Home values vary state by state, as recent U.S. Census data shows. But data also shows that where you live can have a significant impact on your health. Prominent examples include higher rates of respiratory illnesses such as asthma in places where air pollution is more common. However, there are equally important, but less frequently recognized differences in other chronic diseases based on where one lives.
In our research tracking trends in diseases of the heart and circulatory system in the population, we have observed disparities in physical and mental health by geography. Prominent examples include the “stroke belt”, a cluster of elevated rates of stroke in the southeastern region of the United States, high rates of obesity and diabetes in the southeast and in major cities and the southwest, and a recent report of high rates of depression and suicide in western states. Where we live provides access to resources that can either promote or harm our health.
Years of research have not identified a “chronic disease contagion” or other smoking gun behind these elevated rates. Rather, at the root is a complex set of structural, social and cultural factors that influence the behaviors of the people who live in those communities. Structural factors, often referred to as the “built environment,” inform the design of communities and the availability of resources.
For example, communities with sidewalks and recreational parks can promote physical activity for healthy weight maintenance. Communities with supermarkets and other food stores stocked with healthy and affordable options make eating healthy foods easy and convenient.
Social factors can include crime and policing, which influence safety and the mental and physical health of residents. In a satirical yet highly accurate portrayal for reasons underlying the high rates of diabetes among blacks in the ABC show “Black-ish” last season, the narrator warned that a black man running through his community for exercise risks being mistaken for a criminal. Tragic current events that fueled the BlackLivesMatter movement underscore the danger of mistaken criminal identity for black men.
In the recent USA Today news report describing the geographic distribution of depression, the culture of independence and self-reliance in the Mountain West states that inhibits individuals from seeking help for their psychological distress. When combined with the pervasive gun culture, the results are deadly.
Factors influencing health at the neighborhood level cannot be disentangled from the people who live in those communities. For example, high rates of diabetes cluster in cities and regions with large numbers of blacks, Hispanic/Latinos and Native Americans. When these populations also experience higher overall rates of poverty and social disenfranchisement, these vulnerable groups are disproportionately influenced by the neighborhoods where they eat, live and work.
Without reliable transportation, vulnerable populations cannot travel away from food deserts to seek healthy foods. A family struggling with food insecurity may not have disposable income to pay for recreational facilities to be physically active—which would have the dual benefit of promoting both physical and mental health.
In our culture that values and promotes individual choice and behavior, there are examples of residents living in communities with high rates of chronic disease who remain happy and healthy. Perhaps those individuals made different choices or better choices and preserved their health. However, those examples are sadly infrequent and most individuals living in those communities face constraints across multiple levels that they may not even recognize.
Moving individuals away from their communities is neither feasible nor preferred. Rather, lawmakers and public health practitioners should advocate for resources to change the social environment of high-risk communities. Leaders from the community should attack cultural attitudes that interfere with health. Local business leaders should be incentivized to provide different options and better options to promote health. It is only by acknowledging the role of “place” in health that we can implement strategies to reverse the devastating disparities in mental and physical health experienced across our states and local communities.
Mercedes Carnethon, Ph.D. is the Mary Harris Thompson Professor of Preventive Medicine and Chief of the Division of Epidemiology
Kiarri N. Kershaw is an Associate Professor of Preventive Medicine who studies the contribution of social and economic factors on health and well-being