Baltimore's secret history of death: Racism, corporate greed & the most infamous mass-poisoning in American history

Freddie Gray's story ends with the cops, but starts with a system that destroyed the health of an entire community

Published May 6, 2015 4:45PM (EDT)

Protestors walk through smoke Tuesday, April 28, 2015, in Baltimore. (AP Photo/Matt Rourke)   (AP)
Protestors walk through smoke Tuesday, April 28, 2015, in Baltimore. (AP Photo/Matt Rourke) (AP)

Few now doubt the lethality of inequality. Unequal treatment under the law has resulted in case after case of Black lives lost, whether by gunshot, suffocation, or severed spine.

And yet, as tragic as these individual cases are, the lethality of inequality is a problem that goes well beyond the problem of police brutality. More quietly – if no less painfully – lives are being lost every day as a result of entrenched inequities in health that partition Baltimore neighborhoods like yellow police tape.

This is a story that is increasingly being heard. It’s not a new story, nor is it – sadly – a story that is going away any time soon. But, clearly, taking seriously the mantra that “Black lives matter” means understanding, and tackling, the larger problem of health inequality in America.

“Death is a Social Disease”

This story, to some extent, extends back centuries. Indeed, an understanding that there are socioeconomic disparities in death is one of the oldest lessons in the discipline of public health.

In the early 19th century, for instance, the French surgeon Louis René Villermé demonstrated that the level of wealth of a Parisian neighborhood was a primary determinant of the life and death of its residents, a story told by William Coleman in his "Death Is a Social Disease: Public Health and Political Economy in Early Industrial France." As Villermé concluded from his extensive, groundbreaking statistical investigation, “wealth” and “misery” were (as quoted by Coleman) among the “principal causes … which must be attributed the great differences noted among the mortality rates” from neighborhood to neighborhood in post-revolutionary Paris.

Now let’s fast-forward 200 to an America equipped with a welfare state and a highly advanced if problematic health care system. Disparities in health along the lines of race and class nonetheless remain omnipresent. Whatever disease you fancy and whichever organ system you study, you’d be surprised to not find health inequalities by race and class. My own field – pulmonary and critical care medicine – is awash in such racial and socioeconomic disparities, for diseases ranging from asthma to cystic fibrosis. Socioeconomic status is even a major determinant of the basic ventilatory capacity of the lungs. Perhaps this should not be surprising: After all, the poor and socially marginalized have access to poorer quality schools, food, and drinking water – why not air as well?

The pathways through which race and low income separately and together lead to poor health are complex, but the outcomes are straightforward: As in Villermé’s Paris, dramatic disparities in death divide neighborhood from neighborhood in Freddie Gray’s Baltimore. Christopher Ingraham at the Washington Post described this phenomenon best in a piece with the understated headline: “15 Baltimore neighborhoods have lower life expectancies than North Korea.” A baby born today in the well-to-do neighborhood of Roland Park, he notes, could be expected to live to 84, while a baby born in the poor neighborhood of Seton Hill, in contrast, has an estimated life expectancy of 65. Likewise, in the 2012 report “Place Matters for Health in Baltimore,” from the Joint Center for Political and Economic Studies, it is noted that the “premature death rate” in Baltimore in 2007 was 80 percent higher for Blacks than Whites, while an almost 30 year gap in life expectancy separated the healthiest from the sickest census tracts in the years 2005 to 2009.

In his 1944 classic "The Great Transformation," the Hungarian-American scholar Karl Polanyi argued that free-market capitalism did not organically emerge from primordial slime, but that it instead required the guiding hand of the state. Or, as he famously put it, “Laissez-faire was planned.” I would argue that we could extend Polanyi's thesis in a new direction today: Socioeconomic inequalities in health have also, to a great extent, been planned.

Segregation and Neglect: The “Planning” of Health Inequality

Let’s consider, as a case study, the history of segregation in Baltimore. As the executive summary for the “Place Matters” report puts it, a history of “intentional and targeted government policies … institutionalized and perpetuated residential segregation” in Baltimore. A city ordinance passed in 1910, it notes, made it illegal for Blacks and Whites to move to blocks that were predominantly composed of members of the other race; though this ordinance was later found unconstitutional, a variety of other racist housing practices, in conjunction with selective neglect, resulted in the “historical and contemporary clustering of social and economic distress” in certain neighborhoods in Baltimore.

Then, as Emily Badger at the Washington Post traces, after formal segregation, a series of subsequent urban “shocks” – the dissection of disenfranchised communities for construction projects, the advent of mass incarceration, the steamroller of deindustrialization – reinforced the overall pattern of exclusion decade after decade.

The sharp disparities in life expectancy that we now see between neighborhoods in Baltimore, therefore, are no accident. As the “Place Matters” report summarizes, areas of poor health and low-income “map onto areas of Baltimore that have experienced high levels of racial discrimination and segregation and systematic disinvestment over the last century.”  In other words, geographic disparities are “neither arbitrary nor benign,” but are instead the “deathly serious consequences of Baltimore’s past and present racial and class discrimination.”

