In the recent White Coat Die-In demonstrations orchestrated by medical students across the nation, aspiring physicians displayed solidarity with the message that racial injustice is a public health concern that merits the attention and efforts of health care professionals. It is clear from the mobilization and investment of our medical community that there is a desire to engage in clearer articulation and understanding of the health disparities landscape.
In this series of articles, I seek to discuss the notion: how does racism make us sick? It is of course impossible to lay out the relationship between racism and health succinctly. Each one of these paragraphs can (and should be) elaborated upon in entire books, courses, conferences and careers, but this conversation needs to be started.
Structural racism, as defined by the Center for Social Inclusion, is the “blind interaction between institutions, policies and practices that inevitably perpetuates racial disparities and barriers to opportunities.” This system, built into the history of this country, makes people sick because it negatively affects all aspects of life, from economic power and political clout to social mobility, access to health care, living prospects and educational opportunity — it does not exert a shallow, unidirectional oppression. In technical terms, racism is a massive driver of health inequity — the consequence of “systemic and unjust distribution of social, economic, political, and environmental resources needed for health.” Individuals who have less command of financial and sociopolitical clout experience poorer health as a direct consequence.
To be clear, race does not impact the health and experience of individuals as an isolated and singular axis of oppression. Other social identities — socioeconomic status, gender, sexuality — intersect to complicate the issues individuals will face. For example, people of color who occupy different levels on the socioeconomic scale will have different experiences, just as white patients with low socioeconomic status may face many similar concerns. This series of articles, however, seeks to focus primarily on issues of racial identity and the impact structural racism has on people of color in this country. It is also important to mention that racism in the United States was built along the black-white binary. As such, much of the data discussed will focus on African American populations. These issues, however, can be extrapolated to include similar issues among people of color in general. For part one of this article series, I focus on historical routes of segregation and the ways concentration of health hazards in certain spaces helps to explain how structural racism makes us sick.
Racial segregation is a structural kingpin in continuing health and class inequality. Indeed, even when controlled for income, neighborhood segregation has been tied to deprivation of resources and a host of conditions correlated with low birth weight, obesity, cardiovascular disease, and lower life expectancy. To understand this facet of health inequity, we must first understand state-sponsored segregation and how its legacy continues to concentrate health hazards among populations of color.
In the 1930s, New Deal Era Housing policies established the Federal Housing Administration (FHA) in order to make home ownership more widely available to citizens. While this allowed thousands of white families to begin owning homes, the FHA barred black families from similar opportunities. It employed the practice of “red lining” in which black neighborhoods were labeled with low ratings that codified high risk for loan repayment. In doing so, black families were denied mortgage funds, depriving them of the ability to purchase homes and sequestering them to certain geographic locations. Indeed, in the two decades after its creation, the FHA financed 60 percent of American homes, yet less than 2 percent of its loans went to people of color. Government-sponsored segregation that began decades previous provides an important foundation for health inequalities that continue to exist today.
Consider how in the 1950’s, hate crimes against blacks — fires, vandalism, property destruction, lynching — were used as a tactic to scare black families who first tried to move into white neighborhoods. Despite legislation like the Housing Act of 1968 which prohibited discrimination in the sale, rental and financing of housing, real estate brokers continued to “steer” people of color to minority neighborhoods to maintain color lines. In the 1970s, black women were hired to stroll around white neighborhoods as a tactic employed by realtors to scare white families into moving out of neighborhoods quickly and sell their homes at low prices. Consider how these properties, bought cheap off of frightened whites, were then marketed at outrageously inflated prices to black families who had few options due to discriminatory policies that prevented their access to property. These practices set the stage for the mobilization of “white flight” to suburban neighborhoods — a mobility inaccessible to African American families who were left in crumbling, poorly resourced urban neighborhoods. Indeed, it seems integration “was just a phase between when the first blacks move in and the last whites took their children out of the public schools.” Even today, African Americans remain the most segregated population in the United States.
The issues of segregation from the early 20th century created significant barriers to social mobility as well as access to public and private resources, both of which continue to impact factors such as unemployment, education and medical access. In Chicago, black mortality from breast cancer has remained static in the last quarter of a decade, while white breast cancer mortality has decreased by 50 percent, largely due to early mammography detection. Poor neighborhoods of color have fewer breast cancer screening centers; the centers that do exist are often of lower quality due to use of older equipment and fewer mammography specialists. Moreover, individuals on Medicaid must travel longer distances to public hospitals in order to obtain mammograms. (Consider how ideas of noncompliance rarely take into account lack of reliable transportation in neighborhoods that are already resource-constrained.) Dorothy Roberts, a scholar on race, gender and law, captures the issue succinctly when she writes, “Of the 25 Chicago community areas with the highest breast cancer mortality rates, 24 are predominantly black. Only one of these has a hospital with a cancer program approved by the American College of Surgeons Commission on Cancer.” The correlation of lower death rates with developing screening protocols demonstrates that these disparities are due to social differences rather than biological causes. This is where we again see the intersection of historical segregation, disenfranchisement, economic oppression and limited social mobility manifesing as health inequities. The consequences of segregation are real. In Chicago, two black women — mothers, daughters, wives — die every week simply because their breast cancer mortality rates are not the same as their white counterparts.
