In medical school, class is scheduled for approximately 30 hours a week. This includes lectures on basic life sciences, histology, anatomy, and clinical examination skills. In addition, my first semester included approximately three hours of classroom time a month devoted to a supplemental curriculum called Health Systems and Policy, which covers the legal aspects of health care, public policy, and, briefly, health disparities. Now, in my second semester, these efforts have been largely abolished. There is no longer official time allotted for the consideration of sociopolitical issues surrounding the science that our medical training is based on. With so few hours devoted to the social implications of medical practice, I’ve begun to question whether MDs graduate prepared to engage with public health considerations.
Even within these brief sessions on health policy, we discuss only the state of health care inequality, without delving into reasons why these disparities continue to exist. Yet, the “what” and the “why” are equally important. Medical students need to confront the greater sociopolitical context within which health care and medicine exist, because we aim to work within an overarching structure that continues to marginalize certain populations and identities. While the politics of unequal care and treatment is something all citizens should ponder, it is particularly important for practicing physicians to consider and care about health care inequity in a deeper way. Fighting health inequity cannot be divorced from our responsibility as health care providers; we cannot be doctors from 9 to 5, and citizens only once we have left the hospital.
Systems, in addition to people, are responsible for creating health care disparities between white people and people of color. Racism is a massive driver of “health inequity,” a concept defined by the World Health Organization as the consequence of the unequal distribution of socioeconomic, political, and environmental resources required for health.
Race is such a powerful organizing category when it comes to health inequality because of the geographical segregation that occurs based on race. In his 2009 study, sociologist Dr. Clarence Gravlee showed that even when data is controlled for income, neighborhood segregation based on race has been tied to deprivation of resources and a host of conditions correlated with low birth weight, obesity, cardiovascular disease, and lower life expectancy. Understanding health inequity begins with understanding state-sponsored segregation and how its legacy continues to disproportionately affect the health of populations of color.
“Racism is in the past.”
In the 1930s, New Deal era housing policies, such as those implemented by the Federal Housing Administration (FHA), sought to make home ownership more accessible. Unfortunately, this policy was unequally distributed across racial groups. In the two decades after the implementation of this policy, the FHA financed 60 percent of American homes, yet less than two percent of its loans went to people of color. The practice of “red lining” — in which the FHA literally drew red lines around black neighborhoods on maps, marking them as high-risk areas for mortgage default — denied black families the same financial assistance as that given white families, and confined them to certain geographic locations. Such examples of government-sponsored segregation provide the foundation for health inequalities that continue to exist today.
In the 1950s, hate crimes against blacks — arson, vandalism, property destruction, lynching — were used as a tactic to frighten away black families wanting 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 and property values. For example, in the 1970s, realtors hired black women to stroll around white neighborhoods in an attempt to scare white families into moving out of neighborhoods quickly and selling their homes at low prices, according to an article published in The Atlantic in 2014. These properties were then sold for outrageously inflated prices to black families who had few options due to discriminatory policies that barred their access to other communities.
These practices set the stage for the mobilization of “white flight” to suburban neighborhoods — a movement inaccessible to black families that were left in crumbling, poorly-resourced urban neighborhoods. The resulting problems included faraway health screening centers, few grocery stores, hazardous pollutants, reduced health literacy, diminished financial means, and general lack of access to health resources.
Your local hospital
In Chicago, while white breast cancer mortality has halved in the last few years, largely as a result of greater mammography detection, black breast cancer mortality has remained static. In this one city, more than 100 black women die from breast cancer every year because they don’t have access to the same medical resources that their white counterparts do. That’s almost two black women — mothers, daughters, wives — dying unnecessarily every week.
The correlation between lower breast cancer mortality and the development of contemporary screening protocols shows that these disparities are due to social differences rather than biological causes. Poor neighborhoods of color have fewer breast cancer screening centers, and the ones they do have are often older, of lower quality, and operated by fewer mammography specialists. Moreover, individuals on Medicaid are often forced to travel longer distances to public hospitals to obtain mammograms. Segregation creates barriers to social mobility as well as access to public and private resources, all of which continue to impact factors such as unemployment, education, and medical access.
Take deep breaths
In 1945, the Altgeld Gardens neighborhood in Chicago was built to provide housing for black WWII veterans. Now, in 2015, the site is referred to as a “toxic donut” due to the incredibly high concentration of surrounding hazardous plants. The housing site holds 90 percent of the city’s landfills, which includes more than 50 hazardous landfills and 250 chemical waste dumps that leak toxins into the region. These examples of Locally Unwanted Land Use (LULU) have resulted in significant increases in cancer risk, miscarriage, neonatal disorders, asthma, and other medical concerns. The concentration of toxic landfills — and thus exposure to health risk in this neighborhood — is not random. City officials and governance dictate the construction and placement of these hazardous sites, and it is in the execution of these decisions that the value of certain lives is explicitly and implicitly conveyed. More than 60 percent of Altgeld’s residents are below the poverty line, and 90 percent of them identify as African American. Despite incredibly high rates of cancer and lung disease linked to this industrial pollution, however, there has been little progress or government attention.