The health disparities that have resulted from the combined dynamic of segregation and neglect are, in other words, entirely unsurprising. Even more obviously, they have absolutely nothing to do with some intrinsic predilection for black or poor people for unhealthy behaviors. Health inequality was, in other words, planned.

Consider that even equitable access to health care – something that should be relatively easy to achieve – remains a problem in Baltimore. Despite the long-standing presence in the city of Johns Hopkins – one of the great American academic medical centers – one report from the city notes that (based on a 2009 survey), 19.8 percent of Blacks – as opposed to 8.3 percent of Whites – reported having “unmet medical needs” in the previous year. Looking through the lens of class, the disparity is even wider: 1.1 percent of those in the highest income category, as opposed to 26.3 percent of those in the lowest, had unmet needs. Similarly, about a third of blacks reported having “unmet mental health care needs,” as opposed to 8.5 percent of Whites. First segregation, then neglect.

But peeling the onion of health inequalities is trickier still. Another layer – that of the environmental determinants of health – must enter our picture too.  Let’s consider, by way of example, another tragic moment in the life of Freddie Gray, which took place well before the tragedy that ended it. Let’s address the grotesque problem of lead.

Winners and Losers, Lead and Freddie Gray

Freddie Gray, as excellently reported by Terrence McCoy in the Washington Post, was a victim of what I’d call the most infamous mass poisoning in American history. Like countless other (especially minority) youths, Gray and his siblings were exposed to unambiguously hazardous levels of lead as children. Lead poisoning is a terrible problem in places like Baltimore, and more generally has been, as McCoy describes “an especially cruel scourge on African American communities.”

The detrimental neuropsychiatric effects of lead have been explored in countless studies: As one review summarizes, lead – a potent neurotoxin – may cause reduced IQ, academic performance, motor skills, and memory, together with a higher risk of ADHD and juvenile delinquency. Now, as McCoy correctly emphasizes, there is no way to know for sure, in Gray’s individual case, what contribution lead poisoning had on his development or his troubled life. It is, however, abundantly clear that lead has retarded the development and lives of countless individuals like him.

But there is a crucial point to be made here. This racially and class-biased environmental poisoning was not the result of some tragic, delayed misunderstanding of an environmental threat. The historians Gerald Markowitz and David Rosner describe the sickening saga of lead paint in their superb book, "Deceit and Denial: The Deadly Politics of Industrial Pollution." The potential health threat of lead was not a recent discovery. Indeed, as they describe, countries in Europe began banning the use of lead paint for interior home use as early as 1909 (e.g. in France, Austria, and Belgium). In the United States, however, the powerful lead industry flexed its considerable muscle to ensure that home interiors continued to be needlessly and stupidly coated with the unsafe paint for decades. It was, as they describe, only the combination of strenuous community activism with an evaporating market that persuaded the industry to give up on fighting to put its product in paint, and to instead focus its energies on keeping it in gasoline (another story entirely).

At the end of the day, the lead industry, in the defense of profit, irreversibly poisoned entire communities of children over many generations. As a result, many of these children would never reach their full potential in life. The cost to society has been incalculable, and the problem is by no means behind us.

All of which is to say that neither the high lead levels in Freddy Gray’s veins as a child, nor the severing of his spine decades later, should be considered “accidents.” Health inequalities were made.

Such inequalities are far too often de-linked from the chain of history. A failure to recognize the critical historical links obfuscates the reasons for racial or class differences in health behaviors like diet, exercise, and smoking. These are then seen, in turn, as the primary drivers of health disparities. Yet, differences in behavior should more correctly be seen as downstream consequences, as mediators of larger historical and economic forces. Under the profound, unrelenting, and suffocating stress of poverty and racist exclusion, it should be no mystery why “healthy living” is nigh impossible. (And kudos to those who manage it – I for one could not.)

Putting aside the problem of causality, however, let’s take a moment to recognize the summative toll that these inequalities have on health in Baltimore.  In the Baltimore City Health Disparities Report Card of 2013, the following is considered: It is assumed that all Baltimore residents have the same “premature mortality rate” (i.e. death before age 75) as that of those who live in areas with a median household income of greater than $75,000. Under that hypothetical, how many less might die?

Under such an assumption, according to the report, “50.1 percent of deaths citywide could potentially be averted.” In other words, at least according to this one admittedly crude and simplistic metric, it might be said that half of premature deaths in Baltimore happen on the butcher’s block of inequality.

Police brutality is a critical issue, and one that must not be neglected, but the lethality of inequality is a larger problem still. But ending this bloodbath won’t come cheap. Ameliorating health disparities won’t be achieved, for instance, by telling people to eat their fruits and vegetables or by shooting stern glances at smokers.

Rolling back health inequality would, on the contrary, necessitate an assault on economic inequality itself.

Adam Gaffney is a physician and writer whose work has also appeared in USA Today, Jacobin, Dissent, and In These Times.  His website is www.theprogressivephysician.org. Follow him on twitter at @awgaffney.


By Adam Gaffney

AG is a physician and writer in Massachusetts.  He blogs at www.theprogressivephysician.org and is on twitter at @awgaffney.

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Baltimore Freddie Gray Health Health Inequality Inequality Lead Racism Segregation Systemic Racism