Upstream Undertaking: The Effect of

Socioeconomic Factors on Cardiovascular

Issues in African Americans

Ananya Devadiga
2/23/18

G/T Intern Mentor

Dr. Melissa Kiehl
 When a patient enters a medical clinic or office, a doctor’s views are usually constrained

to the four walls of a patient room. However, as much medicine the doctor gives, the underlying

cause could be elsewhere. Many health issues arise from a patient’s environment, their housing

conditions, access to grocery stores, job and income. A high blood pressure issue could be a

symptom of stress at work or inadequate housing. Giving this patient antihypertensive drugs

solves the problem in the short term. A patient’s obesity may be the result of grocery stores being

located 45 minutes away, also known as a food desert. This patient’s only food supply is through

fast food restaurants or convenience stores at local gas stations. A person may have low

education levels, making it difficult for them to understand their disease, or it could be the

underlying cause of their other issues. Research has shown that race and ethnicity often

determine a person’s socioeconomic status. Education tends to be the common link between all

the upstream factors. Since African Americans tend to be less educated than their Caucasian

counterparts, this only creates a domino-effect in addition to the other socioeconomic factors.

The problem here is many doctors don’t know what to do when the issues lie outside the medical

practice. Several organizations have been started to train these so called upstreamists to address

these problems of living and working conditions. Education is one of the dominant factors that

affect cardiovascular issues in African American patients, as it contributes to low socioeconomic

status, fueling the deterioration of health. There are several upstream factors that affect health,

however, education seems to link all of them together. Low levels of education leads to

unemployment with in turn leads to poor housing, living in food deserts, desperation leading to

substance abuse, and so on. The purpose of this paper is to define socioeconomic factors,

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analyze how education impacts African American health, and describe the links between

education and housing conditions, food deserts, substance abuse and other minor socioeconomic

factors.

In general, there are several health disparities between African Americans and

Caucasians in the United States. Blacks were behind whites in at least four positive health

indicators, including percentages of persons aged <65 years with health insurance, adults aged

>65 years vaccinated against influenza and pneumococcal disease, women receiving prenatal

care in the first trimester, and persons aged >18 years who participated in regular moderate

physical activity. Blacks also had higher proportions of certain negative health indicators than

whites, including new cases of gonorrhea, deaths from homicide, persons aged 6--19 years who

were overweight or obese, and adults who were obese (Health disparities experienced by black

or African Americans --- United States, 2005). For insurance coverage, 75.8% of whites used

private health insurance while only 54.4% of blacks used it. The death rate for African

Americans was generally higher than whites for heart diseases, stroke, cancer, asthma, influenza

and pneumonia, diabetes, HIV/AIDS, and homicide (Profile: Black/African Americans, 2015).

Socioeconomic factors or social determinants of health are any non-medical factors that

affect health. The main link between all of the determinants is education. Education links to

health in many ways. It contributes to human capital by “developing a range of skills and traits,

such as cognitive skills, problem solving ability, learned effectiveness, and personal control”

(Zimmerman, et.al, 2015). Education also means better health through an individual’s

knowledge on health and healthy behaviors also known as health literacy. Eventually, it provides

more and better job opportunities which also affect economic resources available to a person

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(Bharmal, et. al., 2015). "Because education develops one's ability to gather and interpret

information and to solve problems on many levels, it increases one's potential to control events

and outcomes in life. Moreover, through education one encounters and solves problems that are

progressively more difficult, complex, and subtle, which builds problem-solving skills and

confidence in the ability to solve problems" (Zimmerman, et.al, 2015). Education not only

allows individuals to have the skills to process health information better, but it also allows for

better job opportunities, leaving the individual in a better financial situation.

