Imagine walking a mile or so home from the bus stop with your hands full of groceries. Imagine walking a mile or so to the bus stop when you are ill so that you can go to the doctor. This is the reality for so many Americans. Inequities in transportation contribute poor health outcomes reported for low-income people, particularly those of color. Specifically traffic-related air pollution and minimized autonomy to safely practice active forms of transportation (e.g. walking, bicycling). The structural and built environments that low-income people of color occupy have been heavily influenced by histories of racism in infrastructure and neighborhood development in United States, and continues to influence people's health today.
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A historical factor contributing to modern day inequities in transportation includes the expansion of suburban living, which took place in the 1950s. Suburban living was an exclusionary phenomenon that served as an extension of Jim Crow ideology—there were restrictive covenants that barred most Black, Asian, and Hispanic families from living in suburban neighborhoods at all. It was commonly believed that the presence of people of color in subdivisions would lower the value of the properties and banks refused to loan money to people living in the inner city, which were primarily occupied by people of color. Suburban living promoted the use of automobiles for transportation because the sprawled out living meant that more people needed cars to get around. This expansion to suburbs led to the vast expansion of America’s highway system.     

The highway boom resulting from the rise of suburbia in the mid-twentieth century, which consisted of the building of the American interstate highway system, was completely destructive for the thriving Black neighborhoods of that time as well as other communities of color. Not only was housing destroyed for prospering Black communities, but churches and businesses were lost as well. Losing pivotal local institutions altered the sense of community that Black populations experienced, which has implications that are still felt today.    
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Seeing that highway infrastructure has historically been built through black and brown neighborhoods, it is not surprising to see that communities of color are still likely to live near highways. Hispanic people are 38% more likely and Black people are 30% more likely than White people to live within 300 meters of major highways, where rates of respiratory and cardiovascular diseases are increased.[1] The EPA estimates that the heavy concentration of minuscule air particles from highway traffic causes up to 100,000 annual deaths in the U.S., which serves as one mechanism for the number of chronic illnesses that people of color disproportionately experience. These preventable conditions have taken their toll on the healthcare system, specifically in safety net medical centers which are more likely to treat patients of color who are low income. The health costs associated with poor air quality from the U.S. transportation system is roughly $50 to $80 billion dollars, with the presence of communities near major highways and roadways driving the costs.[2] 

Low-income people of color are also more likely to live in communities that do not support active transportation. Only 49% of low-income neighborhoods have sidewalks and only 5% have requirements for bicycle lanes, which limits the health benefits that low-income persons of color could gain from walking and biking.[2] Not having the physical infrastructure necessary to navigate one’s neighborhood safely leads to an increase in road injuries as well. Black people and Hispanic people are twice as likely to be killed while walking compared to white people. Likewise, black people are 30% and Hispanic people are 23% more likely to be killed while bicycling than white people.[2] Living in a physically underdeveloped neighborhood without a car also makes it harder to access public transportation, which makes accessing grocery stores and medical care increasingly difficult. People must walk to bus stops that are often just outside of their neighborhoods, which can be a journey in an of itself.

Black and brown people are stigmatized for our disproportionate rates of chronic and infectious diseases. The social and physical environments forced upon black and brown people, however, often constrain our agency and influences our health behaviors. Living in a highly polluted environment or in a neighborhood without sidewalks has health consequences that goes beyond individual control. There is a lot of work to be done to improve the infrastructure of low-income neighborhoods of color in ways that can enhance rather than disrupt our communities.      

References

1. Boehmer, T. K., Foster, S. L., Henry, J. R., Woghiren-Akinnifesi, E. L., Yip, F. Y., National Center for Environmental Health, CDC, & Agency for Toxic Substances and Disease Registry. (2013, November 22). Residential Proximity to Major Highways — United States, 2010. In CDC Home. Retrieved from https://www.cdc.gov/mmwr/preview/mmwrhtml/su6203a8.htm
2. Zimmerman, S., Lieberman, M., Kramer, K., & Sadler, B. (2015). At the Intersection of Active Transportation and Equity (Rep.). Oakland, CA: Safe Routes to School National Partnership. doi: https://www.apha.org//media/files/pdf/topics/environment/srts_activetranspequity_report_2015.ashx?la=en&hash=4B088BB4405E6FA97B6E552CEEED8D7B6958A265  

A summary of important health news from the past week.

New analysis shows that more than half of the countries making up the United Nations will fail to reduce premature deaths from cancer, cardiovascular disease, chronic respiratory disease, and diabetes by 2030. These were commitments that all countries in the UN agreed to under the latest version of the Sustainable Development Goals (SDGs) that were introduced in 2015. The SDGs are thought of as a blueprint for achieving global well-being with aims ranging from "no poverty" to "quality education."  

Due to a July 1st bill, New York state students will have mental health included in their health curriculum. This is the first state in the country to mandate mental health content in general health courses and is in response to both rising rates of mental health concerns and the stigma associated with mental illness. Students will be taught about mental health and illness as well as relevant skills and resources they can apply to their lives. 

