‘A Foreclosing of Options’: Racial Health Inequality in Washington, D.C.
Black Washingtonians grapple with the largest racial life expectancy gap in the nation. But Sanyu Mojola isn’t satisfied that the burden of finding a solution to decades of health disparities rests solely on residents. “I’m tired of resilience as the answer to the problem,” says the professor of sociology, demographic studies, and public affairs at Princeton University. “Black people are resilient. They have overcome so much, but I want to get to a point where we’re not talking about overcoming. Can we not need to overcome?”
In Death by Design: Producing Racial Health Inequality in the Shadow of the Capitol, Mojola explores the epidemics that Washingtonians have experienced—HIV/AIDS, substance use, violence, and maternal and infant mortality—and probes the unique ways these threats have overlapped. She blends local history; interviews with residents, health advocates, and medical professionals; and sharp data-driven analyses to spotlight the underappreciated public-health disparities facing Black communities, particularly as the city struggles with new threats.
For Mojola, the arrival of the National Guard reframed those disparities again. “The same population—many young Black men, and this time Hispanics [are] being incarcerated as part of ICE [activity],” she says. “When it comes to crime, incarceration is the solution, and it’s the same population that’s being targeted. It seems as if history simply repeats itself—different administrations, different epidemics, different issues—but the same dynamics keep playing out over and over.”
In an era marked by drastic shifts in health care and public-health policy, Mojola sees her work as a pathway to “move the needle and understand better why this racial health gap persists.”
This interview has been edited and condensed.
Naomi Bethune: Under the second Trump administration, we’re seeing dozens of changes to public-health policy, including funding cuts to HIV/AIDS programs. How do these shifting priorities impact Washington, D.C.?
Sanyu Mojola: The story of HIV/AIDS is a strange one. It started off as a highly stigmatized disease. Over the years, it became less stigmatized, and [there’s been] more public compassion, especially towards gay men who were at the front lines and did a lot of the protesting, a lot of the groundwork to get the infrastructure up and running to help people living with HIV and AIDS.
Once the medication started to roll out for free for those who couldn’t afford it, the epidemic started to come under control. And so, you started to have dramatic declines in people dying of AIDS, and HIV became a chronic illness. Over time, new cases started to fall, especially among the white gay men who were so profoundly affected in the early years, while minority groups like African Americans and Hispanics started to be much more affected.
The biggest worry nationally is that once prevention stops and people stop caring, the epidemic might start to increase again, and we might get back to the era of mass death, or at least people getting on medication very late, because HIV destroys the immune system and starts to affect organs. If you get onto the medication late, your health is compromised, and so within D.C., there’s still disproportionately high rates of infection and AIDS deaths in the Black community. Even before the [administration’s] cuts, there was still a large racial gap between Black and white people in the city. The concern with the rollback is the gap hasn’t closed, and so that may just get worse.
You discuss living in “syndemic zones.” Describe those areas and what they mean for African Americans.
The term “syndemic” was coined by an anthropologist, Merrill Singer, and he was trying to understand why some places seem to have a lot of epidemics and how those epidemics interact to make everything worse. The epidemics he studied in particular were substance abuse, violence, and AIDS, so it wasn’t just that, for example, one particular ZIP code had high numbers of all three, but that they interacted. This is why syndemics are dangerous, because they prey on other existing epidemics, and they create new ones or amplify existing ones and make them worse.
[I suggest] that they occur in particular places. “I’m living in a place that has generalized risk, generalized risk for diseases, or generalized risk for epidemics, such that if I’m born into such a neighborhood, or my mother’s pregnant in such a neighborhood, or I live in that neighborhood for a very long time, and I’m continually exposed to the stress from living in that environment. I’m going to be more sick than others if I lived in another neighborhood.” It’s not a characteristic of race or class, but people who are poorer and who are in minority groups tend to live in syndemic zones, because those are the places with economic disinvestment, poorer schools, the environmentally worst places, and the most toxic environments, cluster in these places.
Have these zones been affected by local and federal policing responses?
It’s a tangled history, but the politics are also complicated. It’s not just racial politics, but also class politics. I give the example of the heroin epidemic, where, in fact, more white people inject heroin than Black people do. But when you look at the policies, once the epidemic was perceived to be predominantly white, you start to see a shift in policies where there was a shift from mass incarceration as the approach to mass treatment for heroin addiction. Instead of putting people in jail, people were put into clinics and were not criminalized.
But when it came to crack cocaine, there wasn’t a mass addiction treatment. Instead, there was mass incarceration as a solution. The city has been run by Black mayors for about four decades now, [but] the inequality gets worse. So, you wonder why and how? Because it’s not because people don’t care about the problems of poor Black people. It’s this foreclosing of options.
How did you land on the title, Death by Design?
We have all sorts of individual reasons for why people die. At an individual level, it is idiosyncratic, spontaneous and random, but when you look at it at a population level, there are very clear patterns. If you give me somebody’s ZIP code, I can tell you how long they’re going to live compared to someone in another ZIP code. When you realize that it’s patterned, you realize there’s predictability, then that suggests some kind of planning went into it.
How did that happen? Because map after map, regardless of which decade I looked at, it’s the same patterns. The southeast part of the city has the worst health outcomes. Northwest has the best health outcomes—[and] particular sets of policies that shaped residential decisions and shaped investment decisions. What I was trying to get at with Death by Design is that there’s a policy design that is not accidental. Once we shift away from thinking that health is just about individual decision-making, to health is something that is produced as a result of policy decisions, then we can actually move the needle and understand better why this racial health gap persists.
Each section of your book has a unique playlist. Why?
Analyses of the times show up in the music. For every song that’s in there [for example: “We Need Some Money” by Chuck Brown and The Soul Searchers], I looked at the lyrics, and they capture the debates in the community. [The music] also acknowledges the fact that I’m not writing anything new. Many people have lived through this. They have it in song, which is way more accessible.
When I started doing interviews, I realized, man, [health disparities] can kill. They get under the skin and kill. It’s not some benign thing. It was a hard project to work on. So, the music also gives relief, because you realize there’s life, there’s joy. I wanted to throw in go-go: It’s get-up-and-go-dance music which captures that life goes on. Every day, the sun comes out, kids are playing, people are laughing and cracking jokes, that’s the full story, and I’m just telling a slice.
Long-standing public-health disparities require a coordinated response: What should that work look like in Washington’s neighborhoods?
There’s enough brain power and resources in the city to fix this—if there’s the will. The hope is that my work galvanizes the community of funders, government officials, and local academics who’ve been studying this for a long time to actually figure out—practically—how and what are we going to do for people in Ward 8 [neighborhood in Southeast Washington] other than gentrifying them out? How are we going to improve the health care infrastructure, so people are not having to come to the north and the west [of the city] to find resources?
How are we going to help mothers? How are we going to help babies? How can we get liquor stores out of neighborhoods? How can we increase amenities without displacing people? I hope that there’s some sort of galvanizing that results in action on the ground, as opposed to just a political football for “this is why we need statehood” [discussions—which] are important. I’m not saying they shouldn’t happen, but they shouldn’t be in place of action on the ground, because sometimes people think that they’re making progress by talking. But if the talking doesn’t follow with action, then it’s just talking.
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