How Race Impacts Health

Just Economy Conference – May 13, 2021


In this session, we will trace the historical roots of racism and its impact on people of color, from the weathering effect of discrimination to racially biased health, government and educational systems that have a physical trickle down effect from generation to generation. We will also circle back to today’s current chasm in health and health care based on race and how we can impact its effect by addressing drivers of health.


  • John Lumpkin, Vice President for Drivers Health Strategy and President, Blue Cross Foundation


NCRC video transcripts are produced by a third-party transcription service and may contain errors. They are lightly edited for style and clarity. 

Narrator, 01:09 

All right, Dr. Lumpkin, you are live

Lumpkin, 01:09 

Great. Well, good afternoon. And thank you all for coming. My name is John Lumpkin. I am Vice President for drivers of health strategy at Blue Cross with North Carolina, and the President of the Blue Cross in North Carolina foundation. And it’s, it’s a pleasure to be here to talk about the impact of racism on health. And so let me go to my slides and start off with saying that this has been quite a time for us over the last 15 months as we have lived through an experience that our nation has not seen in the last 100 years. And that experience is related to the impact of COVID. And we all know that COVID has certain risk factors due to age, chronic illness, obesity, diabetes, lung disease, kidney or liver disease. However, what we also learned is that race and ethnicity is associated with increased mortality associated and morbidity, which other injuries that occurred due to illness, based upon race and ethnicity. And for black people in this country, the risk of that is twice as high as it is for white Americans. When we look at other causes of mortality, so in the United States, we can see that all cause mortality is significantly higher for black people in the United States, and also in my home state of North Carolina. And this is true across many factors. One of the factors that has influence upon race and ethnicity have upon mortality is education. The more education someone has, on average, the longer they will live. Yet we know that there is a significant difference between blacks and whites in their mortality, even when they have education. And in fact, the differences between mortality increase with the level of education. So why does this happen? What’s going on here? And why is raced, resulting in such a big difference? Well, first, let me start off with the concept of race. The National Human Genome Project said that the vast majority of genetic variation exists within racial groups, and not between them. That race is a social construct, not a biological construct. So what does that mean? Well, first, let me tell you a little bit about something that are called SNPs, or snips, which stands for single nucleotide polymorphisms. These are the factors in our gene l gene, genetic code that make us us. And the difference between my genetic code and my brother’s genetic code are reflected in the single changes in our genome that result in the differences between us. race has been associated with eight of these differences. Other studies increase it and it goes maybe as high as 10 to 100, are associated with skin pigmentation. Yet when you look at the total human genome, there’s over 335 million snips. So if we want to think about how our genome impacts race, it is very much not effector. And that’s what the Human Genome Project has said that race is a social construct. So how are there differences that we see in our society, based upon what we call race, which frequently is associated promote predominantly with skin color. Well, one has to ask and look at how people’s health different. Some say it’s based upon the choices that people make. But as my former boss when I was at the Robert Wood Johnson Foundation recently visa, Mori said, the choices people make are determined by the choices they have. What does that mean? Well, let’s look at how people live today. And what are the choices that they face. Frequently, people are faced with life-altering decisions, when they have to make the decision between spending their money on housing, or transportation.

