The Sick Side of Town

Introduction

Introduction

A major misconception about health disparities is that they are a product of inherent differences between groups rather than a function of the unequal distribution of rights and privileges across populations. Poor health outcomes are a result of the myriad ways social and political systems are designed to marginalize certain groups by intersections of race, class, gender, or other social attributes. Neighborhoods manifest the differential outcomes of these systems in the quality of their streets and housing, exposure to toxic pollutants, and the presence of protective social networks among other social and physical characteristics, all of which impact health. Understanding how social and political systems perpetuate social inequality, and how social inequities determine disparities, will help inform effective structural solutions to close the gaps. 

About the Haas Institute for a Fair and Inclusive Society

THE HAAS INSTITUTE for a Fair and Inclusive Society at UC Berkeley brings together researchers, community stakeholders, policymakers, and communicators to identify and challenge the barriers to an inclusive, just, and sustainable society and create transformative change. The Haas Institute advances research and policy related to marginalized people while essentially touching all who benefit from a truly diverse, fair, and inclusive society.

At the heart of the Haas Institute are seven clusters of teaching and research that focus on addressing society’s most pressing and pivotal issues related to vulnerable and marginalized populations. Together, the Haas Institute and the research clusters advance research and policy that address game-changing issues that are emerging

Haas Institute Diversity and Health Disparities faculty cluster

The findings in this report synthesize recent research from faculty working in the Haas Institute Diversity and Health Disparities research cluster, whose members are drawn from different disciplines across UC Berkeley. The Diversity and Health Disparities cluster addresses health inequities among racial/ ethnic minorities and other vulnerable populations through research, teaching, and policy activity on deeply rooted social inequalities within our society that result in disproportionate rates of illness and death in marginalized groups. These social inequalities include persistent poverty; unequal access to decent jobs, and quality education and housing; political disfranchisement; racial discrimination; and toxic living and working environments. The cluster focuses on two primary interest areas: (1) neighborhoods and the social economy of health disparities; and (2) health, human rights, and social inequality.

Why bring together neighborhoods, health disparities, and human rights?

A major misconception about health disparities is that health disparities are a product of inherent differences between groups rather than a function of the unequal distribution of rights and privileges across populations. Racial minorities aren’t likely to be sicker or have worse health outcomes because of biological differences. Rather, poor health outcomes are a result of the myriad ways social and political systems are designed to marginalize certain groups by intersections of race, class, gender or other social attributes. Neighborhoods manifest the differential outcomes of these systems in the quality of their streets and housing, exposure to toxic pollutants, and the presence of protective social networks among other social and physical characteristics, all of which impact health. Understanding: 1) how social and political systems perpetuate social inequality, and 2) how social inequalities and inequities determine disparities will help inform effective structural solutions to close the gaps.

How long we live is not solely determined by what we do or who we are; it is determined by where we live. And where we live is often determined by who we are.

Dr. Camara P. Jones, former president of the American Public Health Association, explains this phenomenon of structural inequality in her story, “A Gardener’s Tale”:1

A gardener has two flower boxes: one contains old, rocky soil and the other contains rich, fertile soil. The gardener has two packets of the same seeds in two colors, red and pink. Because the gardener prefers red over pink, the gardener plants the red seeds in the rich, fertile soil and plants the pink seeds in the old, rocky soil. The red flowers planted in the fertile soil flourish, while the pink flowers planted in the old soil are stunted and weak. Year after year, the same thing happens. Ten years later the gardener comes to survey her garden. Gazing at the two boxes, she says, “I was right to prefer red over pink! Look how vibrant and beautiful the red flowers look, and see how pitiful and scrawny the pink ones are.”

Jones’s allegory illustrates two ideas that are central to understanding the connection between place, race, and health.

