The Legacy of Race

Health Care Disparities: ZIP Code, Race Predict Lifelong Health Inequities

From the 2018 Community Health Equity Report, courtesy of the Health Action Partnership.

On the day he’s born, the average white resident of Jefferson County is expected to live about 3.5 years longer than the average Black resident.

Jefferson County’s Black residents have higher rates of death due to heart disease, diabetes, stroke and “malignant neoplasms,” or cancerous tumors, than their white neighbors, according to the Jefferson County Health Action Partnership’s 2018 Community Health Equity Report, which studied county and state health statistics.

Infant mortality and low birth weights are twice as likely to occur among black newborns as white ones.

These differences are clear when data is broken down by ZIP code. Historically Black neighborhoods, such as College Hills, Fountain Heights and Titusville, show some of the lowest life expectancies and highest rates of disabilities and infant mortality in the county. Majority-white areas tend to show better health outcomes, an effect that is most pronounced in high-income areas such as Mountain Brook and Vestavia Hills.

In this, Jefferson County mirrors the rest of the nation. Black Americans generally have more health problems and chronic illnesses, and consequently shorter life expectancy.

Black residents of Jefferson County have higher rates of mortality across most major chronic illnesses, based on data gathered in the 2018 Community Health Equity Report. (Courtesy of the Health Action Partnership.)

Dr. Monica Baskin, a professor of preventative medicine at the University of Alabama at Birmingham and the Department of Medicine’s vice chair for culture and diversity, has studied health care disparities for much of her career and was one of the leaders of the Health Equity Report research. Baskin said health care disparities are caused by a complex web of factors, from inherent inequalities in the medical field to the simple ability to get from your door to your doctor.

“Data from this investigation point to an overall pattern of social and economic distress clustered in low-income and nonwhite neighborhoods that limit opportunities for people in these communities to live healthy lives,” the Health Equity Report’s executive summary said.

Beyond personal characteristics, “there are these other things that seem to be highly correlated with who is healthy, who gets sick, who lives longer,” Baskin said.

Dr. Allyson G. Hall is a professor and the director of graduate programs in healthcare quality and safety at UAB and has studied the relationship between ethnic background and socio-demographic factors that impact health and environment. Hall said the connection between race and health is less about biology and more about social context and history minorities experience.

“The point I want to emphasize is it is not race per se, it is more what being Black in America means,” Hall said.

Location, Location, Location

The 2018 Health Equity Report and its predecessor, a 2013 report titled “Place Matters for Health in Jefferson County, Alabama,” both focus on a simple concept: Where you live will impact your health for your entire lifespan.

Neighborhoods no longer are segregated by law, but many of the Black communities that were created by Jim Crow laws, exclusionary zoning and discriminatory home loan practices still have similar demographics decades later.

Multi-generational Black communities were also created in the agricultural Black Belt region of the state after the Civil War, when freed slaves continued to live, work and raise families in those areas. Just more than half the population in the Black Belt counties is African Americans.

A 2014 study by Northwestern University School of Medicine, published in the American Heart Association research journal Circulation, tracked occurrence of cardiovascular disease across Black, white and Hispanic participants for 10 years and documented the level of racial segregation where each participant lived, measured by comparing racial composition within the individual’s census tract to the composition of the surrounding area.

The study found that Black participants had a 12% higher risk of developing cardiovascular disease with each standard increase in neighborhood segregation, even after adjusting for neighborhood characteristics, socioeconomics and individual heart disease risk.

Discriminatory policies, whether enacted by the government or by private institutions such as banks, kept many Black families as lifelong renters, even if they had the money to afford middle-class homes in white neighborhoods. The practices subjected them to interest rates that drove homeowners to foreclosures.

This helped create a system that, even after laws were changed, kept Black families in the same neighborhoods and reinforced cycles of poverty, limited opportunities and inability to accumulate wealth from home equity, to pass on to their children. About 16.8% of all Alabamians live in poverty; among Black residents that rate rises to 28.4%, according to 2019 data from Alabama Possible, a nonprofit focused on addressing root issues of poverty.

In several Alabama counties, including some Black Belt counties such as Greene, Lowndes, Perry and Wilcox, Black poverty levels approach or surpass 40% of the population. Not a single county has a white poverty level above 25%.

In Winston County, 90.6% of Blacks are impoverished, compared to only 15.4% of white residents.

