Prevention is Key; Addressing the Disparities in the United States Healthcare System

Dr. Tony Iton has spent over a decade studying how the environment impacts health. This was shown most notably through a phenomenon known as the immigrant paradox. Researchers gathered that new immigrants in poor neighborhoods tend to have longer lifespans than immigrants who assimilated into the American lifestyle. Dr. Iton cites this case study as one of the many pieces of evidence that indicate how, when it comes to lifespan, the “zip code in which a person lives has more of an impact when compared to the genetic code of a person” (Tony, 2019). Often, this zip code principle leads to generations of children inheriting problems through no fault of their own. 

The immigrant paradox stands as an anomaly, as most financially strained neighbors tend to experience lower age expectancy with the lack of healthcare facilities surrounding them. Typically, a whole area is affected by a similar set of diseases. For example, many lower class areas in Scotts County, Indiana during the 90s were a part of the densest number of deaths related to HIV. The negative health trend in poor communities indicates that future generations growing up in these areas could possibly be physiologically affected. This could lead to a disadvantage in the health of these individuals and an accumulation of health problems.

Dwellers of poverty-stricken areas have to deal with a myriad of negative factors, such as high stress levels, lower socioeconomic status, and hindered access to  hospital care. With a visit with a physician being expensive, many of the lower socioeconomic classes are unable to anticipate health problems and practice preventive measures. Furthermore, lack of coverage for pre-existing conditions in certain regions of America can cause a deficiency in preventive care for patients, and this may ultimately build healthcare disparities amongst vulnerable populations.

Figure One: This Venn Diagram helped structure the essay into the three different components that help preventive care; individual based, community based and hospital based

On the individual level, there are many stressors that negatively affect lower socioeconomic populations, leading to high levels of hormones and changes in genetic expression. From the moment they are born, lower class children are faced with a myriad of stressors that are often reflected in physiological changes. There are few prevention measures put in place to help these children face unpredictable lifestyles. Their constant worries may lead to an increase in stress related hormones and eventually cause chronic stress. In normal doses, stress markers work to activate the cortisol pathway to increase blood sugar levels, allowing the brain to focus on one task in what is called the “flight or fight” response. However, in cases of chronic stress, the excessive levels of cortisol can result in  a myriad of long-term health problems, such as increased blood sugar, weight gain, suppressed immune systems etc. 

The years of instability can build up on individuals, like they did for Baltimore resident Kiarra Boulware. Boulware had grown up in an environment with many safety hazards, like an insufficiency of food options and neglective parenting. These two factors led to enhanced levels of cortisol and snowballed, with no preventive care causing Boulware to became obese. Ultimately, these conditions played a part in Boulware getting gastric surgery; a life-changing procedure. Boulware, like many other individuals, had racked up underlying issues without any advice from physicians (Khazan, 2018). Cases like this show the subtle physiological changes occurring in dwellers lower income neighborhoods and the shortage of preventive care facilities to address problems until costly but vital procedures are needed to correct them. 

In addition to chronic stress changing the physiology of those in dire circumstances, some studies have tracked the shifts in genetic makeup under different environments. The field of epigenetics explores how gene expression can change without any shifts in the genotypes. DNA methylation is an epigenetic mechanism that occurs when methyl groups are added to genes to generally repress gene expression. Like high levels of cortisol, heavy methylation becomes dangerous over time and can cause long term damage. This excessive methylation has been documented among lower-class African American families. Recently, studies have linked “racial discrimination to changes in methylation on genes that affect schizophrenia, bipolar disorder, and asthma" (Emanuel,2002). 

Another condition that is caused by methylation is chronic pain in the older African American community. The gene associated with chronic pain is known as NR3C1, which triggers the hypothalamic-pituitary-adrenal axis (HPA axis). When a child experiences Adverse Childhood Experiences (ACEs), the feedback system that deals with stress, known as  the HPA, secretes cortisol. The African-American community experiences larger amounts of ACEs when compared to other races; as a result, a person exposed to ACEs has an overexpression of methylation, which suppresses the NR3C1 gene (Aroke, 2019). The suppression of this gene causes the deregulation of the HPA axis and an inability to bring cortisol levels back to normal. As discussed previously, the longer there are higher cortisol levels, the greater the likelihood of high blood sugar. Thus, the connection between gene regulation and chronic pain indicates another disadvantage of the lower class. These pressures may ultimately take over the life of an individual, as there are too many stressors that cause the physiology of the body to change entirely. 

