Health Disparities in the Black Community: An Imperative for Racial Equity in the DC

Health Disparities in the Black Community: An Imperative for Racial Equity in the District of Columbia

2020

Of all forms of inequality, injustice in healthcare is the most shocking and inhumane.

-Dr. Martin Luther King, Jr. Medical Committee for Human Rights, 1966

AUTHORS: Christopher J. King, PhD, FACHE Patricia Cloonan, PhD, RN STUDENT CONTRIBUTORS: Grace Keegan, Data Analyst, Biology of Global Health & Spanish (BS) Amelia Bedri, Health Systems Administration (MS) Edward Kasper, Health Systems Administration (MS) Xerxeser Kayode, Health Systems Administration (MS) Phebean Sheriff, Health Systems Administration (MS) Jonathan Wagner, Health Systems Administration (MS) Cover Photo: Will Joyner Buck Hill was a native Washingtonian, prolific jazz performer, and career mail carrier1 Report prepared at the request of Maurice Jackson, PhD, Inaugural Chair, D.C. Commission on African Americans Affairs (2013-2016) © Georgetown University School of Nursing & Health Studies For more information, please contact: Christopher J. King, PhD, FACHE Associate Professor and Chair, Department of Health Systems Administration Georgetown University School of Nursing & Health Studies 3700 Reservoir Road NW, St. Mary’s Hall | Washington, DC 20057 ck806@georgetown.edu

Dear Community Members and Stakeholders, We are pleased to share the second version of the report initially titled, The Health of the African American Community in the District of Columbia: Disparities and Recommendations1, which was prepared for the DC Commission on African American Affairs in 2016. In an effort to build on lessons learned and articulate an evolving narrative, the title of this report is Health Disparities in the Black Community: An Imperative for Racial Equity in the District of Columbia.2 The title reflects the emergence of recent cross-sector, citywide racial equity initiatives and accomplishments.

Christopher J. King, PhD, FACHE

Maurice Jackson, PhD

Unfortunately, the timing of the report coincides with the COVID-19 crisis, which is magnifying the urgency to address the health of Black communities - locally and nationally. In the District of Columbia, Black residents are disproportionately burdened by pre-existing disease conditions that increase risks of mortality if infected with the virus. These include but are not limited to diabetes, heart disease, cancer, respiratory diseases, and obesity.

Racial disparities in COVID-19 incidence and mortality are the outcomes of a deep-seated history of political, social, educational, environmental, and healthcare injustices that have disadvantaged Black populations for generations. While a higher prevalence of sickness and comorbidity are factors, when compared with Whites, Blacks are less likely to have the opportunity to practice social distancing due to a number of conditions: essential work capacities, hourly wage employment, limited or no internet access, and/or housing in units with multigenerational cohabitation. A trifecta of high risk day-to-day survival needs, pre-existing illnesses, and limited access to timely, high-quality healthcare make Black populations especially vulnerable to infection and mortality.

COVID-19 transmission methods are a reminder that racial inequity is a public health issue. The pandemic serves as yet another cue to action to course correct and dismantle racial injustice for the sake of humanity. In that spirit, we will continue to monitor the health and well-being of the District’s Black community – particularly as the city rapidly changes. Findings of this report will inform policymaking, advocacy agendas, appropriation of equitable resources, and education for the general public.

As an educational institution, Georgetown University is intentional about creating a pipeline of leaders with the skills to operationalize racial justice as a means of eradicating disparities in health. A number of students engaged in experiential learning and contributed to this publication. Findings will continue to be integrated in academic curricula throughout Georgetown University, including medicine, nursing, and healthcare policy and management programs.

We hope this second edition will advance your work and the missions of government agencies and organizations throughout the nation’s capital. Together, we can make progress in realizing a city in which all residents can achieve their full health potential.

Sincerely, Christopher J. King, PhD, FACHE Associate Professor, Department of Health Systems Administration Chair, Department of Health Systems Administration Maurice Jackson, PhD Associate Professor, Department of History 1

The Health of the African American Community in the District of Columbia: Disparities and Recommendations (2016) https://communityengagement.georgetown.edu/news-story/state-of-african-american-affairs-in-dc/ 2 Figures documented in this publication were generated before COVID-19

Health Disparities in the Black Community: An Imperative for Racial Equity in the District of Columbia

OVERVIEW Racial equity in health is achieved when race is no longer a predictor of a health outcome. While access to high quality medical care is important, the conditions in which we live play a greater role in shaping health. Improving the health of Black Americans requires intentionality in dismantling historically-rooted policies, practices, and implicitly biased decisions that create an unlevel playing ground for achievement.

Within this context, the 2016 report, The Health of the African American Community in the District of Columbia: Disparities and Recommendations, helped shape the narrative in the nation’s capital – offering concrete recommendations for the healthcare delivery system and the broader ecosystem. As the journey towards racial equity in health is pursued, it will be important to refresh the data and strategically present findings in different contexts. Health Disparities in the Black Community: An Imperative for Racial Equity in the District of Columbia includes additional health indicators, Wardlevel comparison data, and highlights of cross-sector exemplars that reflect a few of the 2016 recommendations. Significant changes in health or socioeconomic statistics are also noted.

Key Highlights • • • • • • • • • • • •

The number of Black residents living with diabetes is 7 times higher than White residents The number of Black residents who die from heart disease is 2.5 times higher than White residents The number of Black residents who die from colorectal cancer is 3 times higher than White residents The number of Black residents who are obese is 3 times higher than White residents The infant mortality rate in Black infants is 4 times higher than White infants Black men represent one out of three newly infected HIV cases Residents from Wards with higher volumes of Black residents (5, 7, and 8) represent the majority of those hospitalized for preventable health conditions The unintentional death rate in Black residents is almost 3 times higher than White residents There is a 15-year difference in the life expectancy between residents in Ward 3 (87) and Ward 8 (72) Compared with all racial and ethnic groups, the median household income for Blacks is lowest ($43,546) – three times less than Whites ($135,263) Compared with all racial and ethnic groups, Blacks have the lowest percentage of bachelor degree attainment - 26%. More than 90% of White residents have a bachelor’s degree or higher Approximately 50% of Black households own their homes, compared to more than 70% of White households

These seemingly intractable disparities, coupled with grassroots advocacy, have led to unprecedented progress in the racial equity space. Local government, local policymakers, the philanthropic sector, and community-based organizations are taking action to achieve a District in which Black residents have equal opportunity for upward mobility, prosperity, and optimal health.

Health Disparities in the Black Community: An Imperative for Racial Equity in the District of Columbia

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Methodology Report findings were generated and synthesized from a variety of secondary data sources including the American Community Survey, Behavioral Risk Factor Surveillance Survey, CDC 500 Cities Project, and the National Cancer Institute. Statistics and trends were also retrieved from citywide hospital community health needs assessments, including dchealthmatters.org – a collaborative that represents four hospitals and four community health centers. Data from the 2017 District of Columbia Health Systems Plan and the 2018 Health Equity Report were also included in the synthesis.

After secondary data were collected and analyzed, questions were developed for key informant interviews. The purpose was to obtain a more informed perspective of the barriers and challenges that contribute to differences in health outcome across populations. Eight (8) key informants were interviewed. Informants included healthcare professionals, public health experts, and community activists.

In most cases, non-Hispanic White residents are identified as the comparison group to express significant disparities in morbidity, mortality, lifestyle behaviors, and socioeconomic conditions.

Limitations and Considerations: Findings include data and trends on the general adult population.

Data for sub-populations are not presented (e.g. children, homeless, returning citizens). Statistics were pulled from a combination of pre-existing local, public, and private data sources. Findings should be carefully interpreted, as data collection periods vary by source. Ranges and specific indicator statistical outputs can be found via citations. Heterogeneity exists within racial groups; Black classifications may include African American, Jamaican, Haitian, Ethiopian, Somalian, and others. Due to data collection limitations in racial origin, these residents are collapsed and presented as Black unless noted otherwise.

The report is a synthesis of findings and does not include new quantitative content. It should be noted that findings are based on pre-COVID-19 time periods.

Context While access to high quality medical care is essential, the health of a population is mostly shaped by the social and environmental conditions of the communities in which we live. Since racial disparities in health are caused by structural or institutional injustices in social, economic, political and environmental systems, quality of life indicators that are correlated with population health outcomes are presented.

Statistics beyond the walls of the healthcare setting help explain why Black residents are disproportionately burdened Image 1: Interaction Institute for Social Change Artist: by many health conditions – offering opportunities for Angus MaGuire | madewithangus.com targeted interventions and resource allocation. The insight also empowers healthcare organizations with information needed to create and deliver racially equitable care and services, which is critical for improving health. Such strategies are also important for building trust and strengthening the partnership between patient and provider.

Š Georgetown University School of Nursing & Health Studies

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In widespread efforts to achieve racial equity in health, caution is needed when operationalizing equity and equality. Image 1 depicts the difference. Equality is based on the assumption that everyone has equal access to opportunity (left) – the height of each box is the same (equality), but all participants do not have access to the event. Equity recognizes the existence of systemic barriers that create differences in access to opportunity. To correct the issue, resources are adjusted (equity) so all participants have access to the event. Racial equity in health requires cross-sector efforts to unearth racialized injustices – with an aim to distribute resources according to need across various institutional settings.

Place Matters According to the United States Census Bureau, the population of the District of Columbia has increased approximately 17% since 2010.2 Out of 717,189 residents, Black residents represent 44% of the total population – a slight decrease from 51% in 2010.3 NonHispanic Whites continue to trend upward at 42% compared to 35% in 2010.4 With a residential segregation index of 695, the city is densely populated and racially divided by Ward. Ninety-two percent (92%) of residents in Wards 7 and 8 – east of the river - are Black while they represent 13% and 5% of those in Wards 2 and 3, respectively. Although in the aggregate, the city boasts an impressive health profile, there is a different narrative when data are stratified by race and place of residence. Life expectancy and quality of life indicators in many communities east of the river do not reflect trends found in other parts of the city. For example, when combining Wards 7 and 8, the life expectancy is 73 years, compared to 86 years when Wards 2 and 3 are combined.

Based on income, education, insurance, housing, and culture, the Community Needs Index (CNI) is correlated with preventable hospitalizations. The CNI is a strong indicator of a community’s demand for healthcare services.6 According to the 2019 CNI, neighborhoods in Wards 7 and 8 have the highest index - indicating significant barriers to health and well-being when compared with communities in the northwestern sections of the city. These conditions contribute to delayed access to medical care and behavioral health services, and higher rates of infant mortality, lower life expectancy, and premature death.

Image 2: Displays disparities in socioeconomic conditions and health outcomes between two vastly different Wards.

Health Disparities in the Black Community: An Imperative for Racial Equity in the District of Columbia

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Life Expectancy Life expectancy is defined as the number of years a newborn is expected to live. In addition to the infant mortality rate, life expectancy is a proxy for assessing the health of a community. These dynamics are clearly illustrated in Wards that are vastly different. For example, the life expectancy in Ward 8 is 72; in Ward 3, 87; a 15-year difference (Table 1).7 Trinidad (70.8), Historic Anacostia (70.2), and St. Elizabeth (68.4 - home of St. Elizabeth’s Hospital) are neighborhoods with the lowest life expectancy in the city. 7

Years of Life

Life Expectancy by Ward (2011- 2015) Table 1: DC Department of Health Center for Policy, Planning and Evaluation

87.6 85.3 81

80.9

79.1 76.4

1

2

3

4

5

74.7

6

7

72

8

Ward

A Changing District

3

Throughout the city, Black residents - particularly longtime residents – have been disproportionately impacted by cultural displacement or gentrification. According to the National Community Reinvestment Coalition, between 2000 and 2013, the city had the highest volume of gentrified neighborhoods when compared with other cities. More than 20,000 residents were displaced.8 In the wake of rising rental and real estate costs, many residents face a high housing cost burden - at least 30% of their income is devoted to housing expenses. To live comfortably, annual household income needs to be at least $132,857 for a two-bedroom apartment at $3,100 per month.9 However, the annual median household income for Black residents is $43,546. Rapidly changing neighborhoods, coupled with a high housing cost burden, can lead to a number of conditions that compromise physical and mental health, including social isolation, food insecurity, and survival stress.

3

An Analysis: African American Employment, Population & Housing Trends in Washington, D.C. https://apps.washingtonpost.com/g/documents/local/report-african-american-employment-population-and-housing-trends-in-washingtondc/2579/

© Georgetown University School of Nursing & Health Studies

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Access to Care Due to the costs of medical care, health insurance is important for annual physicals, preventive screenings, diagnostic services, disease management, and prescriptions. Ninety-six percent (96%) of all adults in the city have coverage.

More than 95% of Black adults have coverage and the percentages of adults with annual routine checkups for communities east of the city are higher than central and west.3 Despite high rates of insurance and routine checkups, coverage alone is not the panacea for prevention. Residents from Wards with high volumes of Black residents (5, 7, and 8) are more likely to be hospitalized for preventable health conditions.10 When compared with their White counterparts with Medicare, preventable hospital stays are two times higher in Black residents with Medicare.3 Out of 368,982 outpatient emergency department visits across DC hospitals, Black residents represent approximately 66% of the visits, Whites represent 16%. While higher morbidity rates play a role in these trends, community members cite broader issues that result in delayed care, including competing “day-to-day survival� priorities, limitations in behavioral health services, and experiences or perceptions of discrimination, bias, and racism.7,11,12

Infant Mortality Death within the first year of life is one of the most widely used proxies for assessing the overall health status of a community. Within the past 13 years, the rate has dropped from 13.1 deaths/1,000 live births to 7.6 deaths/1,000 live births across the general DC population. However, the mortality rate in Black infants is more than four times higher than White infants. The highest rates are in Ward 8 (14/1,000), Ward 7 (9.3/1,000) and Ward 5 (9.2/1,000).7 Birth defects, pre-term births, maternal complications, sudden infant death syndrome, and injuries are the top five leading causes of infant deaths.13 According to subject matter experts, pregnant Black women in the District of Columbia encounter systemic barriers.13 Difficulty obtaining timely appointments, a shortage of providers in close proximity, and inequitable or culturally insensitive treatment are common themes.14

HEALTH CONDITIONS

Heart Disease / High Blood Pressure Among the general DC population, the age-adjusted death rate due to coronary heart disease has trended downward within the past 10 years. During 20052007, the rate was 193.3/100,000. During 2015-2017, the rate was 110/100,000.11 Despite a citywide reduction, the rate of Blacks who die from heart disease is 2.5 times higher than Whites. The most striking disparity can be found in Wards 3 and 8. The death rate due to heart disease is four times higher in Ward 8 when compared with Ward 3.7 The rate of Blacks with high blood pressure is close to two times higher than Whites and other racial groups.3 Tobacco use, high blood pressure, unhealthy diet, sedentary lifestyle, chronic stress, and alcohol are risk factors for heart disease.

Health Disparities in the Black Community: An Imperative for Racial Equity in the District of Columbia

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Stroke Stroke is the fifth leading cause of death in the United States and the fourth leading cause of death in the District of Columbia.7 Among District residents, the ageadjusted death rate due to stroke has slightly increased since 2012. In 2012-2014, the rate was 32.5/100,000 and in 2015-2017, the rate was 37.5/100,000.11 When compared with White residents, the rate of Blacks who die from stroke is two times higher. Risk factors include high blood pressure, cigarette smoking, high cholesterol, diabetes, sedentary lifestyle, and obesity.

Diabetes Diabetes is the seventh leading cause of death in the United States and the root cause of many disabling conditions that affect productivity.16 Examples include end-stage renal disease, non-traumatic lower-extremity amputation, and blindness. Since 2012, the number of adults with diabetes in the District has remained relatively stable (range 7.7% - 8.5%). Citywide, 8.4% of adults are living with the condition and the number of Black residents with diabetes is seven times higher than Whites.3 The age-adjusted death rate due to diabetes for the general population has trended downward since 2005 and stands at 21/100,000, compared to 31/100,000.11 However, the diabetes-related death rate in Black residents is six times higher than Whites. 3 Risk factors include high blood pressure, poor diet, sedentary lifestyle, obesity, and family history.

Mental Health Poor mental health – a risk factor for some chronic diseases and medical conditions - is linked to lower productivity and social mobility.17,18 Citywide, the percentage of adults who self-report more than 14 or more days of poor mental health has been relatively stable since 2014 (range 11.0% - 11.4%). However, nearly 20% of Black residents report fair or poor mental health compared to 4% of White residents.7

Fresh Cut Barbershop Michael Hammond, Artist

Š Georgetown University School of Nursing & Health Studies

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Cancer Cancer is the second leading cause of death in the United States, which translates to approximately 1,660 deaths per day.

Approximately 5% of adult residents in the District of Columbia have been told by a health professional that they have cancer.3 Early detection and early intervention increase survival rates.

Among all cancers, the death rate due to cancer is two times higher in Black residents when compared with White residents.

