Abstract
Achieving health equity for Black people and other people of color in America will be an impossible feat without dismantling racist systems and replacing them with new inclusive systems that create success for everyone. This article highlights activities in Rocky Mount, North Carolina, and the efforts of a community-based nonprofit, OIC, in collaboration with residents, community, and government partners to craft sustainable and replicable solutions.
Introduction
Eastern North Carolina is a rich wonderland of streams, lakes, rivers, and broad fields bordered and surrounded by lush pine and forests. Bands of highways, railroads, and interstates connect once isolated hamlets and villages to urbanized towns and small cities, with universities and colleges sprinkled in between. The tie that binds the people of the East together, though, is the history that so many try to avoid and uncomfortably discuss. We occupy the same spaces in which people were forced to carve out a new world order, established and sustained on inequities. Indigenous peoples’ nations and lands were seized by European settlers who were sent to gain new lands for their monarchs’ expanding empires. Captives from Africa were forced into brutal and dehumanizing systems of imposed labor and servitude, without compensation or reparation, to reshape the environment to sate the appetites of a young nation.
The result of this convergence of humanity was the evolution of oppressive systems in every area that created a new global focus on skin color and ethnicity that, for the first time in history, defined who had access to resources and who did not. Slavery, as an institution, stripped Black and Brown peoples of their wealth, intellectual capital, family, and land to sustain economic and social systems built and based on the exclusivity of wealthy White landowners and create a foothold for America in a changing global ecosystem.
The challenge that all of us now bear, regardless of our heritage, ethnicity, gender, income, or orientation, is how we reverse the impact of poverty, sickness, homelessness, and lack of meaningful education that 400 years of disparity and violence created. For those of us who live in communities that are plagued with all vestiges of poverty, we seek to build a society where equity is now the cornerstone of inclusive, just, and sustainable systems.
Uprooting Inequity
The coastal plains of North Carolina begin in Rocky Mount, a small city of about 55,000 people located east of Raleigh and I-95, whose economy is primarily built on agriculture, industry, government, banking, and health care. The gentle slopes of the Piedmont meet the eastward-flowing Tar River, where a small waterfall segues to a flatter landscape more suitable for plantations of tobacco, cotton, and agricultural and wood products that historically fueled the South through slave labor. This topographical shift is the site where North Carolina’s second-oldest cotton mill, the Rocky Mount Mills, was founded [1]. It supplied the Confederate Army with uniforms. Those same riverbanks, 400 years earlier, were home to a large settlement of the Tuscarora nation. Today, descendants of all three population groups are joined by immigrants of every hue and nationality, and collectively we face baked-in disparities that are the result of inequitable systems that benefit a small percentage of society.
The North Carolina Department of Commerce annually ranks the state’s 100 counties based on economic well-being, and Edgecombe County has received a Tier 1 designation [2]. The current US Census data shows that Blacks/African Americans comprise 57.8% of Edgecombe County’s total population [3]. The overall percentage of people living in poverty in Edgecombe County, according to US Census statistics for 2010, was 23.9%, compared with a ranking of 16.5% in Nash County [3]. According to the Robert Wood Johnson Foundation’s County Health Rankings, out of 100 (being the worst), Edgecombe County is 97 in health outcomes, 97 in length of life, 98 in quality of life, 98 in health factors, 97 in health behaviors, 99 in social and economic factors, and 97 in physical environment, compared to Nash County, which is (in order of the same topics) 76 HO, 85 LL, 54 QL, 76 HF, 79 HB, 77 SEF, and 86 PE, respectfully [4]. This proves the need to address spatial, racial, and health equity disparities in Rocky Mount, whose downtown straddles Nash and Edgecombe, known as the Twin Counties. However, Rocky Mount has learned not define itself by its fragility. Black communities, proud of the fact that they have produced athletes, educators, business leaders, politicians, and activists, have created a momentum that is resurging hope in entrepreneurial success, cultural preservation, and wellness.
