What we did was meaningful. I was drawn to start this publication because it presented an opportunity to break out of the typical crisis-driven flow and ebb of journalism about the field. Harvard wasn’t a publisher, but it was in the business of sharing knowledge, and I thought we could do for public health what Harvard Business Review does for business. I believed there was no public health without the public, and while it took some feints and half-steps to figure out what that meant for our journalism, we eventually settled on assessing every story idea with a simple question: “What would this story change?” Implicit was a corollary question: “And for whom?”

In the meantime, we relaunched the magazine as a digital publication, built out a social media presence, and launched a weekly newsletter. We co-sponsored a well-attended structural racism symposium and special issue, a series on public health data, a Public Health in Action collaboration with The Studio at the Harvard T.H. Chan School, and an event on artificial intelligence with Johns Hopkins Bloomberg’s Global Health Now. We had momentum—visitors to the site almost tripled in last year’s fourth quarter versus the prior year. Almost 15,000 people signed up for Harvard Public Health Weekly, close to 90 percent of them not connected to Harvard.

Readers ate up pieces on processed foods, the health effects of alcohol, and mental health. You also read our beautifully written and photographed narratives like the 10^th anniversary of the Flint water crisis or our look at Christian Happi’s bold aims for African science, and public health’s role in the recent Puerto Rican elections.

Our goal was to publish stories that would help improve health outcomes. That’s hard to measure in three-and-a-half years. But over 40 percent of you opened the newsletter in a typical week. In the last year, readers shared our articles more than 2 million times on social media. We’ve had at least 25 stories republished on other sites and 40 mentions in newsletters. Our stories have been cited in other publications and used in classrooms.

Public health outcomes change slowly, so it’s harder to measure real-world impact. I would love to hear from you about trying an idea you read about in HPH, or even if you just shared the idea with a colleague. Did you use an article from HPH in a class or a meeting? It would be great to hear from you at our inbox, magazine@hsph.harvard.edu. It will be live for a few more months. So will the site, and I encourage you to download articles you found useful.

The pandemic sparked a surge of public health journalism. These are the sites and newsletters I follow closely or scan regularly, and recommend to you:

• Axios Vitals
• Devex CheckUp
• The Examination
• Global Health NOW
• The Harvard Chan Studio
• KFF Health News
• MindSite News
• Public Health Watch
• The Healthiest Goldfish
• Your Local Epidemiologist
• ProPublica
• STAT Morning Rounds
• TradeOffs (podcast)

Also, the new Healthbeat is off to a promising start, focusing for now on Atlanta and New York City.

I have had a long and varied journalism career, much of it spent chronicling the vast impact of high technology. I have never done more meaningful and important work than what we were doing at Harvard Public Health. I am so thankful to the school, colleagues past and present and our fabulous advisory board, everyone who gave me informal counsel, and all the readers who reached out. I rue that we won’t be able to continue. But a wonderful thing about public health is its focus on the public. It is political with a small ‘p,’ rooted in communities.

What’s most important is that you in the public health community (and in the public) stay engaged in doing the good work you do. Keep telling your stories!

Onward,
Michael F. Fitzgerald

The post A farewell to HPH readers appeared first on Harvard Public Health Magazine.

He endured this grueling treatment for a year. Marc and his family then sought a live donor for a kidney transplant since the wait for an organ from a deceased donor could be five years. One of us, Macey Levan—Marc’s cousin—volunteered to be tested in 2008.

As a law student in Indiana, Macey could not travel to Michigan, where Marc was listed as a transplant candidate. Instead, the university where Marc was getting care worked with Macey’s local hospital in Bloomington, Indiana, and Indiana University to complete her donor evaluation. After this complex process, Macey finally donated her kidney to Marc in 2009.

Marc was lucky, especially because he is a Black man. Although Black, Latino, and Native American patients are more likely to be diagnosed with end-stage kidney disease, they are less likely to get live-donor kidney transplants. Over time, kidney transplants are cheaper than dialysis, which cost Medicare almost $100,000 per year per patient in 2021—and private insurers even more.

Black individuals have an almost four times higher rate of end-stage kidney disease, but their rate of live-donor kidney transplantation is more than four times lower than their White counterparts. “The current organ transplantation system is demonstrably inequitable,” concluded the National Academies of Science, Engineering, and Medicine in a 2022 report.

An older study found in 2004 that 81 percent of nephrologists thought transplantation improves the survival of white patients yet only 69 percent believed the same was true for Black patients. This highlights the innate interpersonal racism in transplantation.

Disparities in kidney transplants have persisted since the earliest days of the procedure, in the 1950s. Researchers don’t entirely know why these long-standing racial disparities exist, so fixing this problem has been difficult. Studies have found that the disparities are not caused by racial differences in the size of social networks, medical eligibility for transplants, comorbidities, socioeconomic status, or social determinants of health.

Residential segregation, however, is emerging as a significant barrier to live donor kidney transplantation for Black patients. National data suggest that Black candidates who live in highly segregated neighborhoods have a 10 percent lower access rate to live-donor kidney transplantation; among White candidates, residential segregation did not impact transplantation.

Later research found that living in a racially and ethnically segregated neighborhood is also associated with worse outcomes after the procedure: increased post-transplant mortality, failure of the transplanted kidney, and dementia. Those outcomes may be related to underinvestment in majority-Black neighborhoods, which leads to multiple stressors, including poor living conditions.

Since end-stage kidney disease may be hereditary, family members—a common source of kidney donations—of Black patients are more likely to suffer from the disease, and be unable to donate.

It also matters where the transplant center is located. Black candidates listed at centers in minority-predominant neighborhoods are 64 percent less likely to get live-donor kidney transplantation than White candidates listed at centers in predominantly White neighborhoods.

The cost to kidney donors can be high, as Macey discovered. Although recipients’ insurance often covers medical expenses for the transplant, donors may need to travel, stay in hotels, and miss work. Donors pay an average of $4,000 out-of-pocket, but the cost can rise to about $17,000, further preventing donors from resource-poor neighborhoods.

States can help. In 2023, New York state adopted a law providing direct reimbursement of up to $10,000 to living organ donors for expenses associated with organ donation not covered by insurance. The law was passed to encourage more donors: New York has had one of the country’s lowest rates of registered organ donors.

The public health call to action is clear: We must dismantle structural racism to rectify racial disparities in live-donor kidney transplantation and more broadly in health care. Identifying racial disparities without addressing racism will not achieve health equity.

The public health and clinical communities must study the mechanisms linking segregation to poor access to health care and identify interventions that improve access to health care for minoritized groups, with input from patients. The public health system must also develop national and local policies that invest in residential neighborhoods and provide national funding for medical centers in resource-poor and segregated neighborhoods.

Health equity in live-donor kidney transplantation should be within reach for Black people like Marc, living with end-stage kidney disease. Now is the time to mobilize and fulfill the full promise of the National Organ Transplant Act: equity in access to transplantation.

Macey’s kidney donation to Marc had an abiding impact on their vocations.

The transplant led to her career as a professor dedicated to improving access to kidney transplants from live donors for marginalized groups and reducing the barriers to donation. She was recently elected vice president of patient and donor affairs for the Organ Procurement and Transplantation Network.

Marc’s new kidney allowed him to thrive and continue his passion, working as a journalist.

Image: Adobe Stock

The post Why Black patients are less likely to get life-saving kidney transplants appeared first on Harvard Public Health Magazine.

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 Samuel

(Study in Springer Nature, September 2024)

The post Disparities in end-stage kidney disease survival appeared first on Harvard Public Health Magazine.

—Leah Rosenbaum

(Study in American Journal of Epidemiology, November 2024)

The post How reparations could affect Black mortality appeared first on Harvard Public Health Magazine.

“I was told to control for every variable in my experiment, so I controlled for sex,” says Kibbe, now editor-in-chief of JAMA Surgery and dean of University of Virginia’s School of Medicine. She worked with her colleague, the oncology researcher Teresa Woodruff, to get a $25,000 grant to study the same promising cardiovascular treatment in female rats. Kibbe was shocked by the results: The average female needed much higher doses than her male rats to get the same clinical benefit.

