In a recent article in Health Affairs (and also on page 8-9 of this issue“) David Erickson and Nancy Andrews suggest that a closer collaboration with the health care sector might improve the health of low-income, disadvantaged populations. While noting that much of the traditional work of community development acts “upstream” to improve health, they argue that more direct work with parts of the health care system like the federally qualified health centers and the mainstream medical community would help even more. These suggestions are likely to make sense to many people, but much research suggests that they are in fact the wrong direction.
Health vs. Disease
Mental health professionals have long recognized that illogical language can stymie right action. In the domain of medicine, one of the most common linguistic traps is the substitution of “health” for “disease.” Health is defined by Merriam-Webster as “the condition of being sound in body, mind, or spirit; especially: freedom from physical disease or pain.” Disease is defined by The Free Dictionary as “a pathological condition of a part, organ, or system of an organism resulting from various causes, such as infection, genetic defect, or environmental stress, and characterized by an identifiable group of signs or symptoms.”
The World Health Organization has weighed in on this conversation, defining health as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity” (emphasis added). Most public health leaders agree that the production of “a state of complete physical, mental, and social well-being” is a massive societal task that involves every sector, over the entire life of every individual.
Into this complex linguistic problem, we introduce the term “health care system.” I find this to be a gross misnomer, both because no one system could produce health and because the “health care system” is focused almost entirely on the management of disease. I think we need to rename the “health care system” as the “disease-management system” to be clear what services it performs.
This confounding of health and disease complicates all conversations, including that launched by Erickson and Andrews. The expansion and improvement of the disease-management system in poor neighborhoods would in fact ease the distress of those who are ill. However, improving the system of disease management is not enough to stem the tide of disease.
Fundamental Causes of Disease
Epidemiologists Bruce Link and Jo Phelan have proposed that social conditions are fundamental causes of disease. They are fundamental because they will manifest themselves even in the face of improvements in more proximal causes of disease. Consider: recent advances in nutrition have deepened our appreciation of the need to eat fresh fruits and vegetables. It would seem that such knowledge might improve the health of the whole U.S. population. But instead, the well-to-do have been able to modify their diets quickly and tastefully, while the poor have not. Poor populations lack access to these products, as well as to the money it takes to incorporate them fully into the diet. Even those who can get access to fruits and vegetables don’t have access to the highest quality produce, as those are shipped to wealthy neighborhoods.
Because the fundamental cause of disease is socioeconomic status, the pattern of the well-to-do having better health than the poor will re-emerge over and over, despite advances in our understanding of specific risk behaviors people have and health promotion practices that they might adopt. In fact, the gap between the rich and the poor can actually grow as a result of focus on intermediary behaviors, because those with resources are able to incorporate improvements while those without resources are not. Thus, the gap in health between those at the top and those at the bottom worsens. As health is directly linked to many other positive outcomes, this also creates a feedback loop in which the resource-rich with better health are in an improved competitive position with regard to the resource-poor, creating an ever-widening gap between the groups. This ultimately affects every aspect of life.
Link and Phelan conclude that we must tackle the actual inequalities, and they have focused their research in that direction through the creation of the Center for the Study of Social Inequalities and Health at the Columbia University Mailman School of Public Health.
Neighborhoods and Access to Resources
One of the central resource-distribution systems in the United States is the system of neighborhoods. Neighborhoods have been “sorted” by race, class, sexual orientation, age, religion, lifestyle, and numerous other factors. These separate neighborhoods are inherently unequal in their ability to garner resources. Living in a neighborhood determines one’s level of access to many resources and of exposure to many risks. Wealthy neighborhoods have better schools, better fire service, better garbage collection, better hospitals, better housing, better food shopping choices, cleaner air and water, and more diverse services. Some of the U.S. population is slated to have more disease than others as a result of this system of neighborhood allocation.
For examples of how our society makes resources flow to or away from certain neighborhoods, let us examine two federal policies, redlining and urban renewal. In 1937, the Home Owners Loan Corporation, an agency of the U.S. government, mapped 200 cities and coded their neighborhoods for age of buildings and presence of nonwhite residents. This data was used to create a four-part rating system, which was then available to banks for making lending decisions. This “redlining” system, which restricted credit and insurance in older, less white neighborhoods, codified resource-allocation patterns inherent in segregation: that minorities would have less of any given resource and a poorer quality of whatever of that resource they received. These deficits accumulated over time, showing up in the continuing massive differences in wealth between white and nonwhite groups. They also show up in the increasing loss of social mobility that has been observed in U.S. society.
The urban renewal program shows that neighborhoods play a second, and more complicated, role in health. Carried out between 1949 and 1973, this federal program authorized cities to seize land using the power of eminent domain, clear it, and sell it at a reduced price to developers who had a “higher purpose” for it. Massive sections of urban habitat were cleared as part of this program, and area residents were dispersed. In the course of the dispersals there were massive economic, social, political, and cultural losses suffered by the dispossessed. These losses left them poorer than they had been and at a greater disadvantage compared to the people with stability. In fact, dispossession is an economic catastrophe, one that has been visited and revisited on communities of color many times in the past 50 years.
