Hospitals, Population Health, and Communities of Color: Addressing Root Causes of Poor Health
Let’s rewind the clock to about 13 years ago, when the Institute of Medicine released its landmark report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare. The publication uncovered the healthcare system’s contribution to differences in health outcomes by characteristics such as race and ethnicity. It served as a cue to action for the nation – and for me, it changed the trajectory of my career. Little did I know that I would eventually serve on the frontline with hospital leaders to execute recommendations aimed at eliminating health disparities by providing Culturally and Linguistically Appropriate Services.
Since the release of the report, there has been some progress, as many hospitals across the nation have employed some of the recommendations (e.g., collecting data by race/ethnicity, increasing medical care access points, and developing equity dashboards). However, stark racial disparities persist, and treatment for these differences is estimated to cost $230B, contributing to healthcare expenditures that represent 17% of the nation’s GDP – the highest when compared to other industrialized countries. Clearly, we are missing the mark.
As a former assistant vice president of community health for a large healthcare system, and as a current professor of health systems administration, I have engaged in lively discussions with board members and hospital leaders as they grapple with health reform initiatives. Motivated by new and emerging payment models that shift from fee-for-service reimbursement to prevention and population health financial incentives, healthcare providers are being challenged to think differently about how to provide care to populations with complex psychosocial challenges – many of whom are from communities of color. Common inquiries included, “persons of color represent a large percentage of our readmissions. How do we fix this?” or “persons of color represent a large proportion of unnecessary emergency room visits, most caused by poor chronic disease management. How do we address this?”
In most circumstances, proposed solutions were typical of the healthcare sector – “hire more case managers,” “offer free aerobics and nutrition classes,” or “develop methods to help patients better navigate the healthcare system.” While those interventions have merit, I would offer more unconventional strategies for hospitals that address the root causes of the problem.
But before I share those strategies, I will offer a few reflections on the current climate and our American history.
A series of recent events has sparked national dialogue on the presence of institutionalized racism, bias, and their impact on low-income black communities. It must be noted that these contemporary manifestations are rooted in a history of racial segregation caused by redlining and other systemic injustices – resulting in unequal access to opportunity, disproportionately burdening communities of color for generations. Examples include, but are not limited to: poor air quality, inadequately resourced educational services, limited to no access to affordable healthy food products, and the absence of high quality recreational facilities. Disinvestment in these neighborhoods over the years has sustained low property values and a shortage of employment options with livable wages.
Undoubtedly, these social and economic factors are significant contributors to health outcomes. And I argue . . . even if the best healthcare in the world is available, racial disparities in health will remain intractable until these conditions are resolved.
So what role can hospitals play? One strategy is to rethink the business model. Each year, U.S. hospitals procure nearly $340B in goods and services; total expenditures are estimated at $782B. Total community benefit is estimated at $62B – most of which is devoted to charity care and unreimbursed costs for means-tested government programs. As anchor institutions in their respective communities, hospitals have the capacity to shift resources and stimulate economic development to combat a history of failed policies that have disadvantaged low-income, communities of color. In addition, hospitals can:
- Engage in a structured process to explore how implicit bias may affect internal and external decision-making (e.g., recruitment, hiring, contracting).
- Collaborate with community partners to address gaps in knowledge by applying a racial equity lens in community health needs assessments (CHNAs). The method can be instrumental in providing insight into personal experiences with discrimination, neighborhood resource limitations, as well as the identification of policies and practices that perpetuate racially-driven inequitable conditions. Based on findings, hospitals can work with community partners to build tactics into CHNA implementation strategies.
- Identify minority–owned businesses and develop metrics around localized supplier diversity.
- Support efforts to generate wealth by supporting the start-up of locally owned businesses (e.g., Cleveland Model).
- Offer grants, sponsorships, or loans focused on affordable housing, access to affordable healthy foods, high quality education, and jobs with livable wages.
- Establish coalitions or partner with community-based entities that advocate for racially equitable policies and practices.
By adopting these strategies, hospitals can move a critical step closer to transforming communities and building cultures of health across the nation.
How Do You Know You’re Better than Good Enough?
Do you really think you’re good enough to do this work?
Many underrepresented researchers deal with this question on a daily basis. It was a recurring topic throughout New Connections’ 10th Annual Symposium.
“We all have those doubts,” admitted Risa Lavizzo-Mourey, MD, MBA, President and CEO of the Robert Wood Johnson Foundation.
