Our health status should not be predicated on our place of residence, but that is the case across the country, and particularly true in St. Louis. Life expectancy for someone living in an inner-city zip code is 18 years lower than someone living in a zip code less than 10 miles away.
Many factors have conspired to reduce the health status of African Americans. These include social and structural determinants of health, such as systemic racism and sociocultural barriers.
Public health researchers and practitioners have focused more attention on the role of social determinants of health when discussing health disparities. Health is affected by discrimination, adverse early life events, poor education, unemployment, job insecurity, economic inequality, poverty, neighborhood deprivation, food insecurity, poor-quality housing, housing instability, inadequate built environment, and poor access to health care.
A 2019 study by Zimmerman and Anderson revealed that income inequality was the largest predictor of health outcomes, with race playing an outsized role in the disparity.In St. Louis, poor and low-income neighborhoods are more likely to be unsafe, have exposed garbage, and have poor or dilapidated housing. They also are less likely to have sidewalks, parks or playgrounds, recreation centers, or a library.Poor members of racial and minority communities are more likely to live in neighborhoods with concentrated poverty than their white counterparts.
Individuals living in extreme poverty have “more chronic illness, more frequent and severe disease complications, and make greater demands on the health care system.”
A cross-sectional survey from 1999-2018 revealed that African Americans were 30% more likely to die of heart disease and twice as likely to have a stroke, with the racial trend in cardiovascular risk factors persisting through the study period. In 2019, African Americans were twice as likely to die of diabetic related complications.
In the greater St. Louis community, the social determinants that negatively affect health outcomes have deep historical roots in the poverty and degraded socio-environmental setting of the area. Communities like North St. Louis became purposefully racially segregated through policies that supported the movement of white families into suburban areas, coupled with housing discrimination against African Americans.
In 2021, 19.5% of Black people living in the United States were living below the poverty line, compared to 8.2% of White people, and 8.1% of Asian people. The legacy of segregation continues in such St. Louis neighborhoods to this day, resulting in high concentrations of poverty. A persistent gap in the rate of poverty in the past 30 years means that poverty affects close to 1 in 3 African Americans but less than 1 in 10 whites in both St. Louis County and St. Louis City.
The impact of poverty on children is especially troubling since starting life in poverty has negative consequences for health well into adulthood. Almost half (46%) of African American children under 18 live in poverty in St. Louis County and St. Louis City. African American infant mortality continues to outpace white infant mortality deaths. Within St. Louis City, African American infant mortality rates, at 13.5 deaths per 1000 live born, are three times higher than Whites. The health disparities and resulting negative outcomes have prompted a variety of responses over the decades to address such barriers.
These efforts are evident in the region’s promotion of and provision of healthcare through the region’s health departments and public hospitals. However, a deteriorating healthcare safety net and the lack of a dedicated tax stream in the City of St. Louis to support public health functions have hampered these efforts.
Thelack of available care, particularly for African Americans, is reflected in the fate of public hospitals in the city. A hallmark is the fate of the Homer G. Phillips Hospital, which was in the Ville Neighborhood in North St. Louis. Homer G. Phillips Hospital and was a source of immense pride for its patients and the members of the surrounding community, many of whom were employed by the facility.
Despite some improvement in health status in the St. Louis region over the past decade, race- and gender-based health disparities continue to be concentrated in economically distressed neighborhoods, particularly in North St. Louis. What has been remarkably consistent over the past several decades are the unrelenting, gripping reports on how poverty and racism continue to afflict the St. Louis region and impede progress in achieving health equity.
These disparities will remain intractable until a coordinated approach is undertaken to address the social determinants of health status among African Americans in St. Louis. The persistence of these unconscionable disparities obligates systemic reform to repair the harm done to the African American community through sustained and targeted reparations. Rebuilding our neighborhoods and schools and eliminating intergenerational poverty would go a long way to improving health of African Americans in St. Louis.
Will Ross, MD, MPH, is vice chair of the St. Louis Reparations Commission.