Unequal Cities: The First in Our Book Review Series

We are excited to present a new blog series reviewing books from Health Affairs’ 10 Books about Racism and Health.

The books provide a wide-ranging view of the impact of racism and structural racism on health, from historical to policy. We encourage you to read them (alone, in a book club, etc.) and start new conversations! 

In this blog post, Anna Shetler reviews Unequal Cities: Structural Racism and the Death Gap in America’s Largest Cities, edited by Maureen R. Benjamins and Fernando G. De Maio, published by Johns Hopkins University Press. Both editors are based in Chicago; Benjamins is a senior research fellow at the Sinai Urban Health Institute and De Maio is a professor of sociology at DePaul University. Read an interview with Benjamins and De Maio about Unequal Cities here.

–Claire Altman, IAPHS Blog Editor

Grounded in social determinants of health theory, Benjamins and De Maio use a social justice framework to promote health equity. While city-level data exists elsewhere, they assert that race-specific data are incomplete and, in some cases, based on county measurements rather than cities. The authors claim that their main contribution is in providing city-specific results on racial health inequalities. They focus on cities because a large proportion of Americans live in urban areas, and because of the political power that cities hold in implementing local policies. Findings show that inequality exists both within and between US cities so, ultimately, only by focusing locally can health equity be achieved. In conclusion, the authors argue that city initiatives can help eliminate urban health inequities.

Part I: The history of American health and racial inequities

In Part I, the editors and their co-authors paint the context of health equity by briefly discussing American racial history, noting the nation’s move from explicit to implicit exclusion of Black Americans. They discuss important policies enacted by American institutions, including the US government, over the past 150 years that deteriorated or improved Black and white health, like redlining, the Fair Housing Act, and the Affordable Care Act.

Part II: Variations in racial health inequities across cities

Part II documents how racial health inequities vary across 30 major US cities. Age-adjusted mortality rates, life expectancy, and years of life lost are analyzed among whites and Blacks, and distinguished by the 10 leading causes of death as well as HIV, homicide, and opioids. Boston, El Paso, and New York generally have the highest life expectancies and lowest Black-white health inequities, while cities like Chicago, Memphis, Houston, and Washington, DC have the worst expectancies and inequities. Part II leaves the reader wondering, “why?”

Part III: Why do inequities exist?

Part III helps to answer this question of “why;” however, there is no one right answer. There is substantial heterogeneity by place. Of city poverty, median household income, educational attainment, racial segregation, and income inequality, they find evidence that median household income and income inequality have the strongest associations with mortality outcomes. Richer cities have higher racial inequities and, as income inequality increases, mortality increases for all. Drawing from ecosocial theory, the authors critically note that income and its inequality are “not the cause of poor health; it is the consequence of earlier political and economic processes.”

Part IV: Call to actionable steps

Part IV outlines actionable steps to achieving health equity and provides case studies on local initiatives in Chicago in disseminating research and creating lasting change. First, the authors call for legislatures to recognize that all policy is health policy. Policies need to focus on racial equity, and cannot merely attempt to improve health for all. Umbrella health improvement policies may improve average mortality rates but create larger racial disparities.

In their chapter, Silva and colleagues emphasize the need to include communities in all steps of health equity – which they call “[transformative] collective impact” (rather than community-based research or action) because of the power that must be given to the focus communities. Then, Monnard and colleagues remind us in their chapter that data cannot speak for itself; rather, we as researchers have a moral and ethical obligation to the communities we study. While public dissemination or actively pursuing change may not be in our job descriptions, we have a responsibility in health research to ensure change does happen.

The final chapter of Part IV presents a case study of West Side United, a collaborative effort of 100+ partners to reduce life expectancy disparities on the West Side of Chicago. WSU implements initiatives in education, economic vitality, neighborhood and physical environment, and health and healthcare. WSU has raised millions to invest in community projects and has distributed millions of meals since 2017 (West Side United). Nonetheless, WSU’s overarching goal to reduce, if not eliminate, inequities in life expectancy is a bold undertaking and a “decades-long endeavor.” The authors of this chapter stress the need for local change via local stakeholders rather than relying on short-sighted federal systems.

Limitations and Future Work

Place-based research should expand on this book by examining other racial, ethnic, and immigrant groups–plus smaller cities and rural areas–and by generating public-use datasets.

One limitation of this book is in the racial groups analyzed: non-Hispanic Blacks and non-Hispanic whites, only. As the authors explain, there are limitations in reporting on data for small numbers of other racial/ethnic groups. However, data collection, analyses, and policies directed toward other racial, ethnic, and immigrant subgroups will be necessary to achieve aims of equity.

This book also necessitates including more rural areas in health equity research and action. Cities are not the only geographic entity worth studying especially as cities may obfuscate community-specific inequities. For example, city-level HIV mortality rates are smaller than the national rate, indicating that greater health inequities are present in areas outside cities.

For all the emphasis on creating usable city-level data, the data used in the book are not publicly available (likely because of privacy concerns and data use agreements with the National Center for Health Statistics). However, cities and their communities need access to this data. In the concluding chapter of the book, Benjamins and De Maio suggest city leaders use data from 500 Cities or PLACES, City Health Dashboard, and CityHealth.

Final Comments

I think this is a great book for understanding the basics of health equity and its heterogeneity within the US. While health equity data may paint a bleak picture, the authors encourage us to be optimistic: “Racial inequities in mortality are not inevitable. If health equity can be achieved in some cities, and across multiple causes of death, why not all cities and all causes of death?” I appreciate that they connect these findings to examples of place-based initiatives. The Chicago-based case studies provide concrete examples for how to make such progress toward equity. Researchers and policymakers alike will find something to take away from this book.