One idea she shared, is “having a community like this to help you get through those times.”
Rosita López, PhD, professor of educational administration and leadership and previous faculty chair of the Department of Educational Administration and School Business Management, Department of Leadership and Educational Policy Studies at Northern Illinois University, delivered a plenary addressing the difference between obstacles and opportunities the first day of the Symposium.
Even for someone as accomplished as López, who has been appointed to the President’s Commission on the Status of Women and the President’s Commission on the Status of Minorities, served as chairperson of the Northeastern University El Centro Board for more than 12 years, and received the National Hispanic Hero Award from the National Latino Education Institute, obstacles related to identity can arise when you are a person of color, or a person who is differently abled working in academia. These obstacles are often most profound when institutional workplace diversity lags behind societal realities.
Dr. López recounted her first day at a new job, when she met one such obstacle in the form of a coworker telling her “don’t get too comfortable, you don’t belong here.” She shared another troubling example when, at another institution, she was told that she was just filling an affirmative action quota.
“In those moments of impostor syndrome,” she shared, “my first instinct is to believe this rejection. In those moments, I forget about the three days of interviews, the years of writing, of working, of research that it took me to get to that point.”
The audience burst into applause at this. Apparently, López was not the only scholar from an underrepresented background who had faced the injustice of poor assumptions and outright discrimination.
By meeting these obstacles head on, New Connections’ network of underrepresented scholars are living out something that scholar Shawn Bediako, PhD, explains in an online profile:
“I used to question whether or not I was ‘good enough’ to be an elite-level scholar and social scientist. Once I started applying the techniques I learned through New Connections, however, I became too busy with being productive and didn’t have time to dwell on the ‘am I good enough’ question.”
New Connections scholars have had to work hard to move forward in their professions. On top of the rigor and risk that come with the territory of academia, scholars continue to face challenges relating to deeply ingrained inequities and, yet, succeed under incredibly difficult and sometimes hostile work environments. Through a combination of supporting their work, addressing institutional barriers, fostering relationships, and engaging with other researchers, New Connections is seeing its network reach new heights of success — helping scholars and network members turn obstacles into opportunity.
This post is the final installation in our series highlighting top discussions from the 10th Annual New Connections Symposium. Check out our previous blog post, “How Do You Keep Your Dream Alive?”
How Do You Keep Your Dream Alive?
A person is the product of their dreams. So make sure to dream great dreams. And then try to live your dream.
— Maya Angelou
Ten years ago, Debra Joy Pérez, PhD, MPA, had a dream.
Then an employee of the Robert Wood Johnson Foundation (RWJF), she wanted to address the lack of researchers from underrepresented backgrounds studying health disparities — a topic often overlooked in academia. RWJF started the New Connections program in 2005 to diversify its program portfolio and has never looked back.
At New Connections’ 10th Annual Symposium, Dr. Pérez recalled the first-ever New Connections Symposium.
“It was like going to church. You were part of a network where you could be yourself. You could take your mask off when you walked in the door. Where you weren’t responsible for representing every one of your race. Where the majority of researchers there looked like you. Where other people saw you as a fellow scholar instead of asking how you got there.”
Ten years later, these feelings still ring true for Symposium attendees new and old.
“Safe space; validation; family” were just a few of the themes repeated by the researchers at the Symposium.
“This is different than any other academic conference; people are warm, they hug,” attested Benjamin Cook, Assistant Professor of Psychiatry at Cambridge Health Alliance and long-standing mentor at New Connections’ Symposium and Research and Coaching Clinic. Dr. Cook was accepting a special recognition award on behalf of Margarita Alegría, Chief of the Disparities Research Unit at Massachusetts General Hospital, and Professor, Department of Psychiatry, Harvard Medical School. Dr. Alegría has been involved with New Connections since the beginning of the program, serving as a mentor, workshop and webinar leader, and as a Symposium Chair.
Symposium speakers addressed a range of historically underrepresented researchers — not only members of ethnic or racial minorities, first-generation scholars, and individuals from low-income communities, but also researchers with disabilities, hearing impairments, learning disabilities, and members of the LGBTQ community.