Issues of race and space continue to impact health when one considers environmental implications of segregation. We ask our patients about home environmental hazards and safety in our most basic social histories because we know these factors are important to health. Indeed then, it is shocking to discover that race, even more so than socioeconomic class, is the best predictor of the location of toxic waste sites. At the heart of this issue is the fact that the organization of space is a social product that does not develop organically, especially given the history of segregation in this country. The placement of Locally Undesirable Land Uses (LULUs), which are associated with environment and health hazards, is inextricably tied to how people are separated. As a case study, Altgeld Gardens is a neighborhood in Chicago founded in 1945 in order to provide housing for black WWII veterans. Now referred to as a “toxic doughnut,” the housing site holds 90 percent of the entire city’s LULUs, which includes more than 50 hazardous landfills, and 250 plus chemical waste dumps that leak toxins into the region. These LULUs have resulted in significant increases in cancer, miscarriage, neonatal disorders, asthma and other medical concerns. The medical issues in the community are real, recognizable, and consistent. Unsurprisingly, more than 60 percent of Altgeld’s residents are below the poverty line, and 90 percent of them identify as African American. Despite having the highest rates of cancer and lung disease as linked to industrial pollution, there has been little progress or government attention. People of color are continually more proximate to environmental hazards that seriously impact the health outcomes of entire communities. The lack of progress and effort devoted to remedying these injustices, despite clear evidence of inequality, demonstrates again the intersection between sociopolitical marginalization and illness.
Besides the air we breathe, our neighborhoods also dictate the food we eat. The neighborhoods individuals are able to occupy under racial and financial limits influence the nutritive resources one can access. Food is no doubt related to health, considering that four of the top 10 causes of death hold poor diet as a major risk factor. In 2009, the US Department of Agriculture found that only 8 percent of blacks (compared to 31 percent of whites) live in a census tract with a supermarket containing fresh food. In Detroit, research surveying food security found that on average, supermarkets were 1.1 miles further away in impoverished black neighborhoods compared to similarly impoverished white neighborhoods. This is particularly significant given that 25 percent of these households did not own a car. Access to fresh food is directly correlated to healthier eating. In fact, the addition of one supermarket in a census tract correlates with a 32 percent increase in produce consumption in African American populations. Again, the presence of food deserts — geographic areas where fresh food is limited and instead replaced by high-calorie, high-sugar, high-fat fast food restaurants — is related to the US history of racial segregation. If one cannot afford or access nutritious food, such as in cases of poverty or lack of grocery stores, undeniable health consequences such as obesity, malnutrition and hypertension quickly follow.
It is not rare for medical students to hear about or analyze disparate rates of asthma prevalence and severity among minority populations, yet it is rare that we take the time to examine how the continued presence of racism in our country creates these conditions. As an example, in Los Angeles, Latino, black and Asian children are twice as likely to live in traffic-heavy areas, which correlate with almost triple the frequency of asthma-induced hospital visits. To be very clear, it is not that children of color are inherently more susceptible to afflictions such as asthma, but rather that they are more likely to live in worse, poorly resourced neighborhoods with greater exposure and concentration of unhealthy triggers. When we as medical students are presented with health disparities data that does not include the social and historical context of racism’s contributions, we receive only half the picture. Our understanding will forever be half-baked until we can understand the foundational routes of why these disparities continue to exist.
Race impacts space. Research demonstrates that a greater percentage of black inhabitants in any neighborhood, regardless of income level, is correlated with higher mortality rates for residents, irrespective of their individual race. It is imperative that we understand that these health inequities can be traced back to segregation and the unfair concentration of unfavorable living conditions promulgated by structural racism. Discriminatory policies from the New Deal Era that prevented home ownership and family assets among black families contributed directly to the dramatic gap between black and white median wealth. While recent statistics show the median black-white income gap itself is large ($35,416 for blacks, $59,754 for Whites), the median wealth gap is startling at $113,149 for whites, and $5,677 for blacks. The historical and continued sequestration of people of color into poorly resourced, impoverished and segregated neighborhoods is conclusively linked to health care outcomes.
Spatial and social differences recapitulate one another. Understanding segregation and the forces that continue to reify its harms may help clarify why prescriptions for fresh produce may be more efficacious in combatting obesity than FDA pharmaceuticals. It explains why sending children home with inhalers will not address the cause of their asthma. Why mobilizing racialized tropes of patient laziness as an explanation for poor adherence fails to account for a greater context. Why racial injustice is a public health concern.
As aspiring physicians, there is a lot to consider as we begin to enter the wards. These are not challenges that can be solved with a purely biomedical framework, and we must take issues of structural racism into account in our attempts to help and understand the social situations of our patients. We are sometimes able to help our patients with a scalpel, a prescription pad or a stethoscope. We can always help by being engaged, in tune, and involved in our communities. Racism makes people of color sick by continuing to bar opportunities and access to the resources — inside and outside the hospital — required for health. As we seek to eliminate the products of illness, we need to think more about the production of illness, and the ways we can integrate issues of social justice and public health into our personal and professional consciousness.
This is part one of a series. Part two will focus on incarceration and criminal justice.
For further reading or inquiry:
Been, Vicki. “Locally undesirable land uses in minority neighborhoods: Disproportionate siting or market dynamics?” Yale Law Journal (1994): 1383-1422.
Coates, Ta-Nehisi. “The Case for Reparations.” The Atlantic. June 2014.
Kawachi, Ichiro, et al. “Social capital, income inequality, and mortality.” American Journal of Public Health 87.9 (1997): 1491-1498.
Treuhaft, Sarah and Allison Karpyn. “The Grocery Gap: Who Has Access to Food, and Why it Matters.” The Food Trust. 2010.
Writer-in-Training and in-Training Staff Member
Warren Alpert Medical School of Brown University
The white coat is a scary, scary thing, and I'm still trying to figure out if I should have one. If you like screaming about ethnic rage, dance, or the woes of medical education, we should probably do some of those fun activities that friends do.
I have few answers, many questions. Dialogue is huge. Feel free to email with questions and comments!
