Two Surprising Factors That Make Millions of Americans Sick


The following is an excerpt from Prevention Diaries, by Larry Cohen. Published December 1, 2016, by Oxford University Press.

I tried to get a mortgage for a superb house in East Oakland near my office, but my application was denied without explanation. Later I learned—off the record—that banks were unwilling to lend in that area. They had “redlined” it, meaning they drew an actual red line on the map around certain neighborhoods where they refused to support either residential or commercial development. This neighborhood was extraordinarily racially, ethnically, and economically diverse, with a high percentage of people of color and people with low household income—typical redlining targets. Wealthier white neighborhoods were, needless to say, not subject to this treatment. Eventually, I was able to get the loan, but only because I had a Realtor with a longstanding relationship at the local bank and other business connections that helped me get around the standard practice. Surely the fact that I was a white man with a good income made a big difference—both in my ability to get a Realtor and in the bank’s willingness to lend money to me. While I had the means and access to buck the system that oppressed others in the neighborhood, the vast majority of East Oakland residents did not. 

Redlining and discriminatory lending practices are of course not limited to East Oakland—they are part of a much larger pattern of injustice that relegates low-income communities and communities of color to poor health and other forms of diminished well-being. Redlining also reinforces racial and economic segregation while concentrating poverty, poor housing conditions, and overcrowding into set areas, forcing people to live in inequitable conditions that engender poor health. The sum of this is that financial institutions, by restricting housing options, reinforce certain populations to areas with the fewest resources and access to services, jobs, and transportation. This means homes near toxic sites and polluting industries. It’s no accident that the leading causes of death—heart disease, cancer, diabetes, stroke, injury, and violence—occur with greater frequency and severity in these areas, and with earlier onset. Further, being denied a path to home ownership becomes a huge barrier to building wealth that can be passed on to the next generation. There is seemingly no end to the unfairness wrought by redlining. 

Tony Iton, public health director of Alameda County (California) from 2003 to 2009 (and also a former board member at Prevention Institute), led a study that found a black child born in low-income West Oakland and a white child born 10 miles away in the middle-class Oakland Hills had an average 15-year difference in life expectancy. As appalling as this finding is, it’s only part of the story: life expectancy is a relatively blunt measure that reveals just one element of inequity; it only hints at the lifetime of disparity that accompanies what are too often sicker, shorter lives. 

Virtually every U.S. inner city has these kinds of inequities—as do some suburbs, especially those just outside city limits, and many rural areas. Sir Michael Marmot, an international authority on disparities in health, noted in an interview with the World Health Organization: “If you catch the metro train in downtown Washington, D.C., to the suburbs in Maryland, life expectancy is fifty-seven years at beginning of thThe e journey. At the end of the journey, it is seventy-seven years. This means that there is a twenty-year difference in life expectancy in the nation’s capital, between the poor and predominantly Black people who live downtown and the richer and predominantly non-Black people who live in the suburbs.”

Sadly, I haven’t seen any discernable embarrassment or political fallout over this inequality—or any significant activity to address it in, of all places, our nation’s capital. Marmot has revealed the pattern of diverging life expectancy and income levels in countries around the world. In other countries, the discrepancies in life expectancy track economic status. In the United States, racism and economic injustice are deeply intertwined, exacerbating the inequities. The dismaying links between neighborhood conditions and health have been recognized by groups in Washington, New York City through the creation of transit maps that show the average life expectancy for residents living around each metro stop.

In New York, visual artist and programmer Brian Foo has even used musical narration to map the profound income gaps along a subway line. Public and private projects that are disruptive to neighborhoods, such as electricity substations, freeways, and waste treatment plants, tend to be placed in the very same neighborhoods that are redlined. “This is typical of the pattern you see in poor neighborhoods,” according to Meena Palaniappan, an Oakland resident whose concern led to her becoming co-director of the West Oakland Environmental Indicators Project. “Facilities that serve the whole Bay Area are located here, and West Oakland shoulders the whole environmental burden.” West Oakland residents suffer from predictably higher rates of lead poisoning, cancer, and asthma. One study shows that local children are seven times more likely to be hospitalized for asthma than the average child in California. 

Since the health problems created by inequitable community conditions all eventually require medical treatment and people living with chronic health problems often end up hospitalized, the search for solutions to these disparities in health typically begins in the medical system. The Institute of Medicine has identified three vital elements for achieving greater medical equity: equal access to high-quality treatment, diverse medical leadership that represents the populations served, and treatment that is culturally and linguistically appropriate. 

Where this line of thinking goes wrong is in assuming the medical system can play the primary role in solving the problem; as discussed already, inequity isn’t just medical. It’s a piling on of economic, environmental, and political unfairness. The gap in life expectancy isn’t principally due to differences in treatment, or in biological makeup. It’s related to ordinary community issues with ignored health impacts that degenerate into medical concerns. As Brian Smedley, the executive director of the National Collaborative for Health Equity, puts it, “It’s not your genetic code; it’s your zip code.” The environments in which people live, work, and play shape health and safety outcomes for everyone—but this impact is even more so for low-income populations and people of color, who bear the brunt of injustice manifested in challenging living conditions and social stigmas. As Marmot writes, “It is about opportunities in life … social conditions that shape the physical environment one lives in.

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