Culture of Health Blog

Law and policies should address, not compound, inequities. This is personal and something I carry with me.

I was 10 years old when a man in my northern New Jersey community was beaten to death outside a neighborhood cafe. Soon after, another community member was beaten and sustained brain damage. The number of victims—all of whom were of South Asian descent—grew over the years. The violence ranged from verbal abuse to brutal assaults and murder. It wasn’t uncommon for my home and other South Asian homes to be vandalized while having to hear racial slurs.

Officials denied that these attacks were hate crimes and ethnically motivated. Research and data on discrimination and hate crimes against South Asians simply did not exist, and there wasn’t much diversity among local officials. It was therefore difficult for community members to get the protection we needed. It wasn’t surprising that there were subsequent and repeated acquittals of people who perpetrated the violence. Even living in the shadow of the Statue of Liberty, we didn’t feel a sense of freedom to live our healthiest lives because our laws didn’t do enough to stop racially motivated violence. It was years later when hate crime laws took effect.

When Dr. Rex Archer returned to his hometown of Kansas City, Missouri, to lead its health department in 1998, he was shocked by the city’s inequities. Life expectancy for white residents was 6.5 years longer than that of black residents. Gathering more data, he estimated that about half of the city’s annual deaths could be attributed to conditions in neighborhoods like segregation, poverty, violence, and a lack of education.

I also confronted stark disparities by neighborhood in my years as Philadelphia’s health commissioner, as does most every health commissioner/director across the country. It is truly unsettling to see how small differences in geography yield vast differences in health and longevity. In some places, access to healthy food, stable jobs, housing that is safe and affordable, quality education, and smoke-free environments are plentiful. In others, they are severely limited. Data can help us better understand the health disparities across our communities and provide a clearer picture of the biggest health challenges and opportunities we experience.

My sons are both in college, one at Howard University in Washington, D.C., and the other at Knox College in Galesburg, Illinois. Raising African American boys into adulthood was often stressful. Despite the many advantages and supports we had as a family while they were growing up, I worried about their safety, whether their schools would see and nurture their greatness despite the color of their skin, and whether they would be able to live up to their potential.

As a public health practitioner, I’ve also had the opportunity to observe the amazing efforts of so many caregivers and families with limited resources who heroically “make a way out of no way.” I’ve seen what it takes, for example, for a mom to just get her children to a doctor’s appointment when they each go to a different school because the schools in their neighborhood are not the best she wants for them. I’ve seen the enormous emotional, physical, and mental energy families with fewer economic resources spend simply on surviving day to day—and I know that statistically, the burden of poverty falls particularly heavily on children of color.

I’m now director of University of Wisconsin’s Population Health Institute, which has for nearly a decade compiled the annual County Health Rankings. The rankings have helped communities across the nation see how where we live makes a difference in how well and how long we live. This year we’ve added a layer of analysis that hits home for me, highlighting the meaningful health gaps that persist by race.

We wanted to cover both place and race because county-level rankings can mask the deep divides we have in the health of different groups within communities. Even in counties with the best rankings—and the highest overall level of opportunity for good health—not everyone in every part of the county has access to opportunities for safe housing, adequate physical activity or a good education.

For me, knowing we still have gaps to fill is a call to action, especially as we mark National Minority Health Month. So how do we overturn the current reality and give everyone a fair shot?

We know that where we live, work, learn, and play greatly impacts our health. Especially important among these, and too often overlooked, is the impact of where we live. Housing is tied to health in powerful and inextricable ways. Think about the steps you take each morning to care for yourself, or each evening when you go to sleep. What would happen if you didn’t know where you would sleep that night, or weren’t sure how long you had until you were forced to find new shelter? Would you still take the time to go through your routines, if there was nothing routine about them? Would you set up relationships with health providers if you might not live in the same community next month—or even next week?

I faced homelessness twice and they were the most stressful experiences in my life. Lack of access to stable housing can feel like an insurmountable barrier to achieving good health and well-being—even more so when one is dealing with a chronic illness or other health challenges.

For some, perhaps the mere mention of segregation suggests the past, a shameful historic moment we have moved beyond. But the truth is, residential segregation, especially the separation of whites and blacks or Hispanics in the same community, continues to have lasting implications for the well-being of people of color and the health of a community.

In many U.S. counties and cities, neighborhoods with little diversity are the daily reality. When neighborhoods are segregated, so too are schools, public services, jobs and other kinds of opportunities that affect health. We know that in communities where there are more opportunities for everyone, there is better health.