New Connections is further diversifying its programming by expanding into new sectors, including urban planning, business, education, engineering, and architecture. Attendees in these sectors and more received the following advice on how to keep their dreams alive in the face of the various challenges they run up against every day:
- Stretch beyond your comfort level. Chairperson Shiriki Kumanyika, PhD, MPH, advised the New Connections network to “think, stretch, and innovate. Use mixed methods. Read Toni Morrison, Maya Angelou, ethnographies written about black communities.” In other words, to conduct effective research, go beyond the quantitative data.
- Partner with other researchers. Dr. Pérez shared that “as a Latina, I find myself advocating for African-American health equity all the time. Because I know that if I try to advocate for health equity among Hispanics, I’ll be put down. So I need my African-American colleagues to advocate for Latino health — we need to work together like that.”
- Put your dream above yourself. Dr. Kumanyika coached the audience to repeat this to themselves: “I’m not here for myself. I’m here for those people I’m working on behalf of. I can do this job without having to feel like I belong here.”
And New Connections is committed to helping sustain those dreams. Looking ahead, the program is growing more inclusive of personal experience and academic expertise in an effort to foster greater health equity and enable all in our diverse society to lead healthier lives. Thanks to this ever-expanding network of scholars, RWJF’s dream of a Culture of Health is becoming a reality.
This post is part of a series highlighting top discussions from the 10th Annual Symposium. Check out our previous blog post, “How Will They Know You Were in the Room? The higher calling of health equity research.”
Beyond Just a “Phase:” Acknowledging the Role of Diversity and Culture in Mental Health
Overall, my childhood wasn’t terribly remarkable. I have four older siblings from my dad’s first marriage. Technically, they are my half- brothers and sisters, but those descriptions were not used in our home. Family is family. I spent the most time with my twin brothers, mostly because we are the closest in age. My summers were equally filled with sibling play, love, and rivalry.
However, things changed in my early 20’s. One of my brothers started telling us that he “didn’t feel right.” He became withdrawn and got into more trouble than what was “normal” for him. I didn’t understand this at the time, but his behavior was the onset of what we now know—many years later—as schizophrenia. In our eyes, he was just a young adult going through a “phase.” I recall my grandmother saying that he was “smelling himself.” The concept of mental illness was as foreign to my family as “half-brother or half-sister.” We simply did not understand what was going on; and we certainly didn’t know what we were supposed to do.
My family’s response—or lack thereof—stayed with me for many years. In fact, when my colleagues and I published an article in 2015 (see Earl, Fortuna, Gao, Williams, Takeuchi, Neighbors, and Alegría, 2015), my brother’s experience influenced much of my thinking and motivation. I had questions that I couldn’t find in the extant literature. In general, I wanted to know how my family’s experience related to others. I wanted to better understand what people experience, and how that information could be (mis)understood. In the article, we explored how psychotic-like symptoms were experienced, endorsed, and understood by a sample of African Americans, Asians, Caribbean Blacks, and Latinos.
While reviewing the data and reading several articles, I quickly realized that “abnormal” symptom presentation of mental illness was just as destructive for an individual as delayed treatment or limited access to care. As found in our work, attributions of psychotic-like symptoms varied significantly by race and ethnicity, and were commonly associated with culturally-bound beliefs, practices or personal or familial distress (e.g., death). Diagnostic criteria for psychosis that are based on Western standards may not account for the potential depth and breadth of the ways in which race, ethnicity, and culture can mediate and/or sanction the expression of what might otherwise be considered psychotic-like experiences.
Despite mental health parity, remarkable progress in expanding mental health coverage, and a rise in global awareness, we are still challenged with understanding and accurately assessing this class of disorders. Each year, approximately 1 in 5, or 44 million, Americans are affected by mental illness. Mental disorders like schizophrenia affect about 100,000 people per year. They can be debilitating and often alter a person’s ability to think, communicate, and function properly. As I think about my own family’s experience, I still try to imagine what it’s like for others. Although my brother was eventually diagnosed with schizophrenia, for many others, that may not be accurate or appropriate.
As we move towards building a holistic Culture of Health, we must not forget to include mental health. We must also intentionally acknowledge the role of diversity and culture. In order to be successful in this endeavor, we need to have a shared understanding about what is required to deliver the right type of care to the right people at the right time. We should also be realistic about the shortcomings, committed to establishing favorable population-wide strategies for improvement, and steadfast in our plan to create a society where everyone, regardless of their culture and background, is equipped with the knowledge, services, and support to lead healthy lives.
