Burning in "Other Suns": The Effects of Residential Segregation on Cardiovascular Health.

Abstract

HomeCirculation: Cardiovascular Quality and OutcomesVol. 15, No. 2Burning in “Other Suns”: The Effects of Residential Segregation on Cardiovascular Health Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBBurning in “Other Suns”: The Effects of Residential Segregation on Cardiovascular Health Utibe R. Essien, MD, MPH and Quentin R. Youmans, MD, MSc Utibe R. EssienUtibe R. Essien Correspondence to: Utibe R. Essien, MD, MPH, 3609 Forbes Avenue, Suite 2, Pittsburgh, PA 15213. Email E-mail Address: [email protected] https://orcid.org/0000-0002-4494-5028 Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA (U.R.E.). Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, PA (U.R.E.). Search for more papers by this author and Quentin R. YoumansQuentin R. Youmans https://orcid.org/0000-0001-5818-8091 Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (Q.R.Y.). Search for more papers by this author Originally published2 Feb 2022https://doi.org/10.1161/CIRCOUTCOMES.121.008694Circulation: Cardiovascular Quality and Outcomes. 2022;15:e008694This article is a commentary on the followingExposure to Neighborhood-Level Racial Residential Segregation in Young Adulthood to Midlife and Incident Subclinical Atherosclerosis in Black Adults: The Coronary Artery Risk Development in Young Adults StudyOther version(s) of this articleYou are viewing the most recent version of this article. Previous versions: February 2, 2022: Ahead of Print “I was leaving the Southto fling myself into the unknown…I was taking a part of the Southto transplant in alien soil,to see if it could grow differently,if it could drink of new and cool rains,bend in strange winds,respond to the warmth of other sunsand, perhaps, to bloom”—Richard Wright, Black Boy, 19451The effects of structural racism on cardiovascular health are myriad and concrete. With rampant racialized disparities identified in the prevalence of risk factors, incidence,. morbidity, and mortality related to cardiovascular disease, identifying links on the pathway from health to disease will help us better develop solutions to address such disparities. Racial residential segregation is one well-defined, intentional, systemic process whereby Black Americans were, and in some ways remain, relegated to homogenous neighborhoods and townships.2 While migration out of the South in the late 19th and early 20th centuries led Black Americans to settle in other regions of the United States, occasionally of their own accord, racist practices and policies subsequently forced Black Americans into segregated neighborhoods through exclusionary renting and lending programs bolstered by legal, social, and government support.3 The impact of these policies and practices on generations of Black Americans is palpable, specifically on cardiovascular disease.See Article by Kershaw et alReddy et al4 provide a cogent analysis of data from the Coronary Artery Risk Development in Young Adults cohort published in this issue of Circulation: Cardiovascular Quality and Outcomes. Their analysis, which focuses on Black study participants, examines the effect of neighborhood-level racial segregation on the development of coronary artery calcification (CAC), an important marker of subclinical atherosclerosis that potentiates risk for adverse cardiovascular events. Racial residential segregation was measured by the Gi* statistic using census tracts as proxies for neighborhoods. The authors further evaluated these effects across the life course, assessing CAC development over a subsequent 10 years of follow-up.Their findings are striking. As proof of the effects of racism laid bare, level of neighborhood segregation was inversely related to education attainment and directly related to poverty level. Those participants living in low levels of neighborhood segregation in young adulthood were half as likely to develop CAC when compared with individuals residing in high segregation neighborhoods. Furthermore, residing in a neighborhood with low levels of segregation early in life appeared to be protective. Even if participants moved to neighborhoods with medium or high levels of segregation later in life, they were still nearly half as likely to develop CAC over the follow-up period. Interestingly, while these findings persisted after adjustment for neighborhood poverty and sociodemographic factors, they were no longer statistically significant when adjusted for clinical risk factors for CAC such as smoking, cholesterol levels, and systolic blood pressure.There are several strengths to this study that allow it to stand out as a key addition to the literature linking racial residential segregation to cardiovascular health outcomes. First, the analysis leverages the diverse geographic representation of the Coronary Artery Risk Development in Young Adults cohort4 while using the Gi* statistic, a tool that considers the racial makeup of the surrounding region within its estimation, and is therefore, an apt depiction of the true level of segregation for a given area. Second, it often takes years of subclinical progression for cardiovascular disease to manifest as overt illness. The authors are to be commended for evaluating a marker of subclinical disease like CAC, and for taking a life course approach that captures the effects of neighborhood segregation at multiple points in time. It is the early experiences and exposures in our lives that often shape our futures, making our pasts inescapable, particularly when considering long-term health. The authors’ findings help us to recognize the magnitude of the impact of racism, as the intentional relegation of Black Americans to poorer areas with fewer resources ultimately may result in long-lasting cardiovascular health effects. Finally, the attenuation of the effect of segregation, observed when controlling for clinical risk factors, provides a possible causal link that may explain why the burden of subclinical atherosclerotic disease differs by level of racial residential segregation.Why might cardiovascular health differ between racially segregated compared with