Editor's Note: This article is part of a series in partnership with the All of Us Research Program, which collects and studies health data to help scientists identify health trends. More than 80% of participants are from groups that have been historically underrepresented in research.
Pilar Murphy, PharmD, runs the high blood pressure clinic at the Perry County Health Department in rural Marion, AL. There, she helps her mostly elderly, African American patients manage their long-term diseases, including high blood pressure, diabetes, and heart disease. But sometimes the help they need most is a ride away -- the 2 miles back home from their appointment with her or maybe the 25 to 70 miles to the nearest specialist in Selma, Tuscaloosa, or Montgomery.
"When my car's sitting out there in the parking lot, how can I say 'no'?" Murphy says. The pharmacist once drove a patient home from her appointment. Another time, she took an elderly patient to get glasses an hour away in Tuscaloosa.
Murphy's experience highlights the impact that geography has on health care challenges faced by minorities.
Nearly 70% of the residents of Perry County are African American. More than 40% live in poverty. From lack of specialty care and access to fresh produce to lack of reliable transportation, they face many of the same barriers to good health that minority communities, both urban and rural, across the country face simply because of their address.
"When you live in a neighborhood that doesn't have the same earning potential, doesn't pay the same property taxes, doesn't have the same political power, that directly influences education, the living environment, the kinds of jobs people can get, and people's ability to access timely and appropriate high-quality care," says Tanjala Purnell, PhD, associate director of the Johns Hopkins Center for Health Equity in Baltimore, MD.
Distance to Health Care
Murphy, besides offering the occasional ride to patients, often helps them get grant-funded gas vouchers to cover the cost of travel to doctors' appointments when they can't afford it. But that only helps people who have a reliable car. Those who don't have cars rely on others for rides to specialty care. Sometimes, they use West Alabama Public Transportation. But the limited bus schedule sometimes means that riders have to catch a bus as much as 5 hours before an appointment.
Racial and ethnic minority communities in urban areas face similar challenges.
Majority African American ZIP codes nationwide are nearly 70% more likely than other ZIP codes to be spots that researchers call "primary care physician shortage areas." These locales either lack a primary care provider or they have no more than one for every 3,500 residents.
"If you need to travel to get to a provider, and you don't have a car, just trying to get back and forth to a medical appointment can be an all-day experience," Purnell says. "If you're seeing one of the few providers in your area, these providers may be overburdened."
Busy doctors may not provide the same quality of care as those who see fewer patients in a day. A recent study that analyzed the health records of 5,000 people found that those from disadvantaged ZIP codes were less likely than other people to be tested for obesity during doctor visits.
"People in poor neighborhoods were not only more likely to be obese, but also more likely to have no BMI monitoring," says Lincoln Sheets, MD, PhD, the study author and an assistant research professor in health management and analytics at University of Missouri School of Medicine. "In other words, those at highest risk were not getting screened for obesity as much as they should be."
While the study didn't examine the reasons why this may be, Sheets says that the missing BMI data in people's medical records could point to barriers to comprehensive care in their neighborhoods. "It might be that these neighborhoods are close to the ER, but far from the kinds of medical practices that are designed to provide primary care and preventive care."
One research organization that is concerned about the ways geography has an impact on health is the All of Us Research Program. It looks at factors like environment, lifestyle, and health history to help researchers better understand the factors that affect our health.
The Importance of Walkable Neighborhoods
Besides doctor shortages, studies show that some racial and ethnic minorities are more likely than whites to live in neighborhoods that make healthy living in general a bigger challenge.
Studies of cities including Atlanta, Boston, and San Francisco show that African American people, Hispanic people, or members of other racial or ethnic minorities are more likely to live in less "walkable" neighborhoods.
"Walkability is how good the sidewalks are; how many roads even have sidewalks; access to parks for walking; and the amount of crime in the neighborhood. These things have a direct influence on how much people get out and exercise," Sheets says.
Walkability also includes the number of easy-to-walk-to destinations in an area and the degree to which the streets attract pedestrians through signs, lighting, and landscape. Both rural and urban neighborhoods can rank low in walkability.
In a study that analyzed the health and the living environment of more than 44,000 city dwellers, those who lived in less walkable neighborhoods had higher chances of getting heart disease in the next 10 years.
Other research shows a connection between walkability and obesity -- a risk factor for numerous health problems.
Predominantly African American or Hispanic neighborhoods are also less likely to have a large grocery store that sells fresh produce. Studies that compare poor, predominantly white, urban neighborhoods to equally poor, urban minority neighborhoods show that poor whites have easier access to supermarkets. People of color may need to rely more on convenience stores, which often sell less-healthy canned goods and processed foods.
Rural minority communities face these challenges, too. Some residents of Perry County, AL, are 20 miles from the nearest supermarket. That's why Murphy often teaches patients how to make the healthiest choices among non-perishables that are sold at convenience stores.
"I tell them to look for canned vegetables without added salt and to find fruit canned in its own juice rather than syrup," she says.
Minority communities may lack access to clean, safe drinking water, too. People of color and low-income populations are more likely to live in rural areas with contaminated water or in older housing where water runs the risk of lead contamination.
Research shows that about half of U.S. adults and a quarter of children don't drink tap water every day. A third of U.S. adults aren't hydrated enough, and these numbers are highest among African Americas and Hispanic people.
"In this country, entire groups of people don't have access to basic necessities, like clean water," Purnell says. "We know that lead exposures are associated with mental health problems, developmental disabilities in children, which impacts their ability to learn in classrooms and live healthy lives."
An Unhealthy Legacy
When kids can't learn as well -- either because of individual disabilities or low-quality public education -- it can set them up for a lifetime of disadvantages when it comes to their health. Students of color are more likely than white students to go to high-poverty schools that don't get as much funding as schools in wealthier neighborhoods.
"If your child is in a school that's not well resourced and the child is not getting engaged in educational opportunities at an early level, that impacts what happens in middle school, and then in high school, then whether that child goes to college, and that impacts the child's future earning potential," Purnell says.
Earning potential has everything to do with health. In general, the more money a person makes, the lower that person's risk for diseases or early death. Across all income levels, health generally improves with income. People who have accumulated more wealth have better health than those with less wealth, too.
"Think about the people who have wealth to pass onto the next generation," Purnell says. When people don't have money to pass onto the next generation, the cycle of health inequality continues.
People of color didn't create the health care shortfalls that are a reality of many of their communities, Purnell says. "The burden is not on the individual to get out of an environment and a situation that they did not create. The only way that we can fix this is for society to take ownership of it and commit to making the changes that are needed. Because this just shouldn't be."