The Dollars and Cents of Healthy Choices

There are a lot of individual choices that influence health: dietary habits, exercise and consumption of cigarettes or alcohol, to name a few. For families in poverty, those choices can become more complex or even be taken entirely out of their hands.

Can you afford to go to the doctor to treat a minor injury or illness and still be able to pay all your bills? If not, you may have to delay health care until the situation becomes catastrophic, potentially saddling you with a lifelong chronic illness, a disability or even fatal consequences.

Does your job offer health benefits, or can you qualify for Medicare or Medicaid? If not, preventative treatment and regular prescriptions may be unaffordable, preventing the management of health problems. In areas with fewer employment options or underfunded schools, often a side effect of formerly segregated areas, high-paying jobs with benefits may not exist or may require skills you can’t obtain.

“Poor educational opportunities translate to jobs that are perhaps more dangerous or stressful or less likely to provide you with health insurance, meaning that you have a lower income, which means you may not be able to get the kind of health care you need,” Hall said.

Dr. Allyson Hall,, director of graduate programs in Healthcare Quality & Safety at UAB. Courtesy of Allyson Hall.

Can you afford to make healthy purchases at the grocery store? If your food budget is limited, fresh produce and lean meats may have to be replaced by cheaper, processed foods. These sugary, salty and fatty foods contribute to obesity, diabetes and heart problems.

The Kaiser Family Foundation, a nonprofit focused on health care research and news, published a study in November 2019 about reproductive care in Dallas County. The researchers’ interviews with low-income women reinforced the hard choices they had to make.

“High poverty rates, limited affordable housing, a shortage of vocational training and employment opportunities, and other socio-economic stresses cause many women to prioritize health care and family planning behind other competing needs,” the study reported.

Keshee Dozier-Smith is the CEO of the Rural Health Medical Program Inc., which operates eight comprehensive low-cost medical clinics in Dallas, Marengo, Monroe, Perry and Wilcox counties. The clinics’ patients, about 80% of whom are Black, generally did not receive regular medical care before the clinics opened. Dozier-Smith said she sees many patients forced into difficult medical decisions because of their income.

“People in rural communities are faced with so many unfortunate situations and just surviving,” she said.

Going the Distance

The connection between location and health goes beyond income levels, Baskin said. Easy access to hospitals, grocery stores and even sidewalks are also health factors.

Keshee Dozier-Smith, CEO of the Rural Health Medical Program Inc. (Photo courtesy of Rural Health Medical Program Inc.)

Dozier-Smith said the Rural Health Medical Program was created as a response to the absence of medical facilities, particularly private clinics, in rural areas. Some of its patients will drive across county lines to be able to get primary, pediatric, internal care, dental, vision and mental health services from a Rural Health clinic because there are no other options.

“In Pine Apple, Alabama, there’s a post office, there’s a local grocery, and there’s Rural Health,” Dozier-Smith said.

More than a dozen private hospitals in Alabama have closed over the past decade, according to the Alabama Hospital Association, including the Pickens County Medical Center in March 2020. Many of those hospitals were in rural locations, and Dozier-Smith said leaders at the Rural Health clinics know to expect an increase in patients after a hospital closes its doors.

The Rural Health Medical Program is trying to work with rural hospitals to redirect non-emergency care for uninsured patients to the Rural Health clinics, as treating high volumes of uninsured patients can be a source of financial trouble.

“What you find across rural communities, the emergency room is used as the primary care doctor,” Dozier-Smith said. Sending non-emergency cases to a Rural Health clinic instead “keeps the hospital doors open because we’re able to partner and save money there.”

The Kaiser Family Foundation’s research on reproductive care in Dallas County showed that one hospital in Selma was the only option in the region for labor and delivery. If women needed specialized attention, they must drive about 50 miles to Montgomery or further to Birmingham.

Having a long drive to medical care is more than a matter of convenience, Dozier-Smith said; it makes patients less likely to seek preventative care.

Increased travel times require more time off from work, and not every job offers that flexibility. Some Rural Health patients also don’t have cars or are unable to drive, she said. Without public transit options, these patients will have to rely on a friend, pay someone to drive them or, if they qualify for Medicaid or Medicare, get pre-approved for transportation assistance, limiting both their time and budget for medical care.

“A person may need more than one service, and this is their one day with transportation,” she said, which is part of why Rural Health clinics include so many care specialties. “We take care of all of those needs at one time.”

Though Birmingham does have a city bus system — something that many rural areas of Alabama lack — Baskin said it is not a total transportation solution for residents. Getting to a doctor’s appointment may require walking, multiple bus changes and lengthy waits at bus stops, in addition to limitations of the bus routes and operating hours.

