As if being poor isn't bad enough -- and, trust me, the health disparities are bad indeed -- it's even worse to be poor and also live in an impoverished neighborhood. Yet even that pales in comparison to being poor and Black in America.
I'm writing from Caux, Switzerland where I am part of over 200 people gathered from almost 40 countries to learn about the impact of race and racism on people's lives and find ways to grow, to heal, and to thrive as multi-racial communities. What follows is an integrative summary of several presentations, including those of Harvard Sociologist David Williams and Brian Smedley from the Joint Center for Political and Economic Studies. The full conference program is available here.
Racial health disparities are not new but most of us don't really know the specifics, possibly because there is relatively little discussion of this both in the media and among health care providers. The data in race-conscious societies are bleak. Not only in the United States, but also in Australia, Brazil, New Zealand, South Africa, and the U.K., non-dominant racial groups have significantly worse health outcomes than the dominant racial group.
The pattern is consistent. According to Williams, in race-conscious societies, racial minorities get sick at younger ages, have more severe illness, and die sooner than Whites.
In New Zealand, Canada, and the United States, indigenous men have a life expectancy that is 7 years less than the male average in their respective country. In Australia, the gap is 21 years (Bramley et al, 2004).
Life expectancy is obviously a meaningful outcome, but it is also a rather nebulous one. It's possible to get much more specific. There are 10 different bio-markers associated with aging and stress. These include systolic blood pressure, diastolic blood pressure, body mass index, glycated hemoglobin, albumin, creatinine clearance, triglycerides, c-reactive protein, homo-cysteine, and total cholesterol. Together these comprise the Allostatic Load, the cumulative "wear and tear on the body" that occurs when individuals are exposed to repeated or chronic stress. Geronimus et al., AJPH, 2006 found significant Black-White differences in Allostatic Load in every age category, including 18-24-year-olds where Blacks scored almost 50% higher (White mean=1.1, Black mean=1.6).
The important point here is that this is NOT just driven by poverty or socioeconomic (SES) level more broadly. To be sure, SES also matters. Data show that, at age 25, White college graduates can expect to live 6.4 years longer than their White counterparts who did not complete high school. A similar SES difference is evident in the Black sample where Black college graduates live 5.3 years longer. Yet, the distribution curves barely overlap with Black college graduates having a life expectancy that is 1.8 years LESS than Whites with only a high school education (Murphy, NVSS, 2000; Braveman et al., AJPH, 2010, NLMS 1988-1998). Being poor and uneducated (the two are highly correlated) is bad for your health, but not as bad as being Black.
How is it that race matters in such a tangible way? A comprehensive answer involves multiple pathways, including neighborhood segregation, institutional discrimination, unconscious bias, internalized racism, and environmental (e.g., exposure to toxins) and psychosocial stressors.
Although a detailed discussion of all these pathways is beyond the scope of this article, I'll focus briefly on the effects of segregation (I wrote a bit about unconscious bias in health care here).
According to Williams and Collins (2001), residential segregation affects health outcomes in four different ways:
1. Segregation determines the quality of education and employment opportunities. A national study of the effects of segregation on young African American adults found that the elimination of segregation would erase Black-White differences in in High School graduation rates, in unemployment rates, and in earnings and reduce racial differences in single motherhood by two-thirds (Cutler, Glaeser, & Vigdor, 1997). These variables are directly connected to socioeconomic status and clearly linked to lower health outcomes.
2. Segregation contributes to the creation of pathogenic neighborhoods and housing conditions. Residential neighborhoods are a large predictor of access to quality education as well as social peer groups and exposure to trauma. According to Williams, "in the 171 largest cities in the U.S., there is not even one city where Whites live in ecological equality to Blacks in terms of poverty rates or rates of single-parent households." Moreover, "the worst urban context in which Whites reside is considerably better than the average context of Black communities." (Sampson & Wilson, 1995, p. 41). These living conditions not only limit access to opportunity but also exposure residents to considerably more stress and trauma than those living in better neighborhoods. This is particularly troublesome because racial segregation in the United States is higher than in almost any other nation and in many ways resembles that of South Africa during apartheid (Massey, 2004; Iceland et al., 2002; Glaeser & Vigdor, 2001).
