Consider an Austin neighborhood where the streets aren’t safe for walking, public transportation is spotty and no grocery store is near for buying fresh fruits and vegetables.
You’re also likely to find schools lacking resources, families who can’t afford college and parents toiling in low-wage jobs without health insurance. Chances are the neighborhood is heavily minority.
For years, health officials have released data showing that residents of such low-income neighborhoods suffer more disease and early death than people in more affluent neighborhoods. But now the conversation has shifted — from what’s happening to why.
In Austin, the health department is focusing on inequities, along with University of Texas faculty and nonprofit leaders who say it’s time to end a root cause of ill health: institutionalized racism — an ingrained behavior in which governments, schools, banks, courts and other organizations treat some groups negatively based on race.
Efforts are underway to address inequities. The city is hiring an equity officer, community forums are being held and the city is awarding grants to community groups working in poor neighborhoods. One group is helping pregnant women get prenatal care; another is training residents how to help their neighbors improve their health.
Conversations about the impact of racial bias on health are occurring in other cities. The American Public Health Association has made tackling racism a priority.
A June 2014 report from the Robert Wood Johnson Foundation says that U.S. blacks and Hispanics received worse care than whites on 40 percent of health care measures “even when insurance status and socioeconomic factors like education and income are taken into account.”
National studies have found that blacks are more likely to be undertreated for pain. A mistaken belief they feel less pain could be a reason, a recent study says. Further, minorities are less likely to be given appropriate cardiac medications but are more likely to receive less-desirable procedures, such as lower limb amputations for diabetes, according to a report from the Institute of Medicine.
“The only way you address an issue is by addressing it,” said Shannon Jones III, director of the Austin/Travis County Health and Human Services Department, at an April 5 forum on race and health at Huston-Tillotson University. “The reality is, we need to face it and stop being in denial.”
A tough topic
Institutionalized racism is not easy to discuss — nor does everyone want to hear about it.
National Urban League President and CEO Marc Morial said the talk has spread in recent years partly because America has changed. A country that was 85 percent white in 1965 is now one-third minority, he said.
“There’s a segment that thought with an African-American in the White House that our racial challenges went away,” he said. Instead, Americans hear of unarmed blacks shot dead by police, persistent questions about President Barack Obama’s citizenship and political rhetoric about scary immigrants and refugees.
“I think we are at a very important and exciting moment in our city’s history to be having these courageous conversations,” said Melissa Smith, a family practice doctor and senior lecturer at the UT School of Social Work.
She takes care of low-income people and works with groups promoting equity.
“Inequity in social determinants of health like education, housing, employment and access to healthy foods disproportionately impacts people of color living in poor neighborhoods,” Smith said. “This reveals a legacy of systems and structures that we, as well-meaning people, have inherited that can be referred to as institutionalized racism. If left unchallenged, these social structures perpetuate inequality and contribute to persistent health disparities.”
The State of Texas Children report released April 13 says that 42 percent of Hispanic students and 32 percent of black students are enrolled in high-poverty schools, compared with 6 percent of their white peers.
That same day, Mayor Steve Adler said in a speech on racial inequities at Huston-Tillotson that Austin officials in 1928 “intentionally created inequality by segregating Austin” and by reaffirming the policy in 1957.
“If black people — and later Hispanics — wanted to be connected to utilities, they had to live east of East Avenue. That road later became I-35, which still divides our city,” he said.
That policy ended, but its legacy endures. “Greater Austin is the most economically segregated city in the country,” Adler said.
Austin is one of seven finalists for a $50 million federal grant to use technology to increase transportation options, which Adler said would improve job opportunities for residents of the “Eastern Crescent,” the area from Rundberg Lane in North Austin to Dove Springs in South Austin.
“I believe that we will never have racial equality without economic equality,” Adler said.
Conservative City Council Member Don Zimmerman said he has heard enough about institutionalized racism. The topic is “absurd” and “a political argument,” he said.
“These people making these claims are exactly wrong,” he said. “What they’re going to do is they’re going to institutionalize racism and disparity by what they are claiming. … In all of these conversations I never heard about cystic fibrosis affecting whites more than other groups. Does that mean we shouldn’t focus on that?”