Altgeld is not the exception, but the rule. Shockingly, race, even more so than socioeconomic class, is the best predictor of the location of toxic waste sites. People of color are continually closer to environmental hazards that seriously impact health. The lack of progress and effort devoted to remedying these injustices, despite clear evidence of inequality, demonstrates again the intersection of sociopolitical marginalization and illness.
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 clear, children of color are not inherently more susceptible to afflictions such as asthma; they are, however, more likely to live in neighborhoods with greater exposure to and concentration of unhealthy triggers. It’s not rare for medical students to learn about about disparate rates of asthma prevalence and severity among minority populations, yet it is rare that we take the time to examine how the history and continued presence of racism in our country creates these conditions. Without this, we receive only a fraction of the picture. As aspiring physicians, it’s foolish to focus all our energies and educational attention on combatting the aftereffects of inequality, while ignoring their causes.
Eat your vegetables
Access to fresh food resources is directly correlated to healthier eating. Research by Policy Link in collaboration with The Food Trust found that the addition of one supermarket in a census tract correlates with a 32 percent increase in produce consumption in African American populations. In 2009, the U.S. Department of Agriculture found that only eight percent of black families (compared to 31 percent of whites) live in a census tract with a supermarket containing fresh food. In Detroit, supermarkets were on average 1.1 miles further away from impoverished black neighborhoods than similarly impoverished white neighborhoods. A quarter of these black households did not own a car.
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 history of racial segregation in the U.S. Food is undoubtedly related to health, considering four of the top 10 causes of death hold poor diet as a major risk factor. If one cannot afford or access nutritious food, the risk of obesity, malnutrition, hypertension, and other medical conditions increase dramatically.
Health care isn’t free
When you compound historical oppression with contemporary oppression, the continued limitation of social mobility and its relationship to poor health becomes increasingly apparent. According to the National Association of Home Builders, primary residence property accounts for nearly 50 percent of the median homeowner’s wealth. Discriminatory policies from the New Deal era that prevented home ownership contribute directly to the dramatic gap between black and white financial resources. While recent statistics show the median black-white income gap itself is large — $59,754 for whites compared to $35,416 for blacks—the median wealth gap is startling; the average wealth is $113,149 for whites, and $5,677 for blacks. Racist government housing policies, which prevented black families from obtaining home ownership and accumulating family assets accessible to white families, help account for this disparity.
In medical school, we spend weeks learning the etiology and pathophysiological mechanisms behind breast cancer and cancer biology. Our medical curriculum consistently elevates the scientific method as the beginning and end of our training, when medical practice does not begin or end with science. While there is no doubt that this information is important to the study of medicine, information about social history, patient experience, and differential access is equally important to our careers. Bigger issues — questions on civil rights, public health, dignity, and violence — are central to our understanding of health care, and thereby our efforts and practice as aspiring physicians. It seems less than sufficient to quote the pharmaceutical mechanisms of asthma medication in a time when our patients walk through the streets chanting “I can’t breathe.”
Illness is devastating. It is an ever-looming specter that threatens to rob us of our lives and those of our loved ones. Doctors seek to eliminate the products of illness, and as such, need to think more about the production of illness. The repercussions of racism cannot continue to be isolated into silos of political consideration, or in three hours of “systems and policy” overview each month. The color of one’s skin cannot continue to dictate one’s proximity to sickness, and it is an important part of the solution for aspiring physicians to pay attention to how racial inequalities — past and present — continue to create health care inequity. A myopic focus on health only within the doctor’s office misses half of the equation. We cannot limit our scope of health care only to ideas of medical intervention.
At the end of the day, considerations of structural racism and segregation indicate why prescriptions for fresh produce are more important for combatting obesity than FDA-approved pharmaceuticals, why sending children home with inhalers will not address the cause of their asthma; why tropes of patient laziness as an explanation for poor adherence is harmful; and why systemic racism is definitively a public health concern. Information like this helps not only to bolster our medical understanding of foundations of health inequity, but convince us why caring about these issues is crucial to our professional development. Social medicine is crucial not only to our understanding of national politics and the state, but also our fundamental ability to do our job well.
Jennifer Tsai is a medical student.