The Pyramids of Inequity: Black and White American Demographic Pyramids
One picture to visualize inequity in any society.
In the middle of the pandemic in 2020, I was researching US healthcare costs. As I looked at per-person spend by age-group for healthcare, I charted some population pyramids.
They took my breath away.
First some context, in case you have not been obsessed with demographic pyramids for as long as I have been.
The Inverting Pyramid
For decades we have talked about how population pyramid is inverting in the US (and most developed nations) as more people live longer and birth rates fall.
The US demographic pyramid over the last 50 years has changed as shown below, as the share of older population grows in the total population. The 2nd population pyramid inverts as it starts to expand in the middle and the top while becoming leaner in the bottom.
Here’s an alternate view of that inverting pyramid in fewer age groupings. US population over 65 years of age had the largest percentage point increase in the 2010s, growing to 17% of total population, based on 2020 census.
We can see the top inverting.
I did not stop to think about how this pyramid would look differently for various populations. That is, until I split the data by race and charted more pyramids.
The Non-inverting Pyramids
Splitting the demographics data by non-hispanic black and non-hispanic white americans yielded the white and black pyramids below.
Unlike the overall population pyramid and the white pyramid, the black pyramid does not invert!
For comparison, I looked at Native American demographic pyramid too. Again, not inverting.
A well-known publication of country data said in passing, it is because “black population has lower life expectancy than the white”. That was the extent of their quick explanation.
But why?
Are Black Americans somehow predisposed to die sooner? While early 20th century built myths on the inferiority of colored peoples across the world, no modern anthropological or genetic studies suggest this.
I decided to look at life-expectancy gap by age across black and white Americans. I picked male populations of each race to compare.
Below is the difference between the life-expectancy of US black men vs. white men at various life stages. For example, a male Black American child born in 2018 is expected to live 5 years less than a newborn male white child.
As we can see, as black men progress in life, the life-expectancy gap closes between them and white men and even exceeds them — if only they lived past 80!
Black American men do live to ripe old age, if they live long enough.
[Note: This is pre-Covid data. Covid wreaked havoc in black populations and shifted this line downward by a few years]
What then accounts for the non-inverting pyramid?
Blame Immigration and Birth Rates?
Is it possible that somehow birth rates are higher in black population, causing more younger people than older? Not really. Birth rates have been on the decline across races. Post-civil rights movement, fertility rates dropped in southern black women.
Did immigration into younger age groups skew this towards larger share of young in the overall population? Unlike the hispanic population, the black population mix across age groups wasn’t substantially affected by immigration.
[Note: It is trickier to analyze Hispanic population due to census data limitations and immigration trends. So I’ll defer this discussion for now.]
The Ultimate Inequity is Loss of Life
By now the answer to the why the Black American population pyramid does not invert must be obvious. Or you always knew the answer instinctively and the picture simply reaffirmed or quantified what what you already knew.
Where did all those older black people go?
They died. Untimely deaths.
Large swathe of people have their lives cut short not based on their genes or any other clinical reasons. Inequity did them in. Just in the last 50-years. We are not talking about the 19th century or the early 20th century.
All this happened after the civil rights movement, just in case you happen to think all such problems were solved in the 1960s.
The healthcare world would attribute this to “social determinants of health” (SDOH) — such as wealth, education, housing, and many more.
But we can distill the pyramid disparity down to one word — inequity.
But what does inequity look like? We’ve heard vignettes and examples of early death from violence, poverty, disease and more. Is there a single visual to summarize inequity? Here it is.
When you lay the two dissimilar pyramids on top of each other, we see the contrast is black and white. The white pyramid extends out since it inverts to have more percentage of older people at the top whereas the untimely deaths in the black population robs many the chance to climb that pyramid.
Older black folk have vanished into the white space behind.
Cost of Inequity Measured in Souls
We can easily quantify what this slimmer black pyramid means in terms of lives lost. It is in the millions even if we count just the last 50 years.
Remember, we are not discussing quality-of-life. Hell no! We are discussing life. Period.
When we think of inequity, many dimensions come to mind — health, wealth, education, housing, transportation, broadband access, environment, public policy — just to name a few social determinants. And we can chart the data and impact of each.
For me, this one pyramid summarizes all the inequities and inequalities buried in them — ranking as the saddest picture I’ve ever seen, given its significance not just for the US but for the world’s populations.
Call me double-espresso-woke, if you think present-day dialog on equity is overblown. Reflect on the pyramid above.
Woke or not, the next time you have a debate on access to opportunities, social justice, affirmative action, or reparations for enslaved people, do keep the pyramids of inequity in mind as you constructively debate solutions.
When these pyramids of differing colors resemble each other, we will know we are making equitable progress.
Epilogue: Pyramid of Healthcare Expenses
In case you are wondering what became of my original questions on healthcare expense by race and age group, it yielded this picture.
It shows the relative spend per person in various age groups for blacks and whites.
Observations:
- Per-person spending goes up as we age. That is as expected. We need more care as the years go passing by. So both pyramids are inverted.
- Comparing the “health spending pyramids” relative to whites in the under 45 age groups, per-capita healthcare expense for blacks is far lower than that of whites. Abysmal in the children and adolescents.
- For population 45 and older, it appears as if we’ve almost equal per-capita health spend across most age groups among blacks and whites.
Are we doing a good job for the over-45 black people? Should we declare victory and try to replicate this success elsewhere?
Wait! We know the black population suffers from chronic health conditions at a much higher rate of incidence than the white population. So why is the spend per person approximately the same in the over-45 group?
Well, that may the irony here. We saw how dissimilar population pyramids tell a story of inequity. When it comes to spending, similar pyramids affirm the story of dissimilar pyramids — through the pyramid of inequity for healthcare.