Frequently, people are faced with life-altering decisions, when they have to make the decision between spending their money on housing, or transportation, or health care, or food. And because housing and transportation costs and health care, tend to occur at fixed times in the month. And excess expense, extra expense for housing or car breaks down or a new health care experience, frequently leads people to make a decision to spend less money on food. And this is how they become food insecure. It’s not their choice. Rather, it’s the choices that they have. So when we think about looking at food insecurity, and what are the factors, working for an insurance company, one of the things you might first think of well, maybe food insecurity associated with having health insurance. And a study that was done by the Health Initiative, each one of these dots represents one county in North Carolina. And the dots go up on the scale, if there’s higher levels of food insecurity. And they go to the right on the scale, if they’re higher levels of people who are who have health insurance in that county. And as you can see, there’s no correlation. Well, maybe it’s due to economic factors. And we know in our nation, about 30% of employees with employer-sponsored insurance earn less than $30,000 a year and half of the households making $30,000 a yes or less, are food insecure? Well, what happens when we plot those on a similar kind of graph? What we see is that financial resources have a moderate correlation to food insecurity. But what is really striking here in North Carolina, and many places across the country, that the strongest correlation is between race and going across to the right. each county gets further to the right, if it has a higher percentage of people living there who are African American. So what how does that fit with the concept, that race is a social construct, not a biological construct? If we’re going to understand these differences, we have to look at how people live. People spend on average, well, actually, every one of us does, depending upon whether it’s a revenue year or Leap Year, 525,000 minutes. That’s how long a year is. In each one of those years, people spend about 120,000 minutes working 93,000 minutes watching TV 27,000 minutes eating and drinking, shopping for 15,000 minutes, sports and exercise for 7000 minutes, only 60 minutes in a clinical setting. So we’re going to look how health is determined in our country. It is not those 60 minutes out of half a million minutes. Rather, it’s where people live, learn, work and play. And when we look at the difference based upon race and ethnicity, we have to understand that there are some truths that we have to come to grips with. And we as a nation, have been coming to those grips ever since the murder of George Floyd. However, this is not something that is new. And for those who have lived in a society for any length of time, race, although not addressed, has been an issue. And as James Baldwin said in 1962, then not everything that is faced can be changed, but nothing can be changed until it’s fixed. So what is that reality that we have to face? All of us can remember that Crispus Attucks was the first person killed in the American River. illusion. This happened very new Faneuil Hall in Boston, Massachusetts. Yet the cultural experience almost over 200 years later, of black Americans are less tied up with this act of violence. As much as this act of violence that occurred in 1976, and captured by Stanley foreman in a Pulitzer Prize-winning photo. 

This is a photo of a black American. He’s the lawyer who was walking the city hall for a meeting and was accosted by demonstrators who were out demonstrating against school desegregation in Boston. And this occurred less than a block from where Crispus Attucks was fought died, fighting for the freedom of our nation. My talk will focus on the impact on black people in the United States that has been the impact of racism. And that has been the focus of my own personal journey, my own personal study, but we must understand that racism has impacted all people of color in this nation. In the 1830s, American Indians in the southeast were forcibly removed from where they have lived for centuries, and moved out to Oklahoma. frequently they were rusted from their homes with little time to pack and were forced off their land and to walk from their homes. And 1835 20,000 Cherokees were removed from their homes, and that Trail of Tears 5000 of them died along the way. In total, nearly 60,000 American Indians were removed by federal troops improperly close and poorly fed, resulting in 13,000 of them dying during the 1830s. This is just one of the many assaults on the first people as part of a national program assaulting their culture in their very lives. In the summer of 1919, what was called the red summer, in towns and villages and cities and what and throughout the West, Mexican Americans were subject to torture, lynchings and other violence at the hands of white mobs and law enforcement agencies, such as the Texas Rangers. Historian say that from 1910 to 20 1920, an estimated 5000 people of Mexican descent were killed or vanished in the United States. Over just over 100 years after the deadly force removal of American Indians, a similar pattern of removal in internment by the US government soldiers. This time it was a Japanese living on the west coast. They were forced to move quickly in their proper property was liquidated to be purchased by white purchasers and owners at a significant discount. And they were forced by train into internment camps behind barbed wire and guarded by US citizens. I mean, by US soldiers 120,000 Japanese, most of them US citizens were the victims of this internment. On the east coast, just 11,000 Germans were moved. And this was not a mass movement. Each of them were interviewed. And the determination resulted in 11,000 being in turn. So this is in the history of our country. What about today, when we look here in North Carolina, after the Civil Rights Movement led many to say that we have become a less racially divided country. The data says another thing. African American babies die at twice over twice the rate of white babies and the babies at 1.77 times to rate. African Americans are two and a half, almost two and a half times more likely to die than whites from diabetes and to 2.3 times more likely to die from kidney disease. All of these are significant health disparities that exists here in North Carolina. But similar data can be found in every single state of the nation. Martin Luther King said that All the forms of inequity, injustice in health is the most shocking and the most inhumane. Why does this occur? It occurs because of the systems that we have in place is Don Berwick, the former administrator for this Centers for Medicare and Medicaid Services said, every system is perfectly designed to get the results that it gets. 

