Introduction
“We were poor, but we didn’t realize it, you know … I can remember the times like when we’d get sick, we didn’t go to the doctor. I assume that we couldn’t afford it. But they had those remedies, you know. They’d give you plenty of castor oil and cod liver to clean you out. For earache, they did sweet oil, drop it in your ear. For cuts and things like that, they used spiderwebs to put on there, and they say that would heal that, clear it up … We did not go to no doctor. I don’t remember when I started going to a doctor, I guess when I got grown.” (Eleanor (pseudonym) 00:47)
Eleanor, who chose to use a pseudonym, is a retired Black woman from Scotland County, North Carolina, and the grandmother of multiple grandchildren. Her childhood experiences with medical care—or, rather, lack thereof—reflect a much larger issue with the healthcare system in the United States.
Recent literature has established multiple pathways between racism and health outcomes, including but not limited to environmental and occupational health inequities, psychosocial trauma, inadequate healthcare, and economic injustice (Bailey et al. 1456). The pathway of economic injustice is of particular interest due to the economic motives that played a crucial role in the origin of race and racial stratification in the United States. Tatum (652) argues that race was first mechanized as a social division in the British North American colonies to prevent the formation of a multiracial working-class coalition and legitimize legal racial distinctions in the face of growing labor demands. Further in this direction, Eleanor deduced that her lack of access to medical care as a child was likely the result of her family’s economic status—a status which cannot possibly be isolated from the broader historical context of economic injustices inflicted on African Americans in the U.S. According to Bailey et al., economic injustice includes the “residential, educational, and occupational segregation of marginalized groups to low-quality neighborhoods, schools, and jobs, reduced salary for the same work, and reduced rates of promotion despite similar performance evaluations” (1456). In this essay, I explore the impact of residential segregation as a form of economic injustice on healthcare accessibility and quality in African American communities.
Historical Context of Residential Segregation in the United States
The early- to mid-20th century saw an influx of discriminatory housing policies whose legacy continues to shape racial disparities within the healthcare system today. Most notably, the 1949 Housing Act provided federal funding for urban renewal and public housing projects that oftentimes resulted in the displacement of low-income and marginalized communities (Lampman 5). Furthermore, the Federal Housing Administration (FHA) enacted various redlining policies which denied services such as loans and insurance to those living in neighborhoods with a high concentration of African American residents. Although these discriminatory policies no longer exist, residential segregation is still prevalent in many U.S. neighborhoods today. 2010 U.S. Census data reveals that “the average white person in metropolitan America lives in a neighborhood that is 75% white,” whereas “a typical African American lives in a neighborhood that is only 35% white (not much different from 1940) and as much as 45% black” (Bailey et al. 1456). White et al. indicates that residential segregation “influenc[es] access, utilization, and quality across the full spectrum of health care” (1280), thereby playing a major role in the health outcomes of segregated communities.
Residential Segregation and Healthcare Accessibility
Healthcare accessibility refers to the ability of individuals to obtain necessary healthcare services. This encompasses several dimensions, including but not limited to financial access, physical access, cultural access, and linguistic access. Although other dimensions of healthcare accessibility are important topics of discussion that should be explored further, this essay specifically examines the link between residential segregation and the financial and physical dimensions of healthcare accessibility.
Ana Maria Deaver is a Black and Hispanic woman who lives in a rural county in North Carolina and works as an interpreter at CommWell Health. Similar to Eleanor, Ms. Deaver recalls using home remedies when she was sick as a child because her family could not afford to visit the doctor:
“When we got sick, the first thing my mama say, because I suffer with tonsillitis a lot when I was coming up, the first thing my mama say, ‘I’m gonna get me a bottle of castor oil.’ So castor oil an honey and some garlic, that was our medicine for our cold, and that’s what we were brought up on, castor oil, honey, and garlic. We didn’t go to the doctor as much because you wasn’t privileged to go to the doctor as much, but like I said, my father was a PA, so he used to give us medicine, but my mama always gave us castor oil.” (Ana Maria Deaver 17:02)
As Ms. Deaver demonstrates, the ability to visit the doctor is a financial privilege that many people, particularly those belonging to racial minorities, cannot afford. Research has shown that (1) residential segregation leads to the clustering of poverty in African American communities, and (2) poverty is a fundamental cause of racial health disparities (Cutler and Glaesar 863; Williams and Collins 406). As a result, financial barriers prevent many African Americans living in segregated communities from receiving necessary medical treatment. This is reflected in African Americans’ lower rates of use of healthcare services and increased likelihood of having no insurance or Medicaid coverage (Gaskin et al. 158-59).
Furthermore, healthcare is less physically accessible to African Americans living in segregated communities. Gaskin et al. shows that healthcare providers are less likely to reside in predominantly African American neighborhoods due to low provider reimbursement rates (162); there is an apparent “physician flight” phenomenon present in healthcare characterized by the relocation of providers and hospitals to mostly White areas (Caldwell et al. 105; Yearby 1121). Moreover, the percentage of African Americans residents in a neighborhood is the greatest determinant of hospital closures (Ko et al. 243; Yearby 1119). Compounded with decreased financial access to healthcare services, it becomes apparent why African Americans residing in predominantly African American areas are significantly less likely to use healthcare services compared to White people residing in predominantly White areas (Gaskin et al. 165).
