Black, or Brown, We'd All Live Longer in a More Equal, Less Status-driven Society.
By Phillip Longman
Monday, October 7,
Imagine you got to
choose whether to be born Black or born White in America. Here are a few health
statistics that might inform your decision:
If you chose to be born White, your chances
of dying of Parkinson's disease would be twice as likely as if you chose to be
Black. Your chances of dying from cirrhosis of the liver or Alzheimer's disease
would be 25 percent higher. As a White person, you'd also be two and a half
times more likely to commit suicide.
Based on those facts alone, the decision to
be born White might sound like a pretty bad idea. And sure enough, life doesn't
work out well for many millions of White people in America. But you might also
consider that everyone has to die of something, and dying from these particular
causes has some advantages.
As terrible as Alzheimer's and Parkinson's
are, for example, almost no one dies of them unless they've previously managed
to escape death from other causes for 75 years or more. Cirrhosis of the liver
tends to kill at younger ages, but you can still spend many decades of hard
drinking before it catches up with you. Even for the chance to commit suicide,
one typically has to have survived at least until one's teens, and suicide is
more common among those who have succeeded in growing old than it is among
those who are still young.
By contrast, consider the pros and cons of
choosing to be born Black, based on life tables alone. To be sure, opting to be
Black would reduce your chances of dying from diseases caused by risk factors
that rise with age. But it would also severely reduce your chances of living to
even your first birthday, let alone growing old enough to retire.
This would be particularly true if you chose
to be Black and male.
To start with, your chances of dying before
your first birthday would be roughly 2.3 times greater than if you were born
White. If you managed to make it to age one as a Black male child, your chances
of dying before your 5th birthday would be 80 percent greater. If you survived
to age 15, you'd have a 60 percent greater chance of dying within the next 10
years. If despite these elevated risks of premature death you nonetheless
managed to get to your 45th birthday, you'd still be 80 percent less likely to
live long enough to collect Social Security than if you had chosen to be White.
If you were Black you would also, of course,
substantially elevate your chances of growing up in a poor, crime-ridden
neighborhood, and the health consequences of living in that kind of environment
are extremely adverse. If your neighborhood were, say, New York's Harlem during
the 1990s, as a young man you'd have only a 37 percent chance of living to see
65. By contrast, according to a seminal study published in the New England
Journal of Medicine, if you'd chosen to be White and wound up living in the
unremarkable, predominantly White middle-class Detroit suburb of Sterling
Heights, your chances of still being alive at sixty-five would be above 89
So what would you choose? It may be that
longevity is not the only measure of the good life. You might also, with enough
luck and fortitude, be able to overcome the highly elevated health risks of
choosing to be born Black. Indeed, it is a curious fact that among
African-American males who live to an advanced old age (85 years or older), the
chances of living for another year are actually greater than for White males of
the same age-presumably because the few African-American men who have survived
that long have remarkable constitutions.
Yet who would ever choose to face this
pattern of competing health risks across their life course? It's far more
important to have a good chance to become elderly in the first place than to
embrace the tiny chance of becoming a centenarian in the unlikely event you're
not already dead by 65.
The vast disparities in health and longevity
that exist between the races in the United States violate a fundamental idea of
justice that we all carry with us at least to some degree. It is the idea of
justice as fairness, of what kind of world we would choose to live in if, as
the philosopher John Rawls framed it, we were all impartially situated as
equals before being born and did not know what our station in this life would
be. A society that resists ending the preventable causes of these racial
disparities in heath is a society resisting justice.
But what are those preventable causes, and
what could or should be done about them? To answer that question, let's
consider another thought experiment.
Imagine if, before you were born, you were
told that you could choose to be born either Black or White in America. But if
you chose to be White you would live in poverty and if you chose to be Black
you would be in the lower-middle class. In this thought experiment, you
wouldn't know anything about what our world is actually like except for
estimates of life expectancy for different categories of people.
Those estimates would tell you that choosing
to be White would bring you very little, if any, advantage to health if you
were also poor. For example, according to data developed by the Robert Wood
Johnson Foundation, approximately 35 percent of Whites living below the poverty
line report themselves to be in only poor or fair health. This is quite close,
after we adjust for age differences, to the 32 percent of poor Blacks who
report fair or poor health.
Meanwhile, the health status of Both Blacks
and Whites improves dramatically with higher income while the gap between them
remains small. Among Blacks and Whites living at just four times the poverty
rate, for example, the percent who report poor or fair health drops to 8
percent and 6 percent respectively. Your race per se, in other words, plays
little role in predicting your health compared to your income.
What explains the residual difference in the
health status of Blacks and Whites who have the same-size pay check?
Researchers suggest it may reflect in part the reality that at any given income
level, Blacks tend to have fewer assets than Whites, such as home equity and
financial savings. A Black family earning, for example, $50,000 in income is
less likely to own its own home, less likely to have received an inheritance,
and more likely to be encumbered by debt than is a White family with the same
income. Middle-class Black families are also more likely than middle-class
White families to bear the health consequences of having lived in poverty in
The gap in health status may also reflect the
fact that among families with similar levels of income, as well as educational
attainment, Blacks are more likely than whites to live in neighborhoods with
higher concentrations of crime, poverty, pollution, liquor stores, "junk
food" outlets, and inferior health care. Conscious or unconscious bias
among health care providers may also be at work in explaining the racial health
gap, though your chances of receiving substandard health care in the United
States vary far more according to where you live than according to the color of
Yet even if they remain remarkably small at
any given level of income, racial disparities in health do exist. And these
disparities are large enough to make it rational (if health and life expectancy
are the only criteria) to prefer being born a poor White American than a poor
Black one. But the differences are also far too small to make it rational to
prefer being born a poor White to being born a rich, or even
lower-middle-class, Black. Again, the health status of Blacks who live at just
above the poverty line is substantially better than that of Whites who live
There is a reason why, in English, we use the
word "poor" to refer to both a lack of money and a lack of health. Both
historically and still largely today, poor people are likely to have poor
health, almost regardless of other circumstances.
That poverty is deadly is not hard to
understand, at least at the extreme. To be very poor means not having enough to
eat, being exposed to the elements, and living in areas where homicide and
addiction are leading causes of death or where your access to appropriate
health care is minimal or nonexistent. In addition, both historically and
today, getting seriously sick is likely to make you seriously poor even if you
But if our goal is to overcome the vast
disparities in health that exist in the United States, especially for
African-Americans, we have to absorb two more difficult facts. These facts are
noncontroversial among epidemiologists, even if they remain unfamiliar to most
First, it's not just extreme poverty that is
bad for your health; so is having less autonomy and status than others,
regardless of your income. Among people who have plenty to eat, have equal
access to quality health care, live in safe neighborhoods, and hold down jobs,
health and life expectancy declines with socioeconomic position. While it is
not hard to understand why truly impoverished people of all races die younger
than middle-class people, it's also true that middle-class people die younger
than upper-middle-class people, and that upper-middle-class people die younger
than rich people, even though none but the very poor are wanting for the basic
necessities of life.
The second fact is just as strange, and
equally radical in its implications, both for individuals seeking to maximize
their personal health and for societies that are intent on creating just
institutions. It is that the wider the disparities in status and power that
exist between people within a given workplace, city, county, state, or country,
the more premature deaths happen. Crudely put, inequality kills.
It's a pattern that's found, in greater or
lesser degree, under all forms of government, within rich countries and
not-so-rich countries, in the East and in the West. It also holds true in
countries with universal health care and those without, and among different
The first place researchers rigorously
documented this pattern was in the United Kingdom. There, starting in the
1960s, a team headed by the epidemiologist Michael Marmot began a long-term
study of the health of British civil servants. These bureaucrats had much in
common with one another. None lived in poverty; none were rich. None had jobs
that posed any clear physical danger beyond the risk of paper cuts. All had
equal access to the fully "socialized" British health care system.
Yet as the study went on it became clear that
these bureaucrats were vastly different from one another in their health and
longevity. Specifically, among employees of the same age, those who occupied
the bottom of the organization chart as typists, clerks, and the like were four
times more likely to die over the next 20 years as were administrators at the
top of the hierarchy. Moreover, the differences in death rates did not just
exist at the extremes of the organizational ladder. At every step in between,
health and life expectancy were better one rung above and worse one rung below.
At first, researchers suspected that this
social gradient of disease must be related to lifestyle. People at the bottom
of the organization tended to smoke more, for example. But it turned out that
if you were an administrator and smoked two packs of day, this was far less
dangerous to your health than if you were a clerk who did the same. Similarly,
if your blood pressure or cholesterol levels were high, or if you rarely
exercised, being higher in the organizational chart made these conditions less
threatening to your health than if you were lower. This was true even though
people at the bottom of the organization tended to see doctors more frequently.
Since then, similar correlations between
health and social rank have been observed just about everywhere researchers
have looked. To take just one of the more curious examples, it turns out that
Hollywood actors who win the Academy Award live four years longer on average
than their costars in the same movie. And they also live four years longer than
actors who were nominated for the award but did not win. This four-year
difference in life expectancy may not sound like a lot. But to keep the
implications for population health in perspective, consider that if all deaths
from heart disease were magically eliminated while deaths from other causes
remained the same, the improvement in life expectancy for the population as a
whole would come to just four years.
