Well-being in San Francisco is all too often tied to race and income, according to the 2019 Community Health Needs Assessment (CHNA), a report produced every three years with input from hospitals, the Department of Public Health (DPH) and an assortment of health and human services providers.
The 2019 CHNA identifies a number of healthy improvements. More San Franciscans than ever have health insurance, with just 3.6 percent uncovered. Life expectancy is up. Mortality due to influenza, pneumonia and lung, colon and breast cancers has declined. Cigarette smoking is down; just 11 percent of residents say they’re regular users.
However, the study reveals stark racial disparities, affecting African Americans in particular. While there are negatives for European Americans, such as elevated rates of binge drinking – 25 percent – and cigarette smoking – 15 percent – among high school students; and Latinas, who have the greatest level of food insecurity during pregnancy – 26.5 percent – for Blacks disparities occur across almost all health measures.
Michelle Kirian, a DPH epidemiologist who is listed as a major contributor to the study, explained that for African Americans the social determinants and economic disadvantages that can contribute to poor health are a factor in nearly every category looked at. “African Americans have poorer health by almost all measures as a result of the social and economic conditions they have to live in,” she said.
Heart disease-related hospitalization rates of African Americans in their 40s and 50s are comparable to those seen in people over 75 years old in other races. Emergency room visits are 7.5 times higher for Blacks than other San Franciscans. Life expectancy is 72 years of age compared to 87 for Asians and 82 for Whites. Hospitalization for depression, at 23.7 per 10,000 people, is greater than Whites, at 15.1.
People with less education and lower income and social status have a high risk for mental illness, made worse if they’re also experiencing discrimination and racism. “The accumulation of those experiences has been associated with hypertension, preterm birth and other conditions mediated by stress,” the study reads.
Currently 19 percent of African American children in San Francisco are living in poverty compared to seven percent of Latinx, four percent of Asians and one percent of Whites.
Low income can be a factor in accessing resources that promote health, such as good schools, safe neighborhoods, healthy food and the ability to avoid hazards from poor quality housing and pollution. Which is why the CHNA isolates poverty along with racial inequities as the two foundational issues affecting health in the City. These elements influence five areas the CHNA identifies as heavily impacting health and disease in San Francisco: social, emotional and behavioral health; food insecurity, healthy eating and active living; housing security and homelessness; and safety from violent and trauma.
“Poverty underlies all these health needs because there is a lots of research that what zip code you live in determines the kind of life you lead,” says Jim Illig, a community health manager at Kaiser who co-chairs the San Francisco Health Improvement Partnership, which works to address the needs outlined by the CHNA. He said that a heat map of San Francisco outlining health problems displays an upside down T. “That’s where the lowest income people live. That’s where the most tobacco stores and liquor stores are,” he explained.
The study states, “people who live in communities with higher income disparity are more likely to die before the age of 75 than people in more equal communities.” San Francisco has the highest income inequality in California, with the wealthiest five percent of households earning 16 times more than the poorest 20 percent. Twenty-two percent of residents live below 200 percent of the federal poverty level; $51,500 for a family of four.
Aerobic fitness is 10 percentage points lower for economically disadvantage students, although the study reports many San Franciscans aren’t meeting World Health Organization standards for exercise. Those are one hour of moderate to vigorous activity daily for those ages five to 17; 150 minutes of moderate and 75 minutes of vigorous intensity for adults weekly. Eighty three percent of high schoolers and 67 percent of middle schoolers fall short of this benchmark. In one study, 60 percent of African Americans and Latinx ninth graders didn’t meet fitness standards compared to 30 percent for White and Asian students.
Many San Franciscans are food insecure. The United States Department of Agriculture (USDA) recommends that fruits and vegetables make up at least half of what’s eaten during a given meal. However, two out of three pregnant women in the Women, Infants and Children Eat program and two out of three youths don’t eat five or more servings of fruits and vegetables daily.
The USDA has designated Oceanview, Merced, Ingleside, Visitation Valley, Bayview Hunters Point and Treasure Island as neighborhoods with low food access. The latter two, in addition to the Mission, have just one public access water fountain.
Illig recalled a study that Kaiser did a few years ago. “What we discovered in Bayview was there was no healthy eating. There are no grocery stores that sell good fresh produce and the corner stores are selling bad food,” he said, adding that attempts to add a grocery store in the Tenderloin have so far failed.
Housing insecurity is a contributor to poor health. It’s estimated that 24,000 people in San Francisco live in crowded conditions, including one-third of Chinatown residents. Individuals without permanent shelter face obstacles beyond not having a safe place to rest, including storing medication, eating well, maintaining relationships and going to the doctor.
While the City is exceeding requirements for developing above moderate–income housing, the study notes that it’s building less than a third of the units needed for moderate and low-income residents.