Not only are hormone levels and genetics influenced by poverty, but there are also certain communities that lack preventative health care, which leads to community-based issues. One of the main environmental factors in lower income neighborhoods are “food deserts'': places that lack grocery stores to promote nutritious eating. In the ‘60s, the Small Business Administration (SBA) partnered with the HUD to promote fast food chains in urban, underclass towns. This caused many fast food chains to open up in areas of poverty through the idea of “franchising.” Additionally, fast food restaurants established a disproportionate number of African American managers and bought advertising to target the black populations.

Since the 1968 Fair Housing Act was passed, many laws have pushed for integration of neighborhoods. Despite the drive for fair housing and anti-discrimination laws, though, “American cities remain starkly segregated by race” (McWilliams, 2017). Through various housing audits done by the U.S Department of Housing and Urban Development, it was found that 65% of whites were shown more housing units in suburban areas when compared to their black counterparts (HUD, 2001). The numbers show subtle segregation, as African Americans are not privy to viewing suburban compounds and often live in city spaces. These places of segregation are where many food deserts are located, and, when coupled with the abundance of fast food chains, this may generate various health problems related to a lack of diversity in healthy options for food.  

Unlike the response to the gradual, individual problems that are caused by cortisol build up, there have been preventive measures implemented to eliminate these food deserts. A 2017 study concluded that the opening of a grocery store lowered the levels of cholesterol in residents by 10% by providing more food security to its residents (McWilliams, 2017). Additionally, the construction of parks in impoverished areas has encouraged leading a healthier lifestyle to combat diseases such as obesity.  

With “food deserts'' impacting the weight of communities, there are other environmental factors that can impact the cognition of community youths. The discovery of lead in water stores led to Flint, Michigan’s 2014 (to present) water crisis. Exposure to lead causes IQ to drop and has been associated with diseases like ADHD (Carducci,2019). However, since the Flint crisis became a very public news story, many doctors have been sent to the town to respond to the issue. Those physicians have given Flint children regular blood monitoring and expanded education. Unlike the installation of grocery stores, many of these monitoring systems may not prove to be as useful to work against the damage that has already been done. Depending on the extent of the lead exposure's detrimental effects, Flint children may face challenges and health issues that children of other communities would ordinarily not. With the potential for children of Flint to experience setbacks, there is a threat of developing a steeper decrease in mental cognition with age compared to others. This is a further source of inequality in the healthcare system, as these children are unjustly impacted by environmental events that could damage their future. 

Not only do the individual and community-based issues cause inequalities in healthcare, but there is also a socioeconomic and racial prejudice in the hospital community against diagnosing these patients beforehand. In states that have expanded their insurance under the Affordable Care Act (ACA), there has been a heavy rise in the insurance among the lower class and more primary care physicians serving Medicaid beneficiaries. A primary care physician works to help individuals navigate good health and take preventive measures that would help fight disparities amongst poverty-stricken areas. 

While the addition of primary care would be largely beneficial to address the issues dealt with in the previous sections, many of these primary physicians tend to have a bias against accepting patients with medicare. In fact, a survey done in 2015 shows that only 68% of physicians accept new Medicaid patients (Sommers, 2011). This physician bias against Medicaid patients is remedied by increased Medicaid reimbursements, guaranteeing the physician more money for their patient. The turning away of patients on Medicaid is dangerous, as patients often need intervention to change their lifestyles. Additionally, there have been studies indicating that doctors are less likely to provide a diagnosis for African American patients, as physicians believe that they are able to handle more pain. With both these stigmas occurring around the hospital communities, prevention is avoided once again and a disparity occurs. 

Finally making strides against inequality in healthcare starts with acknowledging how lower classes are physiologically disadvantaged by the environment they are given no escape from, especially in comparison to more affluent, upper class, privileged people. There have been many communities that lack proper structures to promote mental and physical fitness, and that can lead to similar disease trends. And even though insurance bias is not as prevalent in doctors that help cure diseases, the lower numbers of doctors willing to prevent these diseases has had the effect of widening the healthcare disparity. It is necessary for preventive models of healthcare to be set up in lower socioeconomic areas to provide more assistance and to ensure that individuals don’t enter into the dangerous, age-old cycle of inadequate health issues. 

References

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Pacific Standard, McWilliams, J. (2017, June 14). WHY IS THERE SO MUCH FAST FOOD IN POOR URBAN AREAS? https://psmag.com/news/why-is-there-so-much-fast-food-in-poor-urban-areas

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The New England Journal of Medicine, Polsky, D., Ph.D. (2015, February 5). Appointment Availability after Increases in Medicaid Payments for Primary Care. https://www.nejm.org/doi/full/10.1056/nejmsa1413299