In the 1980s, public hospitals exploded with sick and uninsured patients transferred from private hospitals for economic reasons, a practice called patient dumping.  I was a young physician at Chicago’s Cook County Hospital when my colleagues and I documented the negative consequences of patient dumping and contributed to the passage of federal legislation to ban it.  Fast-forward thirty years.  Urban emergency rooms have been shuttered (Fewer Emergency Rooms Available as Need Rises, New York Times , May 17, 2011) in the most vulnerable communities in America for economic reasons, a practice that could be called, “community dumping.”

Community dumping, the abandonment of high mortality communities by hospitals and clinics, contributes to a deadly epidemic of premature mortality in US cities.  Its victims: working age black men and women.  Black men on Chicago’s South side die eight years earlier than whites while black women with breast cancer have almost twice the chance of dying than white women.  Detroit and Harlem are not much better. The annual toll of the racial mortality gap in Chicago alone is 3,200 excess black deaths, more than died in NYC on 9/11 or  from Hurricane Katrina.

How can US cities be spinning in the wrong direction when it comes to racial inequalities in health outcomes?  Adverse racial health outcomes are not merely the result of bad luck, bad choices or bad genetics.  There are three drivers of health outcome disparity. The first has its roots in the structure of urban communities. Vast swaths of urban neighborhoods are hyper-segregated, with high unemployment, high poverty rates, and poor health outcomes. Most low-income urban blacks in the US live under these conditions – lacking immediate access to the institutions and resources that can, over time, increase their lifespan. Community dumping is not just an issue of poverty.  Over 80% of impoverished whites live in economically integrated white communities and as a result have access to the same grocery stores, schools and health facilities as the more well-off residents of those communities. Low income blacks suffer a triple whammy when it comes to health outcomes- being poor, black and living in a hyper-segregated urban neighborhood. The closing of emergency rooms in these communities is part of a larger pattern of public policy-driven social isolation that contributes to mortality.

 A second reason for the racial health care gap is a lack of access to primary health care. Research shows that in Chicago and other urban areas, over 50% of the black/white mortality gap can be attributed to excessive death rates from treatable conditions – such as heart disease and cancer.   High un-insurance rates limit inner-city black men and women’s access to institutions and specialists who could treat these conditions.

The third reason for the black/white health care gap is disparity in the quality of health care.  Because of the limited health care choices open to most blacks they are less likely to receive the same quality of care as whites   Blacks are less likely than white patients to receive mammograms and pap smears.  A black patient with cancer is less likely than a white patient to receive evidence-based treatment. Research shows that 80% of Black Medicare recipients are cared for by 20% of the US physician workforce who are less likely to be board-certified and more likely to report chaotic working conditions and difficulty accessing specialists for their patients.  At Chicago’s Cook County Health and Hospital System, many of the conditions that made it difficult for patients and doctors alike to access needed services when I was an intern over thirty years ago, persist today.

How do we begin to solve the racial mortality gap?  We need to reverse “community dumping” by encouraging capital and organizational investments in community based primary and specialty care in these high mortality neighborhoods. Second, we must implement metrics to measure, track and improve the quality of health care by race and ethnicity.  Foremost, we must reform a US health system that segregates patients and communities by insurance status.  While health reform legislation will provide many black uninsured working men and women access to Medicaid or low cost insurance, it could actually perpetuate the racial mortality gap as patients on Medicaid often have difficulty accessing primary care and specialists. Only a universal health care program, such as single-payer that allows all people regardless of community or income, equal access to the best our health care system has to offer, can lessen racial health disparities and reverse community dumping.