This was back in 2011. More than a decade later, male animals and cells remain the dominant source of study in preclinical research, despite a 2016 mandate from the National Institutes of Health to include sex as a biological variable in both animal and human studies. There are also continued gaps in what we know about women’s health. The number of studies on women’s health still lags behind those on men in most research areas, and exceeds it only in reproductive health. Women remain less likely to be included in clinical trials—they make up only 41 percent of total clinical trial participants, according to a 2022 meta-analysis, which found even fewer female subjects in early-stage clinical trials, designed to test experimental therapies for safety and evaluate potential doses. (The analysis looked at studies conducted between 2016 and 2019; comprehensive data from more recent years is not readily available.)

Kibbe and a team of researchers this year sampled the literature regarding clinical studies in her field of vascular surgery. “It was kind of depressing,” she says. While the number of women in studies has improved over the years, they found less than five percent used any sort of sex-based analysis of disparities. Kibbe’s disappointment extends beyond her own field. Nearly a decade after the NIH policy was established, “we still have the practice of studying mostly male cells, mostly male animals.”

The unequal representation of women in trials means that “ultimately, we have this much bigger risk of not having good data about the safety of pharmaceuticals” for women patients and consumers, says Jill Fisher, professor of social medicine at the University of North Carolina, Chapel Hill. Fisher studies the experiences of subjects and researchers in Phase I trials, where safe dosing limits for later trials are established. Because men are on average larger and have different fat and hormone levels, trial phases with only men may skew the safe dosage results for women.   

Historically, the most serious adverse effects of commercially available drugs have disproportionately impacted women. Legislation in the 1990s loosened restrictions on female trial participation, which brought a new era of women’s health research, but a U.S. Government Accountability Office analysis of ten drugs withdrawn from the market in 2001 found eight of them caused greater adverse reactions for women. A 2020 study found low female participation rates were still leading to the overmedication of women.

These adverse reactions are not easily prevented by adjusting dosing to the smaller average body size of females. A 2022 study found complex reasons behind different drug reactions related to sex beyond weight—including hormones, fat distribution, and immune response. Some medications, such as propofol, may actually require higher doses in females.

The inequities in data persists despite decades of efforts by federal officials to spur more research into women’s health. Last week, the White House hosted its first-ever conference on women’s health care, the culmination of more than a year of focus by the administration through its White House Initiative on Women’s Health Research. The initiative, led by First Lady Jill Biden, worked with various agencies to put hundreds of millions of dollars into the issue, with an emphasis on midlife health (when women disproportionately experience disability compared to men):

• $110 million for technology innovations to be awarded in 2025 through the NIH’s Advanced Research Projects Agency for Health, or ARPA-H;
• $27.5 million initiative from the Substance Abuse and Mental Health Services Agency;
• $500 million from the Department of Defense, announced in September as an annual commitment to research issues that disproportionately affect women, such as Alzheimer’s, rheumatoid arthritis, lupus, and certain musculoskeletal issues. In addition, the DOD and the Veterans Administration established a Military Women’s Health Research Program, aimed at improving care for the more than 200,000 women in active service and the roughly 2 million women veterans.
• $200 million from the NIH toward the groundwork of an interdisciplinary fund for women’s health research.   

The government is focusing on health issues that, in addition to disproportionately affecting women, have long been relatively void of data. Eighty percent of people diagnosed with an autoimmune disease are women, for instance, but only in the last decade have researchers such as Arizona State University’s Melissa Wilson, a chromosomal biologist, started examining whether these diseases might have an evolutionary connection to pregnancy. Her work, she says, gives us a blueprint for how sex differences may influence disease.

“If we understand the root causes, then we can treat them,” Wilson says. Her study–which hypothesizes that the female immune system is amplified to protect against the drain of pregnancy–has sparked creative approaches to diseases like multiple sclerosis, for which scientists are investigating a treatment that mimics a hormone produced during pregnancy.

New funding and approaches still face substantial social hurdles: research into women’s health issues is often guided by assumptions that hormones make females behave less consistently and that the potential for pregnancy requires extreme oversight of women in trials. Fisher at the University of North Carolina has documented that female trial participants have been subjected to barriers not required of male participants, such as being required to stay at a research facility overnight to make sure they could not have sex and get pregnant. Men’s sperm also could be affected by the medications being tested, but where the women were taken off birth control and given daily pregnancy tests, the men were simply trusted not to have sex. At least two of 47 women Fisher interviewed chose to undergo permanent sterilization to be able to participate in clinical trials more easily.    

