Place, Not Race, May Better Explain America's Health Disparities
National statistics routinely show almost shocking health disparities between white and minority populations in the U.S. Nationally, African Americans have higher rates of obesity, heart disease, hypertension and certain cancers, a pattern public health officials have struggled to understand and reverse (and that, in fact, has been a major focus of health initiatives under the Obama Administration).
“When I talk to people who are not in the health profession, people talk about why would there be racial disparities,” says Thomas LaVeist, who directs the Johns Hopkins Center for Health Disparities Solutions. “People would say things like ‘it’s really an access-to-care issue,’ or there is this idea that there’s some kind of genetic effect, that black people are just genetically different from white people, and it’s producing these differences.
“But when you study the topic," LaVeist says, none of those theories make any sense.”
When LaVeist first began researching this 20 years ago, he began to develop a theory that health disparities may actually have more to do with segregation – with the characteristics of the communities in which people live, not with anything intrinsic in their racial differences. Now he’s published a new study in the journal Health Affairs that lends even more support to this idea. Health disparities, the new research suggests, aren’t really about race at all. They’re about place.
“When you look at how segregated this country is, black and white people live in the country together, but we experience the country differently because we’re living in different communities,” LaVeist says. “Maybe the characteristics of communities where blacks are more likely to live are really what’s fueling these disparities.”
LaVeist and several colleagues tested this idea by examining the counterfactual: If society weren’t segregated, would health disparities still exist? They identified a low-income community in Southwest Baltimore, spanning two census tracts, that is fairly equally divided between black and white residents (out of deference to the neighborhood, LaVeist doesn’t name it). The median household income in the area was less than $25,000 during the 2000 census. It has no pharmacy, no practicing physicians or dentists, no supermarkets, and no banks.
Within this integrated community, the researchers found that health disparities all but disappear. There was no significant difference in diabetes rates, or obesity rates among young women (a metric on which large gaps exist nationally). There did remain a difference in hypertension rates, albeit it a much narrower one than national data shows. The lone exception: Whites in this community smoked at a significantly higher rate than blacks.
This suggests that what the national statistics are really telling us is that minorities live in much higher numbers in unhealthy neighborhoods. And that means that in trying to address health disparities nationally, we’ve been looking for the answers to the wrong question. We should be asking what’s going on in these communities, not what’s going on within minority populations.
“Solutions to health disparities are likely to be found in broader societal policy and policy that is not necessarily what we would think of as health policy,” LaVeist says. “It’s housing policy, zoning policy, it’s policy that shapes the characteristics of communities.”
He’s literally talking about things like land-use policy. What’s the density of liquor stores in a community? What’s the proportion of commercial to residential space? And he’s not just thinking about the presence of obvious health resources, the availability of walk-in clinics and direct access to medical care.
“I’m talking about who has a bank in their neighborhood versus who has to go to a check-cashing place,” LaVeist says. “Who has a Whole Foods in their community versus who has to go to a bodega for a loaf of bread, or a 7-Eleven.”
He is talking, in other words, about expanding the public health conversation in this country into something much larger, a debate about everything that defines a community and that contributes to the welfare of its residents.