One way researchers have tried to explain
these and similar findings is to posit that the losers in our society have
become losers because they have poor health. This is no doubt true in some
cases. Clearly, if you're in the hospital for months following a car crash,
lose the ability to walk, and go through life thereafter with hideous facial
scars, it is bound to negatively affect your career prospects. The same would
be true if you were born already addicted to narcotics or positive for HIV.
Or to take a less extreme but far more common
example, say you are a low-level employee working a dead-end cubicle job and
find yourself afflicted at age 30 with prolonged bouts of depression, insomnia,
and more than an occasional hangover. It is possible that these conditions will
make it less likely that you will rise to the top of the ladder than if you
bounced out of bed each morning feeling like the picture of health.
But to conclude in this instance that your
lack of upward mobility is because of your poor health is to beg
the question of why you have developed these afflictions in the first place.
Maybe you would drink in any event. Maybe you'd describe life as stressful
regardless. But would you drink as much, and feel so bad about it in the
morning, if you also felt (like that famous, highly effective, long-lived
alcoholic Winston Churchill) that you were in command and getting important
To continue this thought experiment, what if
you did not feel slighted and powerless at work; if your boss didn't make eight
times your income but only double; if he didn't seem to look down on you and
"your kind"; if losing your job didn't mean losing what little
control you have over your life? What if you didn't feel variously envious,
intimidated, and infuriated by coworkers, neighbors, and people you see on TV
who seem to have it all; if you could point to some way of keeping score in
this life by which you were a winner and life had meaning?
The specific biological mechanisms that lead
from feelings of relative powerlessness and low status to specific diseases are
not well understood at the molecular level. Some researchers have pointed to
the role of cortisol, a steroid hormone released by the adrenal gland in
response to stress that has the effect of suppressing the immune system. Among
people who are overweight, those with high levels of cortisol are more likely
to contract diabetes than those with low levels.
More than 200 laboratory studies have also
shown that the highest cortisol levels are found in people required to perform
tasks outside their control that involve, as the epidemiologist Richard
Wilkinson puts it, "threats to self esteem and social status in which
others can negatively judge your performance." A hard-charging executive
may use the word "stress" to describe his reaction to the burdens of
command, but it is his cowering subordinates who are most likely to feel the
kind of stress that literally changes body chemistry.
The negative effects may be compounded if
those subordinates must also endure the stress and humiliation of either
perceived or real racial or class discrimination. And the effects may be
further multiplied if they have also internalized feelings of inferiority based
on these or other negative stereotypes or social constructions.
In an intriguing study at Emory University,
researchers found, for example, that black men who reported being victims of
racial discrimination experienced an increased risk of heart disease. But a
much greater risk of heart disease was found among African-American men who
agreed with negative statements about Blacks. Indeed, the highest rates of
heart disease were found among African-American men who said they were not
personally victims of racial discrimination but still viewed their own race as
inferior. Put another way, being or believing yourself to be the victim of
racial discrimination is not good for your health, but what's really bad is to
absorb a social belief system that says you are at the bottom.
Cross-country comparisons also establish a
clear link between poor health and social stratification. Among developed
countries, for example, there is no correlation whatsoever between per capita
GDP and life expectancy. But there is a strong correlation between countries
that have low levels of inequality and those in which long lives are most
Sweden and Japan, for example, are very
different countries, but both have extremely low levels of income inequality
and the lowest rates of premature death in the developed world. Sweden achieves
its egalitarianism through a large welfare state that massively redistributes
income and opportunity. Japan has a comparatively small welfare state, but,
according to custom, bosses refrain from paying themselves too many multiples
of what workers earn. For the purposes of maximizing public health, Wilkinson
observes, it does not seem to matter how a nation achieves relative
equality, only that social and economic stratification is somehow kept to a
A similar pattern emerges when we compare how
long White people live in different parts of the United States. To better see
what happens, consider one last thought experiment.
Suppose, before you were born, you were told
that you had to be a White man, but you could choose whether you would live out
your days in Mississippi or Minnesota. If you could not know anything else
about these states except their life tables, what would the rational choice be?
The life tables would tell you that if you
wound up a White man in Mississippi, your chances of not dying before age 65
would be little better than 74 percent, and that if you did live to that age,
you could expect to be dead within 15.35 years. But if you were a White man in
Minnesota, your chances of living to age 65 would be better than 83 percent and
your remaining life expectancy at that point would be 17.49 years.