As a 2006 report by UN-Habitat describes:
“Community leaders, civil society groups, national and international NGOs and academic researchers alike have repeatedly warned that the impacts of forced evictions on the people affected are severe, debilitating and far-reaching. As a result of evictions people’s property is damaged or destroyed; their productive assets are lost or rendered useless; their social networks are broken up; their livelihood strategies are compromised; their access to essential facilities and services is lost; and as violence often is used to force them to comply, they suffer severe and lasting psychological effects as a consequence thereof. Indeed, the prospect of being forcibly evicted can be so terrifying that it is not uncommon for people to risk their lives in an attempt to resist; or, even more extreme, to take their own lives when it becomes apparent that the eviction cannot be prevented.”
The disparity in the rates of disease among the well-to-do and the poor has widened as these two aspects of neighborhood resource allocation—unequal access and instability—have overlapped for communities of color.
I propose that sorted-out neighborhoods are a fundamental cause of disease, in the sense proposed by Link and Phelan; that is, the neighborhood sorting determines access to life-giving resources. The programs proposed by Erickson and Andrews—creating affordable housing, economic development, access to fresh food, and transit-oriented development—are not initiatives that address the fundamental problem of sorting out the city.
Federal Programs and Sorting Out
Current programs directed at neighborhoods have rarely considered the problem of sorting, and can actually aggravate that problem. HUD’s Moving to Opportunity program (see page 31) is perhaps the most egregious, because its very name embodies, in an unfortunately upbeat fashion, the whole history of sorting. MTO acknowledges the impoverishment of some neighborhoods and the wealth of others and helps people move from the former to the latter. This aggravates the underlying problem of sorting by stigmatizing the poor neighborhoods, where opportunity is not, and by sending able volunteers out of the troubled area, where they are needed, to the “better” area, where they can find opportunity.
The federal HOPE VI program, which has been replacing “distressed” public housing with mixed-income developments, is also highly problematic. HOPE VI projects have demolished public housing, dispersed the residents, instituted various rules for return that typically preclude most of the former residents from coming home, and then lost contact with the residents while building the new housing anyway. As a result, the rate of return is very low across the nation. HOPE VI, whatever its rhetoric of inclusion, has, in fact, acted like a 1990s-2000s form of urban renewal, clearing the homes of the poor to replace them with people of a different socioeconomic status and perhaps race.
Once we understand the nature of the sorted-out city, our ability to understand and critique such programs is enhanced. That does not necessarily mean that the answers will be easy to come by or obvious.
Addressing the Sorted-Out City
The repair of the sorted-out city lies in the re-knitting of spaces that have been partitioned by institutionalized policies and regulations that continue to promote exclusionary land use decisions. Such changes do not lie at the level of neighborhoods, but rather have to do with the ways in which cities and regions are organized.
In 1954, the landmark legal case Brown vs. Topeka Board of Education was decided by the U.S. Supreme Court, and it ruled that racially separate schools were inherently unequal. The same logic applies to neighborhoods. How is this to be rectified?
The Rev. James Forbes, who served as the senior minister of Riverside Church in New York City for many years, used the story of the Prodigal Son to outline a community response to the AIDS disaster. “There are three parts to the story,” he noted. “Separation, restoration, and celebration. What makes it possible for the son to go home? What ends the separation? An image. The son is eating in the pigpen and he remembers the table at his father’s house. ‘Even the servants in my father’s house ate better than I am eating.’ This image of a better life inspires him to reconnect with his father, who celebrates his return.”
This archetypal story of repair has important lessons for what the community development field and its allies might do in the face of current circumstances. The first step, in my view, is to acknowledge the toll that sorting has taken on the city. In tours of many cities, I have found that citizens, with minimal instruction, can assess their cities along any given set of criteria. Certainly, the obvious distinctions between the haves and have-nots are easy to see, as are the borders between the two areas, which are sometimes as obvious as railroad tracks. At the same time, people are interested in plotting their common future. Community design meetings are a standard part of good community development practice and they can easily be used to discuss the ways in which separation injures the common life.
Having acknowledged separation, people can begin to think about the second task, restoration. Even simple interventions that humanize the borders begin to transform the sorted-out city into the shared city. A group of artists in Orange, N.J., made a series of installations along the railroad that divides the city, which softened that edge and invited people to travel under the tracks to see a fragile, hidden neighborhood. This has been life-giving to the area, encouraging investment and visits.
At the same time, stopping the wheel of sorting is a crucial part of changing the city. HANDS, the local community development corporation in Orange, has thought long and hard about the seemingly inevitable consequence of reanimating that neighborhood: the current poor residents will be pushed out by people with more income. To address this, HANDS has committed to making its new buildings permanently affordable, protecting and expanding the industrial section of the neighborhood, which offers unskilled employment, and creating a neighborhood center that bridges the social gap between newcomers and established residents.
As the restoration goes forward, there are great moments in which to celebrate. HANDS recently celebrated its 25th anniversary with a party, tours of its work, and a symposium. All of these festivities served to remind people of the mission, acknowledge the accomplishments, reward the hard work, and lift the morale and spirits of all involved. Celebrations are a time to learn, