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Introduction

COVID-19 and the death of George Floyd have called more attention to issues of inequality based on race, gender, income, and other factors.^[1]

Inequality affects many areas of life. At Examine.com, we generally focus on nutrition, but our mission is about health in general. In this article, we’ll be discussing how inequality affects various health factors — including nutrition.

Although inequality is a serious concern worldwide, I’ll mostly be referencing US data, for two reasons. First, there’s more US data available. Second, this article wouldn’t exist if longstanding inequality issues hadn’t suddenly taken center stage after millions of people watched the heart-wrenching death of George Floyd.

1) COVID-19 was not the “great equalizer”

During pandemics, everyone is at risk.

But certain people, notably a few celebrities and politicians, went so far as to make statements along the lines of “COVID-19 is the great equalizer. We’re all in this together.”

Sure, we’re all affected and hoping for the pandemic to end. Nevertheless, the data makes it quite obvious that we’re not all equal when it comes to the pandemic.^[2]

COVID-19 mortality rates are far higher in black people. The theorized causes include notably high housing density, insufficient access to healthcare, and a higher rate of pre-existing conditions.^[3] The Navajo Nation has also been ravaged by COVID-19, despite its low population density, partly due to poverty and insufficient medical resources.^[4][5]

And being a minority doesn’t just make you more likely to die from COVID-19 if you catch it; it also makes you more likely to catch it in the first place. Let’s mention a couple of reasons:

One is the aforementioned high housing density. Physical distancing is easier if you have a big house and an expansive backyard, or even a summer house to escape to, than if you’re packed with other people.

Another is that minorities are overrepresented in “essential professions”,^[6] such as meat and poultry workers.^[7] In April 2020, 3% of those workers from the 115 meat and poultry factories that reported to the CDC were COVID-19 positive.^[8] That may not seem like much, but it’s far higher than the national rate at the time (more than a hundred times, according to the Johns Hopkins data, though lack of widespread testing complicates comparisons), and those workers didn’t have the option to work remotely. Few even had the option to stay home for a while to avoid spreading or catching the disease.

COVID-19 can aggravate inequalities in many other ways. If you’ve been laid off or if your work hours have been reduced, health insurance may have become too costly. If you’re disabled (if your mobility is limited, if you’re visually impaired …), getting essential supplies may be especially difficult. And so on and so forth.

COVID-19 upended normal life all around the world. But lower-income workers, who are more likely to be minorities and typically can’t opt for remote work, were disproportionately affected. Indigenous tribes and black Americans have also experienced higher mortality rates than other groups.

2) Doctors are less likely to believe women and black people

There are alarming racial differences in maternal mortality. Depending on sources, the risk of pregnancy-related deaths for black women is 3–4 times or 2–6 times^[9] higher than for white women.

The birth weights of infants of black women are lower than those of infants of white women, too, and this cannot be attributed to genetics, because newborns from Africa-born black women are closer in weight to newborns from US-born white women than they are to newborns of US-born black women.^[10]

Women don’t have to worry only when they’re pregnant, either. Doctors are more likely to dismiss a health concern (such as chronic pain) when it is expressed by a woman.^[11][12]

And women are not the only victims of care inequality. Most doctors are white, in the US, ^[13] and white Americans (not just laypersons but also medical students and residents) consistently rate the pain of other white Americans higher than the pain of black Americans, which often ends up being undertreated.^[14]

This issue hits home for me. Since 2008, I’ve been living with low-level but constant pain in several parts of my body. It took several years of pain clinics, widespread torn joints, and surgeries with poor outcomes (with a couple dozen MRIs along the way) before a doctor referred me to a geneticist, who finally diagnosed me with Ehlers-Danlos Syndrome (EDS), a genetic collagen disorder.

In the meantime, my pain was dismissed more times than I can count, and I often felt hopeless. To think that if I were black, a woman, or a black woman, my pain may have been dismissed even more often and I may have faced worse outcomes … it boggles the mind. And during most of that time, I was living in Boston, which boasts of several highly ranked hospitals. A location with worse access to care, especially for rare or difficult conditions, would have made my situation even more difficult.

Now, with the COVID-19 pandemic ongoing, it can be harder to diagnose and treat already difficult illnesses. It is definitely harder to make medical appointments, get transport to those appointments, and if you have lost your job, pay for those appointments. In this way too, COVID-19 doesn’t make us more equal but aggravates healthcare inequalities related to race, gender, and income.

