Disparities in Urban Health: The Wounds of Policies and Legal Doctrines

Book Title: Disparities in Urban Health: The Wounds of Policies and Legal Doctrines

Author: Edward V. Wallace

Publication Details: Johns Hopkins University Press, 2024, 208 pp., $29.95 paperback

Health equity is defined as “the attainment of the highest level of health for all people, where everyone has a fair and just opportunity to attain their optimal health.” ² Addressing inequities in health is crucial to helping all people thrive. In Disparities in Urban Health: The Wounds of Policies and Legal Doctrines, Edward Wallace focuses on the inequities in urban environments and sheds light on the history and policies that have contributed to these discrepancies. He asserts that the impact of legislation on health has been neglected. This book is written to fill that gap.

Dr Wallace writes about these topics as a scholar with lived experience. He has a PhD in public health and has spent more than 20 years studying racial and ethnic health inequity. His research centers on reducing obesity and health disparities among African Americans living in urban areas. He is an associate professor in the Department of Africana Studies and an affiliate faculty within the College of Medicine at the University of Cincinnati. In his book, he describes the health impact of some of his experiences growing up in the Edenwald projects of Bronx, New York. He also emphasizes the importance of gaining trust when interviewing many African American and Hispanic residents in low-income neighborhoods about sensitive health topics.

Dr Wallace starts the book by describing nine composite urban families and their environments based on years of interviews. He weaves the families’ stories into multiple chapters to show how those living in urban neighborhoods struggle with health, health care, and poverty. He describes the historical and current backdrop of urban inequities. Chapters address environmental hazards associated with where one lives (eg, air quality, hazardous waste, pests) and how ZIP codes are predictive of health; the importance of oral health and the lack of access to dental care in urban neighborhoods; how poverty is a primary driver of poor health in urban neighborhoods; myriad societal contributions to health disparities; government programs addressing health and poverty; and recommendations for how to improve health for those living in poverty and urban neighborhoods.

Each chapter discusses relevant history, policies, laws, court decisions, or government programs and describes how families have been impacted personally. For example, when examining housing issues, he discusses the implied warranty of habitability. This provision requires landlords to maintain livable conditions but often winds up harming tenants when landlords argue that the tenants’ behaviors are causing the problems (eg, infestations). Tenants worry about being blacklisted if they complain about living conditions. He also considers how the Equal Protection Clause successfully protects many historically vulnerable groups but does not apply to the poor. This clause creates unequal access to medical care. He examines government programs (eg, Medicare, Medicaid, Temporary Assistance to Needy Families and Social Security Disability, Earned Income Tax Credits, the Supplemental Nutrition Assistance Program, and the Healthy Hunger-Free Kids Act of 2010) as they relate to health outcomes.

This book is a good introduction for those not familiar with the issues just described. Dr Wallace weaves together storytelling, historical narrative, and legal doctrines. The interviews of urban families grappling with these issues make the points more meaningful. However, he often meanders. Moreover, so much is covered in this book that many topics are not given in-depth analysis. For example, in his final chapter of proposed changes, he covers 23 recommendations within 26 pages. Among other things, he argues for loan forgiveness for those working in the field of health disparities, empowering communities with advocacy tools, and providing civil lawyers for those who cannot afford legal services related to their health. Although his ideas appear sound, he generally does not cite evidence to support the efficacy of his proposals. Furthermore, throughout the book, the strength of his citations falls short (eg, citing the History channel, blogs, and a PowerPoint presentation). Most egregiously, near the end of the book, he tells a sensationalized story with questionable validity. ³ Despite these shortcomings, Dr Wallace succeeds in raising awareness of equity issues.

Physicians are tasked with being advocates to improve health and health care for all. Understanding the impact of policies and legislation on minorities living in urban areas is critical in the promotion of health equity. The American Medical Association asserts, “Health inequities are no accident. They are the result of deeply embedded policies and systems spawned by structural racism.”⁴ This is precisely Dr Wallace’s thesis.