'Structural racism' blamed for some of state's severe health disparities

Doctor's visit
Bertina Dixon, left, breathes deep for Dr. Fred Lewis during an exam Monday, Jan. 27, 2014 at the Southside Community Health Services medical clinic in Richfield.
Jennifer Simonson/MPR News

Minnesota's infant mortality rate is among the best in the country. Dig a little deeper, though, and the data reveal African-American babies are twice as likely as white babies to die in their first year.

That disparity is the worst in the country. It's one of many examples where Minnesota's overall good health is not shared equally by all.

Race is a well-known predictor of a person's health. On Saturday the Minnesota Department of Health will deliver a report to the Legislature that blames structural racism for some of the persistent health disparities between whites and people of color in the state.

The agency's candor is rare. Many minority groups are praising the report and its tone, which goes much further than previous reports in linking health disparities to unfair government and societal policies.

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"We need to be able to have conversations about some of the tough things that are keeping us from being healthy," said state Health Commissioner Ed Ehlinger.

Teen group
Andre Graham, left, and Carl Lobley, right, demonstrate how they will professionally greet people when staffing a resource center that they plan to open with other teenagers next month at the Midtown Global Market Wednesday, Jan. 29, 2014 in Minneapolis. The two are part of a TEENS group from the Cultural Wellness Center that meets weekly to define and address health issues from a community perspective. They said they want to lead by example and give back to the community.
Jennifer Simonson/MPR News

Major race-based differences are evident in almost every major disease condition in Minnesota the department tracks.

• African-American men are more likely to die from prostate cancer than white men.

• American Indians have much higher rates of diabetes than whites; Latinos are much more likely than whites to die from diabetes.

• Stroke deaths are significantly higher among African-American, American Indian and Asian populations compared to whites.

• American Indian, Latino, and African-American youth have the highest rates of obesity.

• African-American and Latina women are more likely to be diagnosed with later-stage breast cancer.

Disparities in mortality
Disparities in mortality, 2006-2010.
Minnesota Department of Health

Personal behaviors, genetics and medical care play an important in role in health. Researchers, though have also found that health is equally shaped by physical, social and economic factors such as income, employment, education and the condition of neighborhoods.

"Where you live really does affect your health," said Paul Mattessich, executive director of Wilder Research, which pulled together life expectancy data for the health department using Twin Cities death records and zip codes.

"The length of time that people lived really did depend on the neighborhood where they lived," Mattessich said. "If you drive along I-94, go from neighborhood to neighborhood, it can mean a difference of six to eight years."

Racial disparities in mortality rates were the largest in low-income areas. Health disparities still existed in higher income neighborhoods, but they were much smaller.

That's fundamentally unfair, said Ehlinger. "Your health shouldn't be dependent on your income, your educational status, or your skin color, or your zip code."

The health department report boldly says many of Minnesota's health disparities can be traced to structural racism and white privilege.

This isn't the same as racism perpetuated by individuals. Structural racism is sometimes intentional and sometimes not. But the report notes that some policies routinely provide advantages to white people while producing chronic disadvantages for people of color.

Some of the more obvious historical inequities had roots in slavery or government land policies that still affect opportunities for African-Americans and American Indians.

A recent, and more subtle, example of structural racism involved the planning process for the light rail line between Minneapolis and St. Paul, Ehlinger said. The initial plan called for a rapid train schedule with limited stops that he said only benefited the wealthy, downtown business communities.

"It went right through one of the poorest neighborhoods in the Twin Cities, the central [University Avenue] neighborhood and Midway neighborhood, and they weren't going to benefit from this. In fact, it was going to be a negative."

A rail line that didn't serve the needs of the neighborhoods it traveled through would have harmed housing values and the local business economy, and likely the education and health of residents who couldn't use the train to get to where they needed to go.

Ultimately, the community organized and demanded more stops, he said. But in many cases, he added, policies negatively affect poor, racially-diverse neighborhoods.

The health department's report has been a powerful validation to people like Atum Azzahir.

Azzahir started the Cultural Wellness Center in Minneapolis in 1996 to respond to the alarming rates of infant mortality in the African-American community. Her work has largely focused on bringing balance to people's lives. She's long argued the loss of culture and community can make someone sick.

She called the health department's strong language "amazing. We feel like this tree falling in the forest, and no one hearing us. And now we have this report that seems to affirm the direction that we have taken all along."

Infant deaths in Minnesota
Infant deaths in Minnesota
Minnesota Department of Health

The report doesn't offer a clear roadmap for solving Minnesota's health inequities, but it does emphasize the need for the state to work together to improve the health of all residents.

"It's a shift in thinking," said Suzanne Koepplinger, executive director at the Minnesota Indian Women's Resource Center.

Whether that approach inspires Minnesotans or dissuades them remains to be seen. But Koepplinger hopes people won't get hung up on the report's acknowledgement that racist policies and decisions have contributed to some of the state's health inequities.

"I don't see this report as blaming or shaming or asking anyone to feel bad," she said. "I see it as understanding the facts."

The health department says it will examine structural inequities in all of its decisions and policies moving forward, and it encourages all state agencies to follow its lead. The department is also proposing changes in its hiring practices that would give more opportunities to people of color.

It also wants health practitioners and health educators to pay more attention to the cultural practices of patients. This is already occurring in a limited way in some clinics.

At Southside Community Health Services clinic in Minneapolis, all of the patients in the waiting room on a recent afternoon are Latino or African-American like Annqueenette Johnson.

She's here for a routine checkup. Johnson, 54, has fibromyalgia and diabetes. She lives in Fridley and has no car. But she's loyal to Dr. Fred Lewis, so she finds a ride to the Minneapolis clinic every month.

Many of the patients here struggle with poverty, unemployment, or other social conditions that can limit their access to care, Lewis said.

An African-American, he said it helps that he understands his patients' cultural backgrounds. Patients trust him and are more willing to listen to his warnings about fatty foods and smoking, he added.

"That's huge -- to have trust from a patient," Lewis said. "I can probably tell patients things that other providers can't tell them."

Lewis won't eliminate Minnesota's health disparities on his own. But the health department views efforts like his as one way that clinics can advance health equity for more patients.

It's an obvious and fairly simple change. Many other strategies suggested in the report will likely be more difficult. But the health department says Minnesota can't let those challenges stall its progress, because the damage from health inequities will only become more urgent as the state's populations of color continue to grow.

The department's approach risks "alienating some people who believe that if people just picked themselves up by the bootstraps things would be better," Ehlinger said. "We're saying people have individual responsibility, but ... in many cases our environment does not support making healthy choices possible."


The Health of Minnesota - Statewide Health Assessment (Minnesota Department of Health)

Commission on Social Determinants of Health - final report (World Health Organization)