When the South buttered its bread with cotton plantations, former slaves worked the fields for meager wages. Plantation owners housed their workers in drafty cabins built by the river bottoms where the land was unsuitable for growing crops and the atmosphere considered too unpleasant for housing the upper classes. Black workers got a reputation for being lazy and slow; many whites thought their slowness confirmed popular notions of racial inferiority and the inability of black people to properly motivate themselves without white masters.
Were they lazy? A hundred years later, that question is absurd. In the river bottoms, mosquitoes carrying malaria buzzed in and out of the cracks in the workers’ cabins; hookworm infested the soil around communal latrines; poor nutrition meant high rates of pellagra. Plantation workers in the American South did their daily labor with a host of coinfections that would have laid low the strongest and most resolute. Robbed of health, they were also robbed of their economic viability and social respect. The cycle of poverty, born long before the abolition of slavery, continued its iron loop unbroken.
It’s easy to point blame at history for missing the obvious. It seems egregiously blind that the white plantation owners ignored the microbiology behind their workers’ situation. But at the time, most people didn’t understand malaria, hook worm, and pellagra. More importantly, racist ideations were entrenched. What is obvious now was subtle then.
We would do well to remember that we are missing obvious points of health disparity today. What will we know in a hundred years that will make blaming all of poor health on individual behaviors and “illogical” choices seem silly? Will it be the epigenetic imprint of poverty? Will it be city planning that concentrates low-income housing, convenience stores, liquor marts, and payday loans in the same neighborhoods? Is it our corn subsidies that have made soda and sugar cereals into dietary staples?
Individual behaviors do much to determine health outcomes, but individuals have limited power to change in unfavorable structural climates. Mapping the social determinants of health to the policies shaping them is dizzyingly complex and touches more arenas of the political landscape than the Affordable Care Act even begins to approach. Despite enormous effort by health agencies, health equity still seems unattainable.
But while history teaches us to have humility about our knowledge and assumptions, it also reminds us that we have the power to make enormous impact through structural changes. In 1933, the Agricultural Adjustment Act mechanized farms and rendered the plantation system obsolete. Subsequent changes in housing patterns and land use contributed to the total absence of malaria from the American South by 1942. Better bathrooms and the ability to afford shoes eliminated hookworm. During World War II, efforts to enrich flour with nutrients returned niacin to diets and stopped pellagra.
Encouraging people to make healthier choices arms them with knowledge and power to improve their daily experience. While equipping individuals is an important part of our work, seeking ways to alter the social, political, and physical structure of our environments will do more to change persistent health disparities. I consider it a great success that mere decades after malaria was a high cause of morbidity in the US, many residents have no idea it was ever a problem. I have great hope that years from now, some of our “inevitable” conditions will be equally obsolete.