First drawn in 1935, Hu Line illustrates persistent demographic split – how Beijing deals with it will determine the country's future.
- In 1935, demographer Hu Huanyong drew a line across a map of China.
- The 'Hu Line' illustrated a remarkable divide in China's population distribution.
- That divide remains relevant, not just for China's present but also for its future.
Consequential feature<img type="lazy-image" data-runner-src="https://assets.rebelmouse.io/eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJpbWFnZSI6Imh0dHBzOi8vYXNzZXRzLnJibC5tcy8yNTY5OTQxOC9vcmlnaW4uanBnIiwiZXhwaXJlc19hdCI6MTYzNTk3ODY0OX0.8-1X8cQiYysVBCN8rHZOAN70tW-TCvhQTjeSwZVqnmY/img.jpg?width=980" id="daaf6" class="rm-shortcode" data-rm-shortcode-id="bcfc6ba1b3b3723fa0fb613987f83777" data-rm-shortcode-name="rebelmouse-image" alt="A woman stands on an embankment of the Amur river, with Chinese town of Heihe seen in the background, in the Russian far-eastern town of Blagoveshchensk, on August 17, 2020. (Photo by Dimitar DILKOFF / AFP) (Photo by DIMITAR DILKOFF/AFP via Getty Images)" data-width="1024" data-height="683" />
A bather in Blagoveshchensk, on the Russian bank of the Amur. Across the river: the Chinese city of Heihe.
Credit: Dimitar Dilkoff/AFP via Getty Images<p>The Hu Line is arguably the most consequential feature of China's geography, with demographic, economic, cultural, and political implications for the country's past, present, and future. Yet you won't find it on any official map of China, nor on the actual terrain of the People's Republic itself.</p><p>There are no monuments at its endpoints: not in Heihe in the north, just an icy swim across the Amur from Blagoveshchensk, in Russia's Far East; nor in Tengchong, the subtropical southern city set among the hills rolling into Myanmar. Nor indeed anywhere on the 2,330-mile (3,750-km) diagonal that connects both dots. The Hu Line is as invisible as it is imaginary.</p><p>Yet the point that the Hu Line makes is as relevant as when it was first imagined. Back in 1935, a Chinese demographer called Hu Huanyong used a hand-drawn map of the line to illustrate his article on 'The Distribution of China's Population' in the Chinese Journal of Geography.</p><p>The point of the article, and of the map: China's population is distributed unevenly, and not just a little, but a lot. Like, <em>a lot</em>.</p><ul><li>The area to the west of the line comprised 64 percent of China's territory but contained only 4 percent of the country's population.</li><li>Inversely, 96 percent of the Chinese lived east of the 'geo-demographic demarcation line', as Hu called it, on just 36 percent of the land.</li></ul><p>Much has changed in China in the intervening near-century. The weak post-imperial republic is now a highly centralized world power. Its population has nearly tripled, from around 500 million to almost 1.4 billion. But the fundamentals of the imbalance have remained virtually the same.</p><p>Even if China's territory has not: in 1946, China recognized the independence of Mongolia, shrinking the area west of the Hu Line. Still, in 2015, the distribution was as follows:</p><ul><li>West of the line, 6 percent of the population on 57 percent of the territory (average population density: 39.6 inhabitants per square mile (15.3/km2).</li><li>East of the line, 94 percent of the population on 43 percent of the territory (average population density: 815.3 inhabitants per square mile (314.8/km2).</li></ul>
Persistent dichotomy<img type="lazy-image" data-runner-src="https://assets.rebelmouse.io/eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJpbWFnZSI6Imh0dHBzOi8vYXNzZXRzLnJibC5tcy8yNTY5OTQyMC9vcmlnaW4ucG5nIiwiZXhwaXJlc19hdCI6MTY1MDYzMjQwMH0.U6WZlL_YLrj2UWK54XMEszoVri9pW1rCN0k4Tp6uHD8/img.png?width=980" id="263c5" class="rm-shortcode" data-rm-shortcode-id="aca8cef9b29d250688bdb0c574339c7e" data-rm-shortcode-name="rebelmouse-image" data-width="1500" data-height="1176" />
Hu Huanyong's original hand-drawn map of China, showing population density and the now-famous line (enhanced for visibility).
