Benjamins, a Chicago-born senior research fellow at the Sinai Urban Health Institute, helped carry out the largest face-to-face community health survey in the city’s history. De Maio, a professor of sociology at DePaul University, who grew up in Buenos Aires, has held an interest in the social impacts of inequality since he lived through tumult in his home country of Argentina as a student. But each time Benjamins and De Maio authored papers on inequality in health for various conditions, they realized they had to take a broader view if they were to paint a clear picture of systemic inequity in the U.S.
Their new book, “Unequal Cities: Structural Racism and the Death Gap in America’s Largest Cities,” published by Johns Hopkins University Press last month, attempts to do just that: compare mortality rates and life expectancy in the 30 largest U.S. cities. Alongside more than a dozen contributors, De Maio and Benjamins illustrate what is sometimes a vast chasm between the life expectancy of Black and white people in urban America. And they provide a roadmap for how cities can begin to assess their own disparities and address them.
STAT spoke to the two authors in late September. Here is an edited version of that conversation:
Why study death rates and life expectancy specifically?
Benjamins: Life expectancy and all-cause mortality are two of the best single indicators of health because everything else funnels up to them. Levels of morbidity and injuries and all of those other things all are taken into account by that single number. And life expectancy in particular is easy for people to understand and interpret.
And then we realized when you look at inequities in mortality, that’s hard for cities to think about how to move the needle on that. So looking at cause-specific mortality is a secondary step. And that’s really important, because if you really have a problem in a certain cause of death, say cancer or accidents, you know where to funnel more of your effort and more of your resources.
De Maio: All the measures are interrelated. We all really appreciate the power of life expectancy as a clear-cut measure that most people can understand, and that’s our guiding light. But then we get down to things like excess deaths, which also convey a lot of meaning and are really helpful in communicating to broad audiences because it hits home in different ways … just the frank number of excess deaths — the number of people who die every year who otherwise wouldn’t if things were more equitable – that hits home.
Why was it important to you to look at the largest cities?
De Maio: We’ve seen the value of comparative work, of being able to understand our city in relation to others. … It’s one of the most powerful ways of debunking and rejecting any notion that these are biological effects or that these are ‘race-as-biology’ effects. These are true symptoms of structural racism because they vary from place to place. And that’s a really powerful insight.
Benjamins: We focus on cities because most Americans live in cities. … And cities have access to a lot of resources. They have departments of public health with big budgets. They have influence on all types of policies. They can be more nimble than, say, state or federal policies that influence health. So we just thought this is a good way to, if we want to improve urban health equity, you need to start at the city. You need to give them the data so they can make more informed decisions.
Why is there such a lack of data of this kind at the city level?
Benjamins: They’ll have the death records and they’ll have the population counts. Whether or not they put those together to calculate mortality rates … things like Black-white mortality rate ratios is a whole other story. So the country, as a whole, provides the data at the national level. It’s regularly calculated at the state and county level. But there’s just no one who is systematically putting out the numbers at the city level, and for sure, nobody that is putting out inequity data on mortality at the city level.
What inspired you to write the book?
Benjamins: We started with [calculating] breast cancer mortality disparities. And as we added different causes of death, the breast cancer work that was led by Steve Whittman and David Ansell led to some big changes in the city: the development of the Metropolitan Chicago Breast Cancer Task Force, which is now called Equal Hope. They were able to push through some big policy initiatives, including things like quality reporting guidelines for mammography and funding for screening. And that really shrank that gap between the Black and white mortality rates in Chicago. …
Based on that, we looked at some other causes of cancer and then went to some other leading causes of death. But every time we put out a paper, in the back of our mind, it was: Papers don’t give you room to talk about the context, so papers didn’t allow us to compare across causes, and it didn’t allow us to have what we have in the book, which is a focus on the history of anti-Black racism and the theory behind how social structures and norms like that can lead to mortality differences.
What are some notable findings in the book?
