Being healthy isn’t just about making smart choices and behaving in a certain way. Systemic and structural racism can stand between you and good health.
It doesn’t seem right that something as seemingly arbitrary as your zip code can predict how healthy you'll be throughout your life — or how long you’ll live. Yet an increasing number of studies suggest it does. In the U.S., it may even be a better predictor than genetics, gender or lifestyle habits, especially if you’re a Black woman.
Black women in this country typically have shorter lifespans than white women. Data from the Centers for Disease Control and Prevention in 2017, suggested that the average life expectancy for white women in the U.S. was 81.2 years and for Black women — 78.5 years.
Examining data from New York University Langone Health’s City Health Dashboard in June 2019, researchers in the department of population health at NYU’s School of Medicine found that in 56 of the 500 largest cities in the country, people in certain neighborhoods are unlikely to live as long as their neighbors. In fact, in some areas in Washington, D.C., New York and Chicago, there's a good chance that residents will die 20 to 30 years earlier than their neighbors just a few miles away. And these stark changes don’t just occur from one zip code to the next. In some places, life expectancy varies from block to block, according to data from the National Center for Health Statistics.
Linda Goler Blount, M.P.H., the president and CEO of the Black Women’s Health Initiative, lives in a suburb of Atlanta. “If I look at life expectancy where I am versus the area southwest of me, there’s a 14-year difference among Black people. If you look at black versus white people, it’s 20 years (or more),” she told TODAY.
There’s no genetic or biological issue causing these disparities, Goler Blount pointed out. “What we have are policy issues. Those folks in southwest Atlanta have fewer health care providers per capita. The one hospital there is a low-resource hospital.” On top of that, she noted, there are fewer mental health resources, the schools are underfunded, the living conditions are densely populated with multigenerational housing and there is persistent poverty. “A child in Atlanta born in poverty has a 4% chance of ever escaping poverty,” she said.
Dr. Lisa Cooper, the Bloomberg distinguished professor for equity and health at Johns Hopkins Bloomberg School of Public Health and director of the Johns Hopkins Center for Health Equity, told TODAY that the situation in Baltimore is similar, with neighborhoods five miles apart and a 20-year gap in life expectancy. “The death rates for heart disease, for example, might be three times higher than in a neighborhood that’s five miles away. The rates of other conditions like diabetes — or even the rates of homicide — can be two to three, or even tenfold higher, depending on which neighborhoods you’re comparing to each other.” These are not unusual circumstances. The same scenarios are playing out across the country.
What does zip code really have to do with it?
“Zip codes in and of themselves mean nothing,” Dr. Linda Rae Murray, the recent past president of the American Public Health Association and an adjunct assistant professor at the University of Illinois Chicago School of Public Health, told TODAY. “The only reason zip codes have any meaning is because our housing is so segregated. So what we’re really saying is: How does racial segregation housing impact health?”
Murray said the answer is fairly clear. Black and brown communities in the U.S. simply don’t have the same resources as most white ones. This can make basic things — such as exercise, healthy eating, going to a doctor or therapist, getting a good education, a job or finding a home — much more difficult.
In Chicago, where NYU documented the largest gap in life expectancy (up to a 30.1-year difference), Murray pointed out that minority communities don’t have the same kind of park land or level of upkeep as the parks in the predominantly white neighborhoods on the Northside. Everything from the programs at the parks to the libraries, the schools, the number of grocery stores and banks in the neighborhoods is different. “You can go down the list of those sort of community infrastructures, and say clearly that in poor communities, which are disproportionately communities of color, the investment of that kind of public infrastructure just simply isn’t there — and we know that has devastating effects on people’s health.”
For decades, public health experts have been grappling with the social and structural determinants that make it harder for people of color to be healthy. Across the U.S., Black women continue to have higher rates of chronic conditions like diabetes, heart disease and asthma. They’re disproportionately affected by obesity.
They are also more likely to suffer maternal — and infant — mortality. Over the course of her medical career, Murray has observed the number of Black women who die from pregnancy-related diseases actually get worse. “How can you explain that in this rich country,” she said, “when all the parameters, and what we know technically, medically, to prevent women from dying has increased — and yet we’re losing more women?” During childbirth, Black mothers die at about 2.5 times the rate of white mothers, according to the CDC (37.1 versus 14.7 per 100,000 live births in 2018).
“The only reason zip codes have any meaning is because our housing is so segregated. So what we’re really saying is: How does racial segregation housing impact health?”
“We know neighborhood and community conditions are huge contributors to health,” said Cooper. “When you overlay things like access to high-quality housing or to education or jobs, you can see that those neighborhoods that experience those poor health metrics are also the same ones that have fewer fresh food stores. They have more crowded housing conditions. They have higher levels of environmental pollution ... People living in those neighborhoods [can’t] get access to things they need to be healthy.”
Additionally, said Goler Blount, when you have persistent poverty, “the people in the area feel it, they live it every day.” There is a considerable amount of research that looks at the effects of racism and gender discrimination, and how it influences what happens at the DNA level, she said. “It causes ‘weathering.’ Literally Black women and men age faster because of this effect.” They also experience a great deal of stress, including post-traumatic stress from repeatedly seeing police brutality in the media — and Black men, women and children being killed. Studies, she said, suggest that “Black women have at any given time 15% to 20% more of the stress hormone cortisol in their bloodstream (than white women).” They also contend with a host of biases — gender bias, medical bias and implicit bias — that affect the care and pain management they receive.
