Introduction
According to the 2010 U.S. Census, 80.7% of the population lives in urban areas. This large percentage is due, in part, to the inclusion of not only those who live within the city limits but also those who live in the increasingly dense “outer city,” the suburbs surrounding urban areas. Although the population and physical geography of a city can contract and expand over time, cities are all characterized by dense, heterogeneous populations. Cities are also places where residents have more social contact and reliance on one another yet where the differences between poverty and wealth can be in close proximity and contrast starkly with one another.
Neighborhoods play an important role in the individual experience as a city dweller. Wealthy urban neighborhoods give their inhabitants access to green spaces, physical safety, cultural opportunities, and a wide variety of food choices. Poorer neighborhoods, in contrast, often lack some or all of these favorable environmental factors. They tend to be located in areas that are less desirable geographically and often subject to higher levels of pollution, such as near or on the edges of large highways. They are also often isolated from easily accessible transportation, safe and affordable housing, and access to a variety of nonprocessed foods. Access to medical care is limited. Increasingly, these areas are inhabited by underrepresented minorities (URM). This is what is known as the “inner city.”
There is no discipline of study known as “inner-city health,” but “urban health” has become a well-recognized subdiscipline of public health. In 1998 the Journal of Urban Health was founded by the New York Academy of Medicine, which was a first attempt to join epidemiology with clinical medicine and health policy. In 2002 the International Society for Urban Health was founded to provide support to scholars engaged in research, interventions, and program evaluations of urban health issues. More recently, in recognition of the unique health challenges posed by the urban environment, as well as the worldwide population shift toward urban environments, the World Health Organization (WHO) introduced the Urban Health Initiative. This initiative aims to address the health of the nearly 3.5 billion urban denizens worldwide through improved urban planning and development. Specifically, the WHO has set sustainable development goals around numerous determinants of health in the urban environment, including: 1) air pollution, 2) noncommunicable diseases, 3) access to public transport, 4) sanitation and waste management, 5) inequality reduction, 6) access to safe public and green spaces, and 7) climate action and resilience. Although these development goals are designed to have the largest impact in developing nations (with key pilot projects ongoing now in Accra, Ghana and Katmandu, Nepal), most have also proven significant in U.S. populations. For example, air pollution, and particularly the high levels seen in urban environments, has been linked to hypertension, diabetes, and anemia in older U.S. populations. In terms of the health effects of inequality, the United States has recently been shown to have some of the largest income-based health disparities in the world. Urban health, it seems, knows no national boundaries.
An important focus of research in urban health has been to identify the multifaceted determinants of health and how they affect the poorest city dwellers. Depending on the determinant that is assessed, population density can be an attribute or a risk. This chapter delineates how health risks specific to cities affect those who are most vulnerable, describes measures created to address the underlying conditions that bring about illness, and discusses how to sustain those measures in the neighborhoods with the greatest needs.
History
Ring around the rosie A pocketful of posies Ashes, ashes We all fall down.
The origins of this children’s rhyme, first sung in the mid-14th century, reflect the horror of Bubonic Plague, which was responsible for killing as many as one-third of the population of Europe. Many centuries later, the Black Plague was found to be caused by Yersinia pestis, which is transmitted by the fleas harbored on household rats. Rats travel from home to home more easily in densely populated areas. Although there were no “cities” as such in Europe until centuries later, peasants lived clustered around feudal manors, and thus plague disproportionately affected these individuals. Not only did peasants live in closer proximity to one another, but there was also no place that they could go when their community became infected. Lords, on the other hand, could often escape into more rural areas, thus protecting themselves and their families from contagion.
The social aspects of this pandemic were as terrible as the disease itself. Plague became seen as a curse from God. Religious cults emerged, and bizarre rituals developed whereby people would march through the streets flagellating themselves in an effort to purge their sins. More importantly, Jews became the scapegoat for the disease. Individual Jews were tortured into confessing that they had contaminated wells and other public facilities. Eventually, this led to the mass burning of Jewish communities, often with their residents trapped inside. The use of scapegoats to vent frustration at the inability to stem devastating illness has been seen at other points in history as well, such as the targeting of all African immigrants for the recent Ebola outbreak in the United States. Scapegoats are an especially appealing, and appalling, explanations for mass illness in cities, where tainting shared resources such as the water supply, transportation, and food exchange become easy explanations when no other is apparent.
