Large racial differences in health persist in the U.S. Eliminating these health disparities is another public health challenge of our time.
Racial residential segregation is the cornerstone on which black-white disparities in health status have been built in the US. Racial groups characterized by legacies of social exclusion, economic disadvantage and political or geographic marginalization have worse health than dominant racial groups in virtually every society.
These racial differences are not new. In the late 19th century, W.E.B. DuBois wrote that the determinants of poorer health for Blacks compared to Whites was primarily social. His list of contributing factors included bad dwellings, poor ventilation, dampness and cold, poor food, and unsanitary living conditions. Exposing people to living and working conditions that make it difficult to be healthy and live to an advanced age has recently been called “social murder.” DuBois wrote that “The most difficult social problem in the matter of Negro health is in the peculiar attitude of the nation toward the well-being of the race. There have . . . been few other cases in the history of civilized peoples where human suffering has been viewed with such peculiar indifference.”
Inequalities in health are created by the larger inequalities in our society and symbolize the historic and ongoing racial inequities in our society. Eliminating them will require political will and a commitment to comprehensive and sustained improved living and working conditions.
SOME SOBERING STATISTICS
According to a 2016 article in the Journal of Health Politics, Policy and Law, death rates for Blacks are almost twice as high as those for whites. Blacks had higher death rates than whites in 10 of the 15 leading causes of death, including coronary heart disease, cancer, stroke, lung disease, diabetes, chronic kidney disease, end-stage renal disease and hypertension among others. In addition, Blacks get sick at younger ages and die sooner than whites. National infant death rates are higher for Blacks than Whites.
A 20 year CARDIA study of adults found that the incident of heart failure before the age of fifty was 20 times more common in blacks than whites, with the average age of onset being 39 years old for Blacks. National data shows that cardiovascular disease develops earlier in Blacks than whites with 28% of cardiovascular disease deaths among blacks occurring before age 65 compared to 13% among whites.
Designing effective interventions to reduce racial/ethnic health disparities requires that we understand racial and ethnic inequality. In 2013, Blacks earned $0.59 for every dollar of income that whites received. Racial differences in wealth are even more striking with blacks having $0.06 for every dollar of wealth that whites have. Compared to whites, blacks receive less income at the same education levels, have less wealth at equivalent income levels, and have less purchasing power due to the higher costs of goods and services in the residential environments where they are disproportionately located. These disparities make quality health care unaffordable for many minorities.
There has been some debate regarding the advisability of universal versus race-specific initiatives to improve outcomes for vulnerable social groups.
Some evidence suggests that a significant strategy for reducing health disparities are interventions that are focused on the entire population, where those interventions will have a greater impact on the disadvantaged. Classic examples of universal interventions include car seat belt laws, clean drinking water, smoke-free public places and tobacco taxes which have been effective in discouraging smoking. These kinds of interventions depend on government agencies to leverage strong regulatory policies with strategies for enforcement.
Targeted interventions direct efforts toward those in greatest need. Classic examples of these interventions include programs for early childhood development in low socio-economic communities. Conditional cash transfer (CCT) programs are another example of targeted interventions. These are initiatives that provide cash payments to low-income families contingent on regular health care visits, school attendance, or participation in educational programs. Some of these programs have been successful in increasing preventive health services and immunization rates, improving nutritional and health outcomes, and encouraging healthy behavior.
Here’s an example: Because the foundations of health in adulthood are laid in childhood, educational efforts can have a large impact if they start early. The North Carolina Abecedarian Project is a randomized long-term study in which economically disadvantaged, mainly African American, infants were randomly assigned to a high-quality early childhood program. From birth to age five, the program offered a safe and nurturing environment, good nutrition, and pediatric care. By their mid-thirties, participants who had received the preschool intervention had lower levels of multiple risk factors (e.g., elevated blood pressure, metabolic syndrome, and excess weight) than the controls did.
Research over the past four decades has shown that support for government interventions to help Blacks has always been low and has been declining. An important challenge moving forward is to identify when universal interventions can reduce racial and ethnic disparities and when targeted interventions are indispensable.
SEGREGATION AND HEALTH – CONTRIBUTING FACTORS
Biology adapts to environmental conditions. Residential racial segregation is a primary institutional mechanism of racism and a fundamental cause of racial disparities in health. The residential conditions under which African Americans live contribute to their higher incidences of disease and mortality.
First, Blacks in segregated neighborhoods are less likely to have access to a broad range of services typically provided by municipal authorities. Political leaders have been more likely to cut spending and services in Black communities. Because Blacks are less active politically than their economically and socially advantaged peers, elected officials are less likely to encounter vigorous opposition when services are reduced in their areas. This disinvestment of economic resources had led to a decline in the urban infrastructure, physical environment and quality of life in these communities. Further, the reduced tax base due to lower wages and higher unemployment has reduced the ability of cities to provide supportive social services.
Second, the institutional neglect and disinvestment in poor, segregated communities contributes to poorer quality housing. This in turn means increased exposure to environmental toxins, inadequate heat, lack of space, presence of environmental hazards, crowding, elevated noise levels, exposure to litter, inability to regulate temperature and humidity, elevated exposure to noxious pollutants and allergens (including lead, dust mites, etc.) all of which adversely affect health.