The choice would seem clear, but what
explains how stark it is? One big difference between Mississippi and Minnesota
is the number of Black people in each state. But unless you think that Blacks
in Mississippi are responsible for the deaths of huge numbers of White
males-and they aren't-that can't be the reason why White men in Mississippi
live shorter lives than White men in Minnesota. Nor are differences in median household
income between Whites in Mississippi and Minnesota large enough to explain such
a large disparity in health: few Whites in either state are poor enough that
their health is threatened by lack of food or shelter.
The key factor may be how these states differ
in their degree of social and economic stratification. Mississippi is among the
states with the highest inequality of income. Moreover, throughout most of the
last two decades Mississippi has led the nation in the growth of income
inequality, whether as measured by the difference between those at the very top
and those at the very bottom or by the gap in income between the middle class
and the very rich.
Minnesota, by contrast, has much lower
disparities of income, and is much more egalitarian in many other dimensions as
well, including educational attainment, access to health care, and even, dare
we say, cultural style. Garrison Keillor's joke about all the kids in Lake
Wobegon being "above average" contains an important truth: Minnesota
is not a place where invidious distinction is typical, or kindly looked upon.
And perhaps because of that, it is also not a place where stress and insecurity
about social standing and loss of face is very common.
Within the United States generally,
disparities in health among different segments of the population have increased
in lockstep with growing disparities in income and education. By now it's to
the point that poorly educated White Americans, for the first time ever, are
experiencing an absolute decline in their average life span. White males with
fewer than 12 years of education now have a life expectancy of just 67.5
years-just six months longer than the standard Social Security retirement age
set under current law for today's middle-aged and younger Americans. The gap in
life expectancy between White females who go to college and those who don't
widened from 1.9 years in 1990 to 10.4 years in 2008.
Meanwhile, for all but those at the very top
of the ladder, and perhaps even for them, life is shorter than it likely would
be if we lived in a more equal, less socially competitive and status-driven
society-including one that was less obsessed with status distinctions based on
race, education, and profession or that paid less notice than Americans have
since the 1980s to who has the biggest McMansion, the most designer clothes, or
the latest, snazziest smartphone. Inequality may not be an equal-opportunity
killer, but few escape its mortal consequences.
To Live Longer, Move to a New Zip Code
Michelle Obama's "Let's Move"
campaign emphasizes the importance of physical activity for combating obesity,
a point she has driven home by dancing alongside school kids to Beyoncé's
workout video. But another kind of movement may also be important to your
chances of living to a ripe old age: moving to a new zip code.
Between 1994 and 1998, the U.S. Department of
Housing and Urban Development conducted a demonstration project known as
"Moving to Opportunity." The project randomly assigned low-income
families to one of three groups. Those in the first group received a voucher
that they could use to help pay the rent on an apartment, provided that the
apartment was not in a low-income neighborhood. Those in the second group
received a voucher they could use in any neighborhood, while those in a control
group received no voucher.
In 2011, HUD researchers published the
results in the New England Journal of Medicine. The most dramatic finding
was that people assigned to the different groups varied significantly in their
weight by the end of the experiment. Going into the program, participants as a
whole had been substantially more obese than the U.S. population as a whole.
But 10 to 15 years later, those women who had moved to more affluent
neighborhoods were one-fifth less likely to be obese than those in the control
group, and also one-fifth less likely to have contracted diabetes.
This was true even though there was little
difference among all the participants in the numbers who managed to move off
welfare, improve their education, or find a better job. This suggests to
researchers how powerfully our surroundings alone are to determining our habits
and health. Though it might seem strange to say that obesity is contagious, for
example, it does seem that people's risk of it is affected by the weight of
their neighbors, as well as by such environmental factors as whether most of
the food for sale in their environs is junk food, as is often the case in
America's most impoverished neighborhoods.
The results of the HUD demonstration project
are in line with other studies showing the extreme importance of geography and
social environment as determinants of health. A dramatic graphical
representation of this reality can be seen in the accompanying map of the
Washington, D.C., metropolitan area developed by the Commission to Build a
Healthier America. It shows how life expectancy improves by nearly a decade
within just a few stops along the region's various Metro subway lines.
In 2002, the Institute of Medicine published
an oft-cited and controversial report entitled Unequal Treatment: Confronting
Racial and Ethnic Disparities in Health Care. The report concluded
that members of minority groups, even when fully insured, tend to receive
substandard care from their doctors. It cited disparities in how often Whites
and minorities received even routine medical procedures, as well as how often
they underwent specific operations, such as coronary artery bypass surgery.
