Book debunks idea that genetics cause disparities, not racism
AChicago-based health equity researchers Maureen Benjamins and Fernando De Maio have long been interested in the disparities that affect their city.
Benjamins, a Chicago-born senior researcher at the Sinai Urban Health Institute, helped lead the largest face-to-face community health survey in the city’s history. De Maio, a sociology professor at DePaul University who grew up in Buenos Aires, has been interested in the social impacts of inequalities since experiencing turmoil in his home country, Argentina, as a student. But every time Benjamins and De Maio wrote articles on health inequalities for various conditions, they realized they had to take a broader view if they were to paint a clear picture of systemic inequity in the United States. .
Their new book, âUnequal Cities: Structural Racism and the Death Gap in America’s Largest Cities,â published by Johns Hopkins University Press last month, attempts to do just that: compare death rates and life expectancy in the 30s. largest American cities. Along with more than a dozen contributors, De Maio and Benjamins illustrate what is sometimes a vast gulf between the life expectancy of blacks and whites in urban America. And they provide a roadmap for how cities can begin to assess and address their own disparities.
STAT spoke to the two authors at the end of September. Here’s a edited version of that conversation:
Why specifically study mortality rates and life expectancy?
Benjamin: Two of the best health indicators are life expectancy and all-cause mortality, because everything else is heading towards them. Morbidity and injury levels and all those other things are all factored into that single number. And life expectancy in particular is easy for people to understand and interpret.
And then we realized that when you look at the inequalities in mortality, it’s hard for cities to think about how to make a difference on this. The examination of mortality by cause is therefore a secondary step. And this is really important, because if you really have a problem in a certain cause of death, for example cancer or accidents, you know where to channel more effort and more resources.
From Maio: All measures are interrelated. We all truly appreciate the power of life expectancy as a clear measure that most people can understand, and it’s our guide. But then we move on to things like excessive deaths, which also convey a lot of meaning and are really useful for communicating with a large audience, because it affects in different ways … just the frank number of excessive deaths – the number of people who die every year who otherwise wouldn’t if things were more level – it hits home.
Why was it important for you to look at the biggest cities?
From Maio: We have seen the interest of comparative work, of being able to understand our city in relation to others. â¦ This is one of the most powerful ways to debunk and reject any notion that these are biological effects or that they are ârace as biologyâ effects. These are real symptoms of structural racism because they vary from place to place. And that’s a really powerful idea.
Benjamin: We focus on cities because most Americans live in cities. â¦ And cities have access to a lot of resources. They have public health departments with big budgets. They influence all types of policies. They can be more nimble than, say, state or federal policies that influence health. So we thought it was a good way to, if we want to improve equity in urban health, you have to start with the city. You need to give them the data so that they can make more informed decisions.
Why is there such a lack of such data at the city level?
Benjamin: They will have the death records and they will have the population counts. Whether or not they put them together to calculate death rates … things like black and white death rate ratios are a whole different story. Thus, the country as a whole provides the data at the national level. It is regularly calculated at the state and county level. But there is simply no one who consistently publishes city-level figures, and of course, no one publishes data on city-level mortality inequalities.
What inspired you to write the book?
Benjamin: We started with [calculating] disparities in breast cancer mortality. And as we added different causes of death, the breast cancer work led by Steve Whittman and David Ansell brought about big changes in the city: the development of the Metropolitan Chicago Breast Cancer Task Force, now called Equal Hope. . They were successful in pushing through major policy initiatives, including quality reporting guidelines for mammography and funding for screening. And it really narrowed the gap between black and white death rates in Chicago. …
Based on that, we looked at other causes of cancer and then looked at other leading causes of death. But every time we pulled out an article, at the back of our mind it was: articles don’t give you room to talk about context, so articles don’t allow us to compare causes, and that doesn’t allow us to to have what we have in the book, which focuses on the history of anti-black racism and the theory behind how social structures and norms like these can lead to differences in mortality.
