Editor’s Note: This – the final installment of the Kellogg Foundation-sponsored 11-part Series on Race in America – Past and Present – is a compilation of three articles joined together on the topics of health, health care and life spans of Americans and how they intersect with race and class.
Imagine you got to choose whether to be born Black or born White in America. Here are a few health statistics that might inform your decision:
If you chose to be born White, your chances of dying of Parkinson’s disease would be twice as likely as if you chose to be Black. Your chances of dying from cirrhosis of the liver or Alzheimer’s disease would be 25 percent higher. As a White person, you’d also be two and a half times more likely to commit suicide.
By contrast, consider the pros and cons of choosing to be born Black, based on life tables alone. To be sure, opting to be Black would reduce your chances of dying from diseases caused by risk factors that rise with age. But it would also severely reduce your chances of living to even your first birthday, let alone growing old enough to retire.
This would be particularly true if you chose to be Black and male.
To start with, your chances of dying before your first birthday would be roughly 2.3 times greater than if you were born White. If you managed to make it to age one as a Black male child, your chances of dying before your 5th birthday would be 80 percent greater. If you survived to age 15, you’d have a 60 percent greater chance of dying within the next 10 years. If despite these elevated risks of premature death you nonetheless managed to get to your 45th birthday, you’d still be 80 percent less likely to live long enough to collect Social Security than if you had chosen to be White.
The vast disparities in health and longevity that exist between the races in the United States violate a fundamental idea of justice that we all carry with us at least to some degree. It is the idea of justice as fairness, of what kind of world we would choose to live in if, as the philosopher John Rawls framed it, we were all impartially situated as equals before being born and did not know what our station in this life would be. A society that resists ending the preventable causes.
Meanwhile, the health status of Both Blacks and Whites improves dramatically with higher income while the gap between them remains small. Among Blacks and Whites living at just four times the poverty rate, for example, the percent who report poor or fair health drops to 8 percent and 6 percent respectively. Your race per se, in other words, plays little role in predicting your health compared to your income.
The gap in health status may also reflect the fact that among families with similar levels of income, as well as educational attainment, Blacks are more likely than whites to live in neighborhoods with higher concentrations of crime, poverty, pollution, liquor stores, “junk food” outlets, and inferior health care. Conscious or unconscious bias among health care providers may also be at work in explaining the racial health gap, though your chances of receiving substandard health care in the United States vary far more according to where you live than according to the color of your skin.
That poverty is deadly is not hard to understand, at least at the extreme. To be very poor means not having enough to eat, being exposed to the elements, and living in areas where homicide and addiction are leading causes of death or where your access to appropriate health care is minimal or nonexistent. In addition, both historically and today, getting seriously sick is likely to make you seriously poor even if you weren’t before.
One way researchers have tried to explain correlations between health and social rank is to posit that the losers in our society have become losers because they have poor health. This is no doubt true in some cases. Clearly, if you’re in the hospital for months following a car crash, lose the ability to walk, and go through life thereafter with hideous facial scars, it is bound to negatively affect your career prospects. The same would be true if you were born already addicted to narcotics or positive for HIV.
But to conclude in this instance that your lack of upward mobility is because of your poor health is to beg the question of why you have developed these afflictions in the first place. Maybe you would drink in any event. Maybe you’d describe life as stressful regardless. But would you drink as much, and feel so bad about it in the morning, if you also felt (like that famous, highly effective, long-lived alcoholic Winston Churchill) that you were in command and getting important stuff done?
In an intriguing study at Emory University, researchers found, for example, that black men who reported being victims of racial discrimination experienced an increased risk of heart disease. But a much greater risk of heart disease was found among African-American men who agreed with negative statements about Blacks. Indeed, the highest rates of heart disease were found among African-American men who said they were not personally victims of racial discrimination but still viewed their own race as inferior. Put another way, being or believing yourself to be the victim of racial discrimination is not good for your health, but what’s really bad is to absorb a social belief system that says you are at the bottom.
To Live Longer, Move to a New Zip Code
Michelle Obama’s “Let’s Move” campaign emphasizes the importance of physical activity for combating obesity, a point she has driven home by dancing alongside school kids to Beyoncé’s workout video. But another kind of movement may also be important to your chances of living to a ripe old age: moving to a new zip code.
Between 1994 and 1998, the U.S. Department of Housing and Urban Development conducted a demonstration project known as “Moving to Opportunity.” The project randomly assigned low-income families to one of three groups. Those in the first group received a voucher that they could use to help pay the rent on an apartment, provided that the apartment was not in a low-income neighborhood. Those in the second group received a voucher they could use in any neighborhood, while those in a control group received no voucher.
In 2011, HUD researchers published the results in the New England Journal of Medicine. The most dramatic finding was that people assigned to the different groups varied significantly in their weight by the end of the experiment. Going into the program, participants as a whole had been substantially more obese than the U.S. population as a whole. But 10 to 15 years later, those women who had moved to more affluent neighborhoods were one-fifth less likely to be obese than those in the control group, and also one-fifth less likely to have contracted diabetes.
This was true even though there was little difference among all the participants in the numbers who managed to move off welfare, improve their education, or find a better job. This suggests to researchers how powerfully our surroundings alone are to determining our habits and health. Though it might seem strange to say that obesity is contagious, for example, it does seem that people’s risk of it is affected by the weight of their neighbors, as well as by such environmental factors as whether most of the food for sale in their environs is junk food, as is often the case in America’s most impoverished neighborhoods.
In 2007, the Journal of General Internal Medicine published the results of a study of residents at four academic medical centers. Participants were asked to review the medical record of an imaginary patient complaining of chest pain. For half the participants, the record included a picture of a middle-aged Black man; for the rest, a middle-aged White man. Participants were asked to rate on a scale of 1 to 5 whether they thought the patient suffered from coronary artery disease, and, if so, whether they believed that the patient should receive a drug treatment known as thrombolysis.
The study found that participants who scored high for anti-black bias on the Implicit Association Tests were less likely to recommend thrombolysis when the Black man’s picture, rather than the White man’s, was included in the medical record, presumably because they believed the Black man would be a less cooperative patient or perhaps less able to pay. The study’s authors concluded that the “[r]esults suggest that physicians’ unconscious biases may contribute to racial/ethnic disparities in use of medical procedures such as thrombolysis.”
While few now dispute that some doctors may consciously or unconsciously treat patients of color differently, both the nature of that bias and its importance in explaining racial disparities in health care are highly disputed. For example, in focus groups organized by researchers to assess the role of race in medical practice, Black doctors were far more likely than White doctors to say that a patient’s race is a medically relevant factor in determining the best treatment.
As one Black physician in a Philadelphia focus group put it, “I think being an African-American is a risk factor in and of itself. And, I think that when you see an African-American then you need to often be more aggressive than you would, and use different standards than you would for the general White population.”
But perhaps in this way the White doctors were showing insensitivity to racial realities that Black doctors know better and that are indeed medically relevant. As the organizers of the focus groups concluded, since African-Americans as a whole are far more likely than Whites to suffer from hypertension and diabetes, it may be appropriate for doctors to take into account at least some population-based probabilities of disease when deciding protocols of treatment to follow. Color-blind medicine isn’t necessarily the best medicine.
Phillip Longman is senior editor of the Washington Monthly. This article, the 11th of an 11-part series on race, is sponsored by the W. K. Kellogg Foundation and was originally published by the Washington Monthly Magazine.