Mice and men

The use of male animals at the preclinical stage, before treatments are studied on humans, is rooted in a belief that a female mouse’s estrous cycle—the four-day mouse version of a monthlong human menstrual cycle—causes too much variation in the data, particularly data about behavior. Use of male animals remain the norm despite numerous studies, such as a seminal 2014 study by Brian Prendergast, Kenneth Onishi and Irving Zucker, concluding that estrous cycles create no greater variability in female rat behavior than the variability displayed by male rates.

In fact, in some cases, says Bob Datta, a neuroscientist at Harvard University, “the science would have been cleaner had you just used females.” Datta’s lab developed MoSeq, a motion sequencing detection model for observing mice. The AI model unveils the underlying structure of body language, revealing thousands more (and more subtle) data points, exponentially more than any human could see. Datta and his colleagues found that the males displayed twice as much behavioral variability as the females. He now uses female mice for his smaller studies with only one sex. “Not only was our folk wisdom wrong, but we were making the wrong choice,” he says.

Datta’s work builds on a 2022 meta-analysis of 263 rodent studies, which concluded outright that female rat behavior was not more variable than that of males. There is less research about nonbehavioral variables like temperature or heart rate. Early findings by scientists studying those variables, like Annaliese Beery and Arthur Arnold, have been similar to those in neuroscience.

The Biden administration hopes technology innovation will accelerate closing the research gap in women’s health. ARPA-H, which received over 1,700 applications for its $110 million in grant money, in October announced awards for 23 recipients. Work funded includes developing an ovarian cancer treatment using nanoparticles and a person’s own immune system; building an endometriosis blood test; and developing an at-home medication to mitigate the risks of pre-term labor.

Change can’t come soon enough for Melissa Wilson at Arizona State, who says it can seem like “we’re just blindly feeling out there” when it comes to some of the health conditions that affect women. Scientists do have some data to draw on for tests. But, she says, “we could do better.”

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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

The post Making the invisible visible appeared first on Harvard Public Health Magazine.

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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It’s been 35 years since John Parker died after a pickup collided with the bike he was riding on Cheek Road in east Durham, North Carolina, before school. He was six.

His mother, Deborah Melvin-Muse, doesn’t display photos of him, the second-youngest of six children. His brother’s birthday was the day after the crash—and he hasn’t celebrated it since. An older brother carries a deep sense of guilt because he was looking after John that morning.

And Cheek Road, in a predominantly Black neighborhood, still lacks sidewalks for children to safely make their way to the local elementary school.

This, despite the years community activists and academic researchers have spent pleading with city leaders for safety improvements along the busy thoroughfare with sloping shoulders where John died. Drivers zoom along Cheek Road in the Merrick-Moore neighborhood, which connects downtown Durham to industrial sites and newer suburban developments.

Melvin-Muse moved her family out of the neighborhood after John’s death. “Now when I go down there, I look and see, you know, nothing really changed,” she said. “It still looks the same.”

Cheek Road has been “identified as needing improvements” by a local metropolitan planning board, said Erin Convery, Durham’s transportation planning manager, in an email.

“The infrastructure that exists is not well-implemented,” concluded a May preliminary report produced by University of North Carolina-Chapel Hill students who collected data on speeding, noise, and air quality along Cheek Road. “Poorly marked crosswalks and inadequately positioned bus stops show a need for safety and accessibility improvements,” the report said.

Data was difficult to collect because “there were areas we didn’t want to get out of our cars because of the dangerous conditions,” said Ari Schwartz, one of the researchers.

In the 1940s, Black military veterans returning from World War II helped establish the Merrick-Moore neighborhood. Since then, residents say they have endured everything from noisy industrial trucks and speeding cars to illegal tire dumping and air pollution that threatens their health and safety.

Pedestrian deaths are highest in formerly redlined areas, neighborhoods where Black people lived because of discriminatory federal mortgage lending practices, research shows. The lack of sidewalks, damaged walkways, and roads with high speed limits are concentrated in these neighborhoods, studies show, creating a little-recognized public health crisis.