Benjamins: There’s a geographic inequity. ‘Unequal cities’ has a dual meaning. The difference between, say, San Francisco and Baltimore is about a 10-year difference in life expectancy, so that’s huge. You don’t expect to see that, or a lot of people don’t expect to see that. And then within those cities, the levels of inequity are also really unequal. So Washington, D.C., has a 12-year gap between the Black and white life expectancy. That’s just huge, whereas some cities don’t have any gap. El Paso really has a negligible gap, depending on which areas you look at. … So that’s what’s inspiring to us, that some cities have figured out how to get more equitable outcomes.
And in a couple of cities, Chicago and New York, [there are] over 3,000 excess Black deaths every year. To me, those numbers really hit home, the burden and the tragedy. And if it happened from another cause, I think this would be getting so much attention. You think of other things, even Covid… But the scale of 3,000 excess Black deaths in one city, every single year, and this has happened year after year after year, is something that I really wish people would pay more attention to or know about or understand.
De Maio: The book offers a whole set of metrics, of numbers, of ways of evaluating our state and our progress. We’re used to looking at the unemployment rate, maybe even the poverty rate in some places. But why don’t we look at excess deaths? Why don’t we look at the life expectancy gap? We have data to calculate that now. That will be remarkable if we can have more widespread appreciation for using population health indicators as one of the true metrics of how well we’re doing. And then we can hold our systems accountable for that.
This book was written before Covid. You handed it in a month before the pandemic started. How has the pandemic changed the context or made the stakes higher?
De Maio: We have a huge new burden. Covid ranges from the first to the third leading cause of death right now. The data aren’t available to do this level of analysis with the Covid outcomes, but they will come online in the future. It just raises the stakes. It’s undoubtedly going to further amplify some of the inequality patterns that we’ve seen here. And it’s a hypothesis that we can test, that some of the worst-off cities in terms of the inequities we see now will be some of the worst-off cities in terms of the inequities in Covid.
How does this book push forward the conversation on inequity?
De Maio: The findings will resonate with many people in their lived experience, but I also think that most people in society don’t know about the level of health and inequity that we have. They have a sense of the inequality. They have a sense of poverty and social inequality, in terms of economics and wealth distribution. I don’t think most people readily appreciate how much of an impact that has on how long we’re expected to live. That, for me, is a new piece of the conversation that hopefully people get from this book and find of value.
Benjamins: There was a study done of mayors — it’s a little dated now — whether or not they were aware of racial inequities and did they think they could have an impact on them. So I think putting the data out there, getting it into the hands of stakeholders who aren’t necessarily equity researchers, and then giving some examples of what to do next is really kind of the void we’re trying to fill with this book.
Speaking of mayors and stakeholders, for a local elected official or health provider or an employer, it might seem overwhelming, like an insurmountable problem in some ways. How can this book be used as a guidebook?
Benjamins: I think the chapter on West Side United is very helpful because it’s very detailed of how they created the structure of this organization, how they purposely required and solicited community involvement and community organizations’ input, how they put out this bold goal and and made it well-known.
De Maio: They set out this ambitious goal of reducing the life expectancy [gap] in half by 2030. That itself, it’s just this amazing, crystal-clear objective that is something that’s achievable. We’re heading in the wrong direction with Covid and the pre-existing patterns. But they’ve set this target and they’ve said that it’s achievable. … And they’re breaking down that mission by different elements. So it’s not just this nebulous, utopian, let’s-be-more-equal kind of goal; it’s a strategy.
What are some of the most stubborn misconceptions, myths, or misunderstandings that you’re trying to overcome to raise that collective understanding of inequity?
DeMaio: There’s a deep-rooted sense in the United States, the myth of race as a real thing, and that comes up in the reactions. We’ve had some colleagues, some audiences who say, well, how do you tease apart what’s structural and what’s genetic? And the answer is that this is not genetic at all. The differences that we’re seeing are entirely the products of local and national policies that affect people. That’s something that we’ll have conversations [about] for a long time, always battling genetic or biological explanations, which are not based on science and based just on bad thinking.
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