Copyright 2004, Gilbert C. Gee, PhD Neighborhoods and Health Disparities 2004 Summer Public Health Research Institute and Videoconference on Minority Health

Copyright 2004, Gilbert C. Gee, PhD

Neighborhoods and Health Disparities

2004 Summer Public Health Research Institute and Videoconference on Minority Health

Gilbert C. Gee, PhDUniversity of Michigan


U.S. Life Expectancy by Race, 1930-1999

0

10

20

30

40

50

60

70

80

90

Lif

e E

xpec

tan

cy f

rom

Bir

th (

year

s)

White

Black

White 61.4 64.2 69.1 70.6 71.7 74.4 76.1 77.3

Black 48.1 53.1 60.8 63.6 64.1 68.1 69.1 71.4

1930 1940 1950 1960 1970 1980 1990 1999


Per Capita Expenditures on Health Care, Top Five Countries, 1999

$2,313

$2,424

$2,425

$2,794

$4,358

$0 $1,000 $2,000 $3,000 $4,000 $5,000

Canada

German

Norway

Switzerland

U.S.A.


Health Care Expenditures, As Percent of Gross Domestic Product, 1999

9.5

9.6

10.6

10.4

13

0 2 4 6 8 10 12 14

Canada

France

Germany

Switzerland

U.S.A.

% GDP


Life Expectancy at Birth

Women

1. Japan 82.9

2. France 82.6

3. Switzerland 81.9

19. U.S. 78.9

Men

1. Japan 76.4

2. Sweden 76.2

3. Israel 75.3

20.Cuba 75.0

25. U.S. 72.5


• The greater disability burden to minorities is of grave concern to the public health, and it has very real consequences. Ethnic and racial minorities do not yet completely share in the hope afforded by remarkable scientific advances….

• David Satcher, M.D., Ph.D. (2001)


Health Disparities

• Racial disparities are a marker of the health of race relations.

• Explanations– Genetics/Biology (?)– Social Class– Culture– Discrimination– Geography


Political-Economic System

National & State Policies

Community and Occupations

Stratification

Social Networks

Health Behaviors

Genetics

HealthCare


Convergent perspectives

• “Ecological model”– Bronfenbrenner

• Proximal-Distal– Amick

• Fundamental / root causes– Link & Phalen

• Ecosocial theory– Krieger

• Multi-level perspective– Diez-Roux


Why look at neighborhoods as an explanation for health disparities?

1. Whites and ethnic minorities do not live in the same places.

2. Neighborhoods provide fundamental contexts that shape life experiences and exposures

• Environmental exposures may lead to illness• Neighborhoods set and reflect opportunity structures

3. Improving neighborhoods may be a way to eliminate health disparities.


Race varies by geography



Copyright 2004, Gilbert C. Gee, PhDSource: U.S. Census, 2000






Copyright 2004, Gilbert C. Gee, PhDSource: Earle, 2000

Copyright 2004, Gilbert C. Gee, PhDSource: Avakian, 2002




At a more local level of geography




• Real-Estate Boards

– “A Realtor should never be instrumental in introducing into a neighborhood … members of any race or nationality … whose presence will clearly be detrimental to property values in that neighborhood.”

• National Association of Real Estate Brokers, 1924.

• Ended, 1950


• Government

– “If a neighborhood is to retain stability, it is necessary that properties shall continue to be occupied by the same social and racial classes. A change in social or racial occupancy generally contributes to instability and a decline in values.”

• Federal Housing Administration, 1938

– Changes with Civil Rights• Equal Credit Opportunity Act• Fair Housing Act• Community Reinvestment Act• Home Mortgage Disclosure Act


What about today?

• HUD’s Housing and Discrimination Study, 2000

• Audit Methodology

• “Asian and Pacific Islander homebuyers experience consistent adverse treatment 20.4% of the time, with systematic discrimination occurring in housing availability, inspections, financing assistance, and agent encouragement. This level of discrimination is comparable to the level experienced by African American homebuyers…”

Source: The Urban Institute, 2003


Residential Patterns of Whites & African Americans, Detroit, MI, 1990

African AmericansWhites

D=89


Table 1. Metropolitan Segregation* 1980-2000

1980 1990 2000

Black with Whites 73.8 68.8 65.0

Hispanic with Whites 50.7 50.6 51.5

Asian with Whites 41.2 42.0 42.1

Census, 2000 * Index of dissimilarity


Why should public health people care?


http://137.187.213.155/




0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9

% Black

0.5

1

1.5

2

2.5

3

Lyn

chin

g R

ate

Standardized Lynching Rate for 7 Groups of Mississippi Counties by Percent Black -- JS Reed, 1972