Governments invest in roads for people driving through such neighborhoods, but not in safety measures—like sidewalks, crosswalks, traffic circles, and speed bumps—that protect people living in them, researchers and advocates say.

“People will talk about vulnerable communities as if there is a problem with these communities, when in fact it is our systems and policies that have created these failings,” said Darya Minovi, a senior analyst at the Union of Concerned Scientists who studies environmental health and justice.

While the share of Black residents in Merrick-Moore has dropped in recent decades, data shows the neighborhood remains more than 80 percent Black or Hispanic, and households there are typically less well-off than in other parts of the city.

“Local government takes money from the neighborhood but does not invest in it,” said Bonita Green, head of the Merrick-Moore Community Development Corporation and a former city council candidate.

Green said the community group had documented more than 100 auto crashes along Cheek Road during a recent four-year span and at least three pedestrian deaths before 2020. In this fast-growing city of roughly 300,000, students at Merrick-Moore Elementary and others at a nearby high school sometimes walk along the road—where traffic is heavy, drivers are known to disregard the 25-mph speed limit, and the shoulders slope steeply.

When longtime residents like Ponsella Brown see kids walking there or hear about another accident, they remember the death of John Parker, who was in first grade.

“I just cringe,” said Brown, who worked as an administrative assistant at Merrick-Moore Elementary when John died. “Every time it comes up, it’s like really vivid in my mind.”

On the day John died, someone rushed into the office and said a child had been hit by a car on Cheek Road, recalled Brown, who said she ran to the scene.

“I remember the way his head was turned. I remember the spot of blood on his face. Like one speck of blood,” said Brown, who also works for the Merrick-Moore Community Development Corporation and is now a counselor at another school.

Traffic on Cheek Road is expected to increase as the population grows in Durham and surrounding areas, according to a separate April report from UNC graduate students. It noted that during the morning school drop-off time, many cars driving on Cheek Road don’t observe the posted speed limits.

Under an equity program meant to reverse the harm done to communities of color, Convery said, Durham officials are considering traffic-calming measures, including traffic circles, speed cushions, and high-visibility crosswalks.

“We’re open to future conversations that will help us achieve zero traffic deaths and injuries,” Convery said.

Yet a 2017 plan that prioritized more than 600 sidewalk projects based on safety, equity, and demand did not include Merrick-Moore Elementary School on Cheek Road, she said.

A strike by Durham school bus drivers this year only heightened concerns about the lack of safe walking routes for the 650 students who attend the elementary school, according to the April report.

Melvin-Muse, now 67, was at work when she got a call that John had been struck by a truck in front of their house. Before she left home that late May morning in 1989, she put her older kids in charge of the younger ones. They passed the time before school riding bicycles near their house, a few blocks from Merrick-Moore Elementary School, when the accident occurred.

John died two months shy of his 7th birthday from “massive head injuries,” according to The (Raleigh) News & Observer, which wrote about his death on Cheek Road at the time. John was buried in Markham Memorial Gardens, according to his obituary in The (Durham) Herald-Sun.

Melvin-Muse said his death sent the family into a tailspin of grief, anger, and regret.

“It caused a big rip in the family,” Melvin-Muse said.

Melvin-Muse and John’s father later divorced. She said she paid for therapy for her other kids, but they still got in trouble at school, and two of her children ended up living in a home for kids with behavioral health issues. “It was just a bad time,” she said.

Years after the accident, Melvin-Muse said, she worked up the courage to call the driver who had hit her son. When he answered, he didn’t recognize her name, or John’s, fueling her rage, she recalled.

“I wanted revenge. An eye-for-an-eye kind of thing,” she said. “And I plotted to take him out the same way my son was taken out.”

She went so far as to get a job where he worked, the Durham County tax department, only to find he had left a week before she started.

“God knows what was in my heart and what I planned on doing,” Melvin-Muse said. “God moved him out of that place before I got there.”

Top image: For years, community activists and academic researchers have pleaded with city leaders for safety improvements, but Cheek Road in Durham, North Carolina still has few sidewalks. (Fred Clasen-Kelly / KFF Health News)

The post A boy’s bicycling death haunts a Black neighborhood. 35 years later, there’s still no sidewalk. appeared first on Harvard Public Health Magazine.