The wide disparities in health between black and white Americans are more a matter of place -- where people live -- than of race.
That was one of the recurring themes at "Taking Good Care: A History of Health and Wellness in the Black Community," a day-long conference held at Rutgers-Newark last week.
It was sounded implicitly by former Surgeon General Dr. Joycelyn Elders, who delivered the 32nd annual Marion Thompson Wright lecture.
"Today we could all do more for our own health than all the medical discoveries in the past 100 years. We need to take care of our own health," Elders urged.
And it was made explicitly by Dr. William F. Owen Jr., former president of the University of Medicine and Dentistry of New Jersey, in his talk, "My Genetic Code or My Zip Code: Which is More Important?"
Owen cited studies identifying six major social determinants of health outcomes: education, food quality, housing, public transportation, clean air and water, and cultural competency.
He added that these problems affect everyone caught up in them, regardless of race.
"Addressing the social determinants of health is not addressing something for blacks, it is addressing something for every American who is under that circumstance. So this is not a race-related issue. It doesn't even need to be discussed in the context of race."
"My point is these are actionable matters," Owen said, individuals may not be able to change their DNA, "but I can, should and must impact these matters."
Still, it won't be easy to change individuals or institutions. The U.S. healthcare system, Elders said, is a flawed system, and healthcare providers are not up to the task of delivering culturally competent care to a diverse population.
Elders also indicated that those aspects of healthcare most directly influenced by the patients themselves often reflect the reality that an individual's health status is diminished by insufficient education and low socio-economic status.
There are also cultural traditions at work: African-Americans are less likely to go to the doctor for routine preventive care, "because if you don't hurt and you don't bleed, in the black culture you aren't sick." The result, she said, is that a disease like high blood pressure, which often has no symptoms, "kills us because we don't get a check up."
For many of the ills of healthcare, she had the same prescription: "Education, education, education. We have to educate our people, and the group that is going to most help us to improve healthcare is going to be our patients."
Owen agreed on the importance of education, citing one Harvard study that found "more education, measured in four-years blocks, resulted in a longer life, less heart disease, less diabetes, and an improved sense of well-being."
Some might argue, Owen continued, that "this is simply a reflection of less deleterious health-related behavior" because the better educated are less prone to smoking, drinking, and other risky behaviors. But Owen said that when behavioral factors are built into the model, the advantages of education don't go away.
More strikingly, Owen said, "Race did not impact the model." Regardless of whether the individual is "white, black, green, purple -- there is something about more education that results in improved health."
For Dr. Clement Alexander Price, a professor of history at Rutgers-Newark, the interplay of race and health informs our understanding of the American experience.
"I think race matters in a society in which race has been the organizing principle and race has been the lens through which we view real and perceived differences," said Price.
"If we were as attentive to social class, to inequalities in education, inequalities in the distribution of health, we would be less obsessed with the racial origins of disparity than with the social inequalities that race has oftentimes served as a guise for.
The disturbing statistics on African-American health, for Owen, lead to a far more fundamental question, "What is race?"
Race, "is a social construct and so especially in countries like America, that have had, pun intended, such a colorful history around race, race becomes a convenient and visible way of identifying other problems."
He said the conversation is usually couched in terms of health disparities between black and whites, "but I am talking about health disparities for Americans and it's a social issue."
Blacks are concentrated in areas of New Jersey, such as Newark, that are deemed "food deserts" for their insufficient availably of affordable, nutritious, fresh food. "But there are food desert studies showing absolutely no difference in terms of blacks and whites in their health. I can take poor white families, drop them in a food desert," and the impact on their health is the same, Owen said.
"Race is in many ways a surrogate for socio-economic status," Owen said. Health statistics certainly reveal difference among races, "But then I ask the question, what is the credible aspect of the difference, what is it accounting for? Is it race, or is race telling me something else about a difference?" Owen said.
"I am making the argument that race is a surrogate. It's telling me something else and the something else is socioeconomic status -- where you live, how you are educated, what sort of supports you have."
Even the availability of public transportation makes people healthier, regardless of race. Public transit gives people a way to get to their healthcare providers, but it's also deeply connected to the problem of poor nutrition, Owen said.
"Is it any surprise that if you purchase your food from the convenience store, gas station, or liquor store, that you find yourself consuming a poor diet?" Owen said. He cited a study that found "2.5 million American live more than one mile away from a store that has nutritious food, and they have no auto access. Public transportation is a substantial health benefit."
Owen also cited a report on 22 studies around the world that confirmed that higher exposure to carbon monoxide increases the risk of a heart attack or stroke. African-American are concentrated in cities with higher concentrations of carbon monoxide, and their higher level of cardiovascular disease and stroke, "are not a reflection of race."
The day-long conference, which drew more than 600 attendees, is held annually during Black History Month by the Rutgers Institute on Ethnicity, Culture and the Modern Experience. Topics ranged from the healing work of enslaved black women to the current controversy over whether it is possible to develop a prescription drug targeted to black patients.
Dr. Marcus L. Williams, president of the Association of Black Cardiologists, said his organization is working with the American Heart Association and the American Stroke Association to reduce deaths from cardiovascular disease and stroke by 20 percent by the year 2020.
Williams said the major contributing factors in heart disease are diet and other social determinants: "So the key to this is actually you," he told the audience. "It is about you being empowered."