A Microcosm in the City, Potrero Hill’s Mortality Data Speaks to Broader Trends

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In many ways Potrero Hill exemplifies San Francisco as a whole, particularly in terms of its population mix and income.  It’s not predominantly European-American, African-American, or any other ethnicity; not all wealthy, nor all poor.  In addition to its demographics, the 94107 zip code mirrors the City in how and at what age its residents die.

City residents are older than most Americans when they die. Mortality data for 2000 to 2007 indicates that on average San Franciscan women live 3.2 years longer than the average American female; San Franciscan men survive 2.6 years longer than the average U.S. male. When City dwellers do die, the most common cause is cardiac ischemia: decreased blood flow and oxygen to the heart.

Black San Franciscans have a shorter life expectancy than other residents. They also die earliest of all ethnicities when it comes to the vast majority of causes of mortality, including, for men: violence, cardiac ischemia, poisonings and HIV; and, for women: cardiac ischemia, poisonings, diabetes and breast cancer, according to the California Department of Public Health (CDPH).

Not much about what causes San Franciscans to die has changed recently.  Over the last decade and a half, however, there’s been one dramatic, positive, development:  the decline of acquired immunodeficiency syndrome. “HIV is no longer in the City’s top 10, and that’s mainly due to prophylaxis,” said Michelle Kirien, San Francisco Department of Public Health epidemiologist.

The drop in HIV-related deaths is stark. From 2000 to 2003, the disease was one of San Francisco’s leading causes of mortality, second only to cardiac ischemia as a cause of premature death in men. Today, it’s an almost unnoticeable element in mortalities.

When health officials discuss mortality rates and causes of death, they often speak about “Years of Life Lost,” or YLL. YLL is an appealing metric because it doesn’t just measure how many people die due to a given illness, or how old individuals were when they passed.  It gauges the “burden of premature mortality” on a population.  It’s a way to give greater weight to deaths that occur at younger ages than those that take place when people are older. In short, it’s the red flag of death.

From 2000 to 2007 the number of YLL due to HIV/AIDS in San Francisco dropped from almost 24,400 to around 17,600. That steep decline has continued, with the number of people living with Stage 3 HIV – AIDS – growing significantly, according to the City’s most recent epidemiological data. In addition to prevention, the decline in HIV/AIDS-related deaths is largely the result of advances in medications.  The disease has largely been defanged due to the increased use of anti-retrovirals, the advent of protein inhibitors and the more frequent use of genotyping, a way to identify the particularities of a virus that indicate how it could mutate to become resistant, allowing physicians to target it directly.

According to T.J. Lee, program manager at Positive Force, a project of the San Francisco AIDS Foundation, these advances drastically changed how San Francisco’s HIV/AIDS community saw a diagnosis. “I knew people that were a month away [from death]. They had everything set up. They had paid for the funeral. They had given all their possessions away and then all of the sudden, their doctors—last chance—they were like, ‘Here, try these meds,’ and they’re still alive today,” Lee said.

While fewer San Franciscans are contracting HIV/AIDS, and even less people are dying prematurely of it, Black San Franciscans are disproportionately affected by the disease, with higher rates of infection and lower probabilities of survival.  According to Lee, the Hill is a prime example of this stratification. “Potrero is an interesting little microcosm to look at because Portrero has virtually no cases of HIV and AIDS on the northern side of the slope, but you go on the southern side of the slope and there’s a huge, huge community of HIV-positive people that live there. And it’s a disproportionate number, because if you look at the population breakdown by ethnicity throughout the City—I think African-Americans —they represent about six to eight percent of the population, but they represent around 11 percent of the infections,” he said.

Higher death rates from HIV/AIDS extend to how Black San Franciscans fare when it comes to virtually all of the City’s leading causes of death. While CDPH data shows life expectancy for San Franciscans hovers around 82 years of age for the city-as-a-whole, life expectancy for Black San Franciscans lingers at roughly 71 years.

As many City residents live into their eighties another notable shift is occurring: Alzheimer’s and other dementias are increasing significantly as a cause of death. In addition to debilitating the brain, these diseases impair a person’s ability to cope with infections and other physical problems. Between 2000 and 2007, the number of men who died due to Alzheimer’s and other dementias almost doubled. CDPH data shows deaths have grown exponentially ever since. Roughly twice as many women have died of dementias than men in San Francisco since 2000. While the number of women dying of dementias increased less rapidly than that of men during the early aughts, death rates from the disease are now quickly rising for both genders. This was evidenced in 94107, at least through 2007.  From 2000 to 2003, twelve women died of some form of dementia, whereas from 2004 to 2007, that number jumped to 16. It’s important to note that sample sizes for death rates when broken down by zip code are too small to draw broad conclusions.

With HIV/AIDS death rates down, Alzheimer’s, dementias and other nervous system disorders are now the third most prevalent killer, after heart disease and cancers. They’re responsible for nearly 10 percent of deaths in San Francisco. The challenge now facing the City is how to ensure that the management of those illnesses — access to care and prevention —proportionately benefits all segments of the population.