And our system, the system of racism, which involves engagement in the labor market and interacts with criminal justice system and healthcare system at school desegregation, and each of these interact, to results to end up in the results that we get. So let’s look at these factors. Because what they all come into play are the structures in our society, structural racism, that was identified by the North Carolina Institute of Medicine, in their healthy North Carolina 2030 report. structural racism are the public policies, institutional practices, cultural representation, and social norms. These are the systems that lead to the racial disparities in health that we see in the outcomes here in North Carolina, and across the nation. But what does it look on the ground? Let’s start off looking at public policies, institutional practices. And in a study by Samson and Wilson, in 1995, they looked at 171 of the largest cities in the US. And there was not even one city where whites lived in equal conditions to those of blacks. They said the worst urban contexts in which whites reside is considerably better than average context of black communities. And what was true, then 25 years later, is still true today. Let me show you this map. This is a map of North Carolina are my home state. In this map, the darker areas show those counties that have the highest percentage of enslaved people in 1860. Compare that map today, where this map shows those counties where people were, which have the largest percentage of blacks in the county in 2017. And what is really particularly striking is that when we take it to today and look at the county tier system that is in place in North Carolina, in other words, tier-one counties are those counties that have the highest rate of economic challenge is exactly the same counties that had the largest percentage of enslaved people back in 1860. This was due to policies related to federal policies throughout the 200 years that that has occurred that 200 and almost 50 years. And why is that? I’m sorry, 150 years? Well, we can see that in some of the policies related to redline. This is a map of Greensboro, North Carolina. And it shows the areas that were redlined marked in red, where because of federal policy, there were fewer home loans, and no home loans means no homeownership and no accumulation of wealth across generations. Some 80 some odd years later, when you look at Greensboro, North Carolina, and this map shows the light areas are those with low home value, and low home and low-income other people who live there. The same areas that were redlined in 1936 are areas that today are areas of intense poverty, and in fact are designated as areas of racial or ethnic concentrated areas of poverty. But that is not the only history and result of redlining. Because of these differences in homeownership, it is no surprise that there’s a dramatic difference in people who are black who live under the federal under 200% of the federal poverty level. Now that’s significant. Because without income you go, you end up going to different schools. And as you can see, there’s a significant difference based upon income in this graph, between the LSAT scores of individuals, children who live in these communities, and the difference between the lowest income and those at the highest income is over 400% now That’s the difference between attending Harvard or attending a community college. So children who start out behind in poor communities go throughout their school career and end up behind many times for the rest of their lives. But this legacy of redlining implies more than just the incomes, we know that it impacts incomes of people who live in neighborhoods that as well as it also exposes them to pollution. 

Black households with incomes between 50 and $60,000 live in neighborhoods that are more polluted than white households living below $10,000 a year redlined black communities are on average five to 13 degrees Fahrenheit warmer than non redline neighborhoods. And women who are exposed to high temperatures or air pollution are more likely to have premature, underweight or stillborn babies. redlining has a legacy that persists not only in the impact on income, but also an impact upon health. The further evidence about the impact of disparities and housing on health-related to exposure to pollution. More than half the 9 million people living hazard they’re living near hazardous waste sites are people of color. 6.5 million African American residents live in areas with higher than average pollution. And black Americans are three times more likely to die from exposure to air pollutants. And when you wrap that all up to what we’ve seen with COVID, there’s clear evidence that there are higher COVID death rates in areas with high fine particulate pollution, which many people of color are disproportionately exposed to. We see structural racism also in public policies, institutional practices. Here in North Carolina, when you compare the population of North Carolina, we see that blacks are just 22.1% of the population, and whites are 64.1%. Yet when you look at the prison population, the numbers are reversed. Over half of the prison population are African Americans. And more are other people of color. Is this to say that black Americans are more likely to be criminals? Well, let’s look at the data, and how public policy and implementation has had an impact upon that. And to do that, let’s look at the war on drugs. This was begun by Richard Nixon in 1971. And when we look at the impact 50 years later, we begin to understand what we mean by structural racism. First, let’s look at the data. This is data from the Census Bureau, and also data taken from FBI and other sources of information. Despite what people believe, black Americans do use illegal drugs at a rate that’s lower than white Americans. And their involvement in the drug trade is about the same. But when you look at rates of criminal justice engagement, black Americans are arrested at a rate nearly three times higher than white Americans. They’re incarcerated at significantly higher rates, both at the state and federal level. How could this be? The only answer is that there are differences and who gets pulled over? There are differences and who gets arrested, there are differences and who gets convicted. And there are differences and who goes to jail. And the only way you can explain it as the structural differences in society, there’s structural racism, and how the war on drugs was implemented. structural racism is also represented through cultural representations. And by that I mean discrimination. There’s a study that was done where two black men and two white and both young well-groomed, well-spoken, college-educated men with a aniko resume is applied for 350 advertise entry-level jobs and what the Waukee, Wisconsin. In each team, one said he was on parole. And the other said they’d served an 18-month prison sentence for cocaine. And they switched up between the black one thing that was in prison and the white one saying they’re in prison. And what they found that was easier for white male with a felony conviction to get a job than a black male whose record was clean.