Newton’s Third Law postulates that “for every action, there is an equal and opposite reaction.” Although this theory concentrates on dynamic physical interaction, the concept of matching energy for energy is a staple principle of program development that Opportunities Industrialization Center of America (OIC), a national community-based not-for-profit, has embraced to launch a transformation in our communities.
Shift in the Clinic and the Classroom
Health is the sum total of a person’s lived experiences combined with genetic predispositions. Health disparities are first addressed by dismantling every facet that helped create them. While we cannot alter or shape a person’s genetic makeup, we can provide education and support to people living with health challenges.
Since 1969, the Rocky Mount affiliate of OIC of America has provided an array of community-based services including workforce development, skills and trades training, basic education services, and now health care. OIC’s family medical centers are located in, and governed by, the communities in which they operate, and they believe that the best solutions to the problems we face are found among the people who deal with those challenges daily.
Proximity to affordable and quality health care and wellness services does matter, but how people are received when they arrive at resource centers is just as important. For this reason, we must be intentional about prioritizing employment pathways for people of color in clinical and administrative environments. Clinical providers and support team members who look like their patients and have shared life experiences help build trust with people who have suffered from the indifference of inequitable health care institutions. Outstanding patient experience for everyone, regardless of their ability to pay for care, contributes to how patients engage with their provider teams. When patients enter into our facilities, they see a literal rainbow of ethnic diversity in every facet of our care. This dynamic bases relevance, intellect, engagement, and unyielding focus on creating the potential for great health outcomes for all our patients. When they see our leaders, they see themselves.
Health disparities are inextricably linked to economic disparities. Economies based on cheap labor do not provide for those who work the hardest and have the least. One approach to solving this dilemma is a stronger emphasis on entrepreneurial support. More disposable income combined with appropriate education and understanding as well as access to relevant health care equals better health. If we can influence our students to prioritize their health while they’re in our classrooms and not working full time, they might prioritize their health when they have jobs or can afford their own health insurance. That new shift and focus might extend their quality of life and create an attitude of prioritizing health for generations after them.
Collaborating with local industries to strengthen opportunities for our community residents not only creates living wages and health care benefits for students and other residents, it also opens doors for burgeoning entrepreneurs who seek to change their futures and their children’s futures through their ingenuity and intellect.
Support for Black-owned Businesses and Wealth Creation
Today, OIC is weaving an interconnected fabric of support for Black business owners by subsidizing workspace, providing business development consulting support, and recruiting academic talent to assist them further from North Carolina Central University and the University of North Carolina at Chapel Hill. OIC and partners are creating an epicenter of small manufacturers, craftspeople, contractors, and artisans working together to leverage community power to lead a renaissance downtown, and to create a sustainable, more equitable Rocky Mount. According to the US Census Bureau Survey of Business Owners, Rocky Mount is second only to Charlotte in creating new Black-owned businesses in North Carolina, seeing 64% growth from 2012 to 2017 [5]. We hope to build momentum that will attract finance and investment networks, and to create an environment of cultural affirmation and mutual respect.
Wealth creation, in order to shift and impact the damage of historic and institutional racism, must translate to generational wealth transfer. Harvard’s Joint Center for Housing Studies reported in 2017 that the proportion of the US population living in high-poverty neighborhoods has increased from 43% (2000) to 54% (2015) [6]. The September 2017 report “The Road to Zero Wealth: How the Racial Wealth Divide is Hollowing Out America’s Middle Class,” showed that by 2020, Black households would lose nearly 18% of the wealth they held in 2013; Latinos would lose nearly 12%; and White wealth would increase 3% [7]. It was estimated that by 2020, White households would own 86 times more wealth than Black households (68 times more than Latino households). Some may believe that these inequities directly come from individual lifestyle choices and behaviors, but the research in this report supports the fact that “the racial wealth divide persists across all levels of educational attainment and family structures,” regardless of class or lifetime achievement [7]. White high school dropouts own more wealth than Black and Latino college graduates [8]. Furthermore, single-parent White households own more wealth than two-parent Black households [9]. The “Road to Zero Wealth” report states that: “Wealth is the buffer families need when faced with unexpected economic shocks like a lost job or a broken-down car. Wealth is also the capital available to families to take advantage of economic opportunities, like buying a home, saving for college or investing in the stock market” [7].
