What do you think is the single most important predictor of life expectancy at birth in the U.S.? Genetics? Education level of parents? Single parent families?
It turns out none of these are correct. The single most important predictor of life expectancy at birth is the zip code you are born in. These differences can be tremendous for communities just a few miles apart.
In Washington, D.C., for example, a baby born in the Barry Farm neighborhood can expect to live for 63.2 years. Yet, less than 10 miles away, a baby born in Friendship Heights and Friendship Village can expect to live 96.1 years, according to CDC data. That is a 33 year difference in life expectancy between two groups of people living less than 10 miles apart!
This zip code effect on life expectancy is due to social determinants of health. The CDC defines five domains of social determinants of health. They are:
- Health Care Access and Quality
- Education Access and Quality
- Social and Community Context
- Economic Stability
- Neighborhood and Built Environment
Social determinants of health account for one third of the deaths in the U.S. and 80 % of chronic disease. Lets compare Barry Farm and Friendship Heights in these domains
Barry Farm
There is only one hospital in the area and it is closing in 2023 due to economic and quality issues. Access to primary care is poor. Although there are some clinics in the area, they do not inspire confidence. Insurance coverage is mostly Medicaid. Private employer provided insurance is almost non-existent. Health literacy is low as evidenced by low high school graduation rate, high emergency department use for primary care issues and low use of existing primary care clinics. Another indicator of poor health literacy is a very high smoking rate. Barry Farm is a high density urban neighborhood where most people rent as opposed to own their homes. 92% of residents are black and median annual income is $13,750. The crime rate is high and many residents live in a deteriorating housing project that is scheduled for demolition. There is no place to buy fresh food. There is a recreation center with artificial turf for basketball and soccer. Access is mostly by car, but there is a Metro stop near the recreation center. Walking in the neighborhood is considered unsafe because of the high crime rate.
Friendship Heights
There is one private not-for profit hospital in ward 3 where Friendship Heights is. There are multiple other hospitals in Northwest DC where Friendship Heights is located. There are numerous primary care clinics nearby and access is easy. Over 80% of residents have employer sponsored health insurance. Health literacy is high. More than 85% of residents over age 25 have a bachelors degree or higher. The median annual income is $168,414. Most residents own their own homes. 67% of the residents are white and only 6% black. The crime rate is low, violent crimes only 6% higher than the national average. There are multiple grocery stores offering fresh food including Whole Foods, Rodman, and Amazon Fresh. There is a recreation center that offers multiple opportunities for outdoor exercise. Walking in the neighborhood is considered safe.
Structural Racism
Across the country, zip codes that have low life expectancy at birth have majority black or native american populations. In fact, the lowest life expectancy at birth in the country is in Stilwell, Okla., Census Tract 3769. This is a primarily Native American neighborhood with greater than fifty percent child poverty. The life expectancy at birth there is 56!
It is no accident that African Americans and Native Americans are concentrated in communities with high levels of poverty, lack of access to health care, poor access to education, high crime rates and live in deteriorating housing, most not owning their own homes. The following is a quote from an article in the New England Journal of Medicine. Here is a link to the whole article: How Structural Racism Works — Racist Policies as a Root Cause of U.S. Racial Health Inequities.
“In 1933, the federal government established the Home Owners’ Loan Corporation (HOLC) to expand homeownership as a part of recovery from the Great Depression.8 To guide determinations of mortgage-worthiness, HOLC created maps of at least 239 U.S. cities. Using racial composition as part of its assessment, HOLC staff literally drew red lines (hence “redlining”) around communities with large Black populations, flagging them as hazardous investment areas whose residents would not receive HOLC loans. Redlining made mortgages less accessible, rendering prospective Black homebuyers vulnerable to predatory terms, thereby increasing lender profits, reducing access to home ownership, and depriving these communities of an asset that is central to intergenerational wealth transfer. “
In addition to this federal policy establishing structural racism, many majority white communities instituted restrictive covenants preventing homeowners from selling their homes to African Americans. Although red lining was officially ended by the fair housing act in 1968, the damage was already done. Most African Americans and Native Americans were already too poor to live anywhere else.
Although structural racism is not listed among the CDC social determinants of health, it is obviously the largest underlying factor in zip codes or census tracts that have low life expectancy at birth.
The Blame Game
Instead of recognizing social inequities as the root cause of most ill health in the US, clinicians (as well as most of the rest of us) focus on changing individual behaviors. The person with diabetes who does not stick to the diet we prescribe gets labeled “non-compliant.” If we asked her we would learn that there are no grocery stores in her neighborhood that sell unprocessed foods, and even if there were, she could not afford them. She is taking care of her three grandchildren because their mother is in jail. She lives in substandard housing and has great difficulty getting transportation to her medical appointments. Managing her diabetes is understandably not high on her priority list!
This kind of scenario plays out again and again in our health care system. We focus on changing individual behavior and get frustrated and angry when most of the time it does not work. Non-adherent (a euphemism for non-compliant, which we don’t use anymore) is a word used all too frequently.
How can healthcare organizations address social determinants of health
The National Academies of Sciences, Engineering and Medicine has published a white paper called Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation’s Health. It is quite long, but you can download the pdf for free and it is definitely worth reading. Click on the link above for the website.
The authors of the white paper identified five activities that healthcare organizations can undertake to address social determinants of health. They are: awareness, adjustment, assistance, alignment, and advocacy.
Awareness
The best way for individual clinicians to increase their awareness of the pervasive influence of the social dimensions of health is for them to make home visits. Other team members such as social workers, behavioral health professionals and pharmacists should also make home visits at least on occasion. I made home visits for all the years of my time in practice and I saw for myself how living conditions affect people’s health. Asking people about social determinants of health helps awareness too, but nothing is as powerful as a home visit.
Adjustment
Adjustment means altering the parameters of care to help people overcome barriers to care. An example might be offering telehealth visits for people who have transportation difficulties. This is another opportunity to do home visits when an in person visit is needed.
Assistance
Assistance means reducing social risk by helping people connect with existing community resources. Those could be ride sharing services, FQHC dental clinics, food banks, financial assistance programs or any other existing community resources. Assistance of course requires that members of the team know what those resources are and communicate with them regularly.
Alignment
Alignment means working with existing social resources in the community, helping coordinate their activities and supporting them financially and helping them raise funds from other sources. An example might be working with local groups to coordinate providing healthy meals to people with food insecurity (Check out this JAMA article detailing how many children in the US have food insecurity: Food Insecurity Common Among US Children).
Advocacy
Most important of all is working to change policies to promote equity. Join and support organizations that work for equity. Write or call your congressperson and/or senator to support policy changes that decrease inequity in all the social determinants of health. Health care professionals carry more weight than they realize with city councils and legislators. Use that influence! Your congressperson should know who you are!
Bottom Line
Your zip code determines your fate and how long you will live. That is caused by vast inequity in the social determinants of health. Stuctural racism is at the root of much of this inequity. We should all consider this unacceptable. It is up to every one of us to advocate for polices that reduce inequity. We all should have at least some of the things people enjoy in Friendship Heights.