There is mounting evidence that the widening economic gap between the rich and the poor is largely responsible for the differences in health between the rich and the poor. In fact, there is a 'gradient effect' in this relationship: each socioeconomic group (in other words, groups defined by social and economic characteristics like education, income, etc.) has better health than the group just below it in the hierarchy, and this is especially true among the poorest families. A good education, a living wage, a decent occupation, and the accumulation of modest wealth (assets like a house and savings), enable families to be healthy. In fact, education and income levels are among the strongest predictors of good health.
Race and ethnicity are also very important predictors of poverty and wealth. In other words, Black families or Native American families, for example, are more likely to live in or near poverty compared with white families. However, after sorting out families by income and wealth, there are still differences within each level by race.

Note that I use the term 'race' as it is commonly used in and out of the research literature. There is actually no scientific distinction between, for example, people with dark skin vs. people with light skin, other than skin color – a distinction which is no more meaningful than size of ears or shape of belly button. There are, however, very important historical and cultural differences between many 'racial' and ethnic groups which are often confused with the idea of genetic differences so great as to imply a separate 'race.' Scientifically, this is nonsense, but the language persists both in and out of the scientific community, so I will use it in this article in light of its historical usage.

Health and Race

To continue, differences exist by race and ethnicity within all economic levels in the quality of education, family wealth at a given level of income, the stability of employment, and the health risks associated with the job.In other words, for most causes of death and disability, African Americans, Latinos, and American Indians suffer poorer health outcomes relative to whites at any given level of income. Housing segregation is a likely contributor to this outcome. Racial discrimination, as seen in part through housing segregation, affects health in numerous ways: restricted access to resources and opportunities, polluted air, water, and other environmental conditions, psychological factors that affect health, such as higher stress, limitations to residents’ access to health-promoting resources such as full-service grocery stores and safe, walkable neighborhoods,Race and ethnicity play a major role in the explanation of health disparities (in other words, the differences in health status among different groups of people). For example, low-quality education systems and subsequent poor student performance in segregated low-income communities, are shaped in large part by racism that remains pervasive in society. In addition, there is a negative impact of chronic, race-related stress on health. This race-related stress and its negative health consequences cut across the income levels of families. For example, one study indicated that middle-class black women with health insurance in Prince George’s County, Maryland, had poorer birth outcomes than white women with the same income and professional status. Examples of the negative impacts of 'institutional racism' (in other words, the normal functioning of social institutions in such a way that they negatively affect minorities) include: a lack of providers of color in hospitals and clinics; a lack of multilingual staff; a lack of culturally competent caregivers in communities; patterns of unequal diagnosis and treatment; a lack of responsiveness by medical training institutions outright racism within health care institutions by medical practitioners.Various studies have shown that victims of racism often experience a sense of hopelessness and inability to envision a positive future. This contributes to mental health problems among people of color, such as depression among women, violence and suicide in men, and substance abuse. These conditions may be compounded by the concept of 'environmental racism,' which refers to contributing factors in health disparities due to such things as poor housing conditions and a lack of clean air and water.

The interplay of ethnicity and income is particularly destructive to the health of immigrants. Immigrant communities face multiple challenges such as obtaining quality health services, acculturating into a new society, and gaining access to service systems and supports. These problems have been compounded by recent funding cuts to public health and hospital facilities, which have forced these facilities to restrict a range of critically important 'safety net' services. Experts agree that there has been an increase in diseases and conditions among immigrants that were not apparent a few years ago, such as asthma and hepatitis C. There have also been widely reported increases in substance abuse and domestic violence.

Neighborhoods and Health

Neighborhoods are an important influence in a wide range of health issues, including: birth outcomes and infant mortality, children’s physical health, child development, adult physical health, overall mortality, health-related behavior, and mental health. High-crime neighborhoods have direct effects on the physical and mental health of victims, and indirect effects on health-related behavior such as the ability of residents to exercise outdoors. A high-crime neighborhood may influence the quality and availability of services and economic opportunities, such as the type and number of businesses that will locate in the neighborhood.

A study of Alameda County (California) provides important evidence for the association between poverty areas and health. After adjusting for variations in age, gender, baseline health status, and race, residents in the poverty area in the western part of Oakland still had an increased risk of mortality over a nine-year period. Further analysis and adjustments for other factors, did not explain the excess risk associated with living in a poverty area. The segregated communities of African Americans are associated with high infant mortality rates. Low-income African Americans are much more likely to live in high-poverty neighborhoods than are low-income whites or Latinos, and African Americans experience the highest amount of residential segregation and isolation from other groups. One study found that African American men ages 25-44 living in areas with the highest segregation had almost three times the risk of dying as those living in areas with the lowest segregation. The risk for African American women was almost twice as great.

A study in 15 communities in the western United States found that residents of communities with higher unemployment rates had higher smoking rates and a higher percentage of calories from fats in their diet. On the other hand, neighborhood characteristics associated with a healthy diet include higher income, higher education, higher housing values, and lower levels of mobility.

A study of premature mortality (earlier than expected death) found that neighborhoods with larger proportions of African Americans, larger proportions of female-headed households, and residents with less education who experienced chronic unemployment had higher levels of premature mortality.

