The conventional and individualistic recipe for good health has long been to eat right, avoid bad habits, exercise regularly, sleep enough, and have regular doctor check-ups. Yet, despite this straightforward prescription, many people in the United States struggle to achieve and maintain good health. While personal behavior and choice are certainly core components of one’s health, they cannot fully explain or account for all that it takes to become and remain healthy.
The reality in this nation is that while people can self-regulate some aspects of their health–such as by following the practices listed above—many other factors that determine health are beyond individual control. These factors include the environments in which people are born, live, learn, work, and play—known as the social determinants of health. These determinants substantially affect and shape health and quality of life—for better or for worse.
Health inequities—defined as disparities that are modifiable, associated with social disadvantage, and considered ethically unfair—are preventable health problems that research has shown result from a toxic relationship between how people live their lives and the socioeconomic and physical environments that surround them. An inequity that has long held the attention of public health researchers, and that was recently catapulted into the national spotlight, are the longstanding, severe, and preventable race-based differences in the survival rates of black mothers and their infants.
Health is much more than a predetermined outcome of an individual’s biological and genetic makeup, as well as more than a matter of individual behavior and access to quality health care and coverage. Health is also a social production.
Longstanding place-based inequities for black mothers and infants
As studies have shown, these longstanding inequities are centrally caused by racism—a system of power that unjustly hoards vital, life-building opportunities and resources for a category of people who are artificially deemed as racially superior, while disempowering and denying those assets to groups devalued as racially inferior. This system creates a racialized landscape in which people of color tend to experience worse health outcomes than white people, with black and Native American communities facing some of the steepest environmental barriers to socioeconomic well-being. These barriers include but are not limited to: segregated communities with substandard healthy food options and hazardous housing conditions; and unwalkable neighborhoods that are systematically polluted and isolated from the quality of life levers needed to meaningfully participate in society. Such levers include equitably resourced health care and school systems as well as accessible public transportation that connects people to gainful job opportunities.
There is perhaps no time in a woman’s life when her health matters more than when she decides to become a mother. Yet, no matter how hard women work to have the best pregnancy and birth outcomes possible, black mothers in the United States—regardless of wealth or educational background—are still three to four times more likely to die during and after childbirth. Their babies share this fate, and are twice as likely to die in infancy as their white, non-Hispanic counterparts. To meaningfully rectify this inequity will require a fight-fire-with-fire systems approach—in which all stakeholders, sectors, and political structures are engaged to tackle racism first and foremost. This includes identifying and acknowledging the cumulative and compounded effects of this historical system of oppression; the full extent to which it is embedded within U.S. society; and chiefly, how racism manifests not just in black women’s everyday environments but also in those of their families and larger communities.
The biological inheritance of built environments
We literally embody, biologically, the societal and ecological conditions in which we grow up, develop and live.Dr. Nancy Krieger, Harvard University, "What's Killing America's Black Infants?"
People’s environments matter a great deal in how healthy or unhealthy they can and will be throughout their lifespans. As the National Academies of Sciences, Engineering, and Medicine recently reported, “The historic and ongoing interplay of structures, policies, norms, and demographic and geographic patterns shapes the life of every individual across the country, and its effects persist over multiple generations.” Simply put, health is much more than a predetermined outcome of an individual’s biological and genetic makeup, as well as more than a matter of individual behavior and access to quality health care and coverage. Health is also a social production. It is a dynamic and cumulative embodiment of people’s prior and ongoing experiences in society and is shaped by the interaction of several forces. As emerging research shows, people’s health can even be shaped by the lived experiences of their ancestors.
