Health Inequities Have Systemic Causes

The racial categories to which we're assigned, based on how we look to others or how we identify ourselves, can determine real-life experiences, inspire hate, drive political outcomes, and make the difference between life and death.         Swati Sharma        

Part 1 of this 3-part series focused on the origins and consequences of environmental racism and injustice.

Part 2 began to explore the racist underpinning that leads to profound health inequities between Blacks and Whites.

Today’s newsletter (Part 3) continues to dispel Myth 3, “If Blacks Have Worse Health Outcomes than Whites, It’s Because of Their Own Poor Choices,” by investigating additional systemic causes beneath these inequities.

The insidious nature of systemic racism is in its invisibility to so many of us, especially White people. You can’t find it on a map, locate it in a building, or point out the car window in a drive around the neighborhood, satisfied you finally found it.

If you’re White, you can easily be utterly oblivious to systemic racism.

For a long time, I couldn’t—in my own mind—come up with a satisfying explanation for why inner-city neighborhoods always looked so run down, why the employment rate for Black teens in urban areas was so low, or why the infant mortality rate for African Americans was so high in the U.S.

I knew some of these issues connected directly to ongoing discrimination and disinvestment, but I never had a good enough handle on the history or the facts. I certainly couldn’t begin to explain it in all its complexity.

If you’re African American, though, you know for sure systemic racism exists because you experience various dimensions of it on an ongoing basis. Perhaps you can’t fully explain its amorphousness as you confront it, yet it remains part of your current reality.

Beneath Every Element of Systemic Racism …

There’s an important and disturbing history behind every element of systemic racism, and it is no different in health and medicine.

In Sunday’s post, we saw that the American medical system changed standards for medical training in the early 20th century, which profoundly impacted the training of Black doctors. Five of the seven Black medical schools at that time were forced to close, severely limiting the number of Black students who could be trained for decades. Remember: Blacks were barred from White medical schools until the late 1950s and did not enroll in any significant numbers for more than another decade after that.

Thus, for much of the 20th century, African Americans often had to either seek care from those who were not fully medically trained (if they didn’t live near a Black M.D.) or seek care from White doctors and other medical personnel (if they would even see Black patients) who frequently didn’t treat them well.

For a long time, Whites believed that Blacks were impervious to pain. White doctors believed “Negro lungs were deficient by at least 20 percent." [1]

A 2016 National Academy of Sciences study showed that half of 222 medical residents and students “endorsed at least one myth about physiological differences between black people and white people, including that black people’s nerve endings are less sensitive than white people’s. When asked to imagine how much pain white or black patients experienced in hypothetical situations, the medical students and residents insisted that Black people felt less pain. This made the providers less likely to recommend the appropriate treatment." [2] (emphasis added)

Several other 21st-century scholarly studies documented pervasive bias in the healthcare treatment of African Americans. They found clear evidence that race and ethnicity remain significant predictors of the quality of healthcare that Black men, women, and children receive.[3]

If you’re White and reading this, what would it be like—for good reason—to have little trust in the people and systems serving you in healthcare?

In my four years of research, I kept returning to the brutal legacies of residential segregation. They show up in our health spheres, too.

Across the U.S., especially in higher-poverty neighborhoods and communities—where Blacks live in disproportionate numbers to Whites—we see food deserts and health care deserts. Frankly, though, deserts are not the appropriate term. What is?

Food and medical apartheid.

Let’s start with food apartheid. Food apartheid involves intentionality in systemic and perverse policies and practices. In poor neighborhoods, food apartheid manifests through a proliferation of corner markets, gas-station convenience stores, and fast-food restaurants in place of fresh-food-based supermarkets and restaurants serving higher-nutrition food. These stores trade primarily in high-calorie, low-nutrition, highly processed food.

Near where I live—in Washington, DC—more than three-quarters of Ward 7 and Ward 8 residents (both with greater than 90% African American) have disproportionately high numbers of food insecure residents, with only three grocery stores (two of which were substandard) in 2020 serving the two wards.

In contrast, Ward 6 (59% White) had 13 grocery stores, and Ward 3 (70% White) had 17. Does this add up to you?

Let’s shift to medical apartheid.

There have been a scant few physicians and specialists in Wards 7 and 8 for decades.

Although a state-of-the-art hospital is finally under construction in Ward 8 (to serve both Wards), as of 2020, neither ward had emergency trauma care, urgent care, or obstetrical care. With the investment of Ward 7 and 8 council members and Mayor Bowser, the wards have recently seen the relocation of a community health center and the construction of two new urgent care centers. For over a half-century, these wards went without such facilities, having to cross town to wealthier wards to receive care or cross the eastern border into Prince George’s County.

These are neither accidents nor the natural order of things.

It was with full intention that Wards 7 and 8 ended up so underinvested and marginalized. You'll see the pattern you find in D.C.’s most eastern wards repeated intentionally in metropolitan areas across our great land.