“And on top of that, Black people and brown people have the added effect of racism on poor health outcomes and life expectancy,” Goler Blount said. “All of these factors combined — when you’re in a zip code with concentrated, persistent poverty and with no way out — shorten the lifespan.”
“All of these factors combined — when you’re in a zip code with concentrated, persistent poverty and with no way out — shorten the lifespan.”
An extensive 2017 report on the state of health disparities in the U.S. by the National Academies of Sciences, Engineering and Medicine found that “the burdens of disease and poor health and the benefits of well-being and good health are inequitably distributed” in this country. The report’s authors attributed this imbalanced distribution to social, environmental, economic and structural factors (such as poverty, unemployment, low educational attainment, inadequate housing, lack of public transportation, exposure to violence and the social and physical deterioration of neighborhoods), adding that these inequities lead to “pronounced differences in opportunities for health.”
How are these disparities playing out with the COVID-19 crisis?
For months, major news outlets have been reporting on how the coronavirus pandemic is disproportionately affecting Black communities and other communities of color. A study published in the August 2020 issue of AIDS Patient Care and STDs, which analyzed the infection rates of both COVID-19 and HIV in white U.S. counties versus non-white ones, found that white communities had lower infection rates of both viruses, but it wasn’t because white people have stronger immunity. Their circumstances put them at reduced risk, comparatively, and give them greater ability to limit their exposure. Researchers concluded that residential segregation, structural racism and social determinants of health are the key factors driving higher rates of infection in communities of color.
“We know that ‘zip code’ definitely matters — even more so than genetic code — for health, and we see that across a large number of U.S. cities,” said Cooper. “How that’s playing out today is that those are the same neighborhoods where there are fewer [COVID-19] testing facilities, fewer hospital beds, fewer ICU beds.” So, not only are the residents of these neighborhoods less healthy to begin with, their access to care and testing is also limited.
Cooper explained that with the Johns Hopkins COVID-19 Dashboard, which tracks how the novel coronavirus is spreading around the globe, you can click on a particular county and see stats like how many hospitals and hospital beds there are, how many health care professionals, the overall population, the area’s income level, as well as the fatality rate among people who get infected.
“What’s interesting is you can look at the map and see where people live and where there are no testing facilities in their counties,” she said. “You can see why people probably don’t know that they’re infected, so they’re out and about spreading to other people because they have no way of getting tested. That’s why a lot of people are saying that it’s not race that’s a risk factor for COVID-19, it’s racism.”
“You can see why people probably don’t know that they’re infected, so they’re out and about spreading to other people because they have no way of getting tested."
Murray added that these are also the same neighborhoods where many workers don’t have paid sick leave. “People have to choose between paying their rent and buying food — and staying home if they think they’re sick,” she said. Beyond making it harder to recover from any illness, not having the luxury of taking sick days can make it more difficult to control the spread of COVID-19.
Based on analyses of COVID-19 data and known health disparities, Goler Blount suggested that if an effective vaccine isn’t available within the next three years, “we could be looking at 200,000 to 500,000 deaths among Black people,” as well as a potential 30% to 32% unemployment rate and 40% poverty. In that scenario, “the economic devastation becomes overwhelming,” she said. “This is one of those rare opportunities we have to predict the future and put policies, procedures and strategies in place to keep that from happening.”
What can we do to fight racism — and improve health outcomes for Black people in the U.S.?
Combating systemic and structural racism is deeply complicated. It requires substantial work from politicians, policy makers, community leaders, public health advocates, economists, business owners and others. But as individuals — and allies — there are things we can all do to help turn the tide.
“We each have a part that we can play,” said Cooper. “Each of us has a neighborhood where we live, a place where we work, other organizations that we’re involved in where we have a voice — and that’s where you can share your knowledge and understanding of these issues in order to have influence.” Additionally, she emphasized, we all have the right to vote for leaders who will address the issues that are important to us.
“What I tell people, in terms of organizing,” said Murray, “is stop where you are and start organizing wherever you are. If you’re a parent and you’re active in your PTA, start there. If you’re a religious person and you spend a lot of time in the church, start there. If you’re a health professional and you’re really focused on your job, start with the health care system.”
Implementing a single-payer health care system is our country’s most immediate need, said Murray. “Anyone that’s living and breathing in the country ought to be able to get medical services and not be worried about being turned away,” she said. “We have to make it easy for people to get access to medical care, and we have to make it equitable — it shouldn’t cost money out of pocket.” She also added that increasing diversity among health care professionals so that the people who provide healthcare look like the people they’re taking care of is crucial. “What that means is that we have to change our opportunities around education, especially for poor kids, Black and brown kids, so they have a chance to think about becoming health care workers and really helping to improve the health of our community.”
“Anyone that’s living and breathing in the country ought to be able to get medical services and not be worried about being turned away."
There needs to be a shift in mindset too. A lot of people think about health as something that’s largely within our control, said Cooper. “They think that if you just make certain choices or you behave in a certain way you can be a healthier person — just stop smoking, don’t drink alcohol, eat properly, exercise and go to the doctor. What they don’t realize,” she said, “is that the decisions we make and the behaviors we engage in are shaped by our environment and opportunities … and many of those things aren’t within an individual’s control.”
When large swaths of our population don't have the same opportunities to be healthy it impacts everyone. But if we pay attention to all the groups in our country and try to fight for what we believe is an equitable and fair balance, we can make real progress, said Murray. “But that’s the hard part, understanding where you have those privileges — or luck — that other people may not have, and then asking yourself, ‘What can I do to address this problem?’”