PHILADELPHIA—The goal that Lorraine Speaks has set for herself seems simple: Eat better. Barely 5 feet tall, the 58-year-old weighs 240 pounds. To lose weight, she knows she'll have to cut back on processed foods and the bags of miniature cookies that are her go-to snack.
Three weeks into a weight-loss program at the 11th Street Family Health Services here in North Philadelphia, instructor John Kirby helps Speaks focus. He suggests she aim for three servings of fruits and vegetables daily. It's a good goal, Speaks says, but do canned vegetables count? In the transitional housing facility where she lives, the kitchen is shared and fridge space is limited, so keeping fresh vegetables is difficult.
Preparing them is a challenge, too. "I want to eat squash and zucchini and all that," she tells Kirby. "But, I don't know how to cook it."
Statistically, as a black woman surrounded by poverty, Speaks is at a disadvantage. In the predominantly African-American and Hispanic neighborhoods of North Philadelphia, nearly two-fifths of all adults are obese, according to the city's Department of Public Health. That's more than twice the rate among people who live a few miles south, in Philadelphia's bustling city center, where most of the residents are white. Nationally, more than half of all black women are obese, compared with about a third of white women.
As the country grows in diversity and struggles to control medical costs, the greater burdens of health risks, disease, and premature death among people of color and the poor are a matter of increasing urgency. While the "biggest loser" program at 11th Street is aimed at changing people's eating and exercise habits, activists here and scholars around the country say that efforts focused on shifting individual behaviors probably won't be enough to change the broader patterns of inequities in health.
Some experts point to the need for transforming the traditional health care system, in which people of color are less likely to have insurance or to get decent medical care. This has been the Obama administration's main strategy in expanding insurance coverage under the Affordable Care Act.
But, people who study these disparities say the problem isn't just a matter of what happens in an individual's home or in the exam room but of what life is like in an entire neighborhood. Researchers emphasize social and economic factors, such as employment, education, and social networks—whether people have the resources to protect their health. In racially segregated neighborhoods such as this one, with its crumbling infrastructure and history of institutional neglect, the main obstacle to good health is poverty.
A growing number of programs across the country focus on rebuilding healthier neighborhoods—improving housing conditions, opening grocery stores, developing public transportation, and creating green space for play and exercise. All of these efforts are important, but they may do little, many scholars say, to close the gap on health unless they are part of a broader plan to mitigate the effects of poverty that includes improving early education, creating jobs, and building a stronger safety net for those in need.
"You can't solve racial and ethnic disparities if you don't deal with income differences," says Sherry Glied, dean of New York University's Robert F. Wagner Graduate School of Public Service. As the federal Health and Human Services Department's assistant secretary for planning and evaluation in 2010-12, she helped write the first national action plan on health disparities. "Poverty and poor education," Glied says, "are just terrible for people's health."
DEPTH OF DISPARITIES
Philadelphia is known as a city of "eds and meds," where world-class hospitals, pharmaceutical companies, and universities drive the economy. Last year, more students trained to be doctors in Pennsylvania than in any other state but New York. Yet in the neighborhoods that stretch north from the public-housing developments around the clinic at 11th and Parrish streets, this world of success is little in evidence.
In North Philadelphia, only about one-eighth of all adults have gone to college. The unemployment rate is three times the national average, and the rate of shooting deaths is among the highest in a violence-prone city. Compared with neighborhoods nearby, children are more likely to be uninsured, obese, or hospitalized for asthma. Men and women can expect to die as much as a decade earlier than Philadelphians in the city center.
The picture here is stark. But similar disparities play out across the country. Despite dramatic advances in medicine, the gaps related to many conditions have held steady and, in some cases, widened.
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Black children in 2008 were more than twice as likely to die before their first birthday as white and Hispanic children, according to the Centers for Disease Control and Prevention. Infant mortality is closely associated with a mother's health, socioeconomic status, and prenatal care. Hispanic infants who live in segregated urban centers, where the gap in mortality rates compared with infants in integrated neighborhoods may actually be getting worse, are at a disadvantage, too, according to an analysis by the Joint Center for Political and Economic Studies, a research group focused on improving socioeconomic status for people of color.
Repeated studies have shown that black children have the highest rates of asthma diagnoses and hospitalizations. While genes may play a role in causing asthma, inadequate medical care and exposure to environmental triggers—mold, cockroaches, polluted air—make things worse. Across all ages and races, Americans of color were more than twice as likely to die of asthma in 2009 than white people were, the American Lung Association reported in 2012. And as the overall mortality rate declined in the previous decade, that gap did not close.