Many communities that have these “health care deserts” also have food deserts, where access to full-service grocery stores is limited. The U.S. Department of Agriculture defines a food desert as an area where at least 500 people, or a third of the population, live more than a mile from a supermarket or grocery store in urban areas, or more than 10 miles in rural areas.

The Health Equity Report mapped food deserts in Jefferson County against population demographics. Many of these deserts were in the areas where the report had also tracked the lowest life expectancy rates.

As with medical access, physical distance to a grocery store causes time, inconvenience and expense to become limiting factors to purchasing healthy foods.

Dozier-Smith said many of the Rural Health clinics’ patients who don’t live near a supermarket are in farming communities that may grow produce, but there is no mechanism to connect those growers with their neighbors as potential customers. Finding food suppliers that accept Supplemental Nutrition Assistance Program assistance funds as payment is another hurdle for low-income families.

“It seems impossible to a family who is going through that” to find a way to get healthy food, Dozier-Smith said.

As a partial solution, she said the Rural Health Medical Program has created its own clinic food pantry, partnering with churches, farmers and grocery stores. In Dallas County, one of Rural Health’s recent COVID-19 testing sites also provided boxes of food or cleaning supplies through partnership with the local housing authority.

A Rural Health Medical Program COVID-19 drive-through testing site. (Courtesy of Keshee Dozier-Smith.)

Baskin said the results of the Health Equity Report showed clearly that safe transportation is linked to health. The Health Action Partnership that created the report has worked with Birmingham city government to include the data as part of its Complete Streets criteria for determining where to build and repair sidewalks, bike lanes and streets, Baskin said.

In addition to pedestrian access to services, Baskin said good sidewalks, trails and parks also enable running, walking and other activity at no cost, encouraging healthy choices.

Mind and Body

Stress isn’t just mental; it can make itself known all over the body. Chronic high levels of stress can cause a weakened immune system and susceptibility to diseases such as diabetes, high blood pressure and heart disease.

Poverty is one source of chronic stress. A 2013 Gallup survey, analyzed and published by the Brookings Institution in 2015, showed that poor individuals — those in families of four with household incomes less than $2,000 per month, based on 2013 federal poverty guidelines —reported higher rates of pain, worry, stress, sadness and anger than middle- or upper-class individuals.

Additionally, Baskin said data is starting to show that experiences of racial discrimination can cause poor mental health and physical strain similar to other types of stress.

Dr. Monica Baskin, professor, preventive medicine, UAB. (Courtesy of Baskin)

For example, a March 2018 study published in Circulation, a research journal from the American Heart Association, showed links between experiences of discrimination and an increase in inflammation in the body, which is connected to heightened cardiovascular risks in Black women. Other studies have documented an increase in stress hormones after negative race-related experiences.

The research is far from conclusive about causes and effects at this point, but Baskin said it’s worth acknowledging that racism can play a role in lower life expectancies for minority populations. “We need to pay attention to that,” she said.

“How Many More Times Do You Need to Measure This?”

The 2018 Health Equity Report included a list of recommendations, from local community initiatives to governmental policy changes, to improve health disparities in the counties’ underserved areas. One of those recommendations was to rely on feedback and expertise from the residents of these areas on the best ways to reach their communities.

After publishing the report, Baskin said the feedback she received was straightforward: “How many more times do you need to measure this?”

“Individuals living in these communities are very well aware that they lack the resources that other communities have,” Baskin said.

The 2013 and 2018 reports are helpful to track progress in health care equity efforts, Baskin said, and they plan to continue these reports in the future. However, tracking data won’t ease poverty, reopen rural hospitals, fix sidewalks or bring grocery stores to food deserts.

Since the Health Equity Report was released, Baskin said, the Health Action Partnership has been looking for ways to address policies and practices that “perpetuate the same types of communities having the same poor outcomes.”

That has included supporting changes to improve insurance access and coverage, nutritional assistance and projects like Birmingham’s Complete Streets guidelines. Baskin said she would like to see schools become a resource hub for families in providing services such as food assistance and mental health care.

“We recognize we have a responsibility to move things upstream a little more,” she said, adding that the Health Action Partnership has now partnered with about 100 organizations on various approaches. For the Rural Health Medical Program, Dozier-Smith pointed to projects such as the food pantry and a planned mobile clinic as ways to remove barriers.