First, unequal neighborhood conditions produce disparities in health outcomes. Bad neighborhoods are not the product of bad people, nor are some people intrinsically less healthy than others. Rather, some people live in places with health-supporting conditions like access to fresh food and taxation of tobacco products, and some do not. Manuel Pastor and UC Berkeley Professor and Diversity and Health Disparities cluster member Rachel Morello-Frosch argue, “These factors can be as critical to health outcomes as are access to medical insurance or health care, if not more so”.2 At a time when the United States spends 17.9 percent of the GDP on healthcare, it is critical for policymakers to shift the way policies are designed to reduce health disparities.3

Second, differences across neighborhoods are not naturally occurring. They are the product of federal, state, and local policies interacting with the actions of private markets. For example, the redlining maps created by the government-sponsored Home Owners’ Loan Corporation in the 1930s have had lasting effects on neighborhood disinvestment, residential segregation, and racial disparities in housing access and wealth accumulation4 —all of which affect health.5

Focusing research and policymaking on neighborhood conditions provides scholars, communities, and decision-makers the opportunity to understand and address the processes linking broader social and economic factors to health outcomes in very concrete ways.6

This policy brief reviews recent scholarship from members of the Diversity and Health Disparities cluster and offers important insights to meet the intertwined challenges of neighborhood inequalities and racial health disparities.

The brief first reviews how the inclusion of place in research about health disparities initiates a new dialogue about the basis for persistent racial/ethnic health disparities that departs from discriminatory ideas linking them to what are thought to be natural differences. Cluster members’ research findings show how neighborhood inequalities like safety and environmental exposures manifest in individual biology and physiology and how the distribution of diseases and poor health occur along lines that mirror other inequalities. This suggests that improving neighborhood conditions and building health equity can reduce disease and morbidity.

The brief next considers how residential segregation contributes to differences in neighborhood conditions and racial/ethnic health disparities. Greater segregation is connected to increased risk for extreme heat exposure, higher incidence of violence, and increased risk for hypertension. This research implies that housing policies and development decisions have a direct effect on health outcomes. Taken together, the research presented in this brief provides new ways the think about health disparities and their causes, consequences, and potential remedies.

What is a neighborhood?

Place and health literature relies on available data to analyze the relationship between the characteristics and features of a geographic area and health outcomes. These data are traditionally captured using geographic boundary indicators such as zip code and census tracts. Oftentimes, such measurements do not accurately reflect the lines that residents use to define their neighborhood or relevant policymaking boundaries such as congressional districts. This brief will use the term “neighborhood” to describe the organic area surrounding a particular place or group of people. The terms and definitions below represent the most frequently used measurements in place and health research to date.

Census tract

Region includes an average population of 4,000 residents. A “block-numbering area” is the equivalent in rural regions. Intended to demarcate relatively homogenous populations with regard to social and economic characteristics. Defined by the US Bureau of Census.1.1

Census block group

Region includes an average population of 1,000 residents. Block groups tend to be more homogenous, with regard to social and economic characteristics, than census tracts and can reveal hidden pockets of poverty and affluence. Defined by the US Bureau of Census.

Census block

Region includes an average population of 85 residents. Block data are less useful for health research because relatively little data are reported at this level. Defined by the US Bureau of Census.1.1

Commuting zone

Region is a geographical aggregation of counties similar to metropolitan areas, but covers the entire United States including rural areas. The population of a commuting zone is not defined; it may range from 1,200 to more than 16 million residents. 2.1

Zip code

Region includes a population of 30,000 or more residents. Zip codes are typically not homogenous in their sociodemographic characteristics. Defined by the United States Postal Service.1.1

Community-defined measure

Occasionally, research relies on study participants to define neighborhood boundaries. Participants in a 2012 study led by Nuru-Jeter and Richardson viewed the blocks on which they live as their neighborhood.3.1

  • 1. Jones, 2000
  • 2. Pastor & Morello-Frosch, 2014
  • 3. CMS, 2017
  • 5. Diez Roux et al., 2016
  • 6. Diez Roux et al., 2016
  • 1.1. a. b. c. Krieger et al., 1997;
  • 2.1. Chetty, et al., 2014
  • 3.1. Richardson & Nuru-Jeter, 2012