Credit: Chinese Journal of Geography (1935) – public domain.<p>Why is this demographic dichotomy so persistent? In two words: climate and terrain. East of the line, the land is flatter and wetter, meaning it's easier to farm, hence easier to produce enough food for an ever-larger population. West of the line: deserts, mountains, and plateaus. Much harsher terrain with a drier climate to boot, making it much harder to sustain large amounts of people.</p><p>And where the people are, all the rest follows. East of the line is virtually all of China's infrastructure and economy. At night, satellites see the area to the east twinkle with lantern-like strings of light, while the west is a blanket of near total darkness, only occasionally pierced by signs of life. In China's 'Wild West', per-capita GDP is 15 percent lower on average than in the industrious east.</p><p>An additional factor typifies China's population divide: while the country overall is ethnically very homogenous – 92 percent are Han Chinese – most of the 8 percent that make up China's ethnic minorities live west of the line. This is notably the case in Tibet and Xinjiang, two nominally autonomous regions with non-Han ethnic majorities.</p><p>This combination of economic and ethnic imbalances means the Hu Line is not just a persistent quirk, but a potential problem – at least from Beijing's perspective. Culturally and geographically distant from the country's east, Tibetans and Uyghurs have registered strong opposition to China's centralizing tendencies, often resulting in heavy-handed repression. <br></p>
Long-term strategy<img type="lazy-image" data-runner-src="https://assets.rebelmouse.io/eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJpbWFnZSI6Imh0dHBzOi8vYXNzZXRzLnJibC5tcy8yNTY5OTQzMC9vcmlnaW4uanBnIiwiZXhwaXJlc19hdCI6MTYzMjI2MDM5Nn0.snaVUeTX38-YjR567pzTOSOUKBh320wrSD6mat90R-M/img.jpg?width=980" id="ce6bf" class="rm-shortcode" data-rm-shortcode-id="daeae9f5179eb1de69fd641c3fb5d1cf" data-rm-shortcode-name="rebelmouse-image" alt="TENGCHONG COUNTY, CHINA - MARCH 12: (CHINA OUT) A woman knits a sweater aside a street at Heshun Township on March 12, 2006 in Tengchong County of Yunnan Province, China. Heshun, the remote town on China's southern border, once had very close contacts with the outside world. Since ancient times, it has been a trade center due to neighboring Myanmar famous for jade. As many overseas Chinese ancestors lived in 600-year-old Heshun, almost every resident in the town has friends and relatives abroad. (Photo by China Photos/Getty Images)" data-width="1024" data-height="689" />
Street view in Tengchong, on China's border with Myanmar.
Credit: China Photos/Getty Images<p>But repression is not the central government's long-term strategy. Its plan is to pacify by progress. China's 'Manifest Destiny' has a name. In 1999, Jiang Zemin, then Secretary-General of the Chinese Communist Party, launched the 'Develop the West' campaign. The idea behind the slogan retains its political currency. In the last decade, Chinese Premier Li Keqiang has repeatedly urged the country to "break through" the Hu Line, in order to modernize China's western half.</p><p><span></span>The development strategy has an economic angle – adding industry and infrastructure to raise the region's per-capita GDP to the nation's average. But the locals fear that progress will bring population change: an influx of enough internal migrants from the east to tip the local ethnic balance to their disadvantage.</p><p><span></span>China's ethnic minorities are officially recognized and enjoy certain rights; however, if they become minorities in their own regions, those will mean little more than the right to perform folklore songs and dances. The Soviets were past masters in this technique.</p><p>Will China follow the same path? That question will be answered if and when the Hu Line fades from relevance, by how much of the west's ethnic diversity will have been sacrificed for economic progress.</p><p><strong>Strange Maps #1071</strong><br></p><p><em>Got a strange map? Let me know at </em><a href="mailto:email@example.com">firstname.lastname@example.org</a><em>.</em><br></p>
Pandemics have historically given way to social revolution. What will the post-COVID revolution be?
- The US is approaching 500,000 COVID-19 deaths. What can we learn from one year of loss and chaos?
- The lessons are clear. Among them are realizing our fragility as a species, our codependence as humans, and the urgent need to move beyond social injustice and inequity.
- As with the Renaissance following the Black Plague of the 14th century and the explosive creativity of the 1920s post Spanish influenza, this is our turn to redefine the course of history. Let's not mess this up.