Breast Cancer Nationwide, breast cancer is the leading cause of cancer mortality in women.19 In the District, approximately 80% of women between the ages of 50 and 74 have had a mammogram within the past two years. Screening rates are slightly higher in Black women (82%) than White women (79%).3 While the overall number of new cases has declined (143/100,000, 2010-2014) vs. (134/100,000, 2012-2016)3, the diagnosis rate is slightly higher in White women. However, death rates are 1.5 times higher in Black women. According to key informants and community assessment findings, late detection and barriers to timely follow-up care are key contributors. Breast cancer is associated with age, heredity, obesity, and alcohol use.

Prostate Cancer Prostate cancer is a leading cause of cancer mortality among men in the United States.20 In the District, 38% of men over the age of 40 have had a Prostate Specific Antigen (PSA) test within the past two years. The number of new cases in the District has declined (198/100,000, 2007-2011) vs. (128/100,000, 20122016).3 However, new cases in Black males is more than 1.5 times higher than White males; the death rate in Black males is two times higher. Age and African ancestry are the two greatest risk factors for prostate cancer.20

Image 3

Colorectal Cancer Colorectal cancer is the second leading cause of cancer mortality in the United States.19 In the District, approximately 74% of residents between the ages of 50 and 75 have had either a fecal occult blood test in the past year, a sigmoidoscopy within the past five years AND a fecal occult blood test within the past three years, or a colonoscopy within the past 10 years. The number of new cases in the District has declined (51/100,000, 2003-2007) vs. (38/100,000, 2012-2016).3 However, new cases among Black males is two times higher than Whites and Hispanics.11

Health Disparities in the Black Community: An Imperative for Racial Equity in the District of Columbia

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Consistent with national trends, colorectal cancer death rates in the District have declined. However, the age-adjusted death rate in Black residents is three times higher when compared with White residents. Death rates are also higher in men. Late detection is likely to be factor. Screening percentages are higher among women (78%) than men (69%). Screening percentages are also slightly higher in Whites (78%) than Blacks (72%).3

Lung Cancer Nationally, lung cancer is the second most common type of cancer in both men and women.19 Among the general population in the District, the number of new cases has decreased from 60/100,000, 2006-2010 to 49/100,000, 20122016. Age-adjusted death rates have also trended downward since 2003. These trends are likely attributable to reductions in the number of residents who smoke. In 2011, approximately 21% of adults smoked. In 2018, 14% of adults smoked.3 Despite reductions in the number of new cases in the general population, diagnosis and death rates among Blacks in the city are more than two times higher than Whites and Hispanics.

Smoking is the most significant risk factor for lung cancer.

Cervical Cancer Widespread progress in cervical screening (Pap Test) in the United States has resulted in the cervical cancer death rate dropping by more than half since the mid1970s.19 The number of new cases in the District has remained relatively stable since the 2005-2009 reporting period (range 9.3/100,000, 2005-2009 – 8.7/100,000, 2012-2016).11 The number of new cases in Black women is close to three times higher than White women.3 The Human Papilloma Virus (HPV), which is transmitted through sexual contact, is the most significant risk factor for cervical cancer.

The survival rate for cervical cancer is high when detected early through a Pap Test. Based on recommended guidelines, more than 80% of Black and White residents receive a Pap Test.3

Influenza/Pneumonia Vaccination Influenza is a contagious infection that can lead to pneumonia. Persons age 65 and older with the flu or pneumonia are more likely to die than those who are younger. Vaccines are effective in preventing both conditions. Nearly 60% of residents age 65 and older receive a flu shot in the District of Columbia. Fiftypercent (50%) of Black residents age 65 and older receive the shot.

Approximately 74% of White residents age 65 and older receive the flu shot.11 Low vaccination rates may explain why influenza and pneumonia deaths rates are almost 1.5 times higher in Black residents.3

Š Georgetown University School of Nursing & Health Studies

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HEALTH BEHAVIORS

Unintentional Injuries Unintentional injuries such as poisonings, falls, and motor vehicle crashes are a leading cause of death for Americans. The age-adjusted death rate in the District has trended upward since 2012. According to the most recent data (2015-2017), the rate was (53/100,000), which exceeds the national target (36/100,000). During the period, the unintentional death rate in Blacks (77/100,000) was almost three times higher than Whites and Hispanics.3

Weight/Physical Activity Obesity and a sedentary lifestyle are underlying causes of many preventable health conditions. Citywide, the obesity percent exceeds the national target (30%).3 Approximately 25% of adults are obese (Body Mass Index > =30). However, the percent of Black adult residents who are obese (37%) is nearly three times higher than White adult residents.3 Approximately 26% of adults in the city report no exercise or physical activity within the past 30 days. Percentages are highest in Wards with larger populations of Black residents (Ward 8 – 26%; Ward 5 – 27%; Ward 7 – 38%).7

