Two New York City police officers gestured for me to approach. “There’s someone in this station illegally selling MetroCard swipes,” one said, giving me a stern look. “Can I take a look at your card?” The officers studied my pass, glanced at each other, and studied my pass again. Finally, the second officer handed it back to me, saying, “You’re good to go.”

From the subway platform, I watched the officers to see who they would stop next. One person passed by uneventfully, then ten, then more. The reality of the situation set in: I had been profiled. All day, I asked myself, “Do I look like a criminal?”

My daily commute to school, once mindless, now became an exercise in hypervigilance. Each time I passed those turnstiles in the next weeks, I mentally replayed my encounter with the police officers. My heartbeat quickened and my muscles tensed. The experience lodged in my mind and body, long after the incident, a familiar phenomenon for people who experience discrimination.

A growing body of research suggests that racial discrimination is associated with poorer health outcomes, such as higher risks of cardiovascular disease, inflammation, and poorer immune function. This discrimination is strongly linked to accelerated aging at a cellular level. However, we’re still learning exactly how racial discrimination causes these problems.

As a neuroscientist, I have been interested in how racism’s effects on the brain may play a role. All of us create mental representations of stressful events in the past and anticipate that these events will reoccur. This neurological process keeps the stressor alive in our minds. And this is how racial discrimination becomes a chronic stressor for many Black Americans. Even when we’re not experiencing racial discrimination, past discrimination lives on in our minds, reminding us of what happened and preparing us for the future.

These chronic mental representations can show up in the body by activating our endocrine, cardiovascular, and immune systems. This sustained activation, over time, can harm these systems, weathering them—which can accelerate the aging process and the earlier onset of age-related health conditions.

The premise behind research on factors that accelerate the aging process is that we possess two forms of age; chronological age, which is in relation related to our birthdate, and biological age, which is associated with age-related functioning of cells, tissues, and organ systems. With normal aging, we see a near-linear relationship between these two forms of age. As we get older, a gradual decline in the functioning of our body occurs and this decline precedes age-related health problems.

However, under conditions of chronic stress, the biological aging process begins to outpace that of chronological age. This mismatch in aging may then be a key factor in observing how two different individuals of the same chronological age have different health trajectories.

There have been several biological markers, considered the hallmarks of aging, that have been used to examine accelerated aging. One occurs when our DNA undergoes epigenetic modifications or changes in function that then influence cell and tissue function. These epigenetic changes have been consistently correlated with chronological aging. This led to the formation of epigenetic clocks that predict chronological age based on one’s epigenetic makeup. While these clocks proved to be highly accurate, they also illuminated that certain individuals’ biological ages were older than their current ages; a process known as accelerated epigenetic aging.

Racial discrimination research has examined epigenetic accelerated aging as a potential pathway linking racial discrimination and poorer health outcomes in Black individuals. Emerging evidence suggests that not only do Black Americans exhibit greater epigenetic accelerating aging compared to their White counterparts but greater exposure to racial discrimination is a key factor underlying accelerating aging. These findings have supported earlier work showing strong associations between racial discrimination and other age-related metrics such as inflammation and telomere length. 

Earlier research in my laboratory and others has shown that racial discrimination is associated with greater engagement and connectivity of brain areas associated with stress and emotion. To extend this research, I examined whether changes in brain activity would influence racial discrimination’s effects on accelerated aging.

We found that racial discrimination was associated with greater connectivity between the left locus coeruleus, a brain area critical to coordinating our attention to external or internal stimuli, and the precuneus, an area involved in recalling past personal events. This connectivity pattern, in turn, was linked to accelerated epigenetic aging. These findings proposed a pathway through the brain in which exposure to racial discrimination may affect the way our body ages.

This connectivity pattern provides neurobiological support for the idea that racial discrimination remains psychologically “alive” through greater engagement of brain areas that coordinate and focus attention to past experiences, and in doing so, affect the aging of the body. 

I believe our research points to the growing evidence highlighting the pervasive effects of racism on the health of Black people. Our nation has poor progress in improving race relations; studies highlight a critical need for measures that help protect Black people from the harmful effects of racism.

Programs that address implicit bias, which can lead to discriminatory behaviors, are one form of prevention. States like California and Massachusetts have created legislation mandating implicit bias training for health care providers. President Trump’s executive orders ending all diversity, equity, and inclusion polices and programs in the federal government—and threatening policies in the private sector—jeopardizes this progress. We’re still learning more about the connection between discrimination and the brain, but this we know: Reducing exposure to racism should be paramount in protecting the health of Black people.