First, some facts.<p>This is the biggest existential threat of our generation. We didn't face the tragedy of two world wars and, so far, escaped the ongoing threat of nuclear warfare. It's important to compare the tragedy that we are going through now with the devastation of the Spanish Influenza of 1918, with numbers that seem almost incomprehensible. It is estimated that about <a href="https://www.cdc.gov/flu/pandemic-resources/1918-pandemic-h1n1.html" target="_blank">500 million people</a>, some one-third of the world's population then, were infected by the virus. Of those, 50 million—10 percent—died worldwide, 675,000 of which were in the US. In today's numbers, this would mean that about 2.4 billion people would be infected, and 240 million would die. At the time of writing, there have been about 109 million confirmed infections (surely an underestimate) and <a href="https://www.worldometers.info/coronavirus/" target="_blank">2.4 million deaths</a>. While the numbers are much better worldwide this time around, this data doesn't make us feel any better. We are approaching half a million deaths in the US, another incomprehensible number, getting closer to the number of US losses during the Spanish flu. Denial, the lack of federal leadership, the top-down silencing of scientific evidence and support, complacency, science denial—these are all to blame.</p>
Science is essential.<p>A global pandemic of this magnitude is first and foremost a public health issue and the first line of defense is through science and public policy working in tandem. The fact that we are faring comparatively better than in 1918 speaks to the power of medicine to save lives: ventilators, antiviral drugs, better sanitation, better understanding of how this virus operates. The numbers could have been much better if health policy measures had not become politically weaponized and added to the current ideological divide with tragic consequences. The fact that we now have extremely effective vaccines, some using entirely novel technologies, speaks again to the power of science to save lives. This is a moment to celebrate science in service of humanity's greater good.</p>
We need to rethink who we are.<img type="lazy-image" data-runner-src="https://assets.rebelmouse.io/eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJpbWFnZSI6Imh0dHBzOi8vYXNzZXRzLnJibC5tcy8yNTY1NDg2My9vcmlnaW4uanBnIiwiZXhwaXJlc19hdCI6MTY2NzUxMjM1OH0.tvU-1kMIO1hvjow2pNKKe_i3C526z6cKcYXAGvBGeXQ/img.jpg?width=980" id="c1474" class="rm-shortcode" data-rm-shortcode-id="62c7f27c3a3ce0239daf7342828c0172" data-rm-shortcode-name="rebelmouse-image" data-width="2000" data-height="1125" />
Earth has existed for 4.5 billion years; our species, Homo sapiens, has existed for about 200,000 years.
Credit: desdemona72 via Adobe Stock<p>The pandemic has exposed our perennial fragility as a species. Nature operates under rules that don't include compassion for loss of life. We are not above nature. Technology may give us the impression that we can control the ways of the world, but we are still very much part of the process of natural selection, getting ill as mutant forms of this virus and others create new public health challenges. Natural selection is an endless battle for survival. We cannot trick it into a permanent stop, only into momentary halts. Indeed, as the environment changes, new forms of life emerge and not all of them will be beneficial to us. The melting of the permafrost is bringing up diseases that hit our distant ancestors and against which we are defenseless. Rethinking who we are calls for humility. Humility in the face of our limited resources, humility in the face of forces that are much more powerful than we are. We can dig deep holes and tunnels through mountains, cut down forests and make oceans retreat. But every one of these actions has a profound environmental impact that costs us dearly. Rethinking who we are calls for a reframing of our relationship to the planet. Earth has existed for 4.5 billion years; our species, <em>Homo sapiens</em>, has existed for about 200,000 years. We have just arrived here. Earth will continue without us. We can't continue without it, space exploration notwithstanding. The future of our project of civilization depends on our rethinking of our planetary role.</p>
We are a human hive.<p>The pandemic has given us ample proof of our codependence. We need each other at all levels; the first responders, the farmers and drivers, the supermarket workers bringing food to our tables. It is said that the stability of society is nine meals away. If we don't eat for 3 days, society unravels. And we need energy, supplies, banking systems, clear roads, clean cities, political stability, news, and fast internet. In a beehive, all workers contribute to the survival of the hive as a whole, every job is important. We are a human hive, and must respect all labor, and ensure that all workers are properly compensated. To live with dignity is not a luxury, it is a right.</p>
We must rethink social structure and inequality.<p>The uneven toll of the pandemic has exposed systemic racism and social injustice to levels that can no longer be tolerated or overlooked by anyone, and certainly by those in power. Since at least the origins of agrarian civilization, our ancestors divided into tribes so as to guarantee social cohesion against battling economies. Defined mostly by religious beliefs and social exclusion, such tribal walls have been the signpost of cultures across the globe. We now have a different view of humanity's place on this planet, our togetherness exposed to us in ways that many dislike. A virus doesn't care what you believe in, the color of your skin or how much money you have in the bank. It will attack opportunistically and hijack your cellular material to reproduce. But the extent to which people can protect themselves against such attacks does reveal societal inequities in transparent ways. If you share an apartment with eight people and must go to work every day, taking public transportation to get there, you will be walking into the war zone without a weapon or shelter. </p>
We need to rethink how we work.<p>With fast internet, it's abundantly clear that much of the dislocations to and from work, or frequent trips to distant places for meetings, is unnecessary, costly, and detrimental to the environment. Huge expenses with business real estate can be avoided, and funneled into higher compensation for workers and better computer and connectivity equipment. The notion of a downtown where people go to do business is quickly becoming obsolete. Travel will be mostly for fun and adventure. However, for this to become the new normal, fast connectivity and better equipment must be accessible to all, like electricity and clean water (there's some work still to be done here for sure.) Otherwise, we will be creating another tribal divide (it's here already), between those who have fast access to information and resources and those who don't.</p>
Want to tell someone's future in the US? You don't need a crystal ball, just their zip code.
- Social determinants of health, such as income and access to healthy food, affect well-being long before people may enter medical facilities.
- They're one reason neighborhoods in the same city can maintain life expectancy gaps larger than a decade.
- With growing awareness of how societal ills determine health, medical professionals and their partners are devising more holistic approaches to health.
Just 15 miles from Brownsville, Brooklyn, residents of the Upper East Side in Manhattan have an average life expectancy of 86.4 years.
Source: NYC DOHMH; Bureau of Vital Statistics, 2006-2015<p>Such life-expectancy gaps are common across the United States.<a href="https://www.chicagotribune.com/business/ct-biz-chicago-has-largest-life-expectancy-gap-between-neighborhoods-20190605-story.html" target="_blank"> </a><a href="https://www.chicagotribune.com/business/ct-biz-chicago-has-largest-life-expectancy-gap-between-neighborhoods-20190605-story.html" target="_blank" rel="noopener noreferrer">Residents of Chicago's Streeterville</a> neighborhood can rest easy knowing they will live to be, on average, 90 years old. Chicago's Englewood neighborhood, however, maintains a life expectancy of around 60 years. That's ten years lower than<a href="https://data.worldbank.org/indicator/SP.DYN.LE00.IN?order=wbapi_data_value_2012+wbapi_data_value&sort=asc" target="_blank"> </a><a href="https://data.worldbank.org/indicator/SP.DYN.LE00.IN?order=wbapi_data_value_2012+wbapi_data_value&sort=asc" target="_blank" rel="noopener noreferrer">the world average</a>—in the world's most affluent country. The phenomenon is not just an urban affliction. On the whole, rural community members have lower life expectancies as<a href="https://www.cdc.gov/media/releases/2017/p0112-rural-death-risk.html" target="_blank"> </a>they become more likely to die from <a href="https://www.cdc.gov/media/releases/2017/p0112-rural-death-risk.html" target="_blank">these five leading causes</a> than their city-dwelling peers.</p><p>While it may be tempting to write off these life gaps as the result of lifestyle choices or bad luck, they aren't. They are the consequences of a complex intersection between social, environmental, and cultural conditions that fall under 'social determinants of health.'</p>
The 80/20 rule of health<p>Social determinants of health are those conditions in a person's life and environment that can either aid or degrade their health. They include employment, education, food availability, living conditions, communal support, neighborhood quality, socioeconomic status, and the wider systems that surround these conditions. When such determinants aren't wholesome, they erode health long before someone enters a hospital—at which point, health professionals may have only minutes to turn the tide of years of eroded health.</p><p>As Udai Tambar, vice president for community health at Northwell Health, said, "You can't medicate for social issues, and that's, in a way, the system we have developed. We're trying to medicate for social risks and social factors. <a target="_blank"></a>You can have the best treatments, the best physicians, the best facilities, but unless a patient's non-clinical needs are addressed, none of it will make a difference."<a href="#_msocom_1" target="_blank" rel="noopener noreferrer"></a></p><p>Today, experts generally agree that 20 percent of health outcomes are derived from the care received at medical facilities, 80 percent from the non-clinical care attributed to one's lifestyle, environment, and social circumstances.</p><p>The data bear this out.<a href="https://www.brookings.edu/research/a-dozen-facts-about-the-economics-of-the-u-s-health-care-system/#:~:text=The%20combination%20of%20long%2Dterm,7%20percent%20of%20total%20spending." target="_blank" rel="noopener noreferrer"> </a><a href="https://www.brookings.edu/research/a-dozen-facts-about-the-economics-of-the-u-s-health-care-system/#:~:text=The%20combination%20of%20long%2Dterm,7%20percent%20of%20total%20spending." target="_blank" rel="noopener noreferrer">U.S. health-care spending</a> has nearly quadrupled since 1980, and the country has invested that bankroll heavily in hospitals, nursing facilities, prescription drug development, and medical specialist training. Each is valuable in its own right, yet as a systematic whole, this massive, decades-long investment has not netted proportionate health dividends. In addition to country-wide life gaps, the U.S. has one of the lowest life expectancies, the highest suicide rate, the highest chronic disease burden, and the highest obesity rate when<a href="https://www.commonwealthfund.org/publications/issue-briefs/2020/jan/us-health-care-global-perspective-2019" target="_blank" rel="noopener noreferrer"> </a><a href="https://www.commonwealthfund.org/publications/issue-briefs/2020/jan/us-health-care-global-perspective-2019" target="_blank" rel="noopener noreferrer">compared to other major OECD nations</a>.