Building Black Wealth — The Role of Health Systems in Closing the Gap

Abstract

In 1921, Tulsa, Oklahoma's "Black Wall Street," a financially independent and vibrant community that had been built and sustained by Black Americans, became the site of one of the United States' worst race massacres, fueled by White supremacists. Hundreds of people were killed, thousands were left homeless by fires, and hard-earned, substantial Black wealth and prosperity were destroyed. The fate of many modern-day Black communities and households echoes that of Black Wall Street. Success achieved despite the ravages of structural racism remains in constant tension with economic oppression that, while not always as obvious as the Tulsa massacre, still systematically disadvantages Black communities. Today, Black Americans make up roughly 13% of the U.S. population but hold just 3% of the country's wealth. 1 The median net worth of a White family in the United States in 2019 was $188,200, as compared with $24,100 for a Black family. 1 The racial wealth gap is large, persists across income groups, and has not changed in over a century. 2 Wealth, defined as assets minus liabilities, matters because it is a fundamental determinant of health. 3,4 Health equity strategies that fail to address the racial wealth gap may therefore be ineffective. Health systems, as key institutions responsible for health in the United States, are well positioned to directly promote wealth building among Black staff, patients, and communities. For example, the health care sector is the largest U.S. employer and the largest employer of Black Americans, but Black staff members are often among the lowest-paid employees and have the worst health outcomes. 5 In addition, health systems help to drive their local economies, with both job opportunities and purchasing power. We believe that health systems that do not address the racial wealth gap are abdicating some of their responsibility for improving the health of the country. We alth and He alth Although analyses of disparities frequently focus on income as a social determinant of health, it's an incomplete measure of socioeconomic status, given that households with income above the federal poverty level may still experience "net-worth poverty." 6,7 Income can be sensitive to transient shocks (such as health care expenditures) and may not provide the most robust measure of financial resilience. Wealth, on the other hand, drives health in myriad ways. Wealth affords choice and stability-in housing, education, and nutrition, for example , all of which are well-studied social determinants of health. 8 Wealth provides a cushion for dealing with unexpected emergencies, such as unanticipated medical expenses, involvement in the criminal justice system, or job loss. Wealth also provides a level of security that buffers against the weathering effects of chronic stressors. 9,10 Moreover, greater wealth is independently associated with reduced premature mortality, lower rates of chronic diseases such as hyperten-sion, and improved functional status throughout the life course. 4,11 For example, among people 54 to 64 years of age, those in the lowest wealth quintile have a 17% risk of death and a 48% risk of disability over 10 years, as compared with a 5% and 15% risk, respectively, among those in the top wealth quintile. 12 These associations remain strong in natural experiment studies, The New England Journal of Medicine Downloaded from nejm.org by joelle SINGER on October 7, 2022. For personal use only. No other uses without permission.