Third, the residential conditions of concentrated poverty and social disorder created by segregation make it difficult for residents to maintain healthy lifestyles. For example, the lack of recreation facilities such as athletic tracks, playing fields and swimming pools, and concerns about personal safety can discourage leisure time physical exercise. And these neighborhoods have less availability of healthy products such as fresh fruits and vegetables and whole grains.
Fourth, on average, differences in purchasing power work against good health. Blacks pay more than whites for housing, food, insurance and other services. The high cost and poor quality of grocery items can lead to poorer nutrition.
Fifth, Commercial enterprises tend to avoid segregated urban areas, meaning available services are fewer in quantity, poorer in quality and often higher in prices than those in suburban areas. But the tobacco and alcohol industries have historically targeted poor minority communities. Exposure to stress has been positively associated with tobacco, alcohol and drug use.
Sixth, access to quality health care is more difficult. Poor public and private transportation makes getting to health facilities more challenging. And a lack of health insurance leaves many reluctant to seek medical attention when it is needed. Health care facilities and pharmacies are less likely to have adequate medication in stock to treat those with severe pain. And recent research has documented that Blacks are less likely than Whites to receive appropriate medical treatment and quality of care after they gain access to medical care.
Seventh, the weakened community and neighborhood infrastructure in segregated areas can also adversely affect interpersonal relationships and trust among neighbors.
Finally, the increased exposure to traditional stressors (e.g., unemployment and financial strain); and experiences of discrimination are important psychosocial stressors that adversely affect physical and mental health. Segregation’s increased exposure to these traditional stressors have been exacerbated during the current pandemic.
In conclusion, research has linked residential segregation to an elevated risk of illness and death and shown that it contributes to the racial disparities in health.
We need to build the political will for needed changes – to implement policies that will reduce social inequity. This means building awareness and support and identifying those narratives that will effectively communicate the complex social determinants of health.
Examples of institutional interventions, to reduce the levels and consequences of segregation and its related impacts on health, include:
- Identifying the most pressing health needs in every community and prioritizing those areas for investment;
- state- or federal-level policies that expand the stock of safe, stable, low-income and mixed-income housing;
- funding for section 8 vouchers that could increase access to high-opportunity neighborhoods;
- stronger enforcement of housing and financial regulations to curb predatory lending and housing discrimination practices in minority or underserved neighborhoods;
- incentive programs for Famer's Markets and full-service grocery stores, along with more stringent regulations on fast food and liquor stores, to increase availability of nutritious, affordable foods in underserved areas;
- increased local public health spending to enhance primary and preventive care, which will in turn lower costs of health services and improve health at the individual and population levels (A recent study found that each 10% increase in local public health spending resulted in declines in mortality from major preventable causes of death between 1.1% and 6.9%);
- restructured land-use and zoning policies that reduce the concentration of environmental risks (e.g., the proximity of bus depots to schools or daycares);
- public transportation options that encourage physical activity and minimize pollution risks;
- the creation of public green spaces that promote walkability, exercise, and community cohesion;
- the creation of jobs with wages that enable people to care for themselves and their families; and
- educational initiatives aimed at equalizing access to K-12 education and higher education, improving teacher quality, lifting graduation rates, and reducing the achievement gap.
The substantial health benefits of such interventions are an important benefit that is not widely recognized.
One way to transform the policy debate about racial disparities in health is by emphasizing the substantial economic costs that these differences in health have for our society. A report by the Robert Wood Johnson Foundation Commission estimated that the medical care and lost productivity costs for racial disparities in health amount to a $309 billion annual loss to the economy. These economic costs are a compelling additional policy justification for eliminating health inequities. The recommendations of this Commission have shaped recent federal spending and budget priorities on nutrition and investments in early developmental support for children. More needs to be done.
Getting to these and other solutions requires creativity, collaboration and authentic engagement of all people in a community – a top-down approach will not be sufficient.
We, as a nation, need to increase our awareness of the magnitude and consequences of racial inequalities in health. A national public opinion survey in 2011 found that less than half (46%) of all American adults were aware of health disparities between Black and Whites.
We need to change the hearts and minds of the American public. That same 2011 study found that many Americans viewed poor individual choices and poor personal health behaviors as stronger explanations of impaired health than the social conditions that initiate and sustain them. A FrameWorks Institute study found that many Americans believe minorities do poorly because they lack the core American values of personal responsibility, character, and hard work. Fewer people saw social and economic factors such as unemployment, level of education, housing quality and community safety as important determinants of health.
We need socially advantaged individuals to be able to sympathize with and speak up for the harsh realities of disadvantaged individuals and situation. We need to change the narratives to ones that can lead to positive emotional responses and support. Small changes in framing, language, tone, or details in telling a particular story can make a big difference in emotional engagement.
Effective interventions will be those that are targeted not at internal biological processes – but those that seek to improve the quality of life in the places where Americans spend most of their time – their homes, schools, workplaces, neighborhoods and places of worship
Since health is embedded in policies far removed from traditional health policy, success will depend on integrative and collaborative efforts across multiple sectors of society.
The legacies of racism and their continued manifestations matter for health. Unless and until serious attention is given to addressing institutional racism such as residential segregation, reducing racial inequities in health will likely prove elusive and the costs to our society will remain high.