Source image: Dusan Stankovic / iStock

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—Leah Rosenbaum

(Study in American Journal of Epidemiology, November 2024)

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Benjamin is executive director of the American Public Health Association and one of four editors of the “Ending Unequal Treatment,” a 374-page report published this summer by the National Academies of Sciences, Engineering, and Medicine. The publication is a follow-up to “Unequal Treatment,” the 2003 landmark study by the Institutes of Medicine. That report found that people of color experienced worse health outcomes regardless of their economic circumstances, and it first put the issue of racial inequities in health care on the map. Its recommendations focused on ending racism in the health care system.

In the ensuing two decades, however, little progress has been made in closing those gaps. “We certainly found there has been progress, but it’s been uneven and inconsistent,” Benjamin says.

Benjamin and his coauthors understood that, this time around, they had to grapple with challenges bigger than—and ultimately outside the control of—the health sector. They are challenges both social and structural, either directly caused or exacerbated by structural racism—challenges like racial profiling in the criminal justice system, housing and food insecurity (especially as a result of historic redlining and job discrimination), and pollution and other environmental injustice, which require a different approach from the health system to address. “The injustices we see are based on the way the system is designed, financed, and delivered,” he says. “You are not going to fix them unless you fix the fundamental structural inequities we have in our system.”

The solutions the report recommends are ambitious: expanding access to health insurance (and making Medicaid reimbursement rates more equitable); collecting racial data more systematically; researching and supporting more team- and community-based interventions; and enforcing equity-based outcomes with stricter accountability.

Diversifying data

Benjamin says one easy way to improve data collection about race—and thus reveal patterns in outcomes, better allowing for accountability on equity in health outcomes—would be to include racial information on billing forms. “The tools are there, the technology is there, but we have not invested in the systems to do it,” he says.

University of Minnesota Professor Rachel Hardeman, who directs the Center for Antiracism Research for Health Equity, agrees it’s important to “make the invisible visible” through a “robust and rigorous data infrastructure.” Hardeman began her own work in the field after reading the first Unequal Treatment report in grad school. But she isn’t convinced that the latest report goes far enough. Hardeman would like to see the collection of more qualitative and anecdotal data, particularly from patients who experience interventions that improve care. “It’s not just about the quantitative numbers and logistic regressions,” she says. “We also have to be thinking about the people and the stories behind … every P value.”

Expanding access

Reducing the number of people lacking medical insurance, who are overwhelmingly racial minorities, should be a priority, the report says. “The biggest issue is improving access to care,” agrees Lisa Cooper, a professor at Johns Hopkins Bloomberg School of Public Health and the founding director of the John Hopkins Center for Health Equity, who also served as a reviewer on the report. “Physicians are hampered in what they can do by knowing people don’t actually have the coverage to pay for needed tests and therapies.” (The original report controlled for insurance status, looking at inequities in treatment based on racial bias; the new report examines insurance access as a systemic issue that contributes to inequities in care.)

While the Affordable Care Act (ACA) has dramatically expanded coverage, ten states have not expanded Medicaid, the joint state-federal program for people with low incomes. Many of them are southern states with conservative legislators who have long opposed the ACA on ideological grounds—states that also have large Black and Latino communities. According to a recent Congressional analysis, 1.6 million people in those states are unable to afford insurance; two-thirds of those for whom insurance is a challenge are people of color. Four of those 10 states are also among those reporting the highest level of inequities in patient outcomes. In those cases, the report notes, patients often rely on emergency care, which is both more expensive and less effective than upstream preventative care. Even states that have expanded Medicaid often don’t reimburse at the same rates as the federal Medicare program for seniors, leading to gaps in coverage and denial of care. The report recommends closing this gap to increase the number of people who can access high-quality care.

Greater investment in community-based solutions may also expand access to health. Studies have found that community health workers can be particularly effective with minority populations, both by providing culturally appropriate care and helping to address neglected issues arising from poverty, food or housing insecurity, incarceration, and other issues more likely to affect communities of color.

“There is so much incredible work happening in the communities in little pockets all across the country,” says Hardeman. As an example, she points to the Roots Community Birth Center in Minneapolis, run by and for Black women, which customizes a birthing plan for individuals’ needs. In a recent study of the center, cited in the “Ending Unequal Treatment” report, Hardeman found that it achieved much better outcomes for women of color, with zero preterm births for 284 families in four years. Such models, however, are not well-funded by traditional payment methods. “If there were funding for coordinated and sustainable efforts, I think we would be having very different discussions right now,” Hardeman says.

