Air Pollution and Mortality at the Intersection of Race and Social Class

Black Americans are exposed to higher annual levels of air pollution containing fine particulate matter (particles with an aerodynamic diameter of ≤2.5 μm [PM_2.5]) than White Americans and may be more susceptible to its health effects. Low-income Americans may also be more susceptible to PM_2.5 pollution than high-income Americans. Because information is lacking on exposure-response curves for PM_2.5 exposure and mortality among marginalized subpopulations categorized according to both race and socioeconomic position, the Environmental Protection Agency lacks important evidence to inform its regulatory rulemaking for PM_2.5 standards.

We analyzed 623 million person-years of Medicare data from 73 million persons 65 years of age or older from 2000 through 2016 to estimate associations between annual PM_2.5 exposure and mortality in subpopulations defined simultaneously by racial identity (Black vs. White) and income level (Medicaid eligible vs. ineligible).

Lower PM_2.5 exposure was associated with lower mortality in the full population, but marginalized subpopulations appeared to benefit more as PM_2.5 levels decreased. For example, the hazard ratio associated with decreasing PM_2.5 from 12 μg per cubic meter to 8 μg per cubic meter for the White higher-income subpopulation was 0.963 (95% confidence interval [CI], 0.955 to 0.970), whereas equivalent hazard ratios for marginalized subpopulations were lower: 0.931 (95% CI, 0.909 to 0.953) for the Black higher-income subpopulation, 0.940 (95% CI, 0.931 to 0.948) for the White low-income subpopulation, and 0.939 (95% CI, 0.921 to 0.957) for the Black low-income subpopulation.

Higher-income Black persons, low-income White persons, and low-income Black persons may benefit more from lower PM_2.5 levels than higher-income White persons. These findings underscore the importance of considering racial identity and income together when assessing health inequities. (Funded by the National Institutes of Health and the Alfred P. Sloan Foundation.).