Such inequities abound for other chronic conditions, particularly for black Americans. Their risk of dying before age 75 of coronary artery disease is 52 percent higher than for whites, by the CDC's count. The rate of premature death from stroke among African-Americans is more than twice that of whites. About 7 percent of white adults but more than 11 percent of black and Hispanic adults had diabetes in 2010. Compared with rates from 2006, the gap between white and black women was narrowing, but disparities were widening for all Hispanics, and especially for Hispanic women.
Interestingly, Hispanics in the United States tend to be healthier than their poorer circumstances would suggest. Researchers don't fully understand what they call the "Hispanic paradox." It may be that new immigrants bring with them healthy habits of diet and exercise. But as their children and grandchildren adopt a fast-food culture and collect in segregated neighborhoods where the medical care is subpar, these advantages ebb.
There are reasons to hope. As Americans' average life span lengthened by 11 percent between 1970 and 2010, to 78.7 years, a CDC report found that blacks were living 17 percent longer than before, to age 75.1. Still, a gap persists between blacks and whites, because of wide differences in rates of heart disease, cancer, and—for men—homicide.
The problem of racial and ethnic disparities in health, says Brian Smedley, director of the Joint Center's Health Policy Institute, "literally cuts across the life cycle from birth to death."
A PERSONAL STRUGGLE
Speaks wants to lose weight. She knows that obesity increases her risk of heart disease, diabetes, and other illnesses, and that losing weight could ease her asthma. Plus, she has support. Her adult daughter texts her each Tuesday and Thursday to be sure she boards the first of two buses she takes to 11th Street.
The nurse-led center, run by Drexel University downtown, is a good place to start. In addition to running the "biggest loser" class, Kirby staffs the center's gym, where patients get free use of the equipment and personal training.
Speaks is unemployed and disabled by chronic pulmonary disease. She says her struggle with weight is partly a matter of willpower. "It's the cookies," she says. "I'm going to have to do a cold-turkey thing."
Perhaps the most successful campaign for willpower in U.S. history involves smoking. Over the past 50 years, Americans have been scared, taxed, and guilt-tripped into quitting the tobacco habit, reducing the prevalence of smoking by more than half. Restrictions on advertising, state and federal taxes on cigarettes, and laws prohibiting smoking in restaurants and on public property have recast as repulsive what was once considered sexy.
"We cut down on smoking in this country by making it not OK to light up," says Stuart Butler, in charge of policy innovation at the Heritage Foundation, a conservative think tank. He hopes for a similar change of public sentiment about lifestyles that lead to obesity. He'd like to see teachers and community leaders talk to parents of obese children about the health implications.
The campaign against obesity has borrowed from the assault on smoking. The federal government has raised nutritional standards for food served to children who receive free or reduced-price meals. Next fall, schools are expected to begin implementing a federal ban on the sale of most sugary snacks and beverages. Michelle Obama's "Let's Move!" campaign enlists celebrity power to promote healthy food choices and regular exercise. The first lady recently unveiled an updated nutrition label that offers a clearer picture of the calories and added sugars in packaged foods.
Implementing tougher tactics has been trickier. Philadelphia Mayor Michael Nutter has tried twice to tax sugar-sweetened beverages sold in the city, but the measures failed under industry pressure. Former New York City Mayor Michael Bloomberg's attempt to ban the sale of large surgery drinks—twice ruled unconstitutional—will be considered by the state's highest court this year.
Still, some signs indicate the campaign may be taking hold. Preschoolers who are overweight are far more likely to be obese as adults. But a recent CDC study found that obesity rates among children ages 2 to 5 declined by 40 percent in the past decade, although there was no significant change for older children or most adults.
Heritage's Butler isn't alone, however, in believing that it won't be enough to hold people more accountable to make healthy choices on their own. "The way people actually behave personally is so affected by what happens in the community," he says.
Eating more fruits and vegetables, for example, is far more difficult for someone who cannot afford fresh produce or who lives in a neighborhood where markets don't stock much. That's why Kirby takes patients on a tour of a grocery store and helps them plan menus and shopping trips. The most successful participants in his program are those who can adapt what they learn in class to their own lives, he says, and that requires resources.
