Soil to Struggle: A Qualitative Study of Health in Alabama’s Black Belt

Jared Hirschfield

Below is an abridged version of the full report. To read the full report, click here.

Background

On average, Blacks in the United States have poorer health than Whites.¹ Epidemiological research has also established a rural health disadvantage in the U.S., with rural Americans maintaining significantly poorer health than Americans residing in urban or suburban areas.² While numerous articles and substantial resources have been dedicated to the study of each of these disparities independently, there has been a relative shortage of attention given to the health consequences resulting from the intersection of these identities—that is, Black and rural. Victim to the compounding impact of multiple oppressed identities, rural Blacks often suffer from an even greater health disadvantage than nonrural Blacks or non-Black urbanites.^3,4,5,6,7

Rural Blacks in the US are quite geographically clustered. Over 90% of rural Blacks live in the South, most residing in Black Belt counties.⁸ The Black Belt is a crescent-shaped region of the American South stretching from east Texas to Virginia comprised of counties with disproportionately high percentages of Black residents (usually over 40%). Originally named for its dark, fertile, cotton-growing soil, the Black Belt was home to the vast majority of slaves in the United States. The poor socioeconomic conditions of the Black Belt, fueled by centuries of racism and institutional neglect, have translated into stark health inequities. Compared with the rest of the nation and, in some cases, even with rest of the South, rural Southern Blacks suffer from higher rates of mortality ^3,4,5 and premature death,⁶ and a lower life expectancy.⁷

In an attempt to draw much needed attention to the plight of these communities, this project employed a mixed-methods approach to study population health and health disparities in the rural Black Belt. Data was collected through semi-structured elite interviews with rural health and minority health stakeholders who reside or work extensively in Alabama’s twenty-odd Black Belt counties. Casual visual and photographic observations of Black Belt communities (e.g. health care infrastructure, local food options, housing availability and quality) were used to supplement the interviews.

Findings from the Field

Despite the progress achieved in the Civil Rights Movement, a pervasive culture of racism and segregation in the Black Belt persists. Racism—the type of racism typically associated with a time well before the Civil Rights Movement of the 1950s and 1960s—is alive and well in the Black Belt. Many remarked that beyond being grossly unjust, pervasive segregation and discrimination in the Black Belt surely take their toll on the health of Black residents, an assertion strongly supported by empirical academic studies that demonstrate the deleterious impact of racial discrimination on the mental and physical health of racial minorities.⁹ In addition to considering the impact of race generally, interviewees stressed that the current state of health in the Black Belt must be viewed through a historical lens and with an understanding that the plight of Blacks in the region today is a direct product of the institution of slavery.

Alabama’s failure to expand Medicaid under the Affordable Care Act was referenced by every interviewee as a principal contributor to the poor state of population health in the Black Belt. As it stands, no able-bodied, non-parent adult in Alabama, regardless of income, is eligible for Medicaid. Several explanations for the state’s refusal to expand were offered. Some suggested that partisan politics were the primary factor at play and that the Republican state legislature railed against Medicaid expansion because it represented the legacy of President Obama and the Democrats. Others identified institutional racism as the root cause, citing a fear of Black advancement among some White citizens and legislators and a desire to keep Black Alabamians suppressed.

Poor health literacy and a distrust of medical professionals hinder the implementation and efficacy of medical interventions in the region. Health literacy poses a major downstream challenge for patients. After addressing financial and insurance-related concerns, locating transportation, and taking off of work, patients struggling or unable to understand medical instructions (e.g. how often to take medications or how to reduce preventable conditions by altering dietary intake) face yet another frustrating barrier to care. Similarly, a distrust and fear of medical professionals and the health care system poses major challenges for both patients and health care providers. The horrors of the Tuskegee syphilis experiment, for instance, loom large in the minds of many Black residents in the Black Belt. This “clinical trial” was conducted between 1932 and 1972 in Macon County, Alabama and misled hundreds of Black men to believe they were simply receiving free medical treatment. Men enrolled in the trial who were infected with syphilis were deprived of adequate treatment for the disease, even after penicillin became the standard treatment in 1947.¹⁰ The Tuskegee experiment has naturally made Black residents seriously doubt that the health care system or its predominantly White health care professionals have their best interests at heart.