The only factor that can be consistently applied to the disparity in wealth creation and continuity between White people and persons of color is systemic racism that, for Black people in particular, has been perpertuated through slavery and post-slavery laws and policies, and is maintained today by systems created during Jim Crow (as corroborated by the NCIOM in the “Healthy North Carolina 2030” report) [10].
Transforming Community
It is very difficult, if not impossible, to live healthily in a dwelling or a neighborhood that is not safe or sound. OIC works closely with other community-based organizations and institutions to influence public policy to create affordable housing options and safe communities. Rocky Mount has 14 predominately Black neighborhoods that have been historically segregated, redlined, and inequitably policed. The Blue Cross and Blue Shield Foundation of North Carolina has invested in a local collaboration with OIC, the North Carolina Association of Community Development Corporations, and Legal Aid of North Carolina to create a new effort to Transform Rocky Mount through community-inspired strategies that create sustainable economic vitality.
Linking community-based health care with community economic development leaders and Legal Aid advocates has created a new focus in Rocky Mount for underresourced neighborhoods. The North Carolina Association of Community Development Corporations has led the way in training leaders in these neighborhoods to speak for themselves about how city resources and leadership work with them by creating a Community Academy. Three years ago, Academy members lobbied and persuaded the Rocky Mount City Council to create a Workforce Housing Advisory Commission to address affordable housing issues in those 14 neighborhoods. In the meantime, because the Rocky Mount economy is strengthening and has close proximity to the rapidly growing Raleigh metropolis, our neighborhoods are quickly changing. Hundreds of properties are being purchased and renovated at below-market rates, and resold faster and for a higher value than ever before, observably by people who would never have lived in “those neighborhoods” 10 years ago [11].
While welcoming new residents is a great opportunity for our city, quickly rising housing values are beginning to price seniors and lower-income individuals out of the communities in which their families have lived for generations. Rocky Mount’s “Down East Housing Consortium 2018-2021 Three-Year Consolidated Plan” (CON Plan) found that both owner-occupied and renter-occupied households at 0%-30% of area media income had the largest number of severely cost-burdened households, with elderly homeowner households having the largest number of both cost-burdened and severely cost-burdened households [12].
Affordable housing is defined by the US Department of Housing and Urban Develpment as housing that costs no more than 30% of a household’s monthly gross income, including utilities for renters and including property taxes, insurance, and utilities for owners [13]. Households are cost-burdened if they pay over 30% of their gross household income in housing-related expenses. Households are considered severely cost-burdened if they pay more than 50% of gross income in housing-related expenses. Today, the Rocky Mount City Council is considering a $20-$25 million affordable housing bond to address woeful rental and homeowner options for income-challenged individuals as the housing market in our city quickly heats up.
Health inequities in North Carolina, and perhaps anywhere in the world, will only be eradicated by intentionally replacing and repairing those systems that created and now sustain those inequities through efforts to create and maintain social drivers that increase well-being throughout generations, such as well-funded and quality public school systems; affordable and accessible health care in low-resourced communities; and affordable, safe, and attractive housing available to everyone regardless of their income level or their social status. This must be a priority of government at every level in order to affect transformative wellness systems for all populations in America.
To try only to create solutions to the manifested disparity does not speak to root cause. One or even multiple disparities might be addressed, but just like the whack-amole game, another disparity will pop up somewhere else. Applying the core principles of Newton’s Third Law of physics to a comprehensive and integrated approach gives hope to those who would like to see, in our generation, greatly improved and enhanced health and life outcomes for all people in all places at all times. We must match energy for energy.
Acknowledgments
Disclosure of interests. R.C.B., S.P. and C.B. are employed by OIC Rocky Mount. R.C.B. is the father of C.B. No further interests were disclosed.
- © 2022 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.
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