By Josh Sanburn
April 11, 2016

Health problems in Flint, Mich. are deeper than the ongoing water crisis. In Genesee County, the life expectancy for low-income residents is one of the lowest in the country and appears to be a direct consequence of years of economic decline and a lack of proper public health services.

A new study, published Monday in the Journal of the American Medical Association, found that the life expectancy for a 40-year-old resident in a household with an income below $28,000 in Genesee County was 76.8 years, below the national life expectancy of 78.8. The number makes sense — Flint’s poverty rate is 21.5%, above the national average of 14.5%.

Flint, which has been dealing with the fallout from its lead-poisoned water supply after the city switched its water source from Detroit to the Flint River in 2014 to save money, has been struggling financially for years. While it’s well-known that income and life expectancy are related, the JAMA study found that where you live can also affect how long you live, especially for low-income households.

Read more: Flint’s Water Crisis Explained in 3 GIFs

According to the study, poor Americans in cities like New York, Miami and Santa Barbara, Calif., for example, live several years longer than low-income individuals near cities like Gary, Indiana, Las Vegas, and Oklahoma City. The study raises questions about the effects local public health services have for the lowest-income Americans in places like Flint, which has struggled to provide adequate health services as businesses have left, the population has declined, and the tax base has dried up.

“Genesee County has poverty, but it also has had the deterioration of its infrastructures and institutional services because of what’s happened economically,” says Dr. Aron Sousa, interim dean at Michigan State University’s College of Human Medicine.

The study also finds correlations between obesity and life expectancy for poor households. Flint has struggled for years with food deserts that make it difficult for residents to get fresh groceries. Similarly, there’s a correlation between smoking rates and how long Americans live. A third of Flint residents regularly smoke, and Sousa says the lack of health services has likely contributed to the high rates.

Read more: Michigan Governor Defends Handling of Flint Water Crisis

“A county might be able to provide services to get residents to quit smoking, but in a cash-strapped community that can’t afford it, poor people don’t have the same opportunity,” Sousa says. “That’s why geography is important to your overall health.”

Overall, the JAMA study showed that Americans’ life expectancies gradually increased as their incomes rose. American males in the top 1% live 15 years longer than those in the bottom 1%, no matter their location. There are likely a number of factors at play, including the ability for wealthier Americans to provide for themselves the kind of health care they need without relying on local governments or community services that may not have the funding to make much of a difference.

Contact us at editors@time.com.

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