Health Inequalities

June 9, 2008 6:32 PM

It's like gunning the engine of a car. The recent documentary Unnatural Causes examines the health consequences societal inequalities have on people. The PBS series has a couple dozen embeddable video clips exploring atomic testing, Native American Health, Latino Health and more. One clip examines why when African women come to the U.S., within one generation, their daughters suffer higher rates of premature babies and poorer birth outcomes. One group is putting hundreds of millions of dollars into alleviating health disparities in 14 communities across the country.

More videos and information at the PBS website for the program. Get the DVD.

posted by cashman (11 comments total)

Thanks for this post, it looks like a great documentary!

The videos on diabetes and Native American communities were very informative. The quote about our tax dollars going to genetic research instead of PE teachers being a social injustice was right on. I work for a study that is using dance as a preventative measure in low income Latina girls. We're NIH funded, but as far as I know our primary investigator is the only one getting major research funding to do these sort of basic community interventions. Prevent the disease, and the entire diabetes management industry starts to go under. It's no wonder more dollars go into insulin delivery systems than to pay after school dance instructors or soccer coaches.

Well I definitely feel motivated to go into work tomorrow morning!
posted by wilky at 12:22 AM on June 10, 2008 [1 favorite]

"When Atlanta lawyer Kim Anderson was pregnant with her first child, she did everything right: she ate a healthy diet, exercised, and got the best prenatal care. But her baby was born almost three months premature. This excerpt from When the Bough Breaks explores racism's impact on pregnancy outcomes.".

Kim Anderson, well-educated, Columbia law school grad, successful attorney, who ate all the right things, exercised, and received "the best prenatal care" had a premature baby and they conclude it is because of racism and social inequality?

One of these things seems to be not like the others.
posted by three blind mice at 12:29 AM on June 10, 2008

It's no wonder more dollars go into insulin delivery systems than to pay after school dance instructors or soccer coaches.

Drug companies have better lobbyists than PE instructors. As long as both of you look to Washington for your money this is the only thing which will matter.
posted by three blind mice at 12:35 AM on June 10, 2008

Taken as one example, I could see how three blind mice's statement that "one of these things seems to be not like the others" might hold water. However, the video linked first in the post states that infant mortality for white women with a college education is around 4 deaths per thousand births. For black women it is 10 deaths per thousand births. Prematurely born babies are more likely to die. Kim Anderson is an example of a college educated woman who's baby was born prematurely. While one example alone cannot lead to the conclusion that racism and social inequality result in higher infant mortality for blacks, the statistics the documentary calls upon definitely suggest it.

And I say "suggest it" because correlation does not equal causation. However, I'm guessing the people doing this research are controlling for as much as they can when sifting through the data. You can't exactly do experimental studies for this sort of thing.
posted by Mister Cheese at 12:56 AM on June 10, 2008 [1 favorite]

This is very poor science. What is the purported mechanism by which racism would cause these birth outcomes? And please, don't quote me the guy in the video saying "the stress of racism causes chronic wear and tear on the body's systems" because that is a very long way from being a scientifically meaningful statement.

It is well known that stress can cause miscarriage, and there is a known mechanism for that; but lower body weight? infant mortality? Is there a proven connection there or is this speculation?. Furthermore, it is possible to measure stress and if there is a general heightening of stress levels in American blacks due to racism, it should be possible to demonstrate that. I'm not raising these points because I think they're untrue, but because I don't know that they ARE true. If someone can point me to scientific studies establishing these points I'd be very grateful.

What if the "elephant in the room" is not racism, but rather genetics? What if US-born black women are genetically predisposed to worse birth outcomes? That's one of the possibilities raised in this 1997 study which compared birth outcomes in the USA for US-born and African-born black women.

