Poverty and Racial Inequity as Indicators of Cardiovascular Disease
By: George Song
(Photo Credits: Centers for Disease Control)
Poverty has long been known to be the top indicator of disease prevalence globally. Individuals in lower-income environments often lack access to healthy food, sanitary conditions, health education, and to equitable treatment options for medical issues that arise and contribute to the high morbidity rates associated with decreasing income. This presents a growing problem in the United States, where racial inequity is intricately tied to economic inequity, and where healthcare is not socialized for the full benefit of individuals in those communities.
What is cardiovascular disease?
Cardiovascular disease (CVD) represents a class of health issues affecting the heart and the circulatory system, most commonly manifested as:
Hypertension - high blood pressure, generally chronic, which may lead to other cardiovascular problems later in life.
Coronary disease - disease of the coronary arteries, which provide oxygen to the heart itself. This can lead to cardiac failure.
Stroke - blood clots that result from plaque formation within arteries, which block off blood vessels within the brain. This can lead to death or permanent brain damage.
Heart failure - when the heart stops being effective in pumping blood throughout the body.
Congenital heart defects - birth defects which affect the heart’s ability to pump blood effectively.
Prevalence of CVD increases with age and varies between racial/ethnic groups, with smoking and obesity being the two biggest risk factors for CVD. Unfortunately, 71.3 million people, comprising a third of the American population, are currently affected by cardiovascular disease.
Heart disease is the leading cause of death in the United States, followed by stroke as the third leading cause of death. Death from CVD has greatly decreased over the past century; however, even today, CVD remains a massive public health crisis.
Poverty can be fatal
Many studies have been conducted that relate poverty-area residence with mortality. These studies indicate an observed inverse relationship, in which a decreasing average household income correlates with higher death rates. In particular, a 1998 study shows that within an age cohort of 25-55 years, mortality rates were generally twice as high for poorer individuals. The cohort was also analyzed for mortality from CVD specifically, which identified a mortality ratio between poverty and non-poverty areas of 2.22. This same study also found that 26.6% of the poverty group was Black. Thus, poverty absolutely can be fatal, and Black and Hispanic Americans have been the most affected.
Prevalence of risk factors
Obesity is a significant risk factor for CVD. Obesity is almost always associated with hypercholesterolemia and hypertension, factors that promote the formation of arterial plaques and blood clots, often leading to heart disease and stroke. Studies have shown that 29.2% of Mexican-American men with a high school degree or higher are clinically obese. In women, the numbers are even more staggering, as 47.3% of Black women were found to be obese, regardless of education status. Furthermore, 39.8% of Black individuals were diagnosed with hypertension. Chillingly, CVD mortality was found to be highest in the Black population, regardless of age.
As seen above, in the US, race, ethnicity and socioeconomic status are connected, with minority populations typically living in more poverty-stricken areas. Because of this, race and ethnicity are clear predictors of CVD morbidity and mortality. Black and Hispanic populations are the most affected, and the prevalence of risk factors, especially obesity, is well correlated with poverty, and by extension, race and ethnicity.
The prevalence of obesity can be traced to lower income areas for several reasons:
Healthy food can be hard to access for people residing in those areas;
Healthy food can be prohibitively expensive even if it is physically accessible;
Lack of proper health education can further exacerbate the aforementioned factors above.
Thus, the combination of these conditions serve to increase the risk of CVD among vulnerable, poorer populations.
Healthcare disparities in the United States
Treatment for CVD is often extremely expensive, costing hundreds of thousands of dollars in inpatient and outpatient care per individual hospitalization. Given that hospitalization rates for Black adults remain many times higher per age cohort than those for White adults, and that the rates of uninsured individuals remains high for the Black and Hispanic population (13% and 19%, respectively, in 2018) as opposed to the national average (10%), the cost of each individual hospitalization is an additional, disparate economic burden upon these populations, which are already more at risk for the onset of CVD from existing environmental factors. Thus, this perpetuates a vicious cycle that subjects many individuals from various racial and ethnic backgrounds to an increased risk for CVD and its associated complications.
The future of CVD
There has been tremendous progress in reducing mortality from CVD over the last century. Still, these advancements have not been made equally among all racial and ethnic groups in the United States, and more work remains to fully tackle the issue of cardiovascular disease and other healthcare disparities in minority populations. Education about cardiovascular health topics is important, but more productive would be to ensure that American minorities are equitably insured and in a secure economic position to seek both preventative treatment and post-hospitalization care. The right to treatment should be a basic human right, especially in a country as developed as the United States. The persistence of medical inequity and racial injustice in healthcare has a cost measured in human lives, so we must act immediately.
Mensah, G. A. and Brown, D. W. (2007, February) An Overview of Cardiovascular Disease Burden in the United States. Health Affairs. 26(1). https://doi.org/10.1377/hlthaff.26.1.38
Waitzmann, N. J. and Smith, K. R. (1998, June) Phantom of the Area: Poverty-Area Residence and Mortality in the United States. American Journal of Public Health. 88(6). https://doi.org/10.2105/AJPH.88.6.973
Mensah, G. A., Mokdad, A. H., Ford, E. S., Greenlund, K. J., and Croft, J. B. (2005, March) State of Disparities in Cardiovascular Health in the United States. Circulation 111(10). https://doi.org/10.1161/01.CIR.0000158136.76824.04
Kaiser Family Foundation. Uninsured Rates for the Nonelderly by Race/Ethnicity. Retrieved from https://www.kff.org/uninsured/state-indicator/rate-by-raceethnicity
Centers for Disease Control, (2017). Heart Disease Facts. https://www.cdc.gov/heartdisease/facts.htm