Linguistically Appropriate Services (CLAS) Standards,
and recommendations from the
Guide to Community Preventive Services.
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Health Equity Champion
William F. Benson
President of the International Association for Indigenous Aging
The U.S. is a nation that is rightly concerned with ensuring the best future possible for our children, but as we encounter the aging of the Baby Boomers, we must become a nation equally concerned about our elders. This is not a new revelation to Health Equity Champion - William F. Benson. He has been a national leader and voice for older adults for decades. His influence has been felt at the highest levels of government and in community circles. The Office of Minority Health and Health Equity in collaboration with the Division of Population Health (National Center for Chronic Disease Prevention and Health Promotion) is honored to recognize the powerful advocacy and strategic initiatives of Mr. Benson for older adults, and particularly, elder American Indians and Alaska Natives. We congratulate Mr. Benson for his distinguished and enduring service, and designate him a Health Equity Champion!
--Leandris C. Liburd
Mr. Benson’s work related to elder abuse covers four decades, during which he has developed extensive expertise and is recognized as a national leader in elder abuse, health care fraud and abuse, public health, program development, management, planning and public policy. As President and Chairman of the International Association for Indigenous Aging, Mr. Benson has a long history as both an elder justice and American Indian and Alaska Native elder expert. He is currently Managing Principal of Health Benefits ABCs.
For the past 13 years, Mr. Benson has been a consultant to CDC’s Healthy Aging Program. He also recently helped strategic planning efforts by the Kansas Department of Health and the Environment, the Kansas Health Foundation, and the Mississippi State Department of Health’s new Office of Health Promotion and Health Equity. Since 2000, Benson has hosted First Person, a twice-weekly series of conversations with Holocaust survivors before live audiences at the United States Holocaust Memorial Museum from March through August.
In California, Mr. Benson directed the nation’s largest Long-Term Care (LTC) Ombudsman Program. Many of the cases investigated during his tenure involved abuse and neglect of LTC facility residents. He also directed the California Department of Aging’s Advocacy Assistance and Civil Rights Office, which among other duties included legislative work related to elder abuse such as helping to establish California’s elder abuse mandatory reporting statute.
Mr. Benson worked eight years as staff director on the House and Senate aging subcommittees with the U.S. Congress, where he was the lead staff person responsible for writing Title VII, the Elder Rights title of the Older Americans Act (OAA), including its elder abuse prevention section and a “Native American” section. Mr. Benson also served as subject matter expert for the “Elder Justice Roadmap: A Stakeholder Initiative to Respond to an Emerging Health, Justice, Financial and Social Crisis,” an initiative funded by the US Department of Justice with support from the Department of Health and Human Services.
He led the Administration on Aging (AOA) and the aging network into anti-fraud and abuse work through the HHS-Department of Justice anti-fraud initiative, Operation Restore Trust.
Mr. Benson also serves as National Policy Advisor to the National Adult Protective Services Association (NAPSA), helping to shape NAPSA’s work related to improving states’ Adult Protective Services program and strengthening the federal response to elder abuse including the drafting and enacting of the Elder Justice Act.
“Medicare, Medicaid and the Older Americans Act were each enacted into law in 1965. These major programs have contributed greatly to improving the health status of many older adults and reducing health disparities.
Medicare in particular has been profoundly important in providing health coverage for those over the age of 65, as well as to many non-elderly disabled adults,” said Mr. Benson upon his acceptance of the Health Equity Champion acknowledgement. "Yet, health equity has not been achieved for far too many older Americans, particularly among the poor and among minority populations, whose numbers are growing at a rate far greater than white older Americans, and whom suffer greater rates of poverty. And health equity is a major issue for the non-Medicare eligible older adult population between the ages of 50-64, many of whom are without health coverage through employers. This is especially true for older women. As noted in a July 2009 issue of National Health Statistics Reports, “Health disparities exist across subgroups of older adults and vary by age.”
“Much of our work is focused on our American Indian and Alaska Native (AIAN) population. AIANs rank at or near the bottom of nearly every social, health and economic indicator. They have the highest poverty rate compared to all other racial and ethnic populations – more than twice the national rate. AIAN elders especially suffer health inequities, particularly among those needing treatment for diabetes and other long-term chronic conditions,” added Mr. Benson.
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MMWR Weekly, September 5, 2014 / 63(35);776.
In 2011, life expectancy at birth was 78.7 years for the total U.S. population, 76.3 years for males, and 81.1 years for females.
Life expectancy was highest for Hispanics for both males and females.
In each racial/ethnic group, females had higher life expectancies than males.
Life expectancy ranged from 71.7 years for non-Hispanic black males to 83.7 years for Hispanic females.
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