Traditional public-health approaches may be of limited use in reducing disparities, according to work that Columbia University professors Bruce Link and Jo Phelan have led over the past 20 years looking at why disparities persist despite advances in medical care and social conditions. Public-awareness campaigns aimed at healthy eating and weight loss may reach people who have the resources to respond, but not those who may need them the most. The biggest gaps in mortality, they have shown, occur in conditions that are the most treatable.
It's hard for Americans to get decent health care without insurance. In Philadelphia, only 11 percent of white adults under 65 were uninsured in 2012, compared with 20 percent of black adults, according to an annual survey by the Public Health Management Corp. Among the city's Hispanics and Asians, the rate of uninsured adults was higher still, at 27 percent. Nationally, according to a Kaiser Family Foundation analysis, the disparities in uninsured rates were similar—15 percent for whites, 25 percent for blacks, and 33 percent for Hispanics.
The Affordable Care Act was designed to help the uninsured by making health care accessible to nearly everyone. Besides expanding Medicaid for the poor and subsidizing insurance for many low- and middle-income people, it also invests billions of dollars in community health centers and other organizations that serve millions of people who are poor and uninsured. The law "really offers a transformative opportunity not only for better insurance but for better care and better public health," says Howard Koh, HHS's assistant secretary for health.
Yet, for every two or three Philadelphians who have been newly insured this year, at least one has been left behind, says Antoinette Kraus, director of the Pennsylvania Health Access Network, a coalition of organizations helping people enroll. After the Supreme Court allowed states to decline the expansion of Medicaid, which provides health care for the poor, 25 of them—including Pennsylvania—have done so. That has left about 281,000 Pennsylvanians without coverage, by Kaiser's calculations, including 91,000 blacks and Hispanics. Gov. Tom Corbett, a Republican, has proposed an alternative that would expand Medicaid while limiting some benefits for all recipients and requiring poor people to contribute, which seems unlikely to get the federal approval it needs to move forward.
Nationwide, an estimated 4.8 million residents will lose insurance coverage in the Medicaid-spurning states, which are mostly in the South. More than half are people of color, according to Kaiser.
"Most people in the country have an option of affordable health insurance, unless you happen to be really poor and in a conservative state, and then you get nothing," says Benjamin Sommers, a physician and health economist at the Harvard School of Public Health.
But even universal coverage doesn't guarantee better health. In many ways, as the Institute of Medicine documented in 2002, Americans of color receive poorer care—including a lack of communication from medical professionals and fewer appropriate procedures or medications—even when all other factors, including insurance, are equal. Language barriers and distrust of the health care system play a role. The obstacles are numerous, including hard-to-break habits, the scarcity of health care, the stresses of living in poor neighborhoods, and silent discrimination.
Harvard researchers in 2007 asked physicians to take a widely used computer test that measures subconscious bias and compared the results with how the doctors said they would treat a hypothetical patient with chest pain. The doctors who were found to harbor more racial prejudices were more likely to provide the best clot-busting drug to white patients but not to blacks.
Structural barriers also complicate efforts to address health disparities. Consider a program in Milwaukee that trained low-income minority parents of children with asthma to counsel other parents on how to manage the disease and find resources that could help with housing, insurance, and food. The mentoring program cost a mere $60 per patient each month but reduced episodes of wheezing and visits to the emergency room significantly, according to a study published in 2009 in the journal Pediatrics. Some patients' parents missed fewer days of work.
When grant funding ran out, however, the program was discontinued, said Glenn Flores, the lead author, who is now director of general pediatrics at the University of Texas Southwestern Medical Center. Insurers don't like to pay for preventive programs that might save money in the long run, for fear of later losing the customer—and the financial reward. But a movement is just getting started within the medical world to pay doctors and hospitals based on their success in keeping patients healthy, rather than for each test or treatment. This approach could put more money into programs that help people of color—all people, really—manage chronic conditions.
"It's not just an equity issue," Flores says. "This is a quality issue."
Justice Hill-Blount is feeling better. The 18-month-old is getting a checkup at St. Christopher's Hospital for Children after a bout of wheezing. The toddler probably has asthma, an illness her mother, 32-year-old Jocelyn Hill, knows too well. Hill's own asthma seemed to get worse, she says, when she was shot in the back at age 23. All five of her older children, ages 4 to 15, have it, too. "We haven't been able to outgrow it," she says.
Hill, who is deaf, can't hear her children wheezing. Instead, she watches for signs they are gasping for breath or she lays a hand on their chests as they sleep. She worries about the dust that collects in the carpet of the family's North Philadelphia apartment, which her landlord won't replace. Hunger and asthma are linked, and Hill tries to stretch the family's food assistance to the end of each month.