In Washington State, the King County Board of Health has voted to officially declare homelessness a public health disaster. Last year, 169 people experiencing homelessness died in the County, a record high, and about half of those deaths occurred outdoors. In addition to exposure to the elements, these populations are also more vulnerable to outbreaks of infectious diseases like HIV and hepatitis A. ​

The Department of Health and Human Services has analyzed savings rates within the Accountable Care Organization model of care, in comparison to a managed care systems. Their analysis has shown that the model is yielding greater savings rates in the past five years than the managed care model has in decades. 

​Last week the Centers for Disease Control and Prevention announced that the number of people with Alzheimer’s is expected to triple over the next 40 years—from 5 million cases to nearly 14 million cases. Part of this increase will be due to population growth and longer lifespans. While the body of research around Alzheimer’s has grown in recent years, there is still no treatment or cure for the disease. Experts say that while Alzheimer’s is difficult to prevent, lowering blood pressure has been shown to significantly lower risk, and exercise has been shown to delay symptoms. 

Today we bring you the Morbidity and Mortality Weekly Report (MMWR) podcast from the Centers for Disease Control and Prevention (CDC). This week's topic is chronic pain and covers what it is like to live with chronic pain and how to seek help for pain management. Follow the links below for a short overview or a more in-depth discussion.

A Minute of Health (1:00)
A Cup of Health (4:02)

​By: Deanna Altomara

​Hurricane Florence has created havoc in North Carolina, wreaking damage on homes, flooding whole towns, dismantling beaches and businesses, and killing at least thirty people. Yet as the floodwaters begin to recede, they are revealing the watermarks of a phenomenon that is potentially more dangerous than the storm itself--environmental contamination.

An ad for the NIH's All of Us research program. Photo via Flickr.

A summary of important health news from the last week. 

New restrictions under the Medicare Advantage plans could require patients to try low-priced drugs before high-priced ones. Medicare Advantage plans, which are run under private companies approved by traditional Medicare, cover approximately 20 million people across the country. Critics are concerned that patients will not be treated with their doctors’ drug-of-choice, while proponents argue that this move will pressure drug manufacturers to lower costs. Patients and doctors will be able to request exceptions from this policy. ​

The FDA has determined the use of e-cigarettes among teenagers to be at epidemic proportions, which has led the federal agency to consider taking e-cigarette products off the market. The FDA has also been taking action to limit the astronomical number of sales of e-cigarettes to minors, occurring via online and retail markets. This is the largest single enforcement action in the history of the federal agency.

A team of researchers from Harvard Medical School and the RAND Corporation reported last Monday that from 2006 to 2015, physicians provided no explanation for 29% of the opioid prescriptions they wrote. This research echoes concerns voiced by the Centers for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA) that inappropriate prescribing patterns among physicians in recent years have worsened the opioid crisis. In 2016 alone, 42,000 people dies from opioid-related deaths.

Motivated by personal experience with home health workers, reporter Linda Matchan started looking into home health workers. She found both neglect and abuse at the hands of home health workers, but also stories of people traveling from around the world to improve their lives and the lives of their families. This short documentary tells the stories on both sides. 

Maternal mortality, death that occurs during pregnancy or shortly after, is used by the World Health Organization as an indicator of how healthy one country is compared to others. A common misconception is that maternal mortality is a public health issue reserved for developing nations. The United States, however, has the worst maternal mortality rate of any nation—despite spending more money on hospital-based maternity care than any other country in the world. Ranking 47th globally for maternal mortality, the United States also fares worse than many developing countries in protecting women from death during childbirth.
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When looking at the factor of race, we see that black women are three to four times more likely to die as a result of childbirth than white women. According to the Centers for Disease Control and Prevention, this is one of the widest racial disparities present in women’s health, which is driving the international disparity for the United States. Furthermore, racial disparities in maternal mortality persist across income and educational levels for black women, revealing that traditional social protectants are not effective for black women in the maternal mortality crisis. In New York City, college educated black women are twice as likely to die from childbirth than white women who never finished high school. One study demonstrated this ideology as well by demonstrating that race/ethnicity was the strongest predictor for maternal death or near miss, with Black women suffering disproportionately from maternal death across income lines. [1]

The Serena Williams’ story, among others, help us to put a face to this reproductive injustice. Williams’ narrative paints a picture of how medical providers are not listening to women of color during the deliveries of their babies.

Many black women have turned to doulas to assist during their birthing process so that they can receive culturally competent care that is tailored to them. A doula is defined as a person who is trained to provide advice, emotional support, and physical comfort to mothers before, during, and shortly after childbirth. A doula is not to be confused with a midwife, who is a medical provider who helps to deliver the baby. Doulas and midwives, however, can and often do work together to support women during pregnancy. For many black women it is the difference between life and death.
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Darline Turner, physician assistant and certified doula in Austin, Texas, took matters into her own hands when responding to the pressing human rights concern of disproportionately high rates of maternal mortality affecting black women. She was startled by the nonchalance and lack of urgency surrounding the issue. So she started Healing Hands Community Doula Project, an organization that provides pregnancy care and support to black women of all economic backgrounds. When discussing her vision for Healing Hands Community Doula Project, Turner said, “Any black woman who so desires will be able to have the support, resources, information, education to have a healthy full-term infant and to live to see that infant grow up to be an adult.” 