The disproportionate effects of contagious infections on the urban poor, especially members of racial or ethnic minorities, have been seen in the United States as well. The yellow fever outbreaks that occurred mostly in the mosquito-infested areas of southern cities such as Memphis, Savannah, and New Orleans throughout the 19th and early 20th centuries are one example. Yellow fever is caused by a virus spread by the Aedes aegypti mosquito. It can be highly contagious, leading to death in up to 50% of those with severe disease. As with the plague, wealthier individuals fled the infected cities during the outbreaks. Those who were most vulnerable were recent immigrants. During the outbreak in New Orleans in 1858, public health measures were used only after wealthy citizens became infected.
The first recorded U.S. outbreak of yellow fever occurred in Philadelphia in 1793. People became infected and died at such a rate that most of those able to care for the sick and dying, from health care workers to grave diggers, refused to do so for fear of infection. Through an ironic series of events, African Americans became both the heroes and the victims of this outbreak.
The African American community under the leadership of Richard Allen, founder of the African Methodist Episcopal Church, volunteered to care for the ill. Although this response was rooted purely in moral principles, a myth arose that African Americans carried immunity to the disease, which unfortunately was not the case. African Americans did die at a slower rate than whites, which was surprising given the level of their exposure, giving rise to a credible hypothesis that genotypic immunity existed among some African Americans. Nonetheless, after the epidemic subsided, a racial backlash ensued, and African Americans were blamed for financially profiting from their role. ,
There are many examples that demonstrate that the poorest urban dwellers are the most affected by illness. Infectious disease outbreaks show that when large numbers of people are affected, the economic, cultural, ethnic, and racial factors predict that those with the fewest resources will shoulder the greatest burdens. Therefore treating these communities during crises such as epidemics requires a holistic approach; social well-being and safety must be addressed, along with medical treatment.
The growth of the urban environment and the inner city
Inner-city medical practice has become more important as the populations of both the United States and the world have become increasingly urbanized. In the 1950s, 30% of the world’s population lived in cities. The WHO estimates that as of 2014, 54% of the world’s population lived in urban areas and projects that this will increase to 66% by 2050 ( Fig. 51.1 ).
Interestingly, recent demographic changes in cities have made the principles and eccentricities of inner-city health care germane not only to the inner city proper but also to more peripheral communities. Although traditionally the “inner city” referred to the historic center of a city, the increase in urban migration witnessed in the past half-century, coupled with the gentrification of many historic urban neighborhoods in large cities such as New York, has created the phenomenon of the “outer-inner city.” This term refers to devalued suburban areas that appropriate many of the traditional demographic, socioeconomic, and environmental qualities of the traditional inner-city environment.
Why inner-city health care is unique
Health care in the contemporary inner-city environment (including the outer-inner city) has been influenced greatly by these long-term, large-scale demographic changes. Those who live in inner-city environments tend to be of lower socioeconomic status, have less access to health care, have less education, and be more racially diverse than those who live in other urban environments. Additionally, the physical environments of the inner city tend to offer a dearth of infrastructure resources that would serve to support health while simultaneously increasing detrimental environmental exposures. For example, more than 25% of myocardial infarctions, cerebrovascular accidents, chronic respiratory diseases, and pulmonary cancers worldwide are linked to urban air pollution. Additionally, obesity, lack of environments conducive to physical activity, and poor access to nutritious foods is associated with an increased risk of type 2 diabetes mellitus in urban populations.