This study has been repeated a number of times since then, with very similar results. Why do we have these differences is because racism is permeated throughout our society and how we think there was a project that was called the Beagle project, they looked at 10 million words, in magazines, books, articles, looked at those that the average college student with would level student would read in a lifetime. And this was based upon prior work that has shown that word associations in literature that you read, unconsciously frames how we think about people and things. What they found, after looking through 10 million words, were the most prominent associations for blacks were significantly different than those for whites. for blacks, the word associations in our literature in our culture, were being poor, violent, lazy, dangerous, for whites, who was wealthy, successful, educated, and ethical. It is no wonder when those kinds of associations are permitted to our society, that we have discrimination, where people of color are treated with less courtesy, less respect, they’re given poor service. They’re considered not to be smart of people will be afraid of you. And this is not uncommon for black men, where some white people will walk on the other side of the street when they see them coming down, will be considered dishonest, more likely to be arrested by the police. People act as if they’re better. They’re called names or insulted, or they’re threatened and harassed. Now, all of us remember that little rhyme for when we were children, sticks and stones will break my bones, but words will never hurt me. That’s not really true. There was a study that was done by Brody in 2014. It was done in rural counties in Georgia. They interviewed black teenagers at age 1617, and 18. And they asked them about their experience with discrimination. And those who were more chronically discriminate at 1617 and 18. were assessed, all of them were assessed. And for those who are more chronically discriminated, those individuals had elevated stress hormones, elevated blood pressure, and elevated body mass index, in other words, more likely to be overweight and obese, putting them on the road to poor health in the future. In the only difference in these individuals, these young black men, teenagers, was their exposure to chronic discrimination. discrimination and numerous studies have been associated with things such as coronary artery calcification, which leads to heart attacks, C reactive protein which is a major measure of stress in wear and tear in the body, higher blood pressure, lower birth weight, cognitive impairment, especially as they age, poor sleep, mortality, higher rates, and more likely to be obese. All of these lead to more chronic illness, more obesity, more diabetes, more lung disease, and more kidney disease, which is you remember from earlier on, are closely associated with higher fat, higher risks of death in serious illness during the COVID. Let’s go a little bit further and look at other impacts and factors related to structural racism and look at some of the institutional practices and social norms and how they result in poor health outcomes. adverse childhood experiences in early childhood have been demonstrated to have impact on a child and how they live. But in studies that have been shown with functional MRI, so brain studies of the studies of the brain that look at how the brain functions, shows dramatic differences between the normal on the left, and the child who is exposed to adverse childhood experiences on the right. 