They noted that birth outcomes for African-born black women were similar to those for white women - and far better than those for US-born black women. But of course, African-born black women are not excused from racism, so racism doesn't look like a great explanation.
posted by standbythree at 4:05 AM on June 10, 2008 [1 favorite]

standbythree: Yes, it's tricky to disentangle, but don't write off epigenetics quite so quickly. Environment does play a role, sometimes generations later; consider, eg, the well-documented second generation effects of the Dutch Hunger Winter of 1944. Not surprisingly, women who were pregnant during the famine had lower-than-average birth-weight babies, but surprisingly, when these children grew up (in normal caloric environments) and had their own children, the 2nd-gen children were also smaller than average. If you looked at those babies and compared them to children born to non-Dutch mothers of the same birth cohort, you might conclude that lower birth-weight is a genetic predisposition of the Dutch population -- but the causative agent was an environmental one. It's easy to see the environmental effect in the Dutch case because the deprivation was localized in time and place; when it's a longer-term disparity, it isn't so clear.

So, if data suggests that US-born black women are genetically predisposed to worse birth outcomes, the Dutch Hunger Winter studies teach us to ask "why?"
posted by Westringia F. at 5:54 AM on June 10, 2008 [2 favorites]

What is the purported mechanism by which racism would cause these birth outcomes?

(1) Racism
(2) Income inequality
(3) ??????
(4) Premature birth!
posted by ROU_Xenophobe at 7:25 AM on June 10, 2008

If someone can point me to scientific studies establishing these points I'd be very grateful.

Here you go:

"Environmental Health Disparities: A Framework Integrating Psychosocial and Environmental Concepts"
Gilbert C. Gee, Devon C. Payne-Sturges
Environmental Health Perspectives, Vol. 112, No. 17 (Dec., 2004), pp. 1645-1653

Abstract:
Although it is often acknowledged that social and environmental factors interact to produce racial and ethnic environmental health disparities, it is still unclear how this occurs. Despite continued controversy, the environmental justice movement has provided some insight by suggesting that disadvantaged communities face greater likelihood of exposure to ambient hazards. The exposure- disease paradigm has long suggested that differential "vulnerability" may modify the effects of toxicants on biological systems. However, relatively little work has been done to specify whether racial and ethnic minorities may have greater vulnerability than do majority populations and, further, what these vulnerabilities may be. We suggest that psychosocial stress may be the vulnerability factor that links social conditions with environmental hazards. Psychosocial stress can lead to acute and chronic changes in the functioning of body systems (e.g., immune) and also lead directly to illness. In this article we present a multidisciplinary framework integrating these ideas. We also argue that residential segregation leads to differential experiences of community stress, exposure to pollutants, and
access to community resources. When not counterbalanced by resources, stressors may lead to
heightened vulnerability to environmental hazards. Key words: environmental, environmental justice, ethnicity, framework, health disparities, psychosocial, race, review, stress. Environ Health Perspect
112:1645-1653 (2004). doi:10.1289/ehp.7074 available via http://dx.doi.org/ [Online 16 August
2004]




"Racial Discrimination as a Moderator of the Links Among Stress, Maternal Psychological Functioning, and Family Relationship"
Velma McBride Murry, P. Adama Brown, Gene H. Brody, Carolyn E. Cutrona, Ronald L. Simons
Journal of Marriage and the Family, Vol. 63, No. 4 (Nov., 2001), pp. 915-926

Abstract:
This study focuses on the links between social
contexts and normative family patterns to identify
factors at the societal, community, family, and in-
dividual levels that enhance African Americans'
ability to overcome stressful life events and foster
positive family relationships. The Mundane Ex-
treme Environmental Stress Model was used to
explore these links. From urban and rural areas
in Iowa and Georgia, 383 families with 10- or 11-
year-old children were recruited. Structural equa-
tion modeling was used to test the hypotheses.
Maternal psychological distress was linked with
parent-child relationship quality both directly and
indirectly through its association with intimate
partnership quality. When racial discrimination
was greater, stronger links emerged between
stressor pileup and psychological distress, as well
as between psychological distress and the quality
of both intimate partnerships and parent-child re-
lationships. Future research on African American
family processes should include the effects of ra-
cial discrimination.