There has been a surge of community health solutions like Healing Hands Community Doula Project that have increased culturally competent care for black women, which has been proven by research to be more effective than the medical system’s traditional approach. One such study focused on the impact of doulas on healthy birth outcomes and reveals that expectant mothers matched with a doula had significantly better birth outcomes compared to women who were not assisted by a doula. Doula-assisted mothers were four times less likely to have a low birth weight baby and two times less likely to experience a birth complication involving themselves or their baby. [2] These results show that there is hope that the maternal mortality crisis can be resolved. Doulas actively listen to mothers throughout their birthing process and provide them with emotional support so that the pregnancy process is tailored specifically to the needs of each individual mother.

The research and experiences documented about the doula movement signal that more solutions outside of the medical system may be effective in reducing racial disparities in maternal mortality. When speaking about the maternal mortality crisis, medical ethicist Harriet Washington looks to the past. She notes that “trying to understand a historical problem without knowing its history is like trying to treat a patient without eliciting their medical history–you’re doomed to failure.” Washington claims that the American medical system is still haunted by the history of slavery, which involved medical experimentation on enslaved African women to create the modern practice of gynecology and obstetrics. 

The doula movement and other community health initiatives provide an alternative to the institutional racism that all black women face when entering the medical system, regardless of their level of education or income status. The State of New York has expanded the use of doulas to reduce childbirth deaths. Americans can only hope that the federal government or other state governments will take similar action because women of color cannot continue to wait for this urgent issue of human rights and reproductive justice to be addressed. Their lives literally depend on it.

References

1. Goffman, D., Madden, R. C., Harrison, E. A., Merkatz, I. R., & Chazotte, C. (2007). Predictors of maternal mortality and near-miss maternal morbidity. Journal of Perinatology, 27(10), 597-601. doi:10.1038/sj.jp.7211810
   
2. Gruber, K. J., Cupito, S. H., & Dobson, C. F. (2013). Impact of Doulas on Healthy Birth Outcomes. The Journal of Perinatal Education, 22(1), 49-58. doi:10.1891/1058-1243.22.1.49 

A summary of important health news from the past week. 

With physical activity levels continuing to trend downwards worldwide, a World Health Organization (WHO) study has shown that people are in need of lifestyle modifications. The researchers recorded people's activity levels at work and at home.  Their results showed a distinction between wealthier and lower-income countries: the former seeing a larger shift towards more sedentary occupations and modes of transportation. Even still, physical inactivity proves to be "pandemic" and researchers agree that there is no simple solution to this worldwide problem. In this fight against physical inactivity, they are suggesting that "small changes" in daily life can help combat the lack of activity.  

As climate change hurtles forward, wildfires are predicted to burn more frequently, creating cataclysmic scenes of smoke and ash that have already decimated California this summer. But very little is known about the health consequences of wildfires−so scientists are making these natural disasters into natural experiments. They are collecting data from towns and a local primate research center that have been hit and are likely to be hit in the future, analyzing blood samples, respiratory function, and even donated placentas for clues as to how wildfires impact health. ​

Researchers are showing a renewed interested in an infectious disease model for Alzheimer's Disease, which is a theory that was first suggested in the early 20th century. Some have noticed that the disease show similarities in pattern with infectious disease. Other researchers are interested in exploring the possibility of viruses, like herpes, which may combined with particular genetic combinations to contribute to the development of dementias and Alzheimer's Disease. 

The CDC recently released a report detailing the high incidence of STDs across the country, which many are considering a public health emergency. Montgomery County in Maryland has made efforts to address the high incidence of STDs in their county. The county will start stocking condoms at health centers it runs in four of their public high schools. Two Montgomery County officials are pushing to get condoms stocked in all high schools and middle schools as well. 

​Researchers are making progress in evaluating an existing drug, Ibudilast, in its ability to treat patients with multiple sclerosis (MS). Ibudilast is approved in Japan to treat asthma and prevent stoke, but has not yet been approved in the United States. Researchers in a phase-II trial found that patients taking Ibudilast experienced a 48 percent lower progression of brain atrophy when compared to participants who took a placebo. Other research has pointed to Ibudilast’s anti-inflammatory properties, as well as its potential in treating amyotrophic lateral sclerosis (ALS) as well as substance abuse and addiction.

​This Health Affairs article discusses the role of the United States in hindering advances in global health initiatives due to its own corporate interests. The article points to a recent example from May 2018, when the U.S. threatened to impose trade sanctions on Ecuador if they continued to support a resolution that encouraged women to breastfeed. This was in the interest of the U.S. infant formula industry. The article focuses on past presidential administrations, but mostly focuses on the behavior of the Trump administration. Finally, the article concludes with how other countries can respond to these actions and continue to protect global health initiatives.