The impact of poverty (and related dynamics, such as lack of economic opportunity) lies at the heart of the region’s health disparities. Practically all other factors fueling the health disparities in the region— uninsurance and underinsurance, lack of transportation, educational inequities—have, in some way, a foundation in poverty. The lack of economic opportunity in the Black Belt, most directly manifested in a glaring shortage of reliable employment, is too central to the region’s narrative of poverty to be left out of the discussion. There are simply not enough jobs in the Black Belt, and the consequences of this certainly play out in health disparities. Interviewees suggested that programs aimed at creating local jobs, such as public works initiatives and incentives to attract large corporations to the region, may help indirectly alleviate health inequities in the Black Belt.

Discussion

These insights perhaps generate more questions than answers. For a region as understudied as the Black Belt, that is not at all problematic. As one interviewee put it, the region has “just about every challenge you could throw at it,” and addressing any and all of these challenges is going to require the formulation of many more questions. In the Black Belt, a “perfect” storm of extreme poverty, inadequate housing, high rates of uninsurance, hospital closures, systemic and institutional racism, and educational inequities has resulted in some of the nation’s poorest health outcomes.

The first step in alleviating health disparities in Alabama’s Black Belt should be expanding the state’s Medicaid program. Most directly, Medicaid expansion would extend access to health care to the 140,000 Alabamians who currently fall in the coverage gap.¹¹ Expansion also has the potential to alleviate seemingly non-health-related challenges currently faced by the state, such as mass incarceration. The expansion of comprehensive support programs like Sowing Seeds of Hope should accompany Medicaid expansion to provide Black Belt residents with assistance navigating available resources. Finally, more thought should be given to the development and implementation of initiatives that serve to directly target and reverse the injustices long endured by Black communities in the Black Belt.

Perhaps the most important takeaway from these interviews was the need for a heightened national awareness. Residents of Alabama, and presumably those of other Black Belt states, are typically well aware of the struggles of the Black Belt, while people in other regions of the country are not even aware of the existence of the term “Black Belt,” let alone the centuries-long legacy of slavery, segregation, and ongoing neglect that it connotes. A principle purpose of this report, and hopefully of any that will follow, is to inform the American public of the unacceptable state of affairs in the Black Belt, to open readers’ eyes to the millions of citizens America has left behind, and to demand a better future for all Americans regardless of their zip code or the color of their skin.

References

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7. Singh, Gopal, and Mohammad Siahpush. “Widening Rural-Urban Disparities in Life Expectancy, U.S., 1969-2009,” American Journal of Preventive Medicine 46, no. 2 (2014): e19-e29. https://doi.org/10.1016/j.amepre.2013.10.017.
8. James, Cara, Ramal Moonesinghe, Shondelle Wilson-Frederick, Jeffrey Hall, Ana Penman-Aguilar, and Karen Bouye. “Racial/Ethnic Health Disparities Among Rural Adults — United States, 2012-2015,” Morbidity and Mortality Weekly Report 66, no. 23 (2017): 1-9. https://www.cdc.gov/mmwr/volumes/66/ss/ss6623a1.htm.
9. Paradies, Yin, Jehonathan Ben, Nida Denson, Amanuel Elias, Naomi Priest, Alex Pieterse, Arpana Gupta, Margaret Kelaher, and Gilbert Gee. “Racism as a Determinant of Health: A Systemic Review and Meta-Analysis,” PLOS ONE 10, no. 9 (2015): e0138511. https://doi.org/10.1371/journal.pone.0138511.
10. “U.S. Public Health Service Syphilis Study at Tuskegee – The Tuskegee Timeline,” Centers for Disease Control and Prevention (2015). https://www.cdc.gov/tuskegee/timeline.htm.
11. Garfield, Rachel, Kendal Orgera, and Anthony Damico. “The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid,” Henry J. Kaiser Family Foundation Issue Brief (2019). https://www.kff.org/medicaid/issue-brief/the-coverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid/.