Diversity in the inner city
The population of inner cities today is far more diverse than it was during the late 1960s when the term “inner city” began to be widely used. New waves of immigration from every corner of the globe have brought millions of new residents to the nation’s ports of entry, and many of these immigrants have settled in the inner cities. The ethnic composition of these enclaves varies widely across America. They include large refugee populations from Southeast Asia, East Africa, and Central Europe, as well as Hispanic populations. The immigrant population of the United States has more than tripled since 1970. In 2010, 23% of the U.S. population was foreign born or first-generation American, with the majority living in cities and their centers, up from 20% just 10 years earlier. This increase in diversity has created both challenges and opportunities for America’s cities and health care providers. In addition to the barriers to health care that grow from economic disadvantage, there are also barriers that grow from differences in language and culture.
In 2002 the Institute of Medicine (IOM) published a groundbreaking report titled Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare. This report documents racial and ethnic health care disparities described by more than 100 studies and offers recommendations. Disparities have been verified in health status, health care screening, testing, and treatment for many diseases and conditions. People of color generally have less favorable outcomes than whites. Some examples of health disparities include:
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African Americans die of asthma at rates three times higher than white Americans.
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Asian Americans have hepatitis B at twice the rate of white Americans.
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Both African Americans and American Indians are roughly twice as likely as white Americans to have diabetes.
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Puerto Ricans have asthma at twice the rate of white Americans.
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African American, Hispanic and Latino, and Asian patients with the same condition are less likely to be referred for or receive kidney transplantation than whites.
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African Americans and Hispanics and Latinos with the same conditions as whites are less likely to receive advanced cardiac procedures, such as angioplasty.
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African American patients with diabetes are less likely than whites to have the appropriate glycosylated hemoglobin test, ophthalmologic visits, and influenza immunizations.
In 2012 the IOM published a follow-up report titled How Far Have We Come in Reducing Health Disparities? Progress Since 2000: Workshop Summary. The report notes that, “although some progress has been made . . . no significant change in disparities [has] occurred for at least 70% of the leading health indicator objectives.” Although low socioeconomic status and decreased access to health care both have direct potential effects on health, the importance of the impact of racial and ethnic diversity on health cannot be overstated. Any examination of health and health behavior outcomes necessitates examination of sociocultural and environmental determinants of the outcome in the population. This theoretical approach, termed the “ecological model,” is a contextual understanding of health and health behavior outcomes. Approaching problems from this orientation provides potential points of intervention that can be explored when a change in health outcomes is desired. Furthermore, when different populations are found to have unequal health outcomes, the ecological model is a sociobehavioral, rather than a purely biological, understanding of illness. Put more simply, the ecological environments in which “races” find themselves is what actually determines the difference in health outcome, not genetics.
What then is responsible for the poorer health outcomes observed in multiple epidemiologic studies for people of color? One likely factor is institutional racism. Institutional racism describes societal patterns or institutional behaviors that effectively impose negative conditions against identifiable groups on the basis of race or ethnicity. These negative conditions deleteriously affect the access to and quality of goods, services, and opportunities available to minorities. In fact, the state of being a minority in a population appears to itself convey some adverse health effects. Hue et al. (2008) investigated whether being a minority itself was related to health behaviors known to cause chronic disease. They found that Asian Indians on a Caribbean island were significantly less physically active then the natives on the island. This was remarkable because data showed that Asian Indians in India were generally more active than the island natives. In this sense, race was important as a determinant of minority status only. As the demographics of the inner city continue to change, this finding is an important consideration.
A 32-year-old African American mother presents to the community health clinic with concerns about her youngest child wheezing for the past month. At night, she reports that she can often hear him coughing. Last night, it became so difficult for him to breathe that she called 911 because she doesn’t have a car, and the subway was not running in the middle of the night. Her son spent the night in the county hospital emergency department receiving multiple nebulizer treatments, and her two other children slept at a neighbor’s house. The emergency department physician assistant (PA) referred her for an urgent follow-up appointment. She reports that she is a single mother of three children. She and her children live in an “old factory” that was converted into studio apartments down in the center of town. She says she “hates” her apartment because it’s always cold, nothing ever gets fixed, the water tastes terrible, and the paint is peeling off the walls. She reports a family history of asthma in both of the patient’s siblings. She inquires, “Why do all of my children have asthma?”