</p><p>These other OECD countries don't spend more on health than the United States. In terms of absolute dollars, the<a href="https://data.oecd.org/healthres/health-spending.htm" target="_blank" rel="noopener noreferrer"> </a><a href="https://data.oecd.org/healthres/health-spending.htm" target="_blank" rel="noopener noreferrer">U.S. handily outspends these countries</a>. Instead, these countries spend<a href="https://www.commonwealthfund.org/sites/default/files/2018-12/Multinational%20Comparisons%20of%20Health%20Systems%20Data%202018_RTikkanen_final.pdf" target="_blank" rel="noopener noreferrer"> </a><a href="https://www.commonwealthfund.org/sites/default/files/2018-12/Multinational%20Comparisons%20of%20Health%20Systems%20Data%202018_RTikkanen_final.pdf" target="_blank" rel="noopener noreferrer">a larger portion of their GDP</a> on social services, helping to mitigate deleterious social determinants long before a hospital visit. By<a href="https://www.brookings.edu/opinions/social-spending-not-medical-spending-is-key-to-health/" target="_blank" rel="noopener noreferrer"> </a><a href="https://www.brookings.edu/opinions/social-spending-not-medical-spending-is-key-to-health/" target="_blank" rel="noopener noreferrer">one estimate</a>, other major OECD countries allot, on average, $1.70 for social spending for every dollar on health. The U.S. system is almost the inverse, spending .56 cents on social services for every dollar on health.</p><p>"You need social equity to get health equity," Tambar added.</p>
There’s no pill to cure poverty<p>This pattern of spending is one reason for the U.S. health-wealth divide, a pernicious and destructive social determinant of health. We've seen this divide's handiwork in the life expectancy differences between the Upper East Side and Brownsville, but those are samples of a whole.<a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)30398-7/fulltext" target="_blank" rel="noopener noreferrer"> </a><a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)30398-7/fulltext" target="_blank" rel="noopener noreferrer">According to a 2017 paper in </a><a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)30398-7/fulltext" target="_blank" rel="noopener noreferrer"><em>The</em></a><a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)30398-7/fulltext" target="_blank" rel="noopener noreferrer"> </a><a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)30398-7/fulltext" target="_blank" rel="noopener noreferrer"><em>Lancet</em></a>, the "life expectancy of the wealthiest Americans now exceeds that of the poorest by 10-15 years." And these life-gap metrics signal the end consequences of a myriad of unmet social needs.</p><p><a target="_blank" rel="noopener noreferrer"></a><a target="_blank" rel="noopener noreferrer"></a><a target="_blank" rel="noopener noreferrer"></a>Consider the health barriers common in impoverished areas, where residents lack access to healthy, affordable food. Limited funds make it impossible to update or maintain safe housing without mold or lead-contaminated<a href="https://www.epa.gov/lead/protect-your-family-sources-lead" target="_blank" rel="noopener noreferrer"> </a><a href="https://www.epa.gov/lead/protect-your-family-sources-lead" target="_blank" rel="noopener noreferrer">paint</a> or<a href="https://www.cdc.gov/nceh/lead/prevention/sources/water.htm#:~:text=The%20most%20common%20sources%20of,1986%20may%20also%20contain%20lead." target="_blank" rel="noopener noreferrer"> </a><a href="https://www.cdc.gov/nceh/lead/prevention/sources/water.htm#:~:text=The%20most%20common%20sources%20of,1986%20may%20also%20contain%20lead." target="_blank" rel="noopener noreferrer">water pipes</a>. Narrow or nonexistent transportation options cut off residents from employment opportunities or health-care access. And being surrounded by street crime, unsafe public spaces or no greenways generates sustained high stress, which <a href="https://www.scientificamerican.com/index.cfm/_api/render/file/?method=inline&fileID=123ECD96-EF81-46F6-983D2AE9A45FA354" target="_blank" rel="noopener noreferrer">research shows</a> grinds away at our physical health as fiercely as it does our mental wellbeing.