One positive development, says Cooper, are offices within hospitals that are partnering with outside entities to collaborate on care. “[It is] in the common interest of so many different groups to identify each sector’s role,” she says. “What does the health system do best that it should continue to do, and what can other people, systems, and organizations do in a more effective way?”

Still a ways to go

“Ending Unequal Treatment” is less sanguine about unconscious bias trainings meant to reduce inequities in quality of care and often implemented in medical school or health care settings. While there is strong evidence that implicit bias exists, the evidence about effectiveness of trainings has been mixed. Cooper remains optimistic. “It’s not that it’s ineffective; it’s just that the data are inconclusive,” she says.

Even interventions with good data behind them face hurdles. One major impediment, says Commonwealth Fund President Joseph Betancourt, is that they tend to be funded by foundations—and when the grants dry up, so do the interventions. “We’ve known for a long time that community health workers, health navigators, and health care coaches improve health outcomes,” says Betancourt, who is also an associate professor of medicine at Harvard Medical School and an author of the original “Unequal Treatment” report. Because there isn’t “sustainable financing,” he says, “we are not integrating these successful models into the system.”

Health care, meanwhile, has made strides in quality of care thanks to innovations such as accountable care organizations, which reimburse costs based on patient outcomes, rather than a traditional pay-for-service model. Without taking equity into account, however, such models can actually increase disparities by incentivizing systems not to treat individuals with more complex medical problems, who are more likely to be racial minorities. “If you have these systems that allow people to cherry pick who they care for based on the way they are designed and paid for,” says Benjamin, “then they are driven by a desire to improve revenues over improving care as the primary goal.”

The report recommends embedding equity measures into such models, making equity in outcomes across racial populations a factor not only in how systems are paid, but in how doctors are licensed and hospitals are accredited. “We need to be thinking about racialized health equity outcomes in the accreditation process and payments and bonuses, and embed anti-racism into accountable care models,” Hardeman says. “We haven’t even scratched the surface of this because we haven’t wanted to shake the status quo.”

Ongoing backlash against diversity, equity, and inclusion efforts meant to improve racial justice could make it more difficult to implement some of the report’s recommendations. But its authors don’t shy away from denouncing that backlash. “We should not accept the mistaken assumption that when you give one group of people better care, it takes away from other people’s needs,” Benjamin says.

The biggest impediment to the report’s recommendations is federal funding. Many recommendations would require Congress or state legislators to earmark additional revenue for data collection, Medicaid reimbursement, and discrimination enforcement; they also require government or insurers to supply sustainable funding for health care interventions. Benjamin, however, is optimistic that many of the report’s recommendations could be accomplished by redirecting funds, rather than increasing them. “I’m hoping the next administration and Congress will recognize that health care costs under the current system are going through the roof, but if they follow the recommendations we put in place, they can get better care at lower cost,” he says.

Betancourt agrees. “It’s not necessarily about spending more,” he says, “it’s about spending the resources we have in a smarter way for better outcomes.”

Top image: Ellagrin / iStock

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More than 42 million people who live in the United States still don’t have internet access. People of color and people who live in rural and low-income areas are hit the hardest, thanks to digital redlining—unequal investment practices in broadband infrastructure that can be traced back to the federal government’s neighborhood redlining policies, originating in the late 1930s.

These policies deliberately segregated neighborhoods by race and ethnicity and prevented predominantly Black communities from accessing opportunities, such as homeownership and financial support. Over time, this led to significant economic and social neglect in these communities, contributing substantially to racial health disparities.

Although redlining was outlawed in 1968, digital redlining is a modern manifestation that continues to perpetuate existing inequities, resulting in diminished access to essential services like health care, education, and job opportunities. Digital redlining particularly affects marginalized groups such as Black, Indigenous, and Latino communities, individuals with low income, and those living in rural areas.

Examples of digital redlining include internet service providers charging the same or higher rates for internet access regardless of service quality; targeting advertisements based on personal data, which exacerbates existing inequities; and offering disparate access to and speed of online services based on factors like neighborhood income and racial demographics.

For instance, data from Los Angeles County between 2014 and 2018 showed a direct correlation between race, income, and investment in broadband infrastructure by internet service providers. Not only were Black and low-income neighborhoods less likely to have broadband, but providers were less likely to offer residents competitive prices.

