Unequal Health: Why your zip code trumps genetics when it comes to health

What determines how long you live?

It turns out that your zip code plays a key role.

The California Endowment reported in 2016 that people in communities with little or no access to preventative healthcare, healthy food options, safe parks, and good schools died an average of 15 years earlier than those with access. In fact, a growing body of national research shows that these social determinants—the conditions under which we live, work, and grow—have a bigger impact on our health than things like biology and behavior.

Over the past year, social determinants of health made headlines like never before, as news agencies reported the spread of COVID-19. People living in certain zip codes, largely in Black and Brown communities, from California to Texas to Wisconsin, saw nearly double the rate of deaths compared to other largely White communities. But health disparities like this have been with us for decades, data shows, and persist across all kinds of illnesses, including diabetes, cancer, heart disease, infant mortality, and too many more to name.

At Samuel Merritt University, students learn to recognize health disparities and to identify the social determinants of health that contribute to them. They also have the chance to work on the frontlines helping to address them.

“We take students literally into communities and provide evidence of healthcare disparities,” says Kate Shade, an associate professor in the College of Nursing, who places students in community-health settings—caring for the unhoused, working with older adults living in low-income housing, assisting students and their families at under-resourced schools, and more.

The training is more than a one-off college experience. It opens the door to a host of careers that students might not have considered before, Shade says. Many graduates end up choosing jobs in settings that allow them to connect with the communities they served as students.

One of those is Mark Block, ABSN ’11, who came out of retirement at 56 to fight COVID-19. He’s back at work part-time at the Valley Homeless Healthcare Program (VHHP), which serves about 7,000 unhoused people in Santa Clara County. Block is part of a team of nurse coordinators who oversee motels that have been taken over to care for homeless patients with COVID-19, backpack/street medicine teams that treat people living in encampments, and three mobile medical units.

“I went to nursing school at what was SMU’s San Francisco campus (relocated to San Mateo) and walked to some of my clinicals at San Francisco General. So, the homeless population was kind of front and center for me. That’s when I knew I wanted to serve an underserved population,” says Block, who remembers participating in a homeless count in San Francisco, and seeing homeless patients during his clinical rotations at SF General and the SF VA hospital.

Block enrolled in SMU’s 12-month Accelerated Bachelor of Science in Nursing (ABSN) program later in life, after selling his half of a printing business.

“Mark's work is so profound because it is literally out on the street, finding people and connecting them to resources,” says Associate Professor Loretta Camarano, who, like Shade, helps place students in community health settings. “It takes very special people to be able to do this work.”

30 shots of vaccine

On a recent day in mid-March, Block was in the “bullpen,” a makeshift office in an out-of-the-way wing of what was once the Hampton Inn on Old Tully Road in San Jose, coordinating nurses, psychologists, social workers, and pharmacists providing respite care for about 25 homeless people who have been discharged from various hospitals and are recovering from serious injury or illness, including COVID-19.

“If it was you or me, we would go home and continue to recover,” he explains. “But a homeless person doesn’t have a home to go to … so respite is a bridge for them.”

In the hotel lobby, a team arrives from another site to see if Block can use 30 leftover doses of vaccine.

“Hey, Mark,” says a tall man overseeing the distribution of the shots.

“You’re all set up and ready for action,” Block tells him with a gentle smile. Outside, a dozen or so homeless people spread themselves out six feet apart as they wait to go inside. Some are leaning against their walkers to fill out a health questionnaire.

“Just this week, we started going to encampments. Those are the hardest people to reach,” says Block, who spent years providing street medicine out of a backpack for VHHP.

The single-dose Johnson & Johnson vaccine has made things far easier. “If you give them a dose and want to find them four weeks later … that’s very challenging,” Block says.

Throughout his 10-year nursing career, Block has witnessed “every imaginable social determinant of health.”

Substance abuse is one. So is unreliable transportation. Both worsen one’s health outcomes disproportionately. Those don’t compare to the greatest threat though, lack of housing. “The average life expectancy of a homeless person is right around 50, so all homeless people are at risk of dying on the street,” Block explains.

“We like to say housing equals health,” he says. “While all the services and care are really important (medical, social, financial) it has to start with housing. It's so difficult to make progress in any of these areas without stable shelter.”

Black infants die at twice the rate

Soon-to-be double alumna Shante Myers, ELMSN-CM ’17, DNP ’21, first came face-to-face with social determinants of health and health disparities during her time at SMU.

“I had no idea about how bad the disparity was,” says Myers, a nurse care coordinator/case manager at Kaiser South Sacramento and Mercy General Hospital, recalling the day in her OB-GYN class at the Sacramento campus that she learned African American babies die at 2.5 times the rate of non-Hispanic White babies.

There’s a long list of social determinants that contribute to negative outcomes for babies and their mothers, Myers says: poor nutrition, job and housing insecurities, low socioeconomic status, discrimination and racism, lack of access to care—especially perinatal care. And while these factors affect other groups living in low-income zip codes, Black mothers, in particular, face discrimination, racism, and implicit bias, as well as anxiety and fear when it comes to navigating the healthcare system.