3. Conditions linked to segregation can constrain the practice of health behaviors and encourage unhealthy ones. It is common for businesses to disinvest from low-income communities, which tend to be predominantly Black. This disinvestment includes, as just one example, grocery stores, which makes it difficult for low-income Black families to buy fresh fruit and vegetables -- even when they are committed to eating healthy food.
4. Segregation can adversely affect access to high-quality health care. Segregation limits access to educational and employment opportunities, which in turn limits access to health insurance.
The social disparities in heath outcomes have a clear human cost. According to Woolf et al., 2004, AJPH, it is estimated that in the years 1991-2000, 176,633 deaths were averted due to medical advances. If the death rates of Black were the same as those of Whites, 886,202 deaths would have been averted. According to their data, 5 deaths could be averted just by reducing racial disparities for every life saved by medical advances and eliminating disparities in health would save more lives than current advances in medical technology.
There are economic costs too. According to LaVeist et al., 2009, in the years 2003-2006 the medical care costs associated with racial disparities was $229.4 Billion and lower work productivity and premature death resulted in a cost of $1,008 Trillion. The total cost of $1.24 Trillion is more than the GDP of India, the 12th largest economy in the world. According to Schoeni et al's (2011) study in the American Journal of Preventive Medicine, if all Americans had the better health of college graduates, our society would gain $1.007 Trillion annually. Williams concludes -- and I concur -- that social justice is not only cost-effective but that our society can no longer continue to bear the costs of doing nothing.
Remedies are not simple, certainly not as easy as taking a pill, but change is possible. Medical professionals (and others) can learn to become aware of unconscious bias and municipalities can work with Federal policy makers to de-segregate low-income housing by dispersing small low-rise housing units in middle-income communities rather than consolidating and concentrating such housing in the most economically disadvantaged neighborhoods. Both government and the private sector can also create conditions (e.g., economic incentives) for businesses, including grocery stores, to move into the neighborhoods that currently don't have access to healthy food. Health care can be provided to the poor and uninsured using the model developed by the Church Health Center, which partners with local physicians and health care providers to provide medical and preventive services to the uninsured in Memphis, TN.
In his brief address, Williams issued a challenge to those gathered. It was a challenge later expanded in a different context by Mee Moua from the Asian American Justice Center and then again by Marc Leyenberger from the European Commission Against Racism and Intolerance. The challenge is in multiple parts: to recognize the injustice that exists, to be unwilling to tolerate it, and to insist on a seat at the table -- any table that has influence on either policy or practice -- in order to have a voice in moving toward racial justice. It seems appropriate, gentle reader, to pass this challenge on to you. Let's work toward justice together. Let's do it with love.
Bramley, D., Hebert, P., Jackson, R. T., & Chassin, M. (2004). Indigenous disparities in disease-specific mortality, a cross-country comparison: New Zealand, Australia, Canada, and the United States.
Braveman, P. A., Cubbin, C., Egerter, S., Williams, D. R., & Pamuk, E. (2010). Socioeconomic disparities in health in the United States: what the patterns tell us. American journal of public health, 100(S1), S186-S196.
Geronimus, A. T., Hicken, M., Keene, D., & Bound, J. (2006). “Weathering” and age patterns of allostatic load scores among blacks and whites in the United States. American journal of public health, 96(5), 826-833.
Schoeni, R. F., Dow, W. H., Miller, W. D., & Pamuk, E. R. (2011). The economic value of improving the health of disadvantaged Americans. American journal of preventive medicine, 40(1), S67-S72.
Woolf, S. H., Johnson, R. E., Fryer Jr, G. E., Rust, G., & Satcher, D. (2004). The health impact of resolving racial disparities: an analysis of US mortality data. American Journal of Public Health, 94(12), 2078-2081.
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