Racism and Healthcare

We're all the products of our environment and our genes. But when it comes to health, which factor is the trump card? Would a woman with a family propensity for ovarian cancer avoid coming down with the disease if she were raised on a macrobiotic diet in pollution-free rural North Dakota? Or on the flip side, could a white woman adopted from a middle-class family in Idaho into a poor Hispanic family in New York suddenly become vulnerable to diabetes or asthma?

Figuring out how the interplay of race, socioeconomic status, schooling and other environmental factors influences our health is a complicated challenge. But that's what a new four-hour PBS series, "Unnatural Causes: Is Inequality Making Us Sick?" aims to do. The series premiered March 27 and ends April 17 and will soon be released on DVD. Producers Larry Edelman and Llew Smith say it was inspired by a medical mystery they discovered in their earlier documentary, "Race—The Power of an Illusion, "a series that investigated some common myths and misconceptions about race. They found, for example, that African-Americans have some of the highest rates of hypertension in world, which has been linked to heredity. But West Africans, who share many of the same genes as African-Americans, have some of the lowest blood-pressure rates.

In "Unnatural Causes," the filmmakers raise other disturbing conundrums. For example, the United States spends more than twice the average of other industrialized countries on health care and yet does worse than 28 other countries in life expectancy and 29 other countries in infant mortality. Why are children living in poverty about seven times as likely to be in poor or fair health than children living in high-income households? And why has HIV infection doubled in the African-American population but remained stable among whites? According to the film, the answers are at least in part related to economic conditions, "a continuous health gradient tied to wealth. At each step down the socioeconomic ladder—from the rich to the middle class to the poor—people tend to be sicker and die sooner," the narrator says.

But that's not the whole story. African-Americans, Native Americans and Pacific Islanders at all income levels fare worse than their white counterparts. To the filmmakers, that seemed to indicate that institutional racism as well as poverty has an impact on an individual's health—an interesting idea in itself, and a refreshing relief from the patronizing assumption that "some people" don't know how to take care of themselves or don't make the effort. Smith says the film reveals a more complicated picture: "When we looked at populations and entire communities, you begin to see that there are larger forces at work beyond what an individual can control. That led us to the growing research focused on social determinants of health and health equity." The filmmakers offer plenty of background from experts like Angela Glover Blackwell, founder and CEO of PolicyLink, an advocacy organization for economic and social equity, and Ana Diez-Roux, M.D., a University of Michigan epidemiologist specializing in neighborhoods. But the film's power comes not from experts or statistics but stories of real people.

The first segment of the series, "In Sickness and in Wealth," looks at the lives of a CEO, a lab supervisor, a janitor and an unemployed mother to find out how class determines our access to health care. In "When the Bough Breaks," the filmmakers tell the story of Kim Anderson, a successful Atlanta attorney who, despite being healthy and well above the poverty level, delivers a dangerously premature daughter—a disproportionately common outcome for black women no matter their socioeconomic level. In "Becoming American," we meet Amador Bernal, an immigrant from Mexico who earns $9 an hour at a mushroom farm in Kennett Square, Pa. His health is beginning to suffer—but Bernal has never been to a doctor.

One installment focuses on the Pima and the Tohono O'odham, two Native American tribes in Arizona. A century ago, type 2 diabetes was so rare as to be unheard of in this population. Today, these tribes have the highest rates of the disease in the world: filmmaker James Fortier draws a direct parallel between this fact and the loss of their water rights and farms.

Director Ellie Lee looks at two urban neighborhoods—Richmond, Calif., and Seattle—for a segment called "Place Matters." The Richmond area bears the hallmark lack of access to fresh food and safe streets that defines urban blight. In the Seattle community, leaders and government are working to create an area that promotes the health of its inhabitants. The differences in the residents' futures is stark, says the film. "If you lived in Richmond, you'd be 30 percent more likely to live into old age than if you lived in Seattle. In Richmond, your child would be six times more likely to be hospitalized for asthma than if you lived in Seattle."

The most damning indictment of the U.S. health-care system comes in the last two segments. "Collateral Damage" explores the effect on the lives and health of Marshall Islanders in the South Pacific since the Ronald Reagan Ballistic Missile Testing Site was located there—dislocating thousands of people, destroying their traditional way of life and resulting in a rise in tuberculosis and other diseases encouraged by squalid living conditions. And "Not Just a Paycheck" compares the socio-economic and health repercussions of an Electrolux factory closing in Greenville, Mich., with those in a Swedish community that had endured a similar factory shutdown. Hospital visits in Greenville tripled due to depression, alcoholism and heart disease. In Sweden, there was barely an increase in head colds: citizens there are protected by their country's generous social-welfare programs.

Some of the stories in "Unnatural Causes" are not entirely surprising (especially after Michael Moore's documentary "Sicko"), but they powerfully reinforce the fact that where you live can predict not just how well you live but also how long. According to the producers, more than 120 organizations from The Joint Center for Political and Economic Studies' Health Policy Institute to the Chi Eta Phi nursing sorority have begun to use this film as a teaching curriculum. Once you check out the series, you'll see why.