“I can relate to some of these women’s lived experiences, even though I don’t have kids,” says Myers, who is African American. “These women are inherently stressed just by living in their skin, experiencing daily microaggressions and, add to that, living in the current pandemic and racial unrest.”

That anxiety and distrust leads them to underutilized prenatal care services and, ultimately, to poorer maternal and infant outcomes, Myers says.

This spring, she’s partnered with Sacramento County’s Black Infant Health Program—which provides nutrition, breastfeeding, and stress management services—to study how Black mothers cope before, during, and after pregnancy.

Myers plans to share the results of her research with the idea that it will help to better identify the needs of mothers who may suffer from anxiety and connect them to resources such as primary care, mental health services, stress management, and perinatal care support.

“My hope is that this research will be informative for me and other like-minded colleagues and will shape my approach to care,” Myers says. “As a future nurse practitioner, I will be more on the lookout for signs of postpartum anxiety because I’ll better understand the negative impacts it has on both the mothers’ long-term health as well as the developmental health of their infants.”

Schools double as health centers

As a school nurse to more than 2,300 students at four K-8 schools in the Stockton Unified School District, Phuong Tran, ABSN ’13, says crime, poverty, and access to care are some of the social determinants affecting area students and their families.

About 36% of city residents have an income 150 percent below the poverty level, according to the 2020 U.S. Census Bureau. And in the wake of the Great Recession, about 29% of country residents had no health insurance, a figure that’s been reigned in to under 10% thanks in large part to the county’s adoption of the Affordable Care Act.

It’s tough, Tran says, because some students don’t have health insurance. Others worry about seeking care because they lack the proper legal status to live in the U.S.

As part of San Joaquin County’s effort to help children in the most impoverished areas, Tran reaches out to the families of students having a hard time at school and offers them help finding a mental health counselor, dental care, and other health and wellness services.

“I may be the only medical professional they see,” says Tran. “I’ve had students who haven't seen a dentist in a few years. I ask the parents, ‘How can I help you? How can we help your child?’”

Tran is also part of an effort to reduce obesity in a county where 29 percent of adults and 21 percent of fifth, seventh, and ninth graders fall into that category. At one school in 2019, Tran found that 62 percent of her seventh graders were overweight.

Multiple community health reports in recent years have highlighted Stockton’s healthy food deserts—zip codes with few or no grocery stores and easy access to unhealthy fast food—as contributing factors.

Obesity, of course, can lead to a lifetime of health issues, including diabetes and heart disease. So, when a child is found to be obese, Tran sends a letter home to parents and works with the family to come up with a fitness and meal plan. The district is also trying to help by giving out free fresh fruits and vegetables to families.

“We have great parent liaisons for each of our schools,” Tran says. “They coordinate with the food banks and other nonprofit organizations to come out to the school sites and hand out boxes of fresh produce and fruit to the parents one to two times a month.”

Kind of nursing we need

Tran is among a sizable number of SMU students who end up falling in love with community nursing, after a community placement while in school.

“My community health clinical was with Dr. Camarano. We saw the same students every week and we’d do a lesson plan for these children,” Tran says, referring to children at Maryce Freelen Place, an affordable housing development in Mountain View. “We’d teach them how to hand wash. Another week, we taught them about nutrition and showed them things like the difference in caloric intake between a piece of cheese and a bag of chips. Physical activity was the focus of another week. It’s 100 percent of what I do in my job now.”

Each year, hundreds of SMU nursing students are placed into housing developments, schools, health and social service agencies, and even criminal justice settings, where they spend 10 to 15 weeks getting to know community members. The students work with the community to identify and address health concerns and to provide information and resources. The goal, Shade says, is for soon-to-be nurses to see and experience health disparities and the social determinants that contribute to them for themselves.

Recently, Camarano’s students led a virtual group exercise session for senior residents at an affordable housing complex. One student called out each exercise. A second demonstrated each move. And a third translated directions from English to Mandarin for some of the participants. Exercise is just one way to prevent things like obesity and heart disease, Camarano explains.

This spring, about 20 of Shade’s students provided health education to families in East Bay Head Start programs. As part of the students’ clinical work, they created a map of where City of Richmond families live in relation to nearby petroleum refineries and were able to see how higher rates of asthma correlated with their proximity—not a big surprise since environmental exposures are a known social determinant of health, Shade says.

Instead of focusing solely on genetic or behavioral risks, research tells us that we need to also, and maybe most importantly, think about where a person lives, their zip code, says Shade. “In other words, it's important for nursing students to focus on communities rather than just the individual because that’s where we begin to see patterns that we can devise strategies to address.”

“It's not just about labeling community members with a diagnosis and giving them a prescription … and saying, ‘You're done,’” she says. “It's about asking, ‘How can we prevent this from occurring in the first place? And, ‘How can we address it?’ It’s about finding solutions. That’s what community-public health nursing is.”