<a href="#_msocom_1" target="_blank" rel="noopener noreferrer"></a></p><p>Each of these conditions is bitter in and of itself, but these social determinants often come packaged as part of a social circuit that magnifies the effects of each.</p><p>Unfortunately, dietary fads and the U.S.'s rugged individualism have loudly espoused health to be the culmination of lifestyle choices (for some, even moral rectitude). While lifestyle and choice certainly have their role, an understanding of these social determinants shows how inextricably tied our choices are to our social conditions. As Tambar points out, a person can be well-versed in nutrition, but if their neighborhood is a food desert, their choices are constrained. Social circumstances can limit or adversely influence health in inimical ways.</p><p>As Dr. Mary Travis Bassett, Director of the FXB Center for Health and Human Rights at Harvard University,<a href="https://bigthink.com/videos/mary-bassett-on-new-york-city-health-disparities" target="_self"> </a><a href="https://bigthink.com/videos/mary-bassett-on-new-york-city-health-disparities" target="_self">told </a><a href="https://bigthink.com/videos/mary-bassett-on-new-york-city-health-disparities" target="_self"><em>Big Think</em></a>: "Nobody picks a substandard building to live in with terrible issues of rodent infestation and indoor allergens that trigger asthma. That's not a lifestyle choice. […] It's not about choice; it's about the fact that people don't have enough choice."</p>
Going to the source<img type="lazy-image" data-runner-src="https://assets.rebelmouse.io/eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJpbWFnZSI6Imh0dHBzOi8vYXNzZXRzLnJibC5tcy8yNTIyNDM0Ni9vcmlnaW4uanBnIiwiZXhwaXJlc19hdCI6MTYzMTMwNTc3MH0.m2s2NNhfZz8Aca8H9IL3PK_B5ecVNurz82PuF8s88Js/img.jpg?width=980" id="87250" class="rm-shortcode" data-rm-shortcode-id="b2ca94d906942d55c11a83821ad79632" data-rm-shortcode-name="rebelmouse-image" data-width="6720" data-height="4480" />
Credit: Getty Images<p>Negative social determinants of health provide a massive challenge to the health-care community, but experts and medical professionals aren't powerless to meet it. As Michael Dowling, CEO of Northwell Health, writes in his book <a href="https://healthcare-reboot.com/" target="_blank">"Health Care Reboot"</a>:</p><p style="margin-left: 20px;">This trend toward greater awareness of the social determinants of health is one of the most encouraging developments in health care, for it creates greater awareness among providers of the whole patient, including all of the various elements—most of them outside what might be considered strictly medical issues—that affect an individual's overall health and wellbeing.</p><p>An outgrowth of this growing trend goes by the name "<a href="https://bigthink.com/Northwell-Health/health-care-2634148633" target="_self">upstreamism</a>." Upstreamist practitioners don't only focus on the patient's downstream symptoms; instead, they also turn their attention upstream to incorporate the patient's social determinants of health in their diagnosis. Dowling illustrates this paradigm with an example of a patient with chronic, life-interrupting headaches. Her upstreamist doctor provided her the usual medication but added the unusual prescription of a visit by a community health worker. The health worker found the patient's apartment walls to be infested with high levels of mold. The doctor and health worker told the patient to have her landlord fix the problem and provided the number for a public-interest attorney should the landlord fail to comply.