Residential Segregation and Healthcare Quality
Even when African Americans in residentially segregated areas have access to healthcare services, the quality of the service they receive is oftentimes considerably worse. An extensive body of literature points to significant discrepancies in healthcare quality in residentially segregated areas. Residential segregation is a significant determinant of hospital quality when undergoing surgery; African Americans living in highly segregated neighborhoods are 41 to 96 percent more likely to undergo surgery in low-quality hospitals compared to those living in more heterogeneous neighborhoods (Dimick et al. 1046). Furthermore, institutions that reside near predominantly African American neighborhoods oftentimes care for uninsured patients and are thus underfunded, leading to limited resources and higher rates of patient safety events (White et al. 1282). As a result, adverse health outcomes are observed across the board for African Americans living in segregated areas, such as elevated risks of adult mortality, infant mortality, tuberculosis, and so forth (Williams and Collins 409).
Conclusion and Looking Ahead
Although Eleanor and Ana Maria Deaver make up a miniscule portion of the African American population, their experiences within the healthcare system sadly reflect the experiences of a large proportion of African Americans living in segregated areas. As demonstrated in this essay, inadequate healthcare is one of many pathways that perpetuate racial disparities in health, and its impacts are especially prominent in racially segregated areas. To combat this issue, policies should be implemented to repair discrepancies in healthcare accessibility and quality in highly segregated areas. This includes policies that increase funding to institutions residing near predominantly African American neighborhoods and promote community development in these areas. In the meantime, promoting culturally competent care by training healthcare providers to understand and address the unique needs of diverse populations can help mitigate racial bias in healthcare and improve health outcomes for disadvantaged populations.
References
Bailey, Zinzi D. et al. “Structural racism and health inequities in the USA: evidence and interventions.” The Lancet, vol. 389, no. 10077, 8 April 2017, pp. 1453-1463, https://doi.org/10.1016/s0140-6736(17)30569-x.
Caldwell, Julia et al. “Racial and ethnic residential segregation and access to health care in rural areas.” Health Place, vol. 43, January 2017, pp. 104-112, doi:10.1016/j.healthplace.2016.11.015
Cutler, David, and Glaesar, Edward. “Are Ghettos Good or Bad?” The Quarterly Journal of Economics, vol. 112, no. 3, 1 August 1997, pp. 827-872, https://doi.org/10.1162/003355397555361
Deaver, Ana Maria. Interview with Maddy Kameny. 28 June 2018 (Y-0020). Southern Oral History Program Collection (#4007), Southern Historical Collection, Wilson Library, University of North Carolina at Chapel Hill.
Dimick, Justin et al. “Black Patients More Likely Than Whites to Undergo Surgery At Low-Quality Hospitals in Segregated Regions.” Health Affairs, vol. 32, no. 6, 1 June 2013, pp. 1046-1053, https://doi-org.libproxy.lib.unc.edu/10.1377/hlthaff.2011.1365.
Eleanor (pseudonym). Interview with Madeline Katz. 30 July 2019 (Y-0111). Southern Oral History Collection #4007, Southern Historical Collection, Wilson Library, University of North Carolina at Chapel Hill.
Gaskin, Darrell et al. “Residential Segregation and Disparities in Health Care Services Utilization.” Medical Care Res Rev, vol. 69, no. 2, April 2012, pp. 158-175. https://doi.org/10.1177/1077558711420263.
Ko, Michelle et al. “Residential Segregation and the Survival of U.S. Urban Public Hospitals.” Medical Care Research and Review, vol. 71, no. 3, 19 December 2013, pp. 243-260, https://doi-org.libproxy.lib.unc.edu/10.1177/1077558713515079.
Lampman, Robert. “A history of residential segregation in the United States.” IRP Focus, vol. 34, no. 4, March 2019, pp. 2-9.
Tatum, Dale C. “Donald Trump and the Legacy of Bacon’s Rebellion.” Journal of Black Studies, vol. 48, no. 7, 7 October 2017, pp. 651-674. https://www.jstor.org/stable/26574529.
White, Kellee et al. “Elucidating the Role of Place in Health Care Disparities: The Example of Racial/Ethnic Residential Segregation.” Health Serv Res, vol. 47, no. 3, 8 May 2012, pp. 1225-1231. https://doi-org.libproxy.lib.unc.edu/10.1111/j.1475-6773.2012.01410.x.
Williams, D. R., and Collins, C. “Racial residential segregation: a fundamental cause of racial disparities in health.” Public Health Rep, vol. 116, no. 5, September 2001, pp. 404-416. doi:10.1093/phr/116.5.404.
Yearby, Ruqaiijah. “Racial Disparities in Health Status and Access to Healthcare: The Continuation of Inequality in the United States Due to Structural Racism.” The American Journal of Economics and Sociology, vol. 77, no. 3-4, 29 October 2018, pp. 1113-1152. https://doi-org.libproxy.lib.unc.edu/10.1111/ajes.12230.