integrated locales? For decades, social scientists, anthropologists, health economists, and public health researchers have puzzled over this question.5 Prior work has demonstrated the association between racial segregation and incident cardiovascular disease and mortality, yet the mechanisms by which such associations exist remain largely unclear. Reddy et al4 describe several possible mechanisms falling within three broad and intersecting areas: structural or environmental factors, socioeconomic factors, and physiological factors (Figure). When examining structural determinants, the authors suggest that exposure to environmental factors such as air pollution may drive increased cardiovascular health. Alternatively, limited access to recreation areas, green space, and healthy food options in segregated neighborhoods may affect one’s ability to engage in the behaviors associated with cardiovascular health. From a socioeconomic perspective, the impact of segregation on educational resources can ultimately diminish employment opportunities and earning potential, all of which have been associated with poorer health outcomes. Finally, the authors describe possible physiological factors, specifically the relation of chronic inflammation and increased cardiovascular risk in the setting of segregated neighborhoods with higher rates of stress from community policing and neighborhood violence.Download figureDownload PowerPointFigure. A framework for the effects of residential segregation on cardiovascular health. The figure represents a proposed framework through which racial residential segregation influences cardiovascular risk factors and outcomes. The primary drivers fall within structural and environmental, socioeconomic, and health system factors associated with segregation.Notably, one contributing factor not fully explored in this analysis was that of unequal health care access in segregated areas. Social, economic, and health system factors all combine to determine level of access to health care.3 Because Black-predominant neighborhoods have decades of poor economic and infrastructure investment, it is evident why there may be lower access to hospitals, primary care clinics, pharmacies, and specialist care.6 These issues of access are even more complex when considering the rural versus urban divide given the geographic and digital barriers to care often observed in rural communities.7 Still, given the disproportionate burden of cardiovascular disease faced by Black individuals in the United States, there is an increased need for implementation of well-established preventative efforts—blood pressure monitoring and interventions for hypertension control, cholesterol lowering, smoking cessation, and weight management—many of which require sufficient health care contact. Improving such access, particularly in community-based settings, can help promote individual disease awareness and healthy behaviors long before the need to engage with a clinician because of overt disease.While the work of Reddy et al expands our understanding of the determinants and impact of racial neighborhood segregation on cardiovascular health, we must use these findings to inform solutions moving forward. First, policymakers must prioritize historically segregated, predominantly black neighborhoods for financial investment and social support.8 As we consider how to operationalize such prioritization, we can look to locales and municipalities across the country that have started to implement reparative policies for Black denizens exposed to the legacy of housing discrimination.9 Support for upward mobility, improvements in access to quality education, employment, and transportation, and investment in affordable health services are just some of the potential areas for intentional investment. Second, health systems have a duty to serve as anchor institutions, expanding care catchment areas to include diverse neighborhoods while providing support for addressing the social determinants of health.10 It is a moral obligation to extend primary and specialty care services to neighborhoods affected by segregation to ensure that primary and secondary prevention efforts target those at the highest risk. Third, as clinicians and researchers continue to refine and personalize patient risk assessments, we must consider neighborhood factors, such as racial segregation, and their intersecting effects on the broader social determinants of health. Targeted primary prevention efforts can use neighborhood-level data to reclassify patient and even community risk as we seek innovative solutions to improve health at a population level. Finally, as a society, we must continue to identify the vestiges of discriminatory housing practices that still exist today and mandate their termination so that we end the cycle of segregation that is so clearly tied to health and health outcomes.The effects of structural racism are far reaching and one need look no further than the ongoing syndemic of COVID-19, racial injustice, and cardiovascular health inequities to recognize its insidious nature.11 Whereas more data will help to further clarify the impact of racism, and more specifically racial segregation, on health, there is an urgent need for immediate action to eliminate the perpetuation of racialized inequities in cardiovascular disease. Interventions must be broadly focused and engage policymakers, public health leaders, payers, providers, and patients alike. If we remain intentional and determined, we have an opportunity to right the wrongs of racism, residential segregation, and unequal health care, and ensure that every individual has the opportunity to lead a long, healthy life… and, perhaps, to bloom.Article InformationSources of FundingDr Essien reports funding from the Department of Veterans Affairs Health Services Research & Development Career Development Award CDA-20-049. The other author reports no conflicts.DisclosuresNone.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.For Sources of Funding and Disclosures, see page 115.Correspondence to: Utibe R. Essien, MD, MPH, 3609 Forbes Avenue, Suite 2, Pittsburgh, PA 15213. Email [email protected]edu