</p><p>Dowling's story shows the holistic approach of upstreamism: to take into account all the determinants of health, not only those found within hospital walls. Sometimes, Dowling notes, that will require medical professionals to take the lead. But other times, when there are extra-symptomatic drivers of health, it will mean <a href="https://www.northwell.edu/news/insights/faith-based-leaders-are-the-key-to-improving-community-health" target="_blank">partnering with</a> or supporting social service workers, law enforcement, or legal minds to secure a combination of services to heal the whole person.</p><p>It's for these reasons that many health-care organizations are spearheading initiatives and outreach programs to directly target social determinants of health <em>before </em>they become medical issues. Examples include<a href="https://www.northwell.edu/center-for-gun-violence-prevention/news/the-latest/northwell-receives-1-4m-nih-grant-to-establish-gun-violence-prevention-screening" target="_blank" rel="noopener noreferrer"> </a><a href="https://www.northwell.edu/center-for-gun-violence-prevention/news/the-latest/northwell-receives-1-4m-nih-grant-to-establish-gun-violence-prevention-screening" target="_blank" rel="noopener noreferrer">Northwell's first-of-its-kind gun-violence screening program</a> and<a href="https://pediatrics.aappublications.org/content/early/2015/10/20/peds.2015-3301" target="_blank" rel="noopener noreferrer"> the American Academy of Pediatrics'</a> fight for food security for U.S. children.</p><p>As Tambar points out, this holistic outlook means changing our approach to more than just medicine. It will require many aspects of our society to adopt a multi-lens approach, one that adds an interdisciplinary depth to social problems beyond a solitary profession's expertise. He concluded, "What people are realizing is to holistically serve someone, it's not about you doing it all. It's about partnering with the best person who can do something you can't do."</p>
New research spotlights how low-income Black households face greater financial distress and vulnerability as a result of the pandemic economic crisis.
- A paper by a team of Princeton researchers highlights devastating socioeconomic inequalities between racial groups worsened by the pandemic shutdowns.
- By the middle of June, the rates of new debt were similar for Black and Latinx households at more than 80%, while about 70% of white households reported new debt.
- When the pandemic ends, tens of millions of households will still find themselves stuck in a devastating financial hole, and a disproportionate amount of those will be Black and Latinx households.
A snowballing crisis<span style="display:block;position:relative;padding-top:56.25%;" class="rm-shortcode" data-rm-shortcode-id="192f3f60949a3a4ba8125e80eac68b82"><iframe type="lazy-iframe" data-runner-src="https://www.youtube.com/embed/RK2IfGPSqO0?rel=0" width="100%" height="auto" frameborder="0" scrolling="no" style="position:absolute;top:0;left:0;width:100%;height:100%;"></iframe></span><p>We've known that COVID-19 has been <a href="https://www.cdc.gov/coronavirus/2019-ncov/covid-data/investigations-discovery/hospitalization-death-by-race-ethnicity.html" target="_blank">disproportionately fatal</a> to Black Americans as compared to white, non-Latinx Americans, and that these deaths (as well as hospitalizations) have shone a nasty light on <a href="http://med.stanford.edu/news/all-news/2020/11/deaths-from-covid-19-of-inpatients-by-race-and-ethnicity.html" target="_blank">racial disparities undergirding the U.S. healthcare system</a>. But now a team of researchers from the Princeton School of Public and International Affairs are highlighting devastating socioeconomic inequalities exacerbated by the pandemic. Their report details how low-income Black households experienced higher rates of job loss, greater uncertainty accessing food and medical resources, and higher rates of debt than white or Latinx low-income households.</p>The paper, <a href="https://journals.sagepub.com/doi/10.1177/2378023120970794" target="_blank">published in the journal Socius</a>, is the first of its kind offering systemic, comprehensive, and descriptive estimates of the impacts of COVID-19 crisis on low-income Americans from March 2020 to mid-June. The authors' findings spotlight a snowballing crisis in which a growing number of families with low-income reported financial insecurity, then took on more debt to manage their expenses for resources.
