Melanie Cole, MS (Host): Welcome to Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole. And joining me today is Dr. Sadiya Khan. She's the Magerstadt Professor of Cardiovascular Epidemiology and an Associate Professor of Medicine in Cardiology and Preventive Medicine at Northwestern Medicine. And she's here to highlight the study about neighborhood racial segregation linked to shorter lifespans. Dr. Khan, thank you so much for being here. I'd love for you to tell us about the study of neighborhood racial segregation that's linked to shorter lifespans. Speak about the primary goals of the study.

Dr Sadiya Khan: Thank you so much for having me. We were really interested in exploring this question, because we see this every day in clinic, where different patients, depending on where they may live in their communities, have different burdens of heart disease or risk of cancer. And this contributes to differences in overall life expectancy. And we wanted to ask the question of what is the association with where someone lives and their predicted life expectancy.

Melanie Cole, MS: That is so interesting and really such an important study. So, I'd like you to summarize the key findings for us.

Dr Sadiya Khan: So, the key findings of the study were that neighborhoods that were highly segregated, which means that areas that had a high proportion of black residents, were associated with a lower life expectancy by about four years compared with neighborhoods that had a low segregation index. And that four years for life expectancy is quite a dramatic difference when you think about it in the context of an individual patient.

Melanie Cole, MS: Well, so then speak a little bit about other factors. If we think, this is such a complex topic, really, Dr. Khan, and if you're thinking about all of these outside factors, access to healthcare and stability of housing, environmental pollution, I mean, there's rural and urban deserts and sidewalks, the built environment, there's a lot that goes into this kind of healthcare accessibility. Speak about it and where that would factor in, had it been part of the study. Because as I understand it, some of those things were not part of it.

Dr Sadiya Khan: Yeah. Really great question and it gets at the root of the problem that because residential segregation is so upstream of a lot of these specific aspects of a community, specifically the access to education, the access to healthy foods, the access to green spaces, that communities that have been disinvested in have a higher proportion of Black residents.

And so, all of those things are on this pathway to life expectancy for our patients. But while we're seeing them, it may reflect in risk for heart disease, risk for cancer, and other diseases that are occurring that then lead to this difference in life expectancy. In this study, we specifically looked at three potential mediators and we picked these because we thought these would have the greatest relevance to the association between living in a highly segregated neighborhood and life expectancy. And that was specifically education, income and employment as key socioeconomic factors that really help improve health through improving access to opportunities.

Melanie Cole, MS: So, Dr. Khan, the study mentions that residents in highly segregated neighborhoods are more likely to lack that college education, which you just touched on, live below the federal poverty line and be unemployed, those three things you just discussed. When we think of the bigger picture of those, how do those disparities affect life expectancy? Why is unemployment or college education a factor here?

Dr Sadiya Khan: It's a really important question when we think about how these socioeconomic factors contribute to, like you mentioned, access to healthcare, access to healthy food options, access to green spaces to allow physical activity and promote a healthy lifestyle. When you're in a neighborhood that lacks those resources, then the potential for poorer health is just set up. And so, in some ways, we are reinforcing these health disparities for cardiovascular outcomes, for cancer outcomes and for life expectancy by not going back and investing in these communities.

Melanie Cole, MS: Without tackling this on the bigger level, which we've started to do and you kind of can't help it when you're thinking about that bigger picture, you made a comment in the study, making sure there's equity in terms of educational opportunities, employment and a healthy environment without air pollution or excessive heat exposure at the local level where people are born, live and grow-- this is your comment I'm quoting here-- we're going to miss a larger part of what's already happened before people walk into our clinics. In terms of policy implications, Dr. Khan, what recommendations does the study make for improving overall health and addressing that health equity in the US? Because I think that's the whole key message here.

Dr Sadiya Khan: Absolutely. There's a lot that we can do at an individual level when someone walks into our clinic. But like you mentioned, so much of the factors that contribute to poor health outcomes are within that built environment or where someone lives and their day to day activities. Policy level changes that invest in communities that have historically been ignored or have not had that investment, particularly around investing in schools, investing in green spaces, investing in grocery stores and healthy food options, is really a broader scale initiative that needs to happen.

Melanie Cole, MS: That's a big ask.

Dr Sadiya Khan: I think we need big asks, because this is a big problem.

Melanie Cole, MS: Well, it certainly is and it definitely goes further and as we look at the children as well and that could be a whole 'nother part of this conversation or study is then the kids growing up in those environments and what happens and diabetes that we're seeing and such. So before we wrap up, growing evidence of place-based disadvantage, along those same lines, due to residential segregation that limit access to health-promoting factors, and we're talking about those things. What advice would you give to physicians who wish to improve health equity in their own practices? Because it does go along the age spectrum, and they are seeing kids to older adults with this exact issue.

Dr Sadiya Khan: Yeah. I think one of the things that can sometimes feel overwhelming, is it's such a big problem. How do we each approach it in our individual encounters? And one of the things that's been really helpful has been the assessment of social determinants of health that we've started to integrate. As part of a way to think about, well, if my patient isn't taking the medication that I'm prescribing, rather than considering them non compliant or non adherent, can we get at the reasons? Maybe it's too expensive. Maybe there isn't a pharmacy anywhere near them or so called pharmacy deserts that some people may live in. And how can we better then support them? And so, not just assessing these social determinants of health, but starting to address them and provide support in a more holistic way that goes beyond just individual clinical treatment decisions.

Melanie Cole, MS: Great advice and what an interesting study. I hope you'll join us again as you learn more, Dr. Khan. This was a great conversation and to refer your patient or for more information, please visit our website at breakthroughsforphysicians.nm.org/cardiovascular to get connected with one of our providers. That concludes this episode of Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole. Thanks so much for joining us today.