In a comprehensive and multi-scalar study of social, ethnoracial and gender inequalities in the face of HIV in the US federal capital, Sanuya A. Mojola describes a metropolis where residential segregation, drug consumption, violence and mass incarceration combine, with lasting health effects.
After a first notable work devoted to the epidemic of HIV among young Kenyan women, and as she prepares a new work on HIV in rural South Africa, Sanyu A. Mojola, professor of sociology and public affairs at Princeton University, is interested in Death by Design: Producing Racial Health Inequality in the Shadow of the Capitol to the dynamics of segregation and social and health inequalities in Washington D.C..
The federal capital of the United States is most often studied for its geopolitical role and its political institutions, but more rarely for its urban segregation and health disparities. Mojola explores how the urban history, territorial policies and social structures of the American capital have produced, and continue to reproduce, marked health inequalities between white and black populations. These result in particular in one of the largest gaps in life expectancy in the country between affluent neighborhoods with a white majority and disadvantaged neighborhoods with a majority African-American. The work maintains that these discrepancies arise from a real “ social design », historically constructed and politically maintained. Mojola shows how interlocking systems of inequality (racial, class, and gender) operate through forms of racial and gender containment to continually reproduce health inequalities across generations.
An ambitious sociohistorical and methodological investigation
Mojola traces the evolution of the American capital since its founding at the end of the XVIIIᵉ century until the contemporary period, mobilizing a particularly rich methodological approach. The work combines historical and ethnographic research, participant observations, archival analyses, quantitative data on social matters and surveillance of the HIVas well as in-depth interviews and life stories of African Americans living with the HIV (gay, bisexual or heterosexual men, women and transgender women). This plurality of materials makes it possible to jointly understand individual trajectories, community dynamics and institutional structures that shape health inequalities.
Mojola shows that political decisions and urban planning have accentuated the dynamics of segregation and shaped health trajectories in the poorest and segregated neighborhoods. It thus reaffirms that health inequalities are neither natural nor accidental, but result from deliberate choices in terms of housing, town planning, social, penal and health policies.
At the center of the analysis is the concept of “ racial confinement », understood as a set of institutional, spatial and symbolic mechanisms which organize the unequal distribution of populations and resources. This confinement plays a central role in the formation and reproduction of “ syndemic areas » from Washington, D.C.spaces where several interconnected epidemics concentrate over the long term.
A city shaped by segregation
While life expectancy in the United States has increased overall over the XXᵉ century, strong inequalities persist according to social and racial categories. Mojola highlights a gap of around ten years in life expectancy between the affluent neighborhoods of northwest Washington, predominantly white, and the disadvantaged neighborhoods of the east, predominantly African-American. These gaps, far from reducing, have been maintained, or even accentuated, in the contemporary period, reflecting the depth of socio-territorial inequalities.
The work is structured into five main parts following a logic that is both historical and analytical. The first traces the history of Washington D.C. in three main periods. From the founding period (1790-1890), the racial organization of the city, the concentration of black populations in unsanitary neighborhoods and institutional tolerance of degraded living conditions laid the foundations for lastingly unequal health trajectories.
The second period (1890-1950), marked by formalized segregation and urban renewal policies, saw these inequalities strengthen. Social housing programs, far from correcting segregation, contribute to the spatial fixation of black poverty. Finally, since the 1950s, deindustrialization, the development of highway infrastructure, the exodus of the white middle classes and processes of gentrification have accentuated urban and racial divides.
Throughout the XXᵉ century, African-American populations were concentrated in the east and south of the city. THE redliningby limiting access to real estate credit, contributes to the reproduction of lasting structural inequalities. Historically disadvantaged neighborhoods are characterized by degraded buildings, limited access to quality public services and harmful sanitary environments.
Syndemic zones and cumulative vulnerabilities
Mojola mobilizes the concept of syndemic zones to designate neighborhoods where several health crises occur linked to different vulnerability factors: drug use, violence, epidemic of HIVchronic poverty and degraded social and housing conditions. Social and health inequalities reinforce each other.
Residents of disadvantaged Black American neighborhoods are exposed to several vulnerability factors: limited access to care, economic insecurity, proximity to polluting industries and road infrastructures generating nuisances and health risks, etc. This overlapping exposure produces premature mortality and chronic morbidity.
Mojola shows how racial confinement also structures intimate and sexual life in urban settings. By shaping highly racially homogamous relational and sexual networks, it contributes to amplifying the spread of HIV among black populations. The author is thus interested in black gay and bisexual men, disproportionately affected by HIVbut also to heterosexual black women and transgender women.
HIVdrugs and mass incarceration
Mojola shows how urban, health and penal policies have structured both the expansion of the epidemic of HIV and the responses given to him. It analyzes the role of successive waves of drug consumption in the amplification of the epidemic of HIV in Washington, D.C.as well as in the production “ homicide epidemics » and mass incarcerations linked to “ war on drugs “. It offers a global analysis of the structural, relational and individual dimensions of the syndemic, drawing on longitudinal data, archives and contemporary sources concerning black populations affected by the HIVdrug use and homicides. It focuses in particular on heroin and crack, placing the diffusion of these drugs in a global historical and economic context and describing the supply chains and drug economy in Washington, D.C..
Mass incarceration thus occupies a central place in the analysis. Mojola shows that a considerable proportion of young black men have experienced prison, lastingly unbalancing social, family and sexual relationships. Prisons appear to be high health risk environments, contributing to the spread of HIVwhile leaving prison is accompanied by significant insecurity. Mobilizing the male marriageable pool index by William Julius Wilson, the sociologist shows how the scarcity of men “ marriageable » affects family and relationship dynamics.
Institutions, public policies and collective responsibility
The final parts of the book question institutional responses to health crises. Despite therapeutic progress, notably the arrival of antiretroviral drugs from 1995, racial health inequalities persist. The same neighborhoods remain exposed to opioids, violence, incarceration and public disinvestment.
Mojola analyzes the role of institutional and associative actors, including L’AIDS Healthcare Foundationand shows how some public health responses, while medically effective, are hampered by persistent institutional tensions and racial dynamics.
To reduce these inequalities, Mojola calls for an integrated approach: reform of housing policies to combat segregation, reduction of mass incarceration, strengthening of public health and prevention policies. It insists on collective and institutional responsibility in the production of health inequalities.
Ultimately, although centered on Washington D.C., Death by Design offers an analytical framework that can be transposed to other American metropolises and beyond. The work goes beyond the case of the federal capital to show how cities can produce, through their policies and institutions, lasting health vulnerabilities. Health inequalities appear to be the result of an urban history marked by institutional racism, residential segregation and political decisions unfavorable to black American populations.
Death by Design is part of contemporary debates on the health effects of social, ethno-racial, gender inequalities and the urban legacy of segregation policies in the United States, in dialogue with an already rich literature. The book does not, however, exhaust all the debates relating to the federal capital: it barely examines the effects of community relations within neighborhoods or between groups, remains limited in its spatial analysis and does not address the specific situation of Latin American populations. It nevertheless constitutes a particularly successful example of a comprehensive approach, combining the contributions of social history, urban sociology and public health research, capable of inspiring work carried out in France and elsewhere, which is sometimes compartmentalized. The richness of the data mobilized and their articulation in a structured story constitute a source of inspiration for analyzing social and territorial health inequalities over the long term and in different contexts.