The 2016 County Health Rankings released today provide a chance for every community to take a hard look at whether everyone living there has opportunity for health and well-being. The Rankings look at many interconnected factors that influence community health including education, jobs, smoking, physical inactivity and access to health care. This year, we added a new measure on residential segregation to help communities see where disparities may cluster because some neighborhoods or areas have been cut off from opportunities and investments that fuel good health. 

One of my earliest and most vivid childhood memories is watching from my bedroom window as my city burned in the riots that erupted after Dr. Martin Luther King Jr.’s assassination 50 years ago.  

The next afternoon, my mother brought me to the playground at my school in Southeast Washington, D.C., which somehow was untouched. As she pushed me in a swing, she asked if I understood what had happened the day before and who Dr. King was.

“Yes,” I said. “He was working to make things better for Negroes like you.”

My mother, whose skin is several tones darker than mine, stared at me in surprise. Somehow, even at 4 years old, I had learned to observe differences in complexion.

That is particularly interesting to me now, as I eventually came to believe that “race” is a social construct.

Of course racism and discrimination exist. They are deeply embedded in America’s history and culture—but so too is the struggle against them.

The Columbia Gorge Region where I live is a vast rural area larger than Connecticut but with a population of only 75,000. While many people here are doing well, others live in poverty, or have to drive long distances to get to a doctor’s office. In this land of fruit orchards, one in five people regularly run out of food.

Mandi Rae Pope was once one of those people. A few years ago, during a difficult pregnancy at the end of her husband’s graduate studies, Pope says she was “counting pennies out of a Mason jar to pay for gas.” She struggled with migraines, and they were getting worse. In the midst of all that, our local Women, Infants, and Children nutrition program gave her a prescription for Veggie Rx, a program we started to provide free fresh fruits and vegetables to people struggling with food insecurity. This was a top concern that community members had identified. By using Veggie Rx, Mandi Rae was able to provide fruit to her toddler son, and the more nutritious diet also helped tame her migraines. Grateful for the help, she wanted to pay if forward and expressed an interest in promoting the program.

I grew up in southwestern Ohio, surrounded by woods, corn and soybean fields down the road from a small town. Although my childhood home fits what some might see as a stereotypical description of small town America, I never thought of it that way. Now, as a program officer at the Robert Wood Johnson Foundation (RWJF) working to promote healthy, equitable communities, I’ve had the opportunity to travel to a number of rural places and small town across the United States and see the vast diversity of these places and the people who live in them.

• View related commentary and resources in RWJF's collection on Rural Health in America

Encompassing about three quarters of our nation’s land and home to about 15 percent of the population, rural and small town America is not just one kind of place. It includes the Midwest like the area where I grew up, and nearby Appalachia. It’s also places like the Mississippi Delta and the “Black Belt” of fertile land in the South, unincorporated colonias and many places along the U.S.-Mexico border, remote and geographically isolated “frontier” areas across the West, and Native lands across the country.

Forty-one years after graduating from Yale University, Clyde Murphy—a renowned civil-rights attorney—died of a blood clot in his lungs. Soon afterward, his African-American classmates Ron Norwood and Jeff Palmer each succumbed to cancer.

In fact, more than 10 percent of African-Americans in the Yale class of 1970 had died—a mortality rate more than three times higher than that of their white classmates.

That’s stunning.

The latest National Academies of Science Engineering and Medicine report notes that compared to other fields of health research, health inequities is still a relatively new field that faces significant research and practical application challenges. The consensus report provides specific recommendations including: expanded health disparity indicators, longer-term studies, an examination of structural factors, and new research funding opportunities. RWJF’s Tracy Orleans talks with two of the nation’s leading experts on health equity and health disparities, Dr. David R. Williams and Dr. Paula Braveman, who share their thoughts on some of these issues and the evolution of research with a look to the future. 

Tracy Orleans: Nearly ten years ago you started work together on the RWJF Commission to Build a Healthier America. At the time, gaps in health between groups of people or communities were not news to health experts, but they were surprising to a lot of others. We’ve come a long way since then with a more explicit focus on health equity research. How do you view this shift?

David Williams: For a long time, researchers focused on documenting the health differences between populations. Those differences are now well-established and we’re able to point to more scientific evidence about why the gaps exist. For example, there’s a growing body of research around the effects of epigenetic aging, which shows that people who experience discrimination or other trauma are biologically older than people of the same chronological age. Science shows that their telomeres, which protect chromosomes from fraying, are shorter among both children and adults who are black, poor, or from unstable homes. This type of more explicit health equity research is a rapidly growing field.