In communities that are segregated by race, common characteristics include low

economic development, poor health conditions, and low levels of educational attainment. 12.4%

of African American college graduates between the ages of 22 and 27 were unemployed in 2013,

which is more than double the rate of unemployment among all college graduates in the same

age range (Ethnic and racial minorities & socioeconomic class, n.d.). Only 20.2% of blacks have

a bachelor’s degree or higher, compared to the 34.2% of whites. More black women than black

men had earned at least a bachelor's degree (22.4 percent compared with 17.7 percent), while

among whites, a higher proportion of men than women had earned at least a bachelor's degree

(34.4 percent and 34.0 percent, respectively) (Profile: Black/African Americans, 2015). One can

observe that the need for education in order to have health literacy and the lack of this education

in African Americans as seen by the statistics is what causes the abundance of health issues in

this racial group.

Education can also be linked to other socioeconomic factors. Housing conditions or

neighborhood conditions are closely linked to education. Neighborhood conditions influence

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health through physical characteristics, availability and quality of neighborhood services and

social relationships within the community. Physical characteristics include air and water quality,

overall housing conditions and access to parks (Bharmal, et. al., 2015). An example of the effects

of housing conditions on health can be seen through a patient of Dr. Rishi Manchanda, a doctor

and proponent of upstream action. Veronica, his patient, walked into a clinic in South Central

Los Angeles. She came in with a chronic headache after three inconclusive visits to the

Emergency Room. After taking her vital signs, the medical assistant asked, “Veronica, can you

tell me about where you live? Your housing conditions?” It turns out that Veronica’s house had

roaches, water leaks and mold. Dr. Manchanda came to the conclusion that Veronica had chronic

allergies related to where she lives. After prescribing her some medicines, he sent her to a

community health worker to fix up her home. A few months later, she returned to her follow up

appointment with ninety percent relief, the result of fixing up her home (Manchanda, 2014). This

shows the extent to which housing conditions affect an individual’s health since they are

spending the majority of their time there. Another place individuals spend most of their time is

their workplace. The physical aspects of work could affect the risk of disorders, sedentariness

and obesity. Physical conditions at work, such as ventilation and noise level, psychological

aspects, such as stress and rewards, and social aspects, such as coworker support, all affect

health. The health care benefits provided by the employer affect the health-related decisions

people make (Bharmal, et. al., 2015). The link between education and housing conditions comes

from the fact that lower-income neighborhoods and those with higher proportions of non-white

residents are usually areas with poor housing conditions(Zimmerman, et.al, 2015). In terms of

economics, the average black household median income was $36,515 in comparison to $61,394

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for white households. 25.4 percent of blacks in comparison to 10.4 percent of non-Hispanic

whites were living at the poverty level (Profile: Black/African Americans, 2015). The domino-

effect can be seen here as individuals, in this case African Americans, do not have the education

to get a decent, well-paying job, and end up in a bad financial status which causes stress and the

surrounding area is not suitable for living which affects their health as well.

Food deserts are areas where limited number of stores sell fresh produce and nutritious

food (J. Harrison, personal communication, October 24, 2017). In a TED talk by Ron Finley, he

expressed his concern for his community which had been a food desert, a place where the nearest

grocery market with fresh foods is about a 45 min drive. He says that South LA is “home of the

drive through and the drive by,” which is killing people. Obesity rates are high because of the

lack of proper nutrients, wheelchairs were bought more than used cars, and dialysis centers were

popping up everywhere (Finley, 2013). For African Americans, especially, 34% live in food

deserts (Ethnic and racial minorities & socioeconomic class, n.d.). These neighborhoods tend to

have higher rates of cardiovascular disease, diabetes, and other diseases related to unhealthy

diets. Overall mortality rates are also higher in these areas (Ethnic and racial minorities &

socioeconomic class, n.d.). In Baltimore specifically, it was found that “1 in 4 Baltimore

residents live in a food desert” (1 in 4 Baltimore residents live in a food desert, 2015). Racial

residential segregation also produces and perpetuates social disadvantages such as low quality,

poor schooling and unsafe housing (Bharmal, et. al., 2015). Lower levels of education among

African Americans lead to living in areas with poor conditions, usually racially segregated,

which affects the health of these individuals. The continuing racial residential segregation and

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the economic segregation in urban settings affect the chances of those living in poverty