The resulting headlines were
sensational-"Is Your Doctor a Bigot?" asked one. And there soon
followed fulsome denunciations of the report's conclusions, notably by Dr.
Sally Satel and Jonathan Klick of the American Enterprise Institute. In their
2006 book, The Health Disparities Myth, Klick and Satel claimed that
"[n]ot only is the charge of bias divisive, it siphons energy and
resources from endeavors targeting system factors that are more relevant to
improving minority health."
Today, both sides in this debate have refined
their positions and can point to new information. Professor David R. Williams
of the Harvard School of Public Health still criticizes Satel as "coming
at it from an ideological perspective." But, he adds, "I will say one
thing in her defense. At the time of the IOM report, our conclusion about the
role of unconscious discrimination was based on circumstantial evidence."
That changed in 2007, when the Journal of
General Internal Medicine published the results of a study of
residents at four academic medical centers. Participants were asked to review
the medical record of an imaginary patient complaining of chest pain. For half
the participants, the record included a picture of a middle-aged Black man; for
the rest, a middle-aged White man. Participants were asked to rate on a scale
of 1 to 5 whether they thought the patient suffered from coronary artery
disease, and, if so, whether they believed that the patient should receive a
drug treatment known as thrombolysis.
The study also asked participants to complete
what are known as Implicit Association Tests, or IATs. These tests are designed
to uncover unconscious bias by, for example, asking test takers a series of
questions about whether they associate the word "happiness" with the
word "White" or with the word "Black." In this instance,
the test also asked the residents whether they associated Black patients with
being more or less cooperative with a doctor's orders.
The study found that participants who scored
high for anti-black bias on the IATs were less likely to recommend thrombolysis
when the Black man's picture, rather than the White man's, was included in the
medical record, presumably because they believed the Black man would be a less
cooperative patient or perhaps less able to pay. The study's authors concluded
that the "[r]esults suggest that physicians' unconscious biases may
contribute to racial/ethnic disparities in use of medical procedures such as
While few now dispute that some doctors may
consciously or unconsciously treat patients of color differently, both the
nature of that bias and its importance in explaining racial disparities in
health care are highly disputed. For example, in focus groups organized by
researchers to assess the role of race in medical practice, Black doctors were
far more likely than White doctors to say that a patient's race is a medically
relevant factor in determining the best treatment.
As one Black physician in a Philadelphia
focus group put it, "I think being an African-American is a risk factor in
and of itself. And, I think that when you see an African-American then you need
to often be more aggressive than you would, and use different standards than
you would for the general White population."
were also more likely than White doctors to say that they pay close attention
to whether a patient can afford the prescriptions they write, and to consider
what the circumstances of their patients' lives are like outside the examining
room. In contrast, White doctors in these focus groups tended to dispute that
there is any reason to pay attention to a patient's race in recommending a course
of treatment, and even to warn other doctors against racial stereotyping.
But perhaps in this way the White doctors were showing insensitivity to racial
realities that Black doctors know better and that are indeed medically
relevant. As the organizers of the focus groups concluded, since
African-Americans as a whole are far more likely than Whites to suffer from
hypertension and diabetes, it may be appropriate for doctors to take into
account at least some population-based probabilities of disease when deciding
protocols of treatment to follow. Color-blind medicine isn't necessarily the
The picture also looks different when
researchers pan back and look at how widely medical practice varies in
different areas of the United States. From this perspective, it is place, not
race, that overwhelmingly determines what specific treatments patients receive
for specific ailments.
Blacks tend to live in parts of the country
that have a disproportionately large share of low-quality providers. But as
researchers from Dartmouth Medical School have demonstrated, within
poor-quality hospitals, which include not just inner-city "St. Elsewheres
but often well-known academic medical centers, both Whites and Blacks tend to
be equally mistreated, often by being subjected to unnecessary surgery and
unproven treatments. Moreover, there are some predominantly Black cities, such
as Raleigh, North Carolina, and Birmingham, Ala., that have a long history of
institutionalized segregation but where the researchers did not find racial
disparities in treatment, and there are others, such as Jackson, Miss., where
racial disparities in care are apparent.
More recently, researchers associated with
the Dartmouth Atlas Project have concluded that "where patients live has a
greater influence on the care they receive than the color of their skin."
Reform efforts, they argue, should therefore be focused not on the
headline-grabbing issue of racial disparities, but on improving the quality of
the U.S. health care delivery system in every region where it is poor.
is senior editor of the Washington Monthly. This article, the 11th of an
11-part series on race, is sponsored by the W. K. Kellogg Foundation and was
originally published by the Washington Monthly Magazine.