Internet service also varies significantly by geography: In urban areas, as much as 98.8 percent of people have access (defined by the Federal Communications Commission as the minimum benchmark speed); in rural areas, that falls to 82.7 percent; and in tribal areas, 79.1 percent. Even in areas with broadband, speed and price vary widely; high-income neighborhoods can access speeds up to 400 times faster than low-income neighborhoods at the same price.

The urgency of the problem is underscored by recent legislative efforts to enhance broadband infrastructure. The Biden administration’s ambitious $42 billion proposal aims to provide universal broadband by 2030. The COVID-19 pandemic underscores the importance of access to digital resources, especially with telehealth becoming a crucial lifeline for millions.

The Accurate Map for Broadband Investment Act of 2023 revamps the Broadband Equity, Access, and Deployment (BEAD) Program and is designed to enhance broadband internet access nationwide. The BEAD Program, overseen by the National Telecommunications and Information Administration (NTIA), supports broadband projects. Currently, funds are allocated based on data from the map, and states receive funds in stages. Under the proposed legislation, after the initial distribution, the NTIA will reallocate the remaining funds based on the updated map to ensure equitable distribution.

Another option could be revitalizing the discontinued Affordable Connectivity Program. This bipartisan initiative that began in 2021 and ended earlier this year helped more than 23 million low-income households afford broadband internet through ongoing discounts on internet bills and one-time discounts for purchasing computers or tablet devices.

States and cities are part of the solution, too. The “Minnesota Model” is noteworthy for its legislatively-mandated state broadband speed goals, managed by the state’s Office of Broadband Development. This office oversees the state’s internet grant-matching and technical assistance program, working with the Rural Broadband Coalition to ensure broadband access reaches all corners of the state. And the United Way of the National Capital Area ranked cities including Sacramento, California, Seattle, Washington, and Boston, Massachusetts as some of the best in the nation for digital equity, based on factors including access to low-priced broadband, the number of free Wi-Fi hotspots, and the percentage of adults with internet plans.

There is still much to be done. By leveraging innovative solutions and collaborative efforts and learning from successful case studies at the state and local levels, we can bridge the digital divide so that access to essential services is a right for all and not a luxury for some.

Image: calvindexter / iStock

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On the banks of the lower Mississippi River in St. James Parish, Louisiana, on sprawling tracts of land that break up the vast wetlands, hulking petrochemical complexes light the sky day and night. They piled up over the past half-century, built by fossil fuel giants like Nucor and Occidental. In that time, they replaced farmland with concrete and steel and threaded the levees with pipelines that carry natural gas from as far away as West Texas. When the plants came, the lush landscape of this part of south Louisiana deteriorated.

“The pecans are dry. They don’t yield like they used to,” said Gail LeBoeuf, a longtime resident of the region and a cofounder of the community group Inclusive Louisiana. “The fig trees, the blackberries—all that I came up making a living off of is not there anymore.”

LeBoeuf is a leading activist in “Cancer Alley,” the 85-mile stretch of land between Baton Rouge and New Orleans where strips of residential blocks are sandwiched between the region’s more than 150 petrochemical plants. She has spent the past several years fighting a new wave of industrial development headed to her parish—in particular, to its predominantly Black neighborhoods.

The racialized permitting practices visible across Cancer Alley are particularly pronounced in St. James, where 20 of the parish’s 24 plants are located in the majority-Black 4th and 5th districts—an equivalent of one plant for every 250 people. In 2014, the parish council passed a zoning ordinance that marked much of those two districts for industrial use. That same year, the council barred two chemical companies, Petroplex and Wolverine, from constructing new industrial plants in the majority-White 3rd District. In 2022, the council conceded to White residents’ demands for a moratorium on solar farm development until they commissioned a study to determine if the project might lower their property values or put their homes at risk during a hurricane.

Since 2018, the parish has supported the construction of a new $9.4 billion plastics manufacturing complex owned by the Taiwanese chemical giant Formosa in the 5th District. On a tract of land approximately the size of 80 football fields, the company plans to build 16 facilities that would release cancer-causing pollutants like ethylene oxide and vinyl chloride. The nearest neighborhood is approximately one mile down the road. A study by ProPublica found that Formosa’s emissions could more than triple the cancer risk in some St. James neighborhoods.