She is in the right place. Doctors at St. Christopher's write prescriptions for families to buy discounted boxes of farm-fresh vegetables. The clinic is staffed with social workers. Down the hall, an exam room has desks for attorneys with the Medical-Legal Partnership program, to help with issues of child custody, immigration status, and uncooperative landlords.
The hospital's services fit a broader movement around the country to improve the environment in which people live, work, and play. Some neighborhood-centric efforts have focused on building parks in hopes of increasing exercise opportunities for children and adults, eliminating lead paint from homes, removing hazardous-waste sites, or expanding bike lanes and public transportation.
But even this approach, taken on its own, has shortcomings. Hill says the $15 cost per box of vegetables is too high. Unaware of the legal program, she doesn't tell the doctor about her dirty carpet. Her story highlights how difficult it can be to connect even one individual or family with useful services—much less change a whole neighborhood.
St. Christopher's and other organizations here are trying. Philadelphia's Food Trust has become a national model. The nonprofit has worked to make fresh foods available to low-income families at farmers' markets and corner stores. It spearheaded efforts to get state matching funds to build 88 grocery stores in "food deserts" throughout Pennsylvania, a program the Obama administration is working to replicate across the country.
Grocery stores are to eating well what health insurance is to obtaining medical care—a starting point. The Food Trust also offers nutrition education and cooking classes that focus on preparing familiar foods in a healthier fashion, says Allison Karpyn, the Food Trust's research director.
But a report by researchers in London and at Penn State University published in Health Affairs in February raised doubts about the impact of building grocery stores in poor neighborhoods. The study surveyed residents before and after a supermarket was built and compared them with responses from people in a comparable neighborhood without such a store. The authors found that people who lived near the supermarket felt they had better access to healthy food, but, surprisingly, they didn't eat more fruits and vegetables or achieve a noticeable improvement in their body-mass index.
The study was small, the authors noted, and its participants were relatively old and thus less likely to change their habits. Still, it suggests that simply altering the built environment isn't enough. "If people have grown up in a community without access to parks and green space," says the Joint Center's Smedley, "suddenly putting it there is not going to make people use it."
Ask Dan Taylor, a pediatrician at the St. Christopher's clinic, where Hill's family is treated, what he thinks is needed to improve the neighborhood's health, and his answers are big. Decrease child poverty. Invest more in education. Provide jobs that pay a living wage. He worries about a growing body of research showing that the stresses of living in poverty—the many ways it undermines families and communities—damage children's brains and their long-term health.
A landmark study of thousands of adult Californians, begun in the mid-1990s at Kaiser Permanente, found that "adverse childhood experiences," such as domestic violence or abuse, had a cumulative effect on people's health. The 6 percent of participants who had four or more such experiences were far more likely as adults to be obese or to have cancer, heart disease, depression, or substance abuse. Most of the participants were white and had attended college, prompting two Philadelphia groups, the Institute for Safe Families and the Public Health Management Corp., to survey the City of Brotherly Love in 2012-13. They found that 37 percent of all participants—and more of the black respondents—reported at least four adverse experiences.
"You do what you can," Taylor says, but once a family exits the clinic, "they're going back to a toxic environment that really doesn't focus on children, that doesn't put children first."
Philadelphia is looking hard at the factors that create such an environment. During his first term as mayor, Nutter pledged to improve education and reduce violence. As he started his second term last year, his administration realized that to make progress on those goals it needed to focus more broadly on poverty, explains Eva Gladstein, who leads the new Office of Community Empowerment and Opportunity.
A year in, the office is setting up centers to help people apply for public benefits. It is bringing people together to advocate for more state and federal funding for early education, to increase services for people struggling to stay in their homes, to do more financial counseling and promote savings accounts, and to create 25,000 jobs in the city by 2015. Implicitly, Gladstein says, all of those goals are about health.
Columbia researchers Link and Phelan theorize that disparities persist from generation to generation because people have unequal access to the resources they need to protect their health—money, power, prestige, and positive social connections. Yet Link considers this shift in thinking—looking beyond health care to the context in which people live—a source of hope. It's hard to measure the effect of this change in perspective, he says, but "you can imagine building something like a movement."
The writer is features editor at Maine's Portland Press Herald and covered health care for The Boston Globe.
This article appears in the March 14, 2014 edition of National Journal Magazine as The Health Chasm.
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