Tobacco Use Tobacco use is an underlying cause of some of the most preventable illnesses in the United States. Exposure to second-hand smoke can also lead to respiratory issues in nonsmokers. Consistent with national trends, the percent of adult smokers in the District has declined. In 2011, 21% of adults smoked compared to 14% of adults in 2018. Twenty-two percent (22%) of Black adult residents smoke, which is three times higher than White residents and nearly 2.5 times higher than Hispanic residents.3 A higher prevalence of Black smokers may explain disparities in lung cancer mortality rates.

Sexually Transmitted Infections (STI)4 Chlamydia and Gonorrhea are the most commonly reported STIs in the United States. Since 2014, both bacterial infections have trended upward. In the District, there were 9,007 reported cases of chlamydia in 2018 – which reflects a 57% increase. There were 4,249 reported cases of gonorrhea in 2018 – which reflects a 92% increase in four years. The number of infected residents is highest in census tracts of Wards with larger populations of Black residents (Wards 5, 7, and 8).7 Primary/Secondary Syphilis infection in the District has also trended upward since 2014. There were 282 reported cases of primary/secondary Syphilis in 2018 – compared to 137 cases in 2014.

Concentrated clusters of infection exist in census tracks throughout the city.7

4

Rates of infection were not available by race

Health Disparities in the Black Community: An Imperative for Racial Equity in the District of Columbia

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Human Immunodeficiency Virus (HIV) As a result of comprehensive citywide initiatives aimed at reducing HIV infection, the number of new cases has significantly dropped since 2007. Advancements in pharmacological interventions have reduced AIDS related mortality.

Currently, 12,322 residents are living with the disease.5 For the first time, persons age 50 and older now represent more than 50% of total residents living with the condition. HIV infection in Blacks is three times higher than Whites. In 2018, 360 residents were diagnosed; one out of three were men of color.21 Concentrated clusters of infection exist in census tracks across the city.

SOCIOECONOMIC DRIVERS OF HEALTH6

Families Living Below Poverty Line Poverty is associated with numerous drivers that impact health status such as food insecurity, unsafe or unhealthy housing, and exposure to crime and violence.

Nearly 13% of families in the city live below the federal poverty level. When compared with all racial and ethnic groups, the percent of Black families in poverty is highest at 22%.11 The highest concentrations of families living below the federal poverty line exist in zip codes within the southeast portions of the city - 20019, 20032, and 20020.3

Household Income Median household income reflects relative affluence and prosperity of a neighborhood or community. Jurisdictions with higher median household incomes are more likely to have highly educated residents, lower unemployment rates, and structural conditions that promote physical activity and access to amenities that support well-being.22–24 Citywide, the median household income is $82,604.

Compared with all racial and ethnic groups, the median household income for Blacks is the lowest ($43,546) – three times less than Whites ($135,263).3

Unemployment Unemployment is linked to numerous factors that impact health. Examples include poor nutrition, unhealthy living conditions, and chronic stress. In the District of Columbia, the unemployment percentage for the civilian workforce is 5.9%. Unemployment percentages are highest in Wards with high volumes of Black residents: Ward 5 (6.9%), Ward 7 (9.7%), Ward 8 (12.5%).25

5 6

Change in methodology to account solely for DC residents; prior methods included those tested with out-of-state addresses Socioeconomic figures reflect findings before COVID-19

Š Georgetown University School of Nursing & Health Studies

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Educational Attainment Persons with a bachelor’s degree or higher are more likely to have health insurance coverage, higher paying jobs, and greater freedom to make choices for socioeconomic advancement and healthy living. Close to 60% of adults age 25 and over in the District have a bachelor’s degree or higher. When compared with all races and ethnicities, Black residents have the lowest percent of bachelor degree attainment - 26%. More than 90% of White residents have a bachelor’s degree or higher.3

Food Insecurity The lack of access to affordable, healthy food, results in irregular dietary habits which increase risks for obesity and other forms of chronic disease conditions.

Defined as limited or uncertain availability of nutritionally adequate food, food insecurity has trended downward within the past 10 years. Currently, 11% of DC residents experience food insecurity; 10% of Black households are food insecure.3,7

Home Ownership and Housing Cost Burden Homeownership is linked to financial security, generational wealth building, and greater engagement in civic affairs.