 Earl, T.R., Fortuna, L.R., Gao, S., Williams, D.R., Takeuchi, D.T., Neighbors, H.W., & Alegría, M.A. (2015). An exploration of how psychotic-like symptoms are experienced, endorsed, and understood from the National Latino and Asian American Study and National Survey of American Life, Ethnicity and Health, 20(3), 273-292. doi: 10.1080/13557858.2014.921888.
Tara Earl, PhD, MSW, is an Associate with Abt Associates.
How Will They Know You Were in the Room? The Higher Calling of Health Equity Research
During the New Connections’ 10th Annual Symposium (June 9-10, 2016), Chairperson Shiriki Kumanyika, PhD, MPH, shared the importance of getting “in the room.” In academia, this can mean having a voice in decision-making – from leading a committee to being tenured to chairing a conference. At times, these rooms can be hostile … especially if you’re an underrepresented and/or first-generation scholar.
Kumanyika, professor emerita of epidemiology at the University of Pennsylvania and research professor of community health and prevention at Drexel University’s Dornsife School of Public Health, warned that “people will question how you got into the room. Sometimes, your category is what gets you through the door — we don’t deny that. New Connections is unapologetic about extending special privileges to underrepresented scholars because of the richness they bring to the academic enterprise.”
Similarly, during a Thursday plenary session, Rosita López, PhD, shared her experiences in some of these hostile rooms. Being a Latina in a majority White environment (specifically, as professor emerita of educational administration and leadership at Northern Illinois University), López has met a good number of doubters, or “dream-busters,” as she calls them.
But neither she nor Kumanyika focused on these negative experiences; instead, both focused on the change they wanted to bring about and the importance of paying it forward. It was a theme that ran constant throughout the Symposium.
“No matter how you got into the room,” Kumanyika told her audience of underrepresented scholars, “always be asking yourself how people will know you were there. You have been singled out for the cause of equity. How will the resulting findings, reports, or frameworks indicate your presence?”
Just some of the examples she gave of how to do this included:
- When you’re looking at a bar graph of health outcomes, Black individuals are almost always on the wrong side of the bar graph. When a culturally competent researcher is in the room, s/he should pay attention not just to the findings, but how those findings are presented. Presentation of research can either reinforce the possibility of change, or a sense of intractability.
- It is always easier to develop problem-oriented research versus solution-oriented research. Instead of looking at causes of obesity, for example, Kumanyika challenged the audience to look at causes of health within a community, and work from there.
- Make sure any piece of research you had a part in addresses the tough questions: What implications does this have for eliminating health disparities? How does it address privilege? What direct relevance does it have to policy and practices? If an advocate picked this up, would s/he find action steps to act upon?
Next time you find yourself in a room, whether you’re an early scholar or a tenured professor, start by questioning not how you got there, but how the place will be differentbecause you were there.
This post is part of a series highlighting top discussions from the New Connections 10th Annual Symposium. Stay tuned for upcoming blog posts featuring the views of Rosita López, Risa Lavizzo-Mourey, and other distinguished Symposium speakers.
A Meaningful Step Forward: Improving Motor Skills as a Way to Reduce Childhood Obesity
In 1963, President Kennedy stated that “…children are the world’s most valuable resource and its best hope for the future.” But despite advances in our society since that time, childhood obesity is a major concern in the United States. In the past 30 years, these rates have doubled, and more than 30% of children and adolescents are either overweight or obese, according to the Centers for Disease Control and Prevention. Overweight and obese children are at risk of developing chronic diseases (e.g., heart disease and diabetes), are prone to develop stress and low self-esteem, and are likely to remain obese as adults.
In my work over the past decade, I have advocated for promoting developmentally appropriate movement experiences in early childhood settings. These age-appropriate movement experiences enable individuals to develop a functional understanding of movement concepts (body awareness, space awareness, effort, and relationships), and build competence and confidence in their ability to perform a variety of motor skills (locomotor, non-locomotor, and manipulative).
Developmentally appropriate movement experiences are essential in a child’s life due to the cascading effect of motor skills and physical activity on children’s health and development. Often, children in the greatest need of developmentally appropriate movement programs (e.g., girls, children from communities of color and low-income and under-resourced communities, and children with physical and developmental disabilities) often do not have access to them. Remedying these inequities, and ensuring that young children enter school healthy, active, and ready to learn, are the passions that drive my research.