Equal treatment is not guaranteed even at a doctor’s office. On average, women and black people are believed less often when describing their symptoms, especially pain.

3) Minorities are under-represented in clinical trials

We’ve written before about women being underrepresented in fitness-related trials. This time we’ll focus on minorities, who are underrepresented in a wide variety of health trials.

Here’s just one example: researchers typically enroll few minority participants into cancer trials^[15] and then seldom perform subgroup analyses to see if the intervention may affect minorities differently.^[16]

Why is this a big issue? Well, the purpose of clinical trials is to improve treatment strategies. More specifically, a trial is designed to test an intervention to determine its safety and efficacy, so that people taking the intervention “in real life” can be more certain of benefit and better informed about potential adverse effects. But when 20% of multiple myeloma patients in the US are black^[17] yet less than 2% of trial participants are black,^[18] it’s difficult to tell if the drug works and is safe for a large chunk of the intended patients.

This same reasoning applies to a wide variety of conditions that disproportionately affect minorities yet are studied in trials that enroll relatively few minority participants — conditions ranging from prostate cancer to cystic fibrosis to AIDS.^[19][20][21] If the intervention affects some minorities differently (being less effective or less safe, for instance), the trials aren’t likely to show it. As a result, if the intervention becomes commercialized, it may belatedly reveal itself to be not so effective or not so safe for a given minority.

But why then do trials enroll few minority participants? Is it that minorities are more reluctant to enroll?

Pseudoscience has been used to “prove” black inferiority, and real science has a history of unethical experiments on black people, so it isn’t very surprising that black people are on average 80% more likely to fear participating in biomedical research. What is surprising is that, despite this fear, black people are no less willing than white people to participate in clinical trials.^[22]

In other words: if trials enroll few black people, it is not because black people are less willing to enroll.

So what are the reasons? It may be that federal initiatives haven’t gone far enough, so that awareness of (and access to) trials is still relatively limited in minority populations.^[15] Also, we know that a growing proportion of trials are at least partially funded by the pharmaceutical industry,^[23] for which enrolling a representative sample may not always be the financially expedient choice.

Clinical trials are meant to determine the safety and efficacy of an intervention so that people undertaking this intervention “in real life” can be more certain of benefit. Yet for many conditions that disproportionately affect minorities, clinical trials enroll few minority participants. It follows that if the intervention affects a given minority differently (if it is more likely to cause adverse effects in black people, for instance), the trial isn’t likely to show it.

4) LGBTQ+ people face a disproportionate amount of targeted violence

The year 2017 saw the publication of a systematic review of 74 studies on violence motivated by the victim’s sexual orientation and gender identity.

This review found a high prevalence of violence toward sexual and gender minorities, with an especially high rate of violence against transgender people. Depending on the study, the rates ranged from 6% to 25% for LGBT people in general, and from 12% to 68% for transgender people in particular.^[24]

This review was published two years after a study that found that gay and bisexual men and women were nearly 50% more likely to report adverse childhood experiences such as physical and verbal bullying.^[25]

And even the doctor’s office, unfortunately, isn’t always a safe haven. Data from a national, probability-based telephone survey of US adults shows that 18% of LGBTQ adults (including 22% of transgender adults) reported avoiding health care due to anticipated discrimination, and that 16% of LGBTQ adults reported discrimination in health care encounters.^[26] It’s not hard to imagine why depression and attempted suicide are more common in LGBT populations.^[27][28][29]

LGBTQ+ people are more likely to face verbal and physical violence, and more likely to suffer from depression. Violence is particularly common toward transgender people.

5) Disability is financially costly and reduces opportunities

Around 12% of the US population have significant disabilities.^[30] Since disabilities cover a wide gamut of issues, this sizable chunk of people can be hard to think of as a group. And partly for that reason, they’re easily overlooked when discussing inequality.