Inner-city environments also tend to differ in the environmental exposures to which their denizens are exposed. The location of the inner city, whether at the historical center of a city or on the outskirts, often places living quarters in close proximity to traffic and industry and their attendant noise and pollution or, in the years since the decline of manufacturing, near the waste that those industries produced. These exposures have been associated with increased risks of malignancy, asthma, infectious disease, and cardiovascular disease.
Children are at increased risk from environmental toxicants for both biological and behavioral reasons. Children undergo rapid periods of growth and development, and a toxic exposure during one of these phases can have much more dire physiologic consequences than a similar exposure in fully developed individuals. Additionally, a childhood exposure to a persistent chemical or to a mutagenic chemical has more time to cause its deleterious effects because of the longer remaining life of a child compared with an adult.
Behaviorally, children tend to expose themselves to more environmental toxins than adults. This is because children tend to play outside in the dirt, often without protective clothing, and with not only integumentary but also alimentary exposure because of hand-mouth behaviors. Taken together, these behaviors increase their exposure to air pollution, pesticides, lead, and other environmental toxins in the household. Lead hazards recently came to the fore of national attention when the water in Flint, Michigan was found to have levels well above those deemed safe by the Environmental Protection Agency after the city switched to a less expensive water source. Interestingly, although the blood lead levels did increase in the year after the switch (from 1.19 micrograms per deciliter to 1.30 micrograms per deciliter), the blood lead levels in children < 5 years old living in Flint have been elevated for quite some time, with the highest levels in the last 10 years actually occurring in 2006 (2.33 micrograms per deciliter), at least 8 years before the change in water source. This demonstrates that although the Flint Water Crisis did indeed acutely increase childhood exposures to lead, the problem in this city (and many others across the nation) is a chronic one, with multiple contributing factors. When reading through Case 51.1 , in addition to asthma treatment, what preventive health measures might be indicated for this patient?
A 43-year-old factory worker who emigrated from Central America with his family 6 years ago presents for evaluation of “peeing all night long.” He states, through an interpreter, that for the past 3 months, he has been urinating four to five times per night. The voids are all large volume. Additionally, he reports that his clothes have been feeling “loose” recently. He and his mother, wife, and four children share a one-bedroom apartment. He states that he works 14 hours per day, so he is really not able to exercise at all. He used to play soccer back home, but he states the parks in his neighborhood aren’t safe, so he stopped when he moved to the United States. When you query him about his diet, he states that his apartment has no kitchen, only a “hot plate,” so he gets breakfast and lunch from the vending machine at work. On examination, you note a moderately obese Hispanic male in no acute discomfort. Urinalysis reveals 3+ glucose.
The inner city lacks many of the environmental characteristics that are supportive to a healthy lifestyle. Physical activity is negatively impacted by the lack of green space, built environments that are not conducive to outdoor exercise, and lack of public safety infrastructure. Because physical activity is an integral part of a healthy lifestyle, these deficits in the build environment directly and indirectly affect the incidence and prevalence of myriad chronic diseases, including hypertension, diabetes, cardiovascular disease, and cancer.
The build environment of the inner city impacts not only physical activity but also access to food. The WHO defines food security as “when all people at all times have access to sufficient, safe, nutritious food to maintain a healthy and active life.” Access is further specified as referring to both physical and economic access, and a “healthy and active life” is defined as one inclusive of both the nutritional needs of the population and the dietary preferences. The three pillars of food security identified by the WHO are: food availability, food access, and food use.
According to the U.S. Department of Agriculture (USDA), 14% of U.S. households in 2014 were food insecure, with 5.6% of these households having one or more members who decreased food consumption because of scarcity. African Americans, households headed by a single woman with children, and those with high income-to-poverty ratios were the most likely to be insecure ( Fig. 51.2 ). Geographically, the American South is disproportionately affected by food insecurity ( Fig. 51.3 ).