These experiences have an impact upon the child throughout their life. What are adverse childhood experiences, family financial distress, death, or incarceration of a parent exposure to violence in the home or in the neighborhood. Living with someone who’s mentally ill or has substance use disorder, or being treated unfairly or judged unfairly based upon race, and ethnicity. Look at the first two are the first in the last family financial distress as I’ve shown, black Americans are more likely to have to be living below 200% of poverty. And as I’ve also demonstrated, more likely to be exposed to being judged unfairly due to the race or ethnicity. And this happens even at the age in which children are in preschool. So this happens throughout their lives. What we see in North Carolina, and it’s true in states across the nation, that the percent of children with two or more adverse experiences is more than twice as high amongst black children in North Carolina, as it is amongst white children. And the reason why that number is significant is that when you look at the data for the impact of adverse childhood experiences, that behavior problems are associated with children have had these adverse childhood experiences in the K through 12 environment. These include attention problems in the classroom, social problems, being aggressive, and rule-breaking. And then when you look at their performance, children have been exposed to more than two or three adverse childhood experiences, have less academic attainment, they’re unable to name their letters, they’re unable to understand the story, below-average math skills, and below-average reading skills. The assumption would be that this would be something that would be recognized by the educational system, and treatment would be provided. But now, the way our educational system has treated those who have behavioral problems, is not as a cry for help. But with exclusion, and suspension. The rate of exclusion for children in K through 12, in North Carolina is four times at higher four black children than it is for white children. And this is something that happens not only in K through 12, but also happens as early as preschool. 

It’s a little bit harder to measure. But let me just share with you a story. This is a story, and I’ll call him Jenny. Jimmy, Jimmy’s parents who were black, did everything that they were told was supposed to be right. They enrolled Jimmy and child care right after birth, so they could get in one of the best preschools. But by the time Jimmy was four, he had grown taller than most of the other kids. And the teacher remarked the parents when he started preschool at age four, my he’s a big one. I’m going to have to keep my eye on him. And any time he asked him even an age-appropriate question that was considered to be challenging by the teacher. He was sent to the headmaster of the preschool. That is when the headmaster was available. And when he wasn’t, Jimmy was sent to the cook who was the only other black employee for Jimmy this story turned out okay. His parents removed him from the school and he’s doing much better in another institution. But this is a classic case of how black children are pushed out. And young black men and young black girls are not only Delta FIDE, but they’re demonized in our educational system, leading to poor educational outcomes. But it doesn’t have to be this way. In 1972, across the Carolinas, there was a project that was started based at the University of North Carolina Chapel Hill, called the ABC Darien project. In this project, economically disadvantaged children were randomized to normal care and into another group into a safe and nurturing environment, an environment where they’re given good nutrition, pediatric care, and early in quality early childhood education. The project intervention lasted only until they entered school. But when they follow these same children at age 21, they had better scores. They had more educational attainment, there was less teenage pregnancy, less marijuana use and fewer depressive symptoms. And when they followed them out to age 35, there were fewer of these children, now adults who had diabetes or metabolic syndrome, and there was more individuals with bachelor’s degrees in higher-paying jobs. There are things that we can do to make a difference, we can begin to dismantle the structures in our society that lead to these inequitable outcomes. But we have to have the will. 2600 years ago, Plato said, When equality is given to unequal things, the result will be unequal. And that is shown in this graphic from the Robert Wood Johnson Foundation, where frequently we talk about treating people equally. Yet, if you give everyone the same bike, not all of them will be able to use it. We know that we have to craft the resources we provide to the communities based upon their needs. And for those of us in health, it shouldn’t seem like it’s such a heavy lift to get to that point. Think about prescribing someone as I have done, when in my clinical days with insulin. No one would ever consider giving every single person the same dose of insulin. Why do we think differently about the other interventions in our society that can make a difference about an individual’s health. We can do different. I know many of those who are in the housing field are aware of the Moving to Opportunity experiment that was done by HUD. And this is where poor children with their families were moved to lower poverty neighborhoods. And these children when they grew up, had a 31% higher annual incomes, 300,000 greater lifetime earnings, they were more likely to go to college, and the girls were less likely to become single mothers. We can do better, we can improve our health, but only by addressing the health impact of only by recognizing that addressing the health impact of racism requires dismantling barriers and changing policies both inside the health system that 60 minutes on average, and outside the healthcare system where people live, learn, work and play. So at this point, that’s the end of my presentation. And I’d like to if I can switch over to get see if there any questions or comments please put them in the chat. Ah, there they are. Okay. And sila Wilson comments that number of stoplights and African Americans Communities compared to a number of white communities is another issue in addition to contributing to higher pollution and poor health and word association. In reality, there’s only one race of humans absolutely true. Do you think racism in situations only when one is discussing human beings as opposed to colorize classification, so people would begin to decrease some of the power associated with the word racism. I think we have to talk about race, we have to talk about race, because regardless of what I think, when I walk down the street, people are judging me based upon my race and ethnicity, not on where I went to school, or what I do as a profession. And this happens to our children in schools. It happens to people on the street. And until our nation has a discussion about race on an ongoing basis, and begins to change these structures in our society that lead to the inequities in the health differences that we see. We will not be able to make progress. So if you have any other questions, certainly be happy to answer them if you would put them in the comment section. 