In one data set of people reporting serious limitations, 46% had mobility disability, 39% had problem-solving or concentration limitations, 26% had impaired hearing, 21% had impaired vision, and 43% had more than one limitation.^[30]

Disability can introduce inequality early in life. Children with disabilities spend eight times more time in hospitals, and their healthcare needs can be too expensive for a lower-income family,^[31] especially since health insurances often leave significant gaps: an estimated two out of every five children with special needs are either uninsured or inadequately insured.^[32]

Unsurprisingly, adults too face higher medical costs if they have disabilities, especially if they live alone or in small households.^[33] Moreover, many healthcare facilities aren’t designed or equipped to welcome wheelchair users, in spite of the law.^[34] In the same vein, despite laws against hiring discrimination, disabled people are much more likely to be unemployed or underemployed,^[35][36] which indirectly adds to the financial burden of the disability.

And as if the disability itself and its logistical, financial, and professional costs weren’t enough, people with disabilities are also 50% more likely to be victims of nonfatal violent crimes, and twice as likely to report rape or sexual assault.^[30]

Given all this, it’s unsurprising that depression and anxiety are more common in people with disabilities.^[37]

A variety of laws mandate equal treatment and access for people with disabilities, but those laws are often disregarded. Lower chances for employment add to the financial burden of disabilities. People with disabilities are also more likely to be victims of violent crimes, rape, and sexual assault, and to suffer from depression or anxiety.

6) Inequalities are often compounded

If you have more than one chronic health condition, they are called comorbidities. Diabetes is a substantial health concern on its own, but your situation becomes a lot more complicated if you compound diabetes, depression, and an autoimmune disease.

Such compounding also worsens healthcare inequality. People with more than one disability are more likely to have healthcare-access problems and unmet healthcare needs.^[38]

Let’s imagine a vision-impaired black woman looking for a job. Compared to a white man with no disability, she’ll face three additional obstacles:

• She’s likely to face hiring discrimination because of her disability,^[35][36] as we saw in the previous section.
• She’s likely to face hiring discrimination because of the color of her skin. A 2003 study found that white candidates with criminal records were more likely to be hired than black candidates with no such history.^[39] And since then, little progress has been made: a 2017 meta-analysis found that hiring discrimination against black Americans hasn’t changed much over the past 25 years.^[40] Tellingly, for one of the included studies, the researchers sent fake job applications with “black-sounding” and “white-sounding” names, and the latter received 50% more callbacks for interviews.^[41]
• She’s likely to face hiring discrimination because of her gender. Experiments similar to the one mentioned above uncovered gender bias in recruitment in the US,^[42] Germany,^[43] and Spain.^[44] (Different strategies have been proposed to mitigate gender bias in hiring,^[42] including blind auditions for female musicians.^[45])

And if a black woman does manage to find a job, her problems may not be over yet, given ongoing issues with workplace discrimination based on race^[46] and gender.^[47][48][49]

Life can become substantially more difficult when you have a characteristic that makes you subject to unequal treatment, and when multiple such characteristics interact, the difficulty can become overwhelming.

7) Geographic inequality: rural areas

Health inequality isn’t a problem only for minorities.

Around 79% of the US rural population is white.^[50] Americans in rural areas have higher rates of diabetes and heart disease.^[51] And while, compared to urban areas, rural areas have similar or better healthcare access and quality overall, financial barriers can be greater and certain services (such as for mental health) can be harder to obtain.^[52]

Children in rural areas are also less likely to benefit from preventive medical or oral-health visits, and they’re more likely to be overweight or obese.^[53] Americans aged 10–24 also have nearly double the suicide rate in rural areas.^[54]

Health inequality isn’t a problem only for minorities, but as we saw in the previous section, inequalities are often compounded. Health challenges in rural areas are even more severe for black and Latino minorities, with greater financial barriers to health care, higher rates of risk factors such as obesity, binge drinking, and depression, and less insurance coverage for families and infants.^[55][56][57] Rural Latino neighborhoods in the US have more limited access to health care, transportation, recreational infrastructures, and the Internet.^[58]

Rural America provides much of the country’s water, food, and energy. Yet deep poverty and health challenges persist throughout rural areas, and minorities are especially affected.

8) Geographic inequality: areas without healthy food

The realities of inequality first started to click for me in 2005, when I was in grad school and researching the availability of healthy food in inner-city Baltimore.

I’d been mostly shielded from inequality as a kid, even as the dark-skinned child of a low-income single mom. She hadn’t been so lucky, having grown up in apartheid South Africa; but stories of that life didn’t seem quite real to me. We may not have had brand-name clothes, a new car, or even health insurance, but living in suburban Ohio was fairly unremarkable.