Grocery chains decide where stores go based on economics and density, not race, Zimmerman said, adding that the city doesn’t need an equity officer.
“If you want to talk about a merit-based society, you would pursue things to get to a merit-based society,” he said, such as measuring people by their performance. “If you want to cause divisiveness, you continue to lecture people about race.”
Zimmerman isn’t alone in his beliefs.
Joyce James, a licensed social worker in Round Rock and a racial equity consultant, said she has seen minorities, as well as whites, avoid discussing racism.
“There is still fear,” she said, but “when I have been able to engage with people in the broader context where it’s not about pointing fingers and about blaming, when we can understand … what’s happened to people in their relationships with institutions, I have seen more people be willing to come into that conversation.”
Socioeconomic status clearly affects health, regardless of race. But, even accounting for that, race remains a factor, said the health department’s Jones. He sees the disparities clustered in various ZIP codes.
With gentrification, ZIP codes with some of the highest overall disease mortality have shifted from central East Austin to northeastern Travis County. Housing is often cheaper, and minorities have moved in.
Overall, African-Americans, who make up 8.9 percent of Travis County’s population, have the highest mortality for cancer, heart disease, stroke and diabetes. Hispanics have lower death rates from serious diseases than blacks or whites, although the American-born children of Hispanic immigrants often have poorer health than their parents, including high rates of obesity and diabetes.
In Austin, Seton Healthcare Family executive Greg Hartman said there have been two systems of care, one that mainly serves the privileged and another for the disadvantaged. Long before Seton started operating the public University Medical Center Brackenridge, it was the safety-net provider to uninsured and low-income residents.
“We’re trying very hard not to do that with the new system,” Hartman said, referring to Seton’s new teaching hospital and programs recently put in place to better coordinate care for needy residents. Those efforts involve Seton, Central Health and the new Dell Medical School, which announced Thursday that it had hired Dr. René Salazar, a South Texas native and UT-Austin graduate, to serve as assistant dean for diversity.
Salazar will promote diversity in medical education and help recruit minority students. Experts say increasing the ranks of minority physicians — who are vastly under-represented — is part of the solution to health disparities.
Helping the neighbors
In the past, solutions were dictated by authorities, who told people with ill health to change their ways. But leaders of nonprofits working in communities of color said behavior is only part of it. They want institutionalized racism addressed, and they are urging leaders to ask residents what they need, rather than telling them.
That’s an important message, said James, the consultant.
“If we continue to try and address the issue with the same old thinking, we are not going to get different outcomes,” she said. “In spite of the millions and billions of dollars that have gone into improving the quality of health and educational outcomes, we have yet to realize the outcomes I believe most people want, regardless of race.”
In addition to hiring an equity officer, the City Council has awarded grants to nonprofits working in minority communities. Two of those groups, Mama Sana/Vibrant Woman and the Alliance for African American Health in Central Texas, are collaborating with UT’s School of Nursing on the grants.
Amounts could total $3 million over six years, depending on success rates, said Miyong Kim, a professor and director of the nursing school’s Center for Transdisciplinary Collaborative Research in Self-Management Science.
“We are trying to empower the community members … who are victimized by institutional racism,” Kim said. “We are not only assessing their need, we’re trying to find the strengths and assets that this community can provide.”
Mama Sana is providing health coaches to pregnant women who have language barriers and need access to care. Among them are immigrants and refugees. The Alliance for African American Health is training community health coaches to promote better nutrition, more physical activity and ways to prevent heart disease.
Two other groups also have been active.
The Latino HealthCare Forum surveyed Rundberg residents and is now addressing issues they identified, including obesity and diabetes. Forum members are teaching residents to become health promoters in their neighborhoods, CEO Jill Ramirez said.
In Dove Springs, Go Austin! Vamos Austin! is working with residents who lack access to healthy foods and adequate transportation, said Carmen Llanes, a member of the group.
Much more needs to be done, James said.
“It’s a long journey … and there’s no quick fix,” she said. “The people who are going to be charged with doing this work will need to go through training to examine their own attitudes and assumptions so that they are clear about institutional racism — what it is, how it operates and what keeps it in place. And then they’ll be able to do something about it.”