Geographical impacts on health outcomes

I feel fortunate to be writing this on my way home from an awesome trip abroad with some friends. Internationally, I was particularly amazed by a few things. First and foremost came the incredibly frequent, convenient, and widespread public transportation, and the regularity of walking everywhere one would go in a suitable urban layout. Not only did this make transportation easier and cheaper, opening the door to traveling to any spot in the metro area within tens of minutes, but it was also more conducive to health, as I found myself easily reaching my Apple Watch fitness “goals” just from walking. Additionally, I was astonished at the low prices of quality, nutritious food in grocery stores. Even in dense, urban areas, my friends and I were practically laughing at the prices of fresh produce and other goods, which we often found to be of even higher quality than those at home. Not to mention, even the junk foods were healthier; one soda had approximately a third of the sugar content of that of the same brand in the U.S. Lastly, I was thrilled to see the availability of public outdoor gyms and workout spaces. I enjoyed a creative workout with all sorts of movements–pull-ups, rows, dips, etc.–all just from a few very simple pieces of permanent equipment placed in the ground like bars and pipes.

It was clear to me that, through all of these things, this country had invested in the population’s health, and it showed. The people throughout the city were visibly healthier–and seemingly even much happier–than those at home. The other shocking aspect was how presumably little of a cost could make such a significant change. Nick and I reflected on how simple and easy it would be to install similar outdoor exercise areas in low-income U.S. communities, and how tangible the changes could be in the wellbeing of those communities given the significance of regular exercise in improving health.

However, the unfortunate reality is that such changes are just a mere start, a bandage on a much larger wound. The issue is that social determinants of health in the United States are far deeper-rooted than simple access to a gym. Instead, they touch upon all facets of life, So often, those victimized by one disparity are impacted by a course of interrelated others. As I have found in numerous personal projects and exploration of data, a large portion of these health inequalities–including differences in health outcomes across races–are mediated through geographical barriers, the likes of which have been formed over decades, even centuries of discriminatory practices such as redlining in the housing market.

Figure 1: Average concentrations of common pollutants on two parallel freeways in Oakland, CA. Truck-banned, hillside Interstate 580 contained significantly less black carbon, nitric oxide, and nitrogen dioxide than Interstate 880, which runs through many low-income communities in the flatlands. (Image: Environmental Defense Fund)

As we have noted, spaces to safely exercise are sorely lacking for many low-income groups. There can be limited room in indoor living areas, as well as safety concerns, hazards, or lack of space outdoors. Many of these concerns are environmental, as shown by a prime example of literal discriminatory construction in my local East San Francisco Bay Area. One highway I drive on every single day, Interstate 580, directly separates the wealthy hills from the low-income flatlands of Oakland. On the hills side, one can find quality grocers and markets, while in the flatlands, there’s little to find other than liquor shops and convenience stores. What’s more, this freeway specifically does not allow large diesel trucks, presumably out of concerns over noise and air quality disturbances to surrounding neighborhoods. Meanwhile, a parallel highway runs directly through the flatlands of Oakland and is notorious for intensive, diesel truck-heavy traffic.

It is apparent that these sorts of differences have actual impacts on health; air pollution measures and disparities in health outcomes are evident in such community comparisons. In a previous clinical study, I investigated socioeconomic and health impacts of COVID-19 in a predominantly indigenous Central American neighborhood in the Bay Area. Despite the major public health resources of their home Marin County, California’s wealthiest, this community at one point had the highest COVID-19 positivity rate in the state, and frequently cited lack of nearby testing and vaccination sites as a key issue. For additional insights into the biological translation of disparities, Zone 7 is currently collaborating with Mayo Clinic and our partner for health screenings, Street Medicine Phoenix, to conduct a study of blood cardiovascular measures in low-income and unhoused individuals relative to the rest of the population. We look forward to sharing the results of this work as we obtain them, though we suspect they will be heavily mediated by similar geographic variables.

Though the greater structural issues underlying geographical disparities will require someone far smarter than me to figure out, as well as decades more time, resources, and countless policies, there are some clear and straightforward changes that could be made to improve community health right now. They are clear from other countries, and they work. Providing everyone with the basic tools to improve their health not only should be the bare minimum responsibility of a government or society to its citizens, but it would even be in all parties’ best interest economically, lowering healthcare costs, improving employment and productivity, creating jobs, etc. If we took just a fraction of the time, energy, or money we normally waste on various unsustainable healthcare costs and policy measures, and instead invested it in the simplest health resources for our communities, it could go such a long way. In the meantime, we can only do our part to incrementally build towards this vision.

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