Health is More than Genes and Choices

Vital sign monitor. Photo courtesy of Maxim Tolchinskiy.

Why do the prevention and end results of cardiovascular disease (CVD) worsen as socioeconomic status declines?

CVD is the leading cause of death in America, with over 650,000 people dying from heart disease annually. Certain groups bear a disproportionate burden of this disease; over 75% of CVD-related deaths occur in low and middle-income countries. From 1999 to 2016, the greatest decreases in CVD occurred among Americans with the highest income-based resources compared to those with fewer resources. Race also plays a role in CVD rates, as CVD-related deaths are twice as high for Black men than white men.

CVD is classified as a highly preventable disease, and many doctors and health organizations focus primarily on proximate risk factors—those that are close to the causes of the disease—when discussing CVD prevention. The Centers for Disease Control and Prevention, for example, lists smoking, diabetes, obesity, unhealthy diet, and physical inactivity as CVD risk factors. Their suggestions to reduce risk for heart disease seem limited to medical and lifestyle choices, but we must examine the “fundamental causes of disease” that may lead to these proximate risk factors. Fundamental causes of disease are distal rather than proximate, and risk factors for illness often involve access to resources like “money, knowledge, power, prestige and…[resources in] social support and social network.” These fundamental causes can profoundly shape individuals’ risk for and experience of disease.

To truly reduce CVD risk, we must emphasize the importance of fundamental causes of disease and use this knowledge to implement new policies. Rather than focusing on proximate risk factors, which target health at an individual level, we can leverage our knowledge on fundamental causes to treat health at a population level. Although many pathways for poor health exist, we must focus our attention on the intersection of socioeconomic status and race as risk factors or protectors of CVD. 

One’s socioeconomic status or racial background can influence the amount of chronic stress that they experience over their lifetime, thereby increasing their risk for CVD. Those with low socioeconomic status are more likely to experience high job demands but little agency in decision-making, family turmoil, and poorly maintained living conditions. Moreover, many studies show that racism is a chronic stressor that endangers health outcomes. One study focused on the relationship between discrimination and levels of C-reactive protein (CRP) and found that higher CRP levels are correlated with increased risk of CVD. In this study, African Americans reported their “everyday” experiences of discrimination. More experiences of discrimination were linked to higher CRP levels, suggesting that racism is a distal cause of CVD. Rather than raising awareness surrounding stress, we should contextualize this risk factor to target the crux of CVD prevalence. Creating more equitable environments and building better living conditions can lower people’s “risks of risks” for CVD.

Another example of a risk factor for CVD is obesity. To combat this risk factor doctors often encourage exercising or healthy eating to decrease CVD risk. However, to better combat CVD, we must craft solutions that target the fundamental causes of obesity, which is tied to residing in lower income neighborhoods. One study found that lower socioeconomic status predicted higher levels of stress, which led people to eat more and increased their obesity risk. Moreover, in many neighborhoods of low socioeconomic status, there are fewer supermarkets, thereby increasing the cost of healthy food, which can force poorer people to buy cheaper, less healthy alternatives. Poor dietary options, limited access to fresh fruit and vegetables, and higher prices of healthy food are all associated with obesity. Moreover, in poorer neighborhoods, fast food outlets are more highly concentrated. Low-income residents then are placed at an increased risk for living in a food desert. Neighborhood structures can also affect one’s physical exercise. People in affluent areas are associated with lower CVD risk because of their greater access to practicing physical activity, which is promoted through the wide availability of sidewalks and recreational spaces. Neighborhood crime, which is higher in low-income neighborhoods, can also limit people’s physical regimen and increase their risk for obesity. We must recognize the barriers to combating obesity as low socioeconomic status can put one at risk for more frequent eating, consumption of unhealthy foods, and an inability to exercise. 

A similar pathway for increased risk of CVD includes residential segregation as it places people of color at a disproportionate risk of environmental hazards, increasing their risk for CVD. Long-term exposure to air pollution can lead to rapid buildup of calcium in the coronary artery, which restricts blood flow to the heart and increases risk of CVD. Compared to white children, Latino and Black children with asthma are 2.5 and 2 times, respectively, more likely to live in high-traffic-density neighborhoods. Low-income Black neighborhoods are also exposed to more air pollution than white low-income neighborhoods. Black people are also more likely than white people to live in households with incomes below the household poverty line and live within two miles of multiple industrial sources of air pollution. Arsenic exposure in drinking water is another environmental hazard that increases CVD risk and disproportionately affects rural Indigenous communities in America. Indigenous communities already face the highest poverty rates among racial groups in the U.S., and their heightened risk for arsenic exposure reveals the highly intertwined relationship between income, race, and health disparities. Examining CVD risk, then, should also include the social structures of our society.

When thinking about CVD it is critical that we move beyond the examination of individual life choices and towards the exploration of structural causes. Creating or amending policies can drastically change health outcomes and narrow health disparities that lead to CVD. In relation to increasing healthy diets, policies that provide more food stamps in communities with fewer supermarkets increase access to and affordability of healthy meals. For instance, the creation of the Food Stamp program, the largest nutrition program in America, led to improvements in birth weight for Black newborns. National policies that provide financial support for strengthening ventilation in homes within air pollution zones can serve as short-term solutions for targeting air pollution exposure. Evidence suggests that any sort of zoning mechanism promotes environmental equity, so in the long-term, local zoning codes should ensure that air pollution sources are not stationed near low-income or minority neighborhoods. Communal participation can help form these policies. Additionally, researchers, residents, and policy makers should collaborate to implement larger policy changes that target eliminating socioeconomic disparities; these policies can include higher taxes on the wealthy and supporting better quality education in lower-income and residentially segregated areas to help future generations break the poverty cycle.

While many may think that genes or lifestyle choices are the primary risks for disease, fundamental causes—that is, social conditions that influence access to resources—are vital to understanding disease risk and prevalence. Lowering CVD incidence requires more than medical professionals’ advice on eating healthier or exercising more. To truly reduce CVD risk and prevalence, we must leverage research to inform policy-making; community engagement can encourage the government to implement policies, such as greater access to food stamps or stricter and more widespread enforcement of zoning policies. We as a society need to realize that effectively combating one’s disease requires community action and legislation.   

Alyssa Sales is a CPR staff writer, a junior in Columbia College, and a pre-med student majoring in Neuroscience and Behavior. You can usually find her talking about healthcare equity or on an adventure in SoHo, appreciating New York fashion.