The degree to which the built environment—the man-made communities and surroundings where people live out their lives—matters for health is perhaps most poignantly demonstrated in the relationship between mother and infant. Much attention and research has focused on the impact of an expectant mother’s individual traits and behaviors on a fetus in utero, as well as her access to quality health care coverage and maternal care services. The burgeoning field of epigenetics—the study of heritable changes in gene function one’s environment causes—posits that the influences at play during pregnancy encompass far more than just maternal characteristics. In fact, they reach as far back as the life experiences of mothers’ and fathers’ parents and even grandparents. Studies have observed evidence of a multigenerational biological impact—finding that adverse environmental exposure throughout parents’ lives can reverberate in the physiological development of their descendants for at least two generations to come.
Case study: Lead poisoning
Research on lead poisoning serves as a grim case study of this dynamic—and as a dire prognosis for the thousands of U.S. residents that are regularly at high risk of contact with the neurotoxin. While national guidelines exist, there is no safe level for lead exposure in reality. Once absorbed, lead eventually settles and accumulates in the bones and teeth like sludge build-up at the bottom of a tank. It can stay in a person’s body for decades—if not for their entire life—and is a toxic sludge that doesn’t simply lay dormant. Instead, it can freely leach from the bone back into the bloodstream and tissue, wreaking havoc on every organ system it encounters.
Given American society’s ingrained social and racial stratification, it should come as no surprise that people of color—particularly black Americans, who are disproportionately more likely to live in impoverished neighborhoods—are most at risk of lead poisoning. This entirely avoidable risk was created by negligent policy decisions—as Flint, Michigan’s water crisis highlighted—as well as flawed governing structures that allowed culpable corporate actors and derelict landlords to shirk remediation responsibilities. All the while, these policies condemn generations of families to live in contaminated homes with tainted water pipes and saturated neighborhood grounds. Experiencing a lifetime of bone-deep exposure, these communities tend to suffer from permanent cognitive and physical impairments and disabilities that include but are not limited to: restricted growth; heart and kidney disease that eventually leads to failure; tooth decay; autism and other intellectual and developmental disabilities; and miscarriages.
The result is generations of black women raised in poisoned communities that have likely experienced irreparable harm to their uteruses well before questions of raising a family even enter their minds. These women unknowingly and unwillingly expose their developing embryos to a devastating toxicant, continuing a life-altering, vicious generational cycle that they have little ability to prevent. Lead poisoning demonstrates that individuals and families can do everything within their power to lead healthy lives, but that such efforts don’t stand a chance against the juggernaut of a built environment not designed or equipped to produce good health outcomes.
Racism and the ensuing racialization of place explain persistent health disparities
Racism is a fundamental cause of racial disparities in health. We must confront institutionalized racism if we seek to eliminate those disparities.Dr. Camara Phyllis Jones, MD, MPH, Ph.D.
Even when a built environment isn’t overtly poisoning its residents, its covert influences on day-to-day life are numerous and actively shaping residents’ health. For instance, proximity to a quality grocery store affects how reliably community residents can access nutritious, affordable food. Food insecurity is an all-too-widespread barrier with which roughly 15.6 million U.S. households grapple. This is particularly the case for black residents, who are more than twice as likely to be food insecure as their white counterparts and, thus, are at higher risk of chronic conditions such as obesity, diabetes, and hypertension. It is not by mistake or natural design that black, Latino, and Native American communities tend to have the worst access to supermarkets and are relegated instead to smaller grocery stores that carry limited, higher-priced food options that tend to be less healthy and fresh. This national pattern is commonly referred to as a food desert and is just one example of public policies and actions that have created and maintain the separate and unequal landscape of American communities.