What are the notable discoveries of the book?
Benjamin: There is geographic inequality. âUnequal citiesâ has a double meaning. The difference between, say, San Francisco and Baltimore is about 10 years of life expectancy, so that’s huge. You don’t expect to see it, or a lot of people don’t expect to see it. And then within these cities, the levels of inequity are also really uneven. For example, Washington, DC, has a 12-year gap between black and white life expectancy. It’s just huge, while some cities don’t have a gap. El Paso really has a negligible gap, depending on what areas you are looking at. â¦ So that’s what inspires us, that some cities have found ways to achieve more equitable results.
And in a few cities, Chicago and New York, [there are] more than 3,000 black deaths in excess each year. For me, these numbers really hit home the burden and the tragedy. And if it was from some other cause, I think it would get a lot of attention. You think of other things, even Covid … But the scale of 3,000 excess black deaths in a city, every year, and it’s happened year after year after year, is something I would like really that people pay more attention or know or understand.
From Maio: The book offers a whole bunch of metrics, numbers, ways to assess our condition and progress. We are used to looking at the unemployment rate, maybe even the poverty rate in some places. But why don’t we look at excess deaths? Why don’t we look at the life expectancy gap? We have data to calculate that now. It will be remarkable if we can have a broader appreciation of the use of population health indicators as one of the true measures of our results. And then we can hold our systems accountable for that.
This book was written before Covid. You handed it in a month before the start of the pandemic. How has the pandemic changed the context or raised the stakes?
From Maio: We have a huge new burden. Covid is going from the first to the third cause of death at this time. Data is not available to perform this level of analysis with the Covid results, but it will be uploaded in the future. This only increases the stakes. This will undoubtedly further amplify some of the inequality patterns that we have seen here. And it’s a hypothesis that we can test, that some of the worst-off cities in terms of inequity that we are seeing right now will be some of the worst-off cities in terms of inequity in Covid.
How does this book advance the conversation about inequalities?
From Maio: The results will resonate with many people in their lived experience, but I also think most people in society are unaware of the level of health and inequity that we have. They have a sense of inequality. They have a feeling of poverty and social inequality, in terms of the economy and the distribution of wealth. I don’t think most people easily realize the impact this has on the expected lifespan. This is, for me, a new conversation piece that hopefully people take from this book and find value.
Benjamin: There was a study of mayors – it’s a bit dated now – whether or not they were aware of racial inequalities and whether they thought they might have an impact on them. So I think getting the data out, putting it in the hands of stakeholders who aren’t necessarily equity researchers, and then giving a few examples of what to do next is really kind of a void that we’re trying to fill with. this book.
Talking about mayors and stakeholders, for a local elected official, a healthcare provider or an employer, can seem overwhelming, like an insurmountable problem in some ways. How can this book be used as a guide?
Benjamin: I think the chapter on West Side United is very useful because it is very detailed on how they created the structure of this organization, how they deliberately required and solicited community participation and input from community organizations, how they defined this bold goal and achieved it well known.
From Maio: They have set themselves this ambitious goal of reducing life expectancy [gap] by half by 2030. That in itself is just this amazing, crystal clear goal that is something that is achievable. We are going in the wrong direction with Covid and pre-existing patterns. But they set that goal and they said it was achievable. â¦ And they break this mission down into different parts. So it’s not just this kind of nebulous, utopian goal, let’s be more equal; it is a strategy.
What are the most stubborn misconceptions, myths, or misunderstandings that you try to overcome to elevate this collective understanding of inequity?
DeMaio: There is a deep-rooted meaning in America, the myth of race as a real thing, and it comes back in the reactions. We’ve had colleagues, audiences who have said, well, how do you separate what’s structural and what’s genetic? And the answer is, it’s not genetic at all. The differences we see are entirely the product of local and national policies that affect people. It’s something we’ll have conversations [about] for a long time, always fighting against genetic or biological explanations, which are not based on science and based only on bad thoughts.