Ghetto miasmas, and other apologias.
In her long article in the New York Times Magazine of this past Sunday, Helen Epstein patches together fuzzy, ill-considered statements of her own, together with unquantified and unsupported assertions by some epidemiologsts who should know better, into a strange claim that's sufficiently summed up by the following paragraph (the piece's conclusion):
Whatever the miasma is that afflicts America's minority poor, it is at least partly a legacy of the segregation of America's cities. These neighborhoods, by concentrating the poor, also concentrate the mysterious, as yet poorly understood, factors that make them sick. You'd almost think this new miasma was caused by some sort of infection, because of the way it seems to strike certain neighborhoods and certain types of people. I recently came across a research article by Angus Deaton of Princeton University, reporting that white people who live in cities with large black populations have higher death rates than whites with the same income who live in cities with smaller black populations. It made me wonder whether the deprived, polluted, roach-infested, stressful conditions in which poor blacks live aren't affecting all of us, to some degree. And even if we never find out what the miasma is, this possibility should scare us into treating this as the health emergency it is -- if nothing else will.
What Epstein calls a miasma (the use of such a term is a return to the days before germ theory -- in other words, an abject rhetorical surrender) is what epidemiologists and public health researchers routinely deal with in a variety of other situations: a confusing multiplicity of factors that influence disease. But these factors themselves, with all due respect to Epstein, are by no means "mysterious." Rather, these are the most common and deleterious of behaviors, smoking, drinking, and unhealthy diet, coupled with the those factors most common to poor (and often black) neighborhoods: lack of access to medical care, deteriorating buildings and infrastructure, and unsafe and unattractive neighborhoods. There is no reason why addressing these factors, together with the individual, societal, and governmental choices that make them possible, shouldn't lead us to a better understanding of why black people are sicker than white people. It is true, as Epstein points out, that our current understanding of the interaction of these factors cannot fully explain why black people are sicker than white people. Nevertheless, we need not have recourse to ill-defined psychological mechanisms in order to find the true explanation: we need only continue to study those concrete mechanisms of poverty and illness already familiar to us and well-defined in the literature.
It's curious that what Epstein calls the miasma seems to lose its miasmic nature the minute one crosses the boundaries of the poor neighborhoods in question. That is to say, causal relationships as we generally understand them are to be recognized (according to this account) when applied to actors other than the sick people themselves: for example, no one thinks that the various immoral, stupid, or ill-advised actions of various governments, those that have contributed to these health inequalities, are "mysterious" or "poorly understood." But the minute we start talking about what individual health decisions sick people might make that contribute to their illness (whether it be smoking, drinking, or diet), Epstein looses the bonds of ordinary causality and directs a miasma to be blown onto the scene.
I fear that Epstein is mistaking ordinary scientific confusion, which is attendant on any state of affairs of moderate complexity which scientists try to clarify, for a bona-fide health care mystery that she over-dramatically terms a miasma. It is far more likely that these health inequalities can be explained by a coincidence which is to our grief not at all mysterious: racism's consequences, poverty, lack of education, and the harmful mistakes real people make when leading their lives.