However, only 37% of housing units in the city are occupied by their owners. Approximately 50% of Black households own their homes, compared to more than 70% of White households.26 Housing cost burden is defined as spending at least 30% or more of income on housing.27 High housing expenses cause residents to make difficult choices - prioritizing basic needs such as food, transportation, childcare, and medical care.

Close to 50% of renters in the District experience a housing cost burden. Renters must make at least $132,000 annually to live reasonably in a two-bedroom apartment.28 With a median household income of $43,546, Black residents encounter significant barriers and have limitations in where they choose to live. The high housing cost burden is a key driver of the city’s changing demographic profile.

Health Disparities in the Black Community: An Imperative for Racial Equity in the District of Columbia

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CONCLUSION

C OVID-19 is another reminder of a moral imperative to dismantle racial inequality. At the time of this report, Black residents represented close to 80% of deaths caused by the virus in the District.29 This disparity can be explained through the lens of a legacy of inequality, which has led to high rates of morbidity in Black populations. High rates of chronic diseases, coupled with high risk socioeconomic conditions, explain the manifestation of racial disparities in COVID-19 mortality.

One sector cannot fix the problem. The journey to racial equity requires an explicit and cross-sector approach to eliminate social, economic, and environmental conditions that stymie upward mobility and compromise well-being across the lifespan. As the city continues to experience growth and economic progress, proactive efforts are needed to address policies, practices, and norms that perpetuate segregation and inequitable distribution of resources.

There are also unique opportunities for the healthcare sector. Developing formal partnerships with community-based providers helps ensure patients’ holistic needs are met in real time.

Reconceptualizing community engagement, exercising humility, and shifting power and resources to community-based assets are keys to racial healing and closing the trust gap. Healthcare providers can use their voice to boldly call out racial inequality and its impact on health – and advocate for systemic change.

Hospitals - as anchor institutions – can refine their business models and prioritize inclusive local hiring, local sourcing, and place-based investing.30 They can advance their population health goals by applying a racial equity lens in how care is delivered - ensuring leadership at all levels reflect the community served. They can also conduct community health assessments that support a broader agenda around the identification of deeply embedded inequitable practices that negatively impact Black residents.

“35 years ago, I moved to DC when three pandemics were present: AIDS, crack & gun violence. I still saw DC as a wondrous place. I knew it was a chocolate city and that’s what captivated me about it. In spite of those horrible realities, it was still special to me.

There was more than enough to do, back then. More festivals and much more diversity than now. It’s cleaner, now, but it’s lost the cultural luster. It is losing its character, because it’s becoming much more expensive ironic that it has more money, but losing its character. I don’t know my neighbors like I used to. People don’t seem to see DC as a long-term relationship, but a place to visit for a period of time.

Do I plan to leave in the next 5 years? I don’t plan to, but it’s becoming more sterile, which means it’s losing its appeal. Culture used to be right outside your door. Now you have to Uber to it.”

– Edward Jones, resident, Ward 5 © Georgetown University School of Nursing & Health Studies

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RECOMMENDATIONS This section includes the recommendations from the 2016 publication, The Health of the African American Community in the District of Columbia: Disparities and Recommendations. In addition to themes captured from 26 key informants, recommendations were derived from best practices cited by organizations such as the Local and Regional Government Alliance on Race & Equity, the Democracy Collaborative, the Institute for Healthcare Improvement, and the Institute for Diversity on Health Management.31–34

Social, Economic and Environmental 1.

2.

3.

4.

5.

6.

7.

8.

Employ a racial equity approach when conducting needs assessments to uncover and rectify systemic barriers that perpetuate segregation, neighborhood disinvestment, and inequitable distribution of resources Develop formal mechanisms to proactively examine how planning efforts, policies and business decisions may disproportionately impact people of color Convene anchor institutions, local entrepreneurs and businesses to explore opportunities for localized wealth building initiatives Provide incentives that attract new businesses to historically marginalized neighborhoods Enforce local hiring mandates for city funded projects Develop, support or reinforce policies to ensure the availability of affordable housing across all eight wards of the city Offer incentives and support place-based initiatives to increase the availability of affordable healthy food products and high-quality recreational facilities Develop integrated technology platforms to connect residents with real-time social support services (e.g., food, housing, employment)

Clinical Care and Health Systems 9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