"Social Support, Stress, and Blood Pressure in Black Adults"
David S. Strogatz, Janet B. Croft, Sherman A. James, Nora L. Keenan, Steven R. Browning, Joanne M. Garrett, Amy B. Curtis
Epidemiology, Vol. 8, No. 5 (Sep., 1997), pp. 482-487

Abstract:
Psychosocial factors arising from socioeconomic disadvantage
and discrimination may contribute to the excess risk of ele-
vated blood pressure in African-Americans. The purpose of
this study was to assess the association of social support and
stress with blood pressure in a community-based sample of 25-
to 50-year-old black adults in Pitt County, NC. A stratified
random sample of dwellings was selected in 1988, and 1,784
black adults (80% of those eligible) were interviewed. Analyses
were sex specific and adjusted for age, obesity, and waist/hip
ratio. In separate analyses of emotional support, instrumental
support, and stress with blood pressure, all associations were in
the predicted direction (inverse for support, direct for stress)
but were stronger for systolic than for diastolic blood pressure.
Differences in systolic blood pressure associated with low sup-
port or high stress ranged from 5.2 to 3.6 mmHg in women and
3.5 to 2.5 mmHg in men. In simultaneous regression analyses
of support and stress, each of the separate effects was reduced
for women, but a sizable aggregate effect of low support and
high stress remained [+7.2 mmHg (95% confidence limits =
+1.3, +13.1) for systolic blood pressure and +4.0 mmHg
(95% confidence limits = +0.1, +7.9) for diastolic blood
pressure]. (Epidemiology 1997;8:482-487)



These are just a few examples. There is quite a bit of research out there on this topic. Annecdotally, I can affirm, that yes, it is stressful as hell being black in America.
posted by anansi at 7:44 AM on June 10, 2008 [3 favorites]

ROU, your simplisitic answer to the mechanism question doesn't work (even ignoring step 3 ;) ). Affluent black women have worse birth outcomes than poor whites. "Income inequality" can't be the reason.
posted by standbythree at 8:51 AM on June 10, 2008

Re: American Indian diabetes- I did some research on the topic last year and was astonished to read what the USDA sends over to the reservations as food aid. Look at all that processed junk in there (spot the spam). A steady diet of this stuff over the past few decades combined with a lack of access to whole foods and a largely sedentary reservation lifestyle has resulted in a huge disparity in diabetes incidence. The Pima of Arizona are a great example-- some 500% higher incidence of DMII than the national average. A genetically similar tribe in Mexico whose diet does not include the USDA commodity food package has zero incidence of type two diabetes. This article is a bit old, but it puts forth a very good case for ending the USDA package program and replacing it with a subsidized traditional diet of beans and native vegetables.
posted by The White Hat at 8:54 AM on June 10, 2008

Health Insurance Status by Race/Ethnicity: Total Nonelderly Population, 2006

Nonelderly Uninsured by Race/Ethnicity, 2006

No Usual Source of Care for Nonelderly Adults by Race/Ethnicity and Insurance Status, 2005-2006

Infant Mortality Rates for Mothers Age 20+, by Race/Ethnicity and Education, 2001-2003 *

*I work for the place that produces these slides and reports, but I don't work on the policy side, and don't have a hand in any of the writing or analysis.


From the NYT article based on the Dartmouth report ("disparities" link in the post):

Race and place of residence can have a staggering impact on the course and quality of the medical treatment a patient receives, according to new research showing that blacks with diabetes or vascular disease are nearly five times more likely than whites to have a leg amputated and that women in Mississippi are far less likely to have mammograms than those in Maine.

I'm always surprised when people say "It could be class! It could be genetics! It could be moonmen!" Of course those things could play a role (well, except for the moonmen, I guess). But the lengths to which we will go to deny or distance the role institutional racism plays is just amazing.
posted by rtha at 8:59 AM on June 10, 2008 [1 favorite]