At the Johns Hopkins School of Public Health, I found myself immersed in details of nutritional biochemistry and epidemiology. Meanwhile, some of the people I interviewed for the research project had never thought about “healthy nutrition” because other issues — such as avoiding violence, paying the rent, and, yes, simply getting enough food for their kids and themselves — always took precedence. Processed food was affordable, readily available, and comforting.

“Food deserts” are areas without supermarkets or farmer’s markets, areas where fresh foods are hard to find, areas where processed foods high in sugar and refined oils predominate. Research suggests that food deserts are more common in the US than in Canada or the UK,^[59] and living in one of them, as do around 25 million Americans, is associated with a higher risk of cardiovascular disease,^[60] among other poor outcomes. The bulk of food-desert residents in the US are black or Latino.^[61]

Here’s the kicker: our dorm was in the same food desert where we interviewed local residents, so Johns Hopkins provided students with a free, air-conditioned shuttle to a well-stocked grocery store.

Around 25 million Americans live in food deserts (areas where fresh foods are hard to find; areas where processed foods high in sugar and refined oils predominate). It’s tough to think about optimizing your diet when merely accessing healthy food is difficult.

9) Geographic inequality: areas without clean air and water

The Flint water crisis was big news in 2016. But just because four years have passed doesn’t mean the effects are gone.

In 2014, the city of Flint, Michigan, started using the Flint River as its main water source. Unfortunately, the water was corrosive: it leached lead from the city pipes, and this lead contaminated the residents’ drinking water. The city eventually responded to complaints about the taste and smell of the water: the water source was changed, and many pipes have been replaced.

Unfortunately, lead poisoning is a long-term issue. The children who drank the water for years of their developmental stage are at much greater risk for nervous system damage, impaired physical and mental development, and a variety of other problems.^[62][63] As for adults, they face reduced fertility and an increased risk of many chronic conditions.^[64][65]

Environmental justice aims to end environmental discrimination — the disproportionate harm wrought on certain groups by environmental laws, regulations, and policies (or their violations).

Flint is predominantly black American, with a median income far below the national average, and it took well over a year after complaints began for the national media to widely cover the issue and for city and state authorities to take decisive action. Now, if the water supply of a wealthy area like Beverly Hills or The Hamptons were carelessly contaminated (which, let’s face it, is less likely to happen in the first place), do you think it would take years for the problem to be acknowledged and addressed?

Nationwide, water-quality violations are more common in low-income areas with a greater percentage of minorities.^[66] These areas also face substantially greater air pollution,^[67][68] which is directly tied to increased mortality.^[69] Certain rural areas also have excess lung cancer mortality tied to pollution, poverty, and reduced healthcare access, with a “lung-cancer mortality belt” stretching from rural areas in eastern Oklahoma to rural areas in central Appalachia.^[70]

Health needs don’t get much more basic than clean air and water. Lower-income areas have worse air and water than the rest of the country. “Environmental justice” broadly refers to the will to end the environmental inequity plaguing lower-income and minority communities.

10) Geographic inequality: areas without health-promoting environments

Our natural environment includes forests, mountains, lakes, and whatnot. Our built environment includes anything we’ve built that is part of our living and working environment. Natural or built, either environment can influence our health, safety, and general welfare, but our built environment is both the one we most often interact with and the one we can more readily affect.

Your home is an important part of your built environment. Indoor pollutants contribute to a variety of conditions, including asthma. A building infested by cockroaches can trigger asthma through cockroach antigens found in the insect’s eggs, feces, and saliva.^[71]

In addition to indoor pollution, residents of low-income areas are more likely to face outdoor pollution, which is linked to poor health in both adults and children.^[72][73][74] Children attempting to escape the home environment may also face a shortage of safe parks and other places to play.^[75]

As aforementioned, in lower-income and predominantly black and Latino neighborhoods, supermarkets can be nonexistent. Full-service restaurants are scarce, too, while fast-food restaurants are plentiful.^[76]

A systematic review of 18 studies associated an increased risk of cardiovascular disease to a variety of neighborhood attributes — including walkability, residential density, recreational facilities, and safety from traffic.^[77] These factors are all more likely to be poor in lower-income and minority neighborhoods.^[78][79][80]

The old saying goes, “You are what you eat”. But what you eat, how you go about your day, what you breathe, and a variety of other factors are conditioned upon where you live.