From zoning, housing, and transportation to other forms of land use and infrastructure planning practices, public policies fundamentally shape how communities look, their geographic location, the type and quality of their resources, and how closely situated they are to various opportunities for better health. Thus, policies shape the extent to which community members can be healthy, connected, and thrive. Both explicit and implicit public policies have long determined which neighborhoods are the best and worst to live in as well as which groups of people reside in them. Policymakers decide, for example, in which and how close to communities polluting companies can set up shop. Indeed, it is by intentional public policy and action—not mere coincidence—that those neighboring or fence-line communities near polluting industries and toxic waste sites tend to disproportionately consist of people of color and people who are socioeconomically disadvantaged. The same type of policy decisions helped to create and normalize maternity care deserts in the predominantly black and Latino communities of Washington, D.C., and recently allowed the last remaining pre- and postnatal care facilities in these already under-resourced neighborhoods to abruptly close—without giving proper notice to pregnant patients or having an interim plan in place. This is despite the fact that these specific wards persistently have some of the worst maternal and infant mortality rates in the country.
These are just a few examples of the toxic built environment that too many black mothers and families must navigate. And they are just one aspect of America’s unlevel playing field that consistently denies black residents the equal opportunity to survive, thrive, and be healthy. While it may be easy to point to the many ways in which the Trump administration is intentionally harming and undermining communities of color, it bears reminding that the United States is just 50 years removed from a time when segregation and disparate treatment of black people was openly state-sanctioned. The reality is that in this country, black and white communities’—and therefore black and white mothers’ and infants’—lived experiences vastly differ. They have been and continue to be disparately valued and situated in American society, and thus they tend to live in fundamentally different built environments that are largely immune to wealth and educational achievements.
Through policies and actions, American society has staunchly and repeatedly decreed that the places where black people dwell are at greatest risk of: being discriminately less supported and resourced; underinvested and disinvested in; and isolated, devalued, and trapped. Black communities are also disproportionately plagued by deprivation-induced crime and violence, and are subsequently under-policed yet overly criminalized, preyed upon, destabilized, and stressed out. Researcher Rashad Shabazz aptly labeled this racialized environmental dynamic a spatialization of blackness. There are fiendishly high burdens and costs for people of color forced to navigate systems and environments that not only were not designed to equitably include and support them but, in many cases, were also built to carry on the racial legacy of socioeconomically excluding them while simultaneously exploiting their communities.
Policymakers must address the racial bias in policies that shapes communities
The psychological weight of three generations of black women lives in my womb.Nicole A. Taylor, "Black Mothers Respond to Our Cover Story on Maternal Mortality."
Here, Taylor intuitively reflects on the compounding stress and cumulative toll of being a black woman in America. Her words tacitly concede the role that her reality likely played in the death of her infant. While genes, behavior, and access to health care are important factors in people’s overall health, they cannot define health on their own. The places where people live out their lives also determine their opportunities for success and likelihood of being healthy. Public policies are the primary tools for shaping communities, which in turn play a pivotal role in establishing the level of success and health that their members can expect to achieve. The fates of black mothers and infants are tied together, and the severe disparity in their ability to survive and be as healthy as their white counterparts is rooted in racism. This is a wholly preventable disparity reflecting built environments and lived experiences that have been separate and inequitable since the country’s founding.
This nation’s overall health and socioeconomic vitality depends on the health and well-being of its communities—and it is clear that America is failing to live up to its ideals. Across the country, too many communities—especially black communities—lack sufficient access to the conditions and drivers necessary for good health, including jobs with livable wages and benefits; well-resourced school systems; accessible and connected public transportation; affordable, inclusive, and good-quality housing; and safe neighborhoods with healthy food options and green spaces—to name a few.
Given the creation and explicit use of race in the United States, wherever racial patterns are observed, racism must be recognized as a culprit. This includes reckoning with and rectifying the past and present racialized ways in which the United States structurally designs and invests in whole communities to either thrive or languish. Policymakers must approach this man-made health crisis, born from historical injustices, with a recognition that public policies are powerful tools. They can either bring about equitable change and tangibly level the playing field for those most affected, or they can exacerbate the unjust, toxic environments built and maintained by America’s original sin. The lives and overall health of black mothers and their babies hang in the balance.
Rejane Frederick is an associate director for the Poverty to Prosperity Program at the Center for American Progress.
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Associate Director, Poverty to Prosperity Program