"irrespective of personal traits, individual motivations, or private achievements" and expose

residents, majority of whom lack adequate education, to higher levels of social problems.These

historical, economic, and cultural factors have also shaped and reinforced the racial division of

labor and adverse impact on the low-wage sector. (Zimmerman, et.al, 2015)

Substance abuse is another socioeconomic factor tied to education. A substance abuser is

someone who establishes a pattern of use and continues usage when problems arise because of

the drug use. The main threats from substance abuse are cardiovascular disease, lung disease and

cancer. The tar in cigarettes is toxic to arteries, narrowing the artery to create clots which

increases the risk of heart attacks and stroke (Kefalides, 2008). Specifically for cardiovascular

issues, these issues could range from fast heart rates to heart attacks to infected valves and

arteries. Drugs can also affect the nervous system, creating symptoms such as changes in body

temperature, heart rate and blood pressure, headaches, body pains, heart attacks and respiratory

attacks (Illegal drugs and heart disease, 2017). High blood pressure could eventually lead to

heart attack, stroke, heart failure, aneurysm, weakened blood vessels to kidneys or eyes,

metabolic syndrome, or memory issues (High blood pressure, n.d.). Cocaine users have thicker

heart muscle walls, stiffer arteries and higher blood pressure than non-users which increases their

risk of heart attacks. It is the one of the most prevalent drug in the United States and has

increased. It is also the most common in form of drug abuse that would be found in a hospital’s

emergency room. Along with cocaine are amphetamines and ecstasy which do the same damage

in the body as cocaine and have the same effects on the cardiovascular system (Illegal drugs and

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heart disease, 2017). “Adults with higher levels of education are less likely to engage in risky

behaviors, such as smoking and drinking, and are more likely to have healthy behaviors related

to diet and exercise” (Zimmerman, et.al, 2015). Naturally speaking, there is a high incidence of

substance abuse amongst low educated and individuals of low socioeconomic class. A lot of this

has to do with economic struggles, so when people don’t have as many economic opportunities

they turn to substances for various things. (K. Yousuf, personal communication, December 23,

2017) Lower levels of education could lead to unfortunate conditions which could lead people to

resort to substance abuse, therefore, affecting their health.

Support structures prove to be very important to one’s health. There have been many

studies that examine people who have more social interactions and support structures in place,

who do much better from a health perspective than those individuals that do not. Often times,

things that go hand in hand with poor housing, or low education or socioeconomic class is the

lack of a support structure or lack of social interactions that are positive and then help individuals

with their health. It is very important when, let’s say, an individual is hospitalized, for them to

recover appropriately upon discharge, it is very important to have a social support structure. (K.

Yousuf, personal communication, December 23, 2017)

Why does this matter? More than anywhere else, a person spends most of their time at

home or at a job rather than in a medical clinic or hospital. Giving a person medicine solves the

current internal issues, but what about the day-to-day outside issues? Mold in a run-down house,

stress from not even having proper housing, not being able to find fresh food, and other

circumstances such as these could seriously affect a patient’s health. Obesity, asthma, high blood

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pressure, etc. could be potential results of these resolvable issues. Many people take their house

and food for granted, but people in Baltimore, MD, close to home, don’t have these necessary

aspects. In addition, doctors may recognize the problem but not have the resources to help with

these issues. It is important that doctors have access to resources to solve these sorts of issues as

well. The “Don’t ask, don’t tell” phenomenon is that medical professionals don’t know what to

do if there is a problem with a person’s living conditions or job so they simply don’t ask. There

is a gap between knowing and doing something about it. Then there’s the question of who’s

responsible to do this? And the truth is that there are not enough upstreamists who know how to

put in a system and give resources. Dr. Manchanda, who was mentioned before, has started a

program called Health Begins to train upstreamists and changing the confidence of healthcare

professionals, so that clinicians have the ability to address problems of living and working

conditions. The intertwining of these experts with health professionals and the evolution of the

healthcare system to recognize these causes through the support of policy will help people get

the help they need because in the end “your zipcode could mean more than your genetic code”

(Manchanda, 2014).

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Kefalides, P. T. & Caley, C. F. (2008). Substance abuse. In The New Book of Popular

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