Your access to walkable spaces, the fresh food options you have and ultimately your life expectancy will largely be determined by where you live, but to understand why and to improve people’s lives, you have to go beyond geography.
That’s the message that Dr. Valerie Montgomery Rice, the dean of Atlanta’s Morehouse School of Medicine and a Harvard University-trained physician, conveyed to faculty, staff and students at UC Davis Health in a Facebook forum marking October as Global Diversity Month.
“We’ve figured out that just going into a community and telling people what they should be doing is not enough to expect that people are going to respond and change their lifestyle,” Montgomery Rice said. “We needed policies that would lead to sustainability, particularly in those areas where we had the lowest life expectancy and that were influenced by psychological barriers.”
She joined Gary May, the chancellor of the University of California, Davis, and Allison Brashear, the dean of the UCD College of Medicine, for a presentation laid right at the intersection of social justice and health equity. The talk came as the new coronavirus continues to kill disproportionately high numbers of Latinos, African Americans and Pacific Islanders.
Discussions like this one are crucial, Brashear said, because the COVID-19 pandemic and systemic social injustice “has made it very clear that we need to do more to ensure that everyone in our community has access to high-quality and culturally sensitive health care that they need and deserve.”
May said the conversation was particularly meaningful to him because his mother was among the first group of African-American students to integrate the University of Missouri back in the 1950s during Jim Crow.
“People think that stuff was so long ago, but for me and for many, that was just one generation ago,” he said. “Then, if you fast-forward, when I finished graduate school in 1991 at UC Berkeley, that year, I was one of only 30 African Americans to earn a Ph.D. in engineering. That was 30 in the entire United States. You could have fit us all in one classroom.”
Montgomery Rice also used a personal illustration to bring home the impact of social inequities. In her Facebook presentation, she showed a map of her hometown, Macon, Ga., showing neighborhoods where African Americans were systematically denied services and home-buying opportunities for more than a century after slavery was abolished. Then Montgomery Rice presented a map she’d marked up with a Sharpie showing neighborhoods that still struggle today in Macon versus those that are wealthy.
That city’s highest-income communities remain in areas where African Americans had long been excluded, Montgomery Rice’s map showed, and there remains a redlining of opportunities for outdoor exercise, pre-kindergarten education, access to fresh fruits and vegetables in ZIP codes outside those areas of affluence.
It’s the same pattern identified by researchers in an exhaustive 2006 study of thousands of US counties, noted Montgomery Rice, in which Harvard-based researchers identified eight Americas and the socioeconomic and cultural factors that produced disparate health outcomes.
These so-called social determinants of health shape everything from people’s relationship to exercise and food to how many encounters they’ll have with law enforcement, researchers have found.
Where you grow up will determine your answers to questions like: Were you reared in a place where you could safely ride a bike or walk to a park? Historically, what kind of food did your family eat and what recipes were passed from generation to generation? What kind of preschool education did you receive? How did you access health care?
The origin of some social determinants date back centuries, Montgomery Rice noted in an interview with The Bee. Slavery, for instance, has had a longstanding impact on the nutritional health of African Americans. As enslaved people, they were given proteins and foods considered undesirable, she said, and when slavery ended, many lived on subsistence wages that limited food choices to what was cheapest.
“You saw the beginnings of malnutrition and then poor nutrition that led to diseases like diabetes and hypertension,” she said. “Combining that with (health care) access challenges, those diseases could not be managed appropriately. So, these disparities definitely started early on, and they have sprawled over the years. I believe they are longstanding and systemic.”
To counter these intractable challenges, the Harvard-led Eight Americas researchers urged government and public health leaders to take these steps:
- Identify cost-effective interventions that will reduce the factors that put people at greater risk of chronic diseases such as obesity, diabetes and hypertension. While some interventions may work across all groups, some may need to be specifically tailored.
- Put in place systems to monitor benchmarks for local populations who would benefit from those interventions.
- Publicly report to each community the interventions that are being taken, along with metrics that show the progress.
“We have to ask ourselves what can we do to influence policy,” Montgomery Rice said. “At the end of the day, sustainability of interventions only is realized through policy, so lots of people have had great intentions about how to address housing challenges or transportation challenges or even redlining, right? Many communities have dealt with that. But unless you wrap a policy around it that actually continues to monitor the protection that is afforded to those areas, then you will never see the opportunity for achieving equity and then that, of course, will inform health equity.”
As a Washington Post article recently noted, Montgomery Rice said, African Americans pay 13 percent more, on average, in property taxes than White neighbors in similarly priced homes, yet their neighborhoods often receive less investment in parks and other infrastructure that would benefit their health. Residents should ask public officials to provide data on property tax burdens, Montgomery Rice said, and how spending is apportioned.
What people often fail to see, Montgomery Rice added, is that the recent protests over social injustices are actually directly linked to statistics on longevity and poor health outcomes.
To address this, the Eight Americas researchers recommended that policymakers act to reduce socioeconomic inequalities. One way to do this, Montgomery Rice said during The Bee interview, would be to expand access to preschool education.
Controlled experiments at the Perry Preschool Project in Ypsilanti, Mich., in the 1960s, and the Carolina Abcedarian Project in the 1970s randomly assigned African American children to a preschool program or to a control group that didn’t go to preschool.
After decades of following those children, researchers reported significantly higher education, income, home ownership levels and markedly less involvement with the criminal justice system among those who attended preschool compared with the control group.
The Harvard researchers also recommended that civic leaders remove physical, behavioral and cultural barriers to care and make health insurance and health care more affordable.
It takes courage, Montgomery Rice said, to remove those barriers, those fences that keep certain groups in society from access to services that can improve their lives and ultimately the overall wellbeing of all Americans.
“You have to recognize that the fence actually exists, and most of the time, it’s unintentional,” Montgomery Rice said. “It is about educating ourselves, accepting the fact that we have unconscious biases, because once we recognize that they exist, then we can work on what the solution would be to move that fence because most of the time, it is unconsciously holding us back from helping you to reach your full opportunity.”