Young children do not naturally learn how to run, jump, throw, and catch proficiently. In fact, to become physically active, individuals must have basic competency in fundamental motor skills. For example, a child who is unable to catch or throw with basic proficiency might not engage in activities like baseball, softball, basketball, and handball. Emerging data support that fundamental motor skills are important to lifelong physical activity, and could help support positive developmental trajectories of health for children (Robinson et al. 2015). In general, children who demonstrate lower competence in motor skills and physical fitness, and engage in less physical activity, also demonstrate unhealthy weight outcomes (e.g., overweight and obesity). However, the determining factor that drives this relationship between lower degree of motor skills and higher rates of overweight and obesity is unclear.
Through my research, I examine how to maximize physical activity and motor skills in pediatric populations, through the design and implementation of evidence-based interventions in school-based settings – CHAMP (the Children’s Health Activity Motor Program). We have found that CHAMP is effective in promoting motor skills, physical activity, and self-perceptions in young children. CHAMP could play a pivotal role in promoting positive developmental trajectories of health in children that aid in reducing childhood obesity. And while childhood obesity remains a complex health problem, CHAMP aims to develop an evidence-based early childhood education movement curriculum that promotes positive and sustainable physical activity behaviors that contribute to healthy growth and development.
Leah E. Robinson, Ph.D., FACSM, is an Associate Professor in the School of Kinesiology and Research Associate Professor in the Center for Human Growth and Development at the University of Michigan. Her research examines ways to maximize physical activity and motor skills in pediatric populations through the design and implementation of evidence-based interventions – CHAMP (the Children’s Health Activity Motor Program). To learn more about Dr. Robinson’s research, visit www.robinsonkinesiology.com or http://www.cmahlab.com/.
Healing Our Social Wounds
The last two decades of health research have produced many crucial studies documenting the association between perceived discrimination and ill health.[1,2] Suffice to say, the United States still has a stony road to trod to approach its post-racial aspirations.
Consider these studies of hiring practices. Resumes with white sounding names (e.g. Kristen or Brad) were evaluated more favorably than resumes with black sounding names such as Tanisha or Jermaine. A black applicant with a clean record not only had a lower chance of getting a job than a white applicant with a clean record, but also had job chances comparable to a white felon. Researchers not only discovered that Latinos with a clean record also had similar job chances as a white felon, they also found evidence of race-based job channeling, as applicants are steered to jobs different than the original job. Black applicants reported more experiences of downward channeling compared to whites (i.e., less customer contact, clearer hierarchy, manual rather than white-collar positions), while whites reported more offers channeling up.
Comparisons between highly selective vs. less selective college credentials uncover similar inequalities. A black graduate from a highly selective university (e.g., Harvard, Stanford, or Duke) had better prospects than a black graduate from a less selective university (e.g., University of Massachusetts-Amherst, University of California-Riverside, and University of North Carolina-Greensboro), but had the same chances as a white graduate from a less selective university. Work harder for less indeed.
In another arena, policies – and individuals’ actions and inaction – are driving re-segregation in cities like Charlotte, North Carolina. This comes at a time when health researchers highlight the importance of place for health outcomes, shining a spotlight on processes of neighborhood and school segregation. Place-based health risk factors have a social history. They are the downstream effects of individual attitudes and behaviors that increase social distance from non-whites, abetted by institutional policies.
Employers discriminate against non-whites in one instance; residents flee non-whites in the other. Yet there are underlying factors shared by both. To the extent that these processes involve stereotypes, prejudice, and racial ideologies, social psychological research offers explanations for these phenomena. Studies of prejudice and racial ideologies have explained white opposition to school desegregation, affirmative action, welfare, neighborhood integration, and less punitive criminal justice policy.[7-12] They also suggest that prejudice could signal health risks for those who hold negative emotions directed at vulnerable groups. Presidential campaigns are not the only domains in which anger or resentment finds an outlet.
As researchers and clinicians seek preventions and interventions to improve population health and address health disparities, these studies beg a question: can public health responses help reduce discrimination by targeting the individuals and institutions responsible for preferring Kristen to Tanisha, for valuing a white felon as equally as a black or Latino applicant with a clean record, and for giving a black Harvard graduate the same job chances as a white graduate from a less selective university?