The study<p>The authors aimed to determine the economic impacts of the pandemic on lower income Americans, and spotlight racial disparities within that socioeconomic group. They analyzed factors a family needs to satisfy basic survival needs including job loss, housing instability, and insecurity around food and medical resources.</p><p>"Media coverage has focused on the racially disparate effects of Covid-19 as a disease, but we were interested in the socioeconomic effects of the virus, and whether it tracked a similar pattern," said study co-author Adam Goldstein, assistant professor of sociology and public affairs at Princeton's School of Public and International Affairs in a <a href="https://www.princeton.edu/news/2020/11/30/covid-19-shutdowns-disproportionately-affected-low-income-black-households" target="_blank" rel="noopener noreferrer">Princeton University press release</a>.</p><p>Goldstein noted that it was clear that Black households in America were disproportionately affected amongst low-income households who struggled at the beginning of the pandemic. </p><p>"Even among low-income populations, there is a marked racial disparity in people's vulnerability to this crisis," <a href="https://www.princeton.edu/news/2020/11/30/covid-19-shutdowns-disproportionately-affected-low-income-black-households" target="_blank" rel="noopener noreferrer">said study co-author Diana Enriquez</a>, a doctoral candidate in Princeton's Department of Sociology.</p><p>For the study, the researchers used data that came from two different tracking surveys. The primary data source was a bimonthly survey series of Supplemental Nutritional Assistance Program (SNAP) recipients. The respondents were recruited through the mobile app, FreshEBT, for managing SNAP benefits. Also used was the U.S. Census Bureau's publicly available Household Pulse Survey, which is drawn from representative household samples rather than solely from program recipients. Using these sources, the authors surveyed people who were using the SNAP and Temporary Assistance for Needy Families (TANF) benefits prior to the COVID-19 crisis. Several waves of surveys were sent out between the end of March and mid-June, a window of time when Americans were starting to feel the first economic hits of the shutdowns, but before their economic status had been transformed in a major way. </p><p>Participants were asked about their present and perceived situation related to employment status, housing status, ability to access food and medical resources, and amount of debt. For instance, survey respondents were asked if they currently had stable housing and also if they believed their housing status would be stable after that 30-day period. </p>
Major Findings<p>The authors found that lower-income Americans who were already receiving government assistance had experienced major impacts in all areas except for housing status. <strong>Here were the major findings from each survey wave between the end of April and mid-June:</strong></p><ul><li>Nearly 35 percent of all survey respondents reported losing their jobs by mid-June. </li><li>67 percent said that they missed paying at least one bill at the beginning of the shutdown. </li><li>77 percent of households reported missing a bill or payment on their rent. </li><li>54 percent of individuals said they had skipped meals, were dependent on friends and family for food, or had visited a food pantry due to the shutdown, despite being covered by SNAP. (This figure rose to 64 percent by the end of the month of June.) </li></ul><p>But when the researchers looked at the data in race categories, it was clear that, on average, low-income Black households had taken much greater hits than low-income white households had. The magnitude of racial differences varied across indicators and data sources, but Black respondents fared consistently worse than non-Hispanic whites in both survey data sets, and Latinx respondents fared worse than whites in the Household Pulse Survey.</p><p><strong>Here were the major findings when evaluated on race:</strong> </p><ul><li>At the start of April 2020, 30 percent of Black households reported a job loss. By the end of the month that number rose to 48 percent. </li><li>80 percent of Black households surveyed reported taking on greater debt to cover their bills by the end of April 2020. </li><li>By the middle of June, the rates of new debt were similar for Black and Latinx households at more than 80 percent, while about 70 percent of white households reported new debt. </li></ul>
Implications<p>These survey results have put a magnifying glass on how badly the COVID-19 pandemic has impacted vulnerable households who were already living near the poverty line.</p> <p>"Research shows that these types of debts and unpaid bills — even small ones — can compound over time and trap low-income households in a cycle of financial distress," Goldstein said. And when the survey results are analyzed for differences amongst racial groups, it's clear that those most vulnerable to this snowballing financial devastation are Black and Latnix households. </p> <p>Ultimately, this research shines a light on a disturbing truth emphasized by Goldstein: "Even in a miraculous scenario where the pandemic ends in a few months and low-wage workers are rehired, tens of millions of households will still find themselves stuck in a financial hole without additional infusions of economic relief." </p>
The next era in American history can look entirely different. It's up to us to choose.
- The timeline of America post-WWII can be divided into two eras, according to author and law professor Ganesh Sitaraman: the liberal era which ran through the 1970s, and the current neoliberal era which began in the early 1980s. The latter promised a "more free society," but what we got instead was more inequality, less opportunity, and greater market consolidation.
- "We've lived through a neoliberal era for the last 40 years, and that era is coming to an end," Sitaraman says, adding that the ideas and policies that defined the period are being challenged on various levels.
- What comes next depends on if we take a proactive and democratic approach to shaping the economy, or if we simply react to and "deal with" market outcomes.