Copyright 2004, Gilbert C. Gee, PhDSource: Polednak, 1997


Age-adjusted CVD Mortality, by Birthplace and Gender, NYC, 1988-1992

Fang, et al., 1996


Potential Mechanisms

• Environmental Justice

• Community stressors

• Concentration of poverty

• Clustering of resources


Environmental Justice


Copyright 2004, Gilbert C. Gee, PhDSource: Lopez, 2002

Copyright 2004, Gilbert C. Gee, PhDSource: Lopez, 2002

Copyright 2004, Gilbert C. Gee, PhDSource: Pastor, 2001


Community stress as an analogue of individual stress


Stress Process

McEwen, 1998


Examples

• Crowding

• Social disorganization

• Crime

• Fear


Source: Frankenhauser, et al., 1978


Source: Davison, et al., 1986


Source: Davison, et al., 1986

Copyright 2004, Gilbert C. Gee, PhDSource: Evans, et al., 2000


Street noise or traffic present among homeowners, by social status

0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

Total Black Below poverty

%

Street noise or traffic present among renters, by social status

0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

0.4

0.45

Total Black Below poverty%

Source: 1999 American Housing Survey



Neighborhood Vehicular Burden & Health

Vehicular burden

Lower Upper

Median Median

Health Status ** 68.1 72.1

Depression ** 0.22 0.20

Traffic stress 3.91 4.13

** P < 0.01


-1.56 -0.85 -0.14 0.58 1.29 2.00

TRAFFIC STRESS

65.0

65.8

66.6

67.4

68.2

69.0

69.8

70.6

71.4

72.2

73.0

General Health

LOW HIGH

Upper QuintileLower Quintile

Vehicular Burden

Figure 2. Interaction between Traffic Stress and Vehicular Burden on Health Status

Controlling for all covariates. Traffic stress is centered at its group mean. The lower quintile and upper quintile of vehicular burden refers to the bottom 25% and upper 25%, respectively, of car use density in census tracts. Traffic stress and health status are measured at the individual level. n=1,503

Source: Gee & Taekuchi, 2004


Concentration of economic deprivation


Ethnic Composition of High Poverty Neighborhoods, 1990 Census (Adapted from Jargowski, 1997)

White23%

Black49%

Other4%

Hispanic24%


White28%

Black12%

Asian12%

Hispanic48%

White52%

Black5%

Asian12%

Hispanic31%

High Job Growth Areas

Low Job Growth Areas

Ethnic composition of Low and High Job Growth Areas, Los Angeles, 1990(Adapted from Pastor, 2001)


Source: Federal Reserve, 2001 Survey of Consumer Finances

• Median family net worth, 2001

– Homeowners $171,700– Renters 4,800


Homeownerhip rates by Ethnicity of Householder, 2000 Census

0 10 20 30 40 50 60 70 80

Hispanic

Black

Two or more races

Asian and Pacific Islander

American Indian & Alaskan Native

White Non-Hispanic

%



Housing Appreciation between1967-1988, by Race and Housing

Value

0

10000

20000

30000

40000

50000

60000

Less expensivehomes

More expensivehomes

Th

ou

san

ds

$

White

Black

Source: Oliver & Shapiro, 1997

Copyright 2004, Gilbert C. Gee, PhDSource: Winkleby and Cubbin, 2002


• Alcohol & tobacco advertising (USDHHS, 1998)

• Pharmaceuticals (Morrison, 2000)

• Food stores (Morland, et al., 2001)


Clustering of resources & the potential of resistance


Segregation

Resource Depletion Resource Accumulation

EmploymentEducationNetworks

Municipal ServicesEnvironmental Toxins

EmploymentLanguage, Tutoring

Refuge from Overt RacismLegal Assistance

Foods

Negative Outcomes Positive Outcomes


• “I don’t consider myself a minority when I am there [Little Saigon, California]. When I am in other malls such as South Coast Plaza, I am constantly aware that I am ‘different’ because of my physical traits. It is a belonging need that other places cannot fulfill.”

Quoted in Munzamar, et al., 2000


• “The ethnic enclave is an attempt … to create social and cultural ecological conditions for ease in survival and adaptation.”

• Munzamar, et al., 2000


• Black political power (Laveist, 1993)

• Social capital (Sampson, 1997; Kawachi, et al., 1998)

Copyright 2004, Gilbert C. Gee, PhDhttp://sf.indymedia.org/news/2003/08/1635306.php


Race/Ethnicity

Residential Location

Community Stressors

NeighborhoodResources

EnvironmentalToxins

Community Stress

IndividualStress

Exposure

InternalDose

HealthEffect

EnvironmentalLevel Vulnerability

IndividualLevel Vulnerability

Gee & Payne-Sturges

Environmental Racial Disparities Framework

Residential segregation


A woman walks past a homeless person sleeping on the sidewalk on Mission Street in downtown San Francisco. New York Times

Copyright 2004, Gilbert C. Gee, PhDMonica Almeida/New York Times

Women sit in a coffee shop as a homeless man panhandles for money outside on Market Street in downtown San Francisco.

Copyright 2004, Gilbert C. Gee, PhDNew York Times


Demonstrators from labor organizations and anti-World Trade Organization groups march in downtown Seattle to protest the World Trade Organization talks on Tuesdsay. New York Times. 12/1/99


For further reading:

• Neighborhoods and Health. 2003. Eds: I Kawachi & L.F. Berkman. New York: Oxford University Press

• Building communities from the inside out. 1993. Kretzmann J.P. and McKnight J.L. Chicago: ACTA Publications


Documents

Copyright 2004, Gilbert C. Gee, PhD Neighborhoods and Health Disparities 2004 Summer Public Health Research Institute and Videoconference on Minority Health