Because of segregation, redlining, and deliberate disinvestment, we see health inequities that are shocking and profoundly wrong. And our nation and our leaders across our cities and regions have continuously failed the places where too many African Americans still live.

Profoundly Inequitable Outcomes

As a result, for African American children, we see higher rates of lead poisoning (5x more) and asthma (3x more likely to die) when compared with Whites. For adults, we see higher rates of hypertension (40% affected) and obesity. [4] [5] [6]

Worse, Black adults are far less likely to survive prostate, breast, and lung cancer than White adults. They often don’t have the same access to quality treatment that White cancer patients do.[7] [8]

A Virginia Commonwealth University report argues that:

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“Racism affects the health of black Americans, not only because exclusionary policies [and] … social determinants of health, but also because the experience of discrimination is itself biologically harmful. Chronic stress due to frequent exposures to discrimination and poverty can accumulate, creating wear and tear on the body (known as allostatic load, a condition associated with poor health outcomes and mortality).[9] (emphasis added)        

Overall, White people have significant advantages regarding health from the get-go. Although those advantages don’t translate to every White community in America, they certainly do to most. As a general rule, compared to African Americans, Whites are far less likely to:

• Live in communities where they contend with industries and facilities that pollute or contain toxic waste sites.
• Live in communities with inadequate access to quality healthcare and medical facilities.
• Contend with pollution’s chronic and harmful consequences in their communities.
• Face the adverse and chronic health consequences of living in formerly redlined communities caused by high pollution levels and chemical exposure.
• Encounter low-quality housing conditions or a lack of healthy amenities near their homes (e.g., parks, walking trails, playgrounds).
• Be seen by medical doctors who don’t look like them and are more likely to treat them in a racially biased way.

This is all very troubling and must change.

Next week, I will share a report from the Urban Institute that offers a far more hopeful take on what really matters regarding effective public investments in children. These investments can lead to important and very positive outcomes throughout childhood and, ultimately, longer-term positive outcomes in adulthood!

In the meantime, given how discouraging all of this data and information truly are, as I conclude here, let me share a few pieces of important work happening across the country on environmental justice and health equity.

Here are just three examples:

Justice40 (a White House initiative) - Link.

Tied to the Federal government’s goal that 40 percent of the overall benefits of certain Federal climate, clean energy, affordable and sustainable housing, and other investments flow to disadvantaged communities that are marginalized by underinvestment and overburdened by pollution.?

Connecticut’s Path to Equity Guide to State Policy for Health

The graphic above comes from this guide - LINK. An excellent blueprint for all 50 states.

A hyper-local set of guides re: Tools for Healthy Food Access local to me in the DC area:

https://ndc-md.org/news-and-stories/healthy-food-access

“Of all forms of inequality, injustice in healthcare is the most shocking and inhumane.” Dr. Martin Luther King Jr.’s Address to the Medical Committee for Human Rights, 1966        

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FOOTNOTES

[1] Linda Villarosa, “Myths about physical racial differences were used to justify slavery — and are still believed by doctors today,” The New York Times Magazine, August 14, 2019, https://www.nytimes.com/interactive/2019/08/14/magazine/racial-differences-doctors.html.

[2] Villarosa, 2019.

[3] Smedley , et al, “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care,” Institute of Medicine/The National Academies Press, Washington, DC, 2003, p. 1. ?https://pubmed.ncbi.nlm.nih.gov/25032386/

[4] Risa Lavizzo-Mourey and David Williams, “Being Black Is Bad for Your Health,” U.S. News and World Report, April 14, 2016, https://www.usnews.com/opinion/blogs/policy-dose/articles/2016-04-14/theres-a-huge-health-equity-gap-between-whites-and-minorities.

[5] Lindsay Key, “Lead Exposure, Segregation Combine to Widen Achievement Gap,” Duke Global Health Institute, August 11, 2022, https://globalhealth.duke.edu/news/lead-exposure-segregation-combine-widen-achievement-gap.

[6] “Asthma Disparities in America,” Asthma and Allergy Foundation of America, September 2020, https://www.aafa.org/asthma-disparities-burden-on-minorities.aspx.

[7] Lavizzo-Mourey and Williams.

[8] Richard V. Reeves and Faith Smith, “Black and Hispanic Americans at higher risk of hypertension, diabetes, obesity: Time to fix our broken food system,” The Brookings Institution, August 7, 2020, https://www.brookings.edu/articles/black-and-hispanic-americans-at-higher-risk-of-hypertension-diabetes-obesity-time-to-fix-our-broken-food-system/.

[9] Steven Woolf, et al., “How conditions for wellness vary across the metropolitan Washington region,” Virginia Commonwealth Center on Society and Health, October 2018, p. 10, citing the work of E.D. Carlson and R. M. Chamberlain, “Allostatic load and health disparities: A theoretical orientation,” Res Nurs Health, 2005, 28:4, pp. 306–315.