Analyze service utilization and morbidity data by race/ethnicity, zip code or neighborhood; develop strategic partnerships with community-based organizations to prioritize specific geographic populations Educate and increase awareness of institutionalized racism, bias, and structural causes of poor health Establish coalitions or partner with entities that advocate for policies or practices that promote racial equity Ensure board and senior leadership reflect the diversity of the community served Create culturally tailored clinical services and communication vehicles Expand the capacity and functionality of the Electronic Health Record (EHR) to include social factors Institute practices and protocols aimed at local hiring and contracting with minority owned businesses – particularly those located in historically marginalized neighborhoods Sponsor workforce development and health professional training programs Examine cost of living and offer livable wages for front-line and entry level positions Explore creative ways to engage long-term residents to create healthcare environments that visually preserve a rich African American cultural identity Health Disparities in the Black Community: An Imperative for Racial Equity in the District of Columbia

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PROGRESS TOWARDS RACIAL EQUITY Within the past five years, there has been significant progress in advancing the racial equity agenda.

In this section, a few exemplary initiatives and achievements that reflect the recommendations presented in the 2016 report are highlighted.

Local Government Recommendation - Examine cost of living and offer livable wages for front-line and entry level positions.

Recommendation - Develop formal mechanisms to proactively examine how planning efforts, policies and business decisions may disproportionately impact people of color.

Employ a racial equity approach when conducting community health needs assessments with a goal of uncovering or rectifying systemic barriers that perpetuate segregation, neighborhood disinvestment, and inequitable distribution of resource.

2016 In June 2016, the DC City Council voted unanimously to approve an ordinance to increase the city’s minimum wage for non-tipped workers to $15 per hour by 2020 and to increase the minimum based wage for tipped workers to $5 per hour.35

2018 In 2018, the District of Columbia joined the Government Alliance on Racial Equity (GARE), a network comprised of 80 jurisdictions across the country that work to change policies, programs and practices that sustain and deepen racial inequities in education, health, employment, criminal justice, etc. The District’s membership affords access to a platform for shared learning and best practices in policymaking for racial equity and justice for all.31

In 2018, the Department of Health, Office of Health Equity, released the Health Equity Report for the District of Columbia. The report provides a baseline assessment of health equity and opportunities for health in the city.

Using a social and structural determinants of health approach, population health data on the leading causes of death and projected life expectancy at birth was employed.

In addition, socio-economic data and geographic information systems (GIS) tools offered a snapshot of differential opportunities for health across the city. The report was informed by nine key drivers: education, employment, income, housing, transportation, food environment, medical care, outdoor environment, and community safety. Accomplishments in each of these areas are also documented.7

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Recommendation - Educate and increase institutional awareness of institutionalized racism, bias, and structural causes of poor health.

2019 Introduced to the city council in January 2019, the Racial Equity Achieves Results Amendment Act (REAR Act) of 201936 would require racial equity training for all District employees. The legislation would also include the adoption of a racial equity tool. The instrument would serve as a vehicle for examining policies and business decisions that disproportionately impact racial groups. For example, it would illuminate how people of color are affected by new commercial projects. The bill would also require racial equity performance measures in the development of an agency’s annual performance plan.

While the REAR Act is still under review, it has garnered considerable support from policymakers, local foundations and corporations, as well as community-based organizations.

Philanthropy Recommendation - Develop formal mechanisms to proactively examine how planning efforts, policies and business decisions may disproportionately impact people of color.

Educate and increase institutional awareness of institutionalized racism, bias, and structural causes of poor health

2016 The Washington Regional Association of Grantmakers (WRAG) is a nonprofit membership association comprised of over 100 of the region’s leading foundations and corporate giving programs. In 2016, WRAG took an unprecedented approach to grantmaking and launched Putting Racism on the Table, a learning series aimed to educate funders and the business community about the breadth, depth, and impact of structural racism, implicit bias, and white privilege. Through a series of learning sessions, funders, nonprofits, businesses and civic leaders are learning how to apply racial equity concepts both internally and externally.37

Healthcare Recommendation - Develop integrated technology platforms to connect residents with real-time social support services (e.g., food, housing, employment)

2019 In 2019, DC Health Matters, a collaborative of city hospitals and community health centers, launched DC Health Matters Connect. The web-based platform is a free online directory that connects patients with community-based organizations that offer free or discounted services. Medical providers, social workers, residents and others can use the service to access services in real time by zip code. Categories include food, housing, goods, transit, health, money, care, education, work, and legal.38

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