The Built Environment The quality of the built environment (in other words buildings, roads, parks, etc.) and natural environment influences the health of neighborhood residents. For example, adequate physical activity is an important contributor to many positive health outcomes, but the residents of low-income neighborhoods are less likely to have adequate physical activity due to poorly maintained housing, and higher crime rates. In this environment few incentives exist to encourage physical activity, and lack of safety can seriously inhibit recreation and exercise. Other studies have also shown that exposure to factors such as noise, crime, or violence increases stress. Not surprisingly, one study documented that residents of neighborhoods with high levels of crime and violence experienced more stress than residents in areas with less crime. Chronic stress appears to cause a wide variety of health problems, such as poor pregnancy outcomes, high blood pressure, diabetes, cancer, respiratory infections, and heart disease.

Clean water and air, the availability of parks and recreational opportunities, safe streets, good housing, and easy access to economic opportunities, all contribute to creating a healthy neighborhood environment. On the other hand, exposure to chemical, physical, and biological agents in the environment may be an important cause of preventable disease. Research has shown that low-income communities of color have a higher number of polluting sites than wealthier areas. Furthermore, there is evidence that low-income minorities are concentrated in occupations with greater potential health threats, including exposure to toxins.

Poorly built and maintained homes can result in higher exposures to allergens that trigger asthma, and present greater potential exposure to lead from lead-based paints. Similar issues typically exist in schools and other public facilities in low-income neighborhoods.

Some communities have experienced success in challenging industries, governmental agencies, and businesses. For example, New York City residents in West Harlem, along with the West Harlem Environmental Action Taskforce, were able to link increased asthma rates with high rates of diesel bus fumes from a local depot. Stricter ordinances and standards were established as a result of advocacy campaigns aimed at improving air quality and the overall health of the neighborhood. The successful advocacy utilized air quality testing, asthma tracking, and community mobilization.

Geographic Isolation

The geographic isolation of low-income neighborhoods – a growing trend as much employment and retail move farther from central cities and beyond the reach of mass transit – often leaves neighborhood residents with limited job prospects and inadequate access to services. Lack of access to opportunities effectively places the entire community at risk for poorer health outcomes. Neighborhoods with more unhealthful environmental exposure are also more likely to bear the burden of other negative social or environmental conditions. There is increasing evidence of dramatic increases in asthma rates and other respiratory illnesses in both urban and rural areas. There is evidence, for example, of the overrepresentation of some Asian communities in the dry cleaning industry, which contributes in this group to an increase in lung diseases.

The availability of high-quality, culturally sensitive, neighborhood-based health services is important for access to health care and good health outcomes, but many rural areas and inner-city neighborhoods face serious shortages of these services and facilities. Frequent barriers cited by lower-income, 'non-compliant patients' include transportation difficulties, insensitive treatment, long waiting room intervals, and lack of clarity on the importance of clinical visits.

A study of four states found that census tracts with higher median home values had three times as many supermarkets as other neighborhoods. The study also found that supermarkets were over four times more common in predominantly white neighborhoods compared to predominantly African American ones. It is not only the absence of supermarkets, but also the preponderance of other types of stores that may be related to health outcomes. One study found over three times as many bars in the lowest, as compared to highest, wealth neighborhoods. A study in Baltimore found that liquor stores are more likely to be located in census tracts that are predominantly African American, even after taking into consideration variations in income.

Finally, it is very likely that that there are cumulative and interactive negative health effects on residents who live in segregated, low-income communities over time, and through different periods of the lifespan. For example, children may be poisoned by eating lead-filled paint chips in substandard housing, then affected by mold in poorly maintained schools, and finally exposed to particularly hazardous occupations as adults.

What is to be done?

The field of public health is different than medicine. Generally, medicine involves the treatment of an individual by a doctor or other health care provider. The field of public health, however, has historically involved the concept of prevention – in other words preventing injury or disease before it happens. In addition, public health generally involves groups, populations, or types of people rather than individuals. Public health, for example, involves the activities (or struggles!) of keeping our air, water, and food safe. Medicine, on the other hand, involves the treatment of individuals who have asthma because of polluted air, or intestinal problems because of polluted water or poorly prepared food.

The field of public health arose in struggles in the latter half of the 1800s and 1900s to clean up water supplies and create safer housing conditions for workers in the industrial revolution. However, in recent decades, the field of public health has generally ignored class and neighborhood issues as actual causes of public health problems, but this is changing. For those of us engaged in struggles for healthy families, a living wage, safe water to drink, and safe neighborhoods, this reemerging concept of public health ties all these struggles together in a way that has not been possible in recent decades.

Now that there is an emerging interest in the health consequences of unsafe neighborhoods, poor housing, and low wages, these become public health issues as well as struggles against corporate exploitation and negligent governments. This means that building broader, more effective coalitions to fight these struggles in a new, united way is more possible than ever. The uniting banner of public health makes it clear that the struggle for health care, a living wage, clean air and water, and a safe neighborhood are all the same struggle. The opportunity to unite these many struggles into one powerful coalition is ours to seize.



--David Lawrence writes frequently for Political Affairs and can be reached through us at pa-letters@politicalaffairs.net.