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December 2020 (Volume 98)
Quarterly Article
Arline T. Geronimus
Jay A. Pearson
Erin Linnenbringer
Alexa K. Eisenberg
Carmen Stokes
Landon D. Hughes
Amy J. Schulz
Sep 2, 2026
Aug 19, 2026
Jun 29, 2026
Back to The Milbank Quarterly
Policy Points:
Context: US population health inequity remains entrenched, despite mandates to eliminate it. To promote a public health approach of consequence in this domain, stakeholders call for moving from risk‐factor epidemiology toward consideration of dynamic local variations in the physiological impacts of structured lived experience.
Methods: Using a community‐based, participatory research approach, we collected and analyzed a unique data set of 239 black, white, and Mexican adults from a stratified, multistage probability sample of three Detroit, Michigan, neighborhoods. We drew venous blood, collected saliva, took anthropometric measurements, and assayed specimens to measure allostatic load (AL), an indicator of stress‐mediated biological dysregulation, linking participants’ AL scores and survey responses. In a series of nested Poisson models, we regressed AL on socioeconomic, psychosocial, neighborhood, and behavioral stressors to test the hypothesis that race/ethnicity and poverty‐to‐income ratio (PIR) are conceptually fluctuating variables whose impacts on AL are sensitive to structured lived experience.
Findings: White and Mexican Detroit participants with PIR < 1 have higher AL than counterparts nationally; black participants in Detroit and nationwide had comparable AL. Within Detroit, disparities by PIR were higher in whites than blacks, with no significant difference by PIR in Mexicans. The size of estimated effects of having PIR < 1 for whites is 58 percentage points greater than that of Mexicans and twice that of blacks.
Conclusions: Structurally rooted unobserved heterogeneity bias threatens the validity of independent main effects interpretations of associations between race/ethnicity, socioeconomic characteristics, or place and health. One‐size‐fits‐all analytic or policy models developed from the perspective of the dominant social group insufficiently address the experiences of diverse populations in specific settings and historical moments; nor do they recognize culturally mediated protective resources residents may have developed against material and psychosocial hardship.
Keywords: allostatic load, racial/ethnic population health equity, poverty, urban, weathering.
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