Lumpkin, 41:53 

Arne says, Thank you very much, Dr. Lumpkin. Are the various data points by race the same in cities, towns or rural communities? Are they the same in various parts of the country? They are similar but not the same. So before I came to North Carolina, my home state was Illinois and I was the state health director there. What we see in Illinois is that many of the rural communities, particularly in Southern Illinois, have similar kinds of inequities based upon distance, but the rural communities tend to have very small numbers of people of color. So there is a significant variation from state to state. 

Lumpkin, 42:40 

Lauren asks us says she’s thankful. Thank you, Lauren. And will I share the slides as well, and I happy to share my slides. And hopefully, the sponsors will be able to make those available. 

Lumpkin, 43:01 

See, you all also points out there’s a gap and culturally-specific behavioral health scales, which is always blamed on lack of finances. And that’s, that’s absolutely true. You know, an interesting fact that that just really completely blew me away, I learned a few months ago, was that the compensation that are given to NFL athletes are significantly influenced by the culturally different references based upon race. In other words, assuming a lower mental functioning level for black athletes, has led them to be compensated less for the same level of mental deterioration. That’s an example of how and how, how systemic. Some of the racial concepts are unless we challenged, we’ve seen the same thing in some of the algorithms that are used for treatment. Where there recently was a study that was done where one of the algorithms determine when people would get special services for chronic diseases. It was based upon utilization of medical resources. However, data shows that people of color particularly African Americans are less likely to use health care services than their white counterparts. So if you base it upon the services that are used, black Americans are less likely to get their needed services. Now, what was really interesting and really positive was that the authors of this study demonstrated by setting the level to initiate these additional services based upon diagnosis, eliminated those differences between race and ethnicity. today are and again, thank you. I’m Fran rights do I think a single-payer health system would help shape racial equity in health care? I think that that’s, that’s a different issue. Certainly thinking about single-payer is one of the ways to approach it. But the challenges that we’re talking about are not are not only in the health care system. They’re in where we live, where we work, where we play. And so we have to have a societal discussion about what are the pieces that have been put in place, the policies, the social norms, the laws, the regulations, that perpetuate the racial inequities in our society, because unless we correct those, we won’t make a difference. And we look at communities throughout our nation that have been historically disinvested. You know, redlining is just an example of that, and make not a equal approach, but an equity approach to investing in those communities to raise them up so that everyone who lives in those communities has a fair opportunity to be as healthy as possible. 

Lumpkin, 46:41 

Magdalena says, How does being part of multiple discriminated groups, women, black, queer, black, play an additional factor in health and access to treatment? There, you know, as we look at the multiple factors that lead to discrimination in our society, we see a compounding of the impact on health effects. And that is based upon race. It’s based upon ethnicity. And it’s based upon gender, gender identity, in orientation. And so when we talk about equity in our society, we have to talk about all the spectrums. As I said earlier in my talk, given the amount of time and my own expertise, I focused in on this one particular career. But the goal of health equity means that everyone in our society has a fair opportunity to be as healthy as possible. Where I work at Blue Cross, we say, where we are looking to improve the health and well-being of our members, and communities where they live. But we further go on to say we won’t rest until everyone has access to fair quality health care. 

Lumpkin, 48:15 

So we have a few more minutes for other questions. See no further questions. I’d like to thank all of you so much for spending time with me this afternoon. The work that ncrc is doing is absolutely so critical to the future of our nation. If we don’t invest in those communities that have experienced historical disinvestment for decades and centuries, we cannot get to a more equitable society. And that means everyone has that fair opportunity to be as healthy as possible. Thank you so much. Stay well continue the hard work. It’s good work and it will make a difference. 

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