In March 2023, the Mount Triumph Baptist Church and the local organizations Rise St. James and Inclusive Louisiana filed a lawsuit against the parish government, seeking an end to this alleged practice of discriminatory permitting. They hope to have a moratorium put in place on the licensing of heavy industry “and the correspondingly lethal levels of pollution” in the parish’s Black areas. Environmental advocates hailed it as a landmark case. But last November, a federal judge dismissed the complaint’s racial discrimination claims, pegging them to the 2014 zoning ordinance, and arguing that they are barred by the statute of limitations, which lasts for one year. “Although plaintiffs’ claims are procedurally deficient, this court cannot say that their claims lack a basis in fact or rely on a meritless legal theory,” U.S. District Judge Carl Barbier of the Eastern District of Louisiana wrote in his decision.

Earlier this month, lawyers representing St. James residents presented their argument about the statute of limitations to the U.S. Fifth Circuit Court of Appeals. They claim that the parish’s long-standing practice of discriminatory land use decisions constitutes a “continuing violation” that cannot be dismissed simply because the zoning ordinance was passed outside the one-year statute of limitations period.

“The parish’s decades-long policy, practice, and custom of not only steering and luring lethal petrochemical plants to majority-Black districts, but doing so while implementing protections only for majority-White districts is discriminatory and unlawful,” said Sadaf Doost, an attorney at the Center for Constitutional Rights, in a press release.

The defendant’s lawyers said that the plaintiffs should have taken note of the parish’s discriminatory zoning as soon as the ordinance was passed in 2014 and sued within the year. Judge Karen Hayes, who is hearing the appeal, seemed to challenge this reasoning, which, she said, makes it sound like “if you didn’t sue within a year then you can be discriminated against in a bunch of different ways until the rest of eternity.”

Additionally, the plaintiffs’ lawyers, who are from the Center for Constitutional Rights and Tulane University’s Environmental Law Clinic, pushed back on the district judge’s finding last year that the plaintiffs lacked standing to bring a claim under the Religious Land Use and Institutionalized Persons Act and the Louisiana Constitution’s protection of historic linguistic and cultural origins.

The wide tracts of land along the Mississippi River that chemical companies bought up to build their sprawling industrial complexes were once plantations that used slave labor to grow sugarcane. Louisiana’s state archeologist, Charles McGimsey, believes that every former plantation in St. James contains unmarked cemeteries of former slaves. And so the plaintiffs are arguing that the parish’s land use decisions are discriminatory because they allow chemical companies to build plants on land that is culturally significant.

“Indeed, one of the lingering traumas of slavery is the inability of descendants to locate the gravesites of their ancestors,” the plaintiffs wrote in their original complaint. “But, in those cases where cemeteries can be identified, that location bears profound cultural, historical, and religious significance for descendants.”

Last year, the district judge said that any harm to sites of historic, cultural, or religious significance is the fault of petrochemical companies—not the parish council. On Oct. 7, the plaintiffs’ lawyers countered by arguing that the council’s zoning and permitting decisions have led to the destruction of the unmarked grave sites.

The parish did not respond to multiple requests for comment.

The success of the St. James case will hinge principally on whether the court accepts the plaintiffs’ argument about the statute of limitations, which would apply to four of their seven claims. If the judge also finds the racial discrimination complaints compelling, then the plaintiffs will have a stronger case. In the current judicial-political landscape, there are fewer legal mechanisms to argue cases of discrimination, particularly when it comes to environmental harms.

Historically, environmental groups have had difficulty proving discrimination under the U.S. Constitution’s equal protection clause since it focuses on discriminatory intent rather than prejudicial outcomes. “In order to be able to show that this discrimination is intentional you have to point to this pattern”—the parish council rejecting a solar farm in a White neighborhood but building a plastics plant in a Black one—said Pam Spees of the Center for Constitutional Rights on Monday. “They know what they’re doing.”

As of August, Cancer Alley residents—and any other victims of environmental harms in Louisiana—now have one less legal tool to seek redress. After a long fight against the Environmental Protection Agency, federal judge James Cain ruled that the EPA cannot use a civil rights law that admits legal claims based on “disparate impacts” rather than discriminatory intent to curb toxic pollution in Louisiana.

As difficult as such a fight may appear to be for residents like LeBoeuf, St. James Parish, despite itself, may be helping their case: In the time since the residents first filed their lawsuit in March, the parish has approved two more industrial projects—an expansion of Koch Methanol’s plant and an extension of the Acadian gas pipeline, which would attach to Koch—both zoned for St. James’s 5th District.

Top image: Gail LeBoeuf (left) and Barbara Washington, plaintiffs in a case alleging environmental racism in St. James Parish, Louisiana, speak in New Orleans after a hearing for their case. (Jack Brook / AP Photo)

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