In her book, Why are All the Black Kids Sitting Together in the Cafeteria, Beverly Daniel Tatum quoted Wendell Berry, a white writer who asserted:
“If white people have suffered less obviously from racism than black people, they have nevertheless suffered greatly; the cost has been greater perhaps than we can yet know. If the white man has inflicted the wound of racism upon black men, the cost has been that he would receive the mirror image of that wound into himself. As the master, or as a member of the dominant race, he has felt little compulsion to acknowledge it or speak of it; the more painful it has grown the more deeply he has hidden it within himself. But the wound is there, and it is a profound disorder, as great a damage in his mind as it is in his society.”
Perhaps healing the wounds of historical and contemporary discrimination and racism among vulnerable populations requires that public health responses address the discriminatory individuals, institutions, and ideologies that inflict these health burdens on others. If Berry is correct, health interventions tackling the dominant group’s “profound disorder” may ultimately reduce the damage done to society and the health of its vulnerable populations.
“The most fruitful orientation at a time like our own, when racism is generally condemned in principle, is a clinical one. It is legitimate to assume, at the beginning of the twenty-first century—as it might not have been at the beginning of the twentieth—that racism is an evil analogous to a deadly disease. But the responsibility … is not to moralize and condemn but to understand this malignancy so that it can be more effectively treated, just as a medical researcher studying cancer does not moralize about it but searches for knowledge that might point the way to a cure.”
— George M. Fredrickson, Racism: A Short History 
1 (a). Lewis TT, Cogburn CD, Williams DR. Self-Reported Experiences of Discrimination and Health: Scientific Advances, Ongoing Controversies, and Emerging Issues. Annual Review of Clinical Psychology. 2015;11:407-440.
2 (b). Hudson DL, Neighbors HW, Geronimus AT, Jackson JS. Racial Discrimination, John Henryism, and Depression Among African Americans. Journal of Black Psychology. 2016; 42(3): 221-243.
3. Bertrand M, Mullainathan S. Are Emily and Greg More Employable Than Lakisha and Jamal? A Field Experiment on Labor Market Discrimination. American Economic Review. 2004;94(4):991-1013.
4. Pager D. The Mark of a Criminal Record. American Journal of Sociology.2003;108(5):937-975.
5. Pager D, Western B, Bonikowski B. Discrimination in a Low-Wage Labor Market: A Field Experiment. American Sociological Review. October 1, 2009 2009;74(5):777-799.
6 (c). Gaddis SM. Discrimination in the Credential Society: An Audit Study of Race and College Selectivity in the Labor Market. Social Forces. 2015;93(4):1451-1479.
7. Charles CZ. Won’t You Be My Neighbor? Class, Race, and Residence in Los Angeles. New York: Russell Sage Foundation; 2006.
8 (d). Bobo LD, Johnson D. A Taste for Punishment: Black and White Americans’ Views on the Death Penalty and the War on Drugs. Du Bois Review: Social Science Research on Race. 2004;1(01):151-180.
9 (d). Bobo L. Whites’ Opposition to Busing: Symbolic Racism or Realistic Group Conflict? Journal of Personality and Social Psychology. 1983;45:1196-1210.
10. Gilens M. Racial Attitudes and Opposition to Welfare. The Journal of Politics.1995;57(4):994-1014.
11. Matsueda RL, Drakulich K. Perceptions of Criminal Injustice, Symbolic Racism, and Racial Politics. The ANNALS of the American Academy of Political and Social Science.2009;623(1):163-178.
12 (d). Bobo LD. Race and Beliefs about Affirmative Action: Assessing the Effects of Interests, Group Threat, Ideology, and Racism. In: Sears DO, Sidanius J, Bobo L, eds. Racialized Politics: The Debate about Racism in America. Chicago: University of Chicago Press; 2000:137-164.
13. Samson FL. Racial Resentment and Smoking. Social Science & Medicine. 2015;126:164-168.
14. Tatum BD. “Why are all the Black kids sitting together in the cafeteria?” and other conversations about race. 1st ed. ed. New York: Basic Books
15. Fredrickson GM. Racism: A Short History. Princeton, NJ: Princeton University Press; 2002:158.
(a) Tené T. Lewis is a National Advisory Committee member of the Robert Wood Johnson Foundation’s Health & Society Scholars program. Courtney D. Cogburn is a former Robert Wood Johnson Foundation Health & Society Scholar. David R. Williams is a former National Advisory Committee member of the Robert Wood Johnson Foundation’s Investigator Awards in Health Policy Research and has worked with the Robert Wood Johnson Foundation in numerous other capacities.
(b) Darrell L. Hudson is a Robert Wood Johnson Foundation New Connections Junior Investigator.
Harold W. Neighbors is a former recipient of the Robert Wood Johnson Foundation Investigator Award and other RWJF funded research. Arline T. Geronimus is a former recipient of the Robert Wood Johnson Foundation Investigator Award in Health Policy Research. James S. Jackson is a former recipient of the Robert Wood Johnson Foundation Investigator Award and was co-chair of the Robert Wood Johnson Foundation New Connections Seventh Annual Symposium.
(c) S. Michael Gaddis is a former Robert Wood Johnson Foundation Scholar in Health Policy Research.
(d) Lawrence D. Bobo is a former National Advisory Committee member of the Robert Wood Johnson Foundation’s Scholar in Health Policy Research program.
Frank L. Samson, PhD, is an Assistant Professor in the Department of Sociology at the University of Miami.
Fair and Affordable Housing = Health Equity
My research in housing and health is about social justice and health equity. Through my research, I have learned that low-income housing alternatives to the typically concentrated poverty environments of public housing can have positive health benefits (fig. 1). This work, like other studies, shows that residents using federal housing vouchers have lower rates of diabetes, severe obesity, and cardiovascular disease. However, using housing vouchers to move residents out of their neighborhoods is not, by itself, a sufficient, sustainable, or desirable solution to concentrated poverty neighborhoods. Instead, increasing the availability of healthy resources and quality health care in all neighborhoods is an important part of any commitment to health equity.
My interest in housing policy as a means to address racial health disparities developed over time, but it started with my early work examining how racism influences health. In my dissertation, I examined the metabolic effects of internalizingracist stereotypes, an aspect of a larger racism construct where little research had been conducted. It was an uncommon dissertation topic, to say the least, but I was very interested in the work. It was at a time when the social determinants of health were starting to gain traction, but the seminal Institute of Medicine report had only recently been released. Building a career on the social determinants of health seemed like a difficult road, particularly since we had entered a period where Congress would not increase the budget for NIH, and funding studies on social determinants of health were few and far between. As a result, I embarked on a three-year post-doc that focused on the measurement of body composition and obesity. But in order to understand the racial and ethnic disparities that exist at this micro-level of measurement, I needed to look further upstream. I longed for the work I had been doing on racism, social conditions, and health. I needed to get back to public health, and ask the research questions that I thought address racial and ethnic disparities in health outcomes. I wanted to advocate for causes that were important to me, and to make my work about social justice.
That opportunity arose in 2006, when I was funded under the first New Connections grant cycle. In this work, I showed that the intersection of the housing environment and neighborhood were important to determining the risk of obesity. The grant enabled me to extend my research beyond the individual and into their neighborhoods. At the time I received my New Connections award, I was finishing my post-doc training, and took the grant with me to my new faculty position in the Department of Family and Social Medicine(DFSM) at the Albert Einstein College of Medicine. DFSM has a long history of delivering health care with a social justice mission. With their support, I became more familiar with the physical and social environments that influence access to health resources for people of color. It became clear to me that in order to understand the persistence of racial and ethnic disparities in health outcomes, I had to start at the beginning of the narrative of how people ultimately end up in certain neighborhoods and how policies shaped those neighborhoods.
Residential segregation by race has a long history in the United States. Racial discrimination in housing was at the forefront of the civil rights movement in the 1960s. It predicates racial and economic residential segregation and perpetuates generational poverty undermining upward mobility for Blacks. Racial discrimination in housingcontinues today (fig. 2). It remains a civil rights, social justice, and ultimately a heath equity issue.
More recently, the #BlackLivesMatter movement has reinforced my commitment to naming racism as a cause of racial health disparities, and to resist systems that enforce social injustice. I believe addressing housing discrimination and racial residential segregation is a way to close racial disparities in health outcomes that disproportionately burden Black residents. We should continue to measure these disparities and identify the role that policies play in perpetuating them. In addition, we should advocate for increasing federal funding for housing options for our low-income residents, as well as support redevelopment and zoning policies that allow low-income residents to remain in place, and not become displaced or priced out of their neighborhoods by urban renewal and gentrification. Lastly, we should be open to housing equity solutions that directly address the generational disenfranchisement of Blacks in America.
Earle Chambers, PhD, MPH is an Associate Professor in the Department of Family and Social Medicine at the Albert Einstein College of Medicine.
Photos by Jonathan Giftos, MD, primary care doctor, photographer, and activist
A City in Turmoil, A Nation in Disbelief: The Flint Water Crisis
“My people perish from a lack of knowledge” –Hosea 4:6
Flint, Michigan is a place where many individuals once achieved their American dreams. General Motors was everywhere, and 70,000 men and women went to work at its plant and offices every day. Folks could live in big houses, enjoy leisure at golf courses, and drive big cars. In fact, during the mid-1960s (1964-65), Flint had the highest per-capita income in America.
But today, Flint is a mere shell of its former glory. What remains are abandoned houses, lots infested with weeds, and warehouses lying vacant. It’s a city with high unemployment rates, and where greater than 50% of the children live in poverty. Perhaps not surprisingly, in less than 50 years, the population of Flint has dropped from 200,00 to less than 100,000.
Amid these devastating statistics, there has emerged another crisis in Flint: residents being poisoned by the one commodity that is so precious to life – water. As has been well-documented over the past months, a major challenge now facing the Flint community is to identify which individuals – many of whom are children, pregnant women, and the elderly – are at the highest risk of lead contamination-related health problems, and determine how to identify and treat the outcomes of lead exposure. This is critical, because even after lead exposure ceases, the effects can last for years – or even become permanent.
Cities and states across the U.S. have had a long experience with lead contamination. For instance, the Centers for Disease Control (CDC) has reported increased lead levels in the drinking water in other Michigan cities. And more recently, similar concerns of potential lead toxicity have surfaced in North Carolina and Maine. In all of these cases, the problems of lead contamination could have been foreseen, but water treatment decisions were being made based on cost and feasibility, and environmental regulations were being ignored. This makes the problems of water safety in Flint even more infuriating, says Rebecca Meuninck of the Michigan Network for Children’s Environmental Health. She has called it, “A real public health crisis with a real-life impact.”
And the “real-life impact” is significant. Clinical researchers have acknowledged the devastating long-term effects of lead exposure in childhood. Lead exposure causes deficits in intellectual functioning, academic performance, critical thinking skills, and motor-skills, along with decreased brain volume in adulthood. Researchers also have begun to explore links between childhood lead exposure and various risky behaviors in adulthood, including criminal activity, substance use, and even HIV-AIDS. Because there are no known ways to reverse the harmful effects of lead toxicity, many pediatricians, such as Dr. Mona Hanna-Attisha of Hurley Medical Center in Flint, emphasize prevention strategies and minimizing or eliminating environmental exposure.
We also cannot ignore the presence of racial and socioeconomic disparities in this public health crisis. According to the CDC and other health organizations, minority children and children in low-income families experience higher average blood lead levels. This is likely due to differences in living conditions, housing, and nutrition. Because calcium decreases lead absorption in the body, malnourished children face a greater burden of disease.
Presently, I am working with a group of researchers from the University of Michigan Flint, and a number of clergy, as we develop community based participatory research initiatives targeting parents, school officials, and residents of Flint in an effort to identify any abnormal behaviors, or signs of lead toxicity/contamination within young children. I am also working with Dr. Vicki Johnson-Lawrence, a Social Epidemiologist at UM-Flint, to develop a research model identifying life course issues of comorbidity (diabetes, stress, cancer, cardiovascular disease) as they relate to long-term health disparities. The Department of Public Health & Health Sciences at UM-Flint also has held seminars, and produced infomercials, to enhance public awareness of the specific effects of lead toxicity.
So the problem has been identified. But what’s next? To start, we need communities, public health officials, medical organizations, and the CDC to galvanize efforts to educate and develop behavioral interventions. Our elected officials also have to provide the necessary resources to help devise a solution that will provide hope and a brighter future. And residents need assurances that their water will be safe to drink, their streets will be safe to walk again, and their children will be safe and healthy. So let’s come together for the many thousands here in Flint, and other cities as well, and give the children a brighter hope for tomorrow.
Terry L. Thompson, DHA, is an Assistant Professor, Public Health and Health Sciences, University of Michigan-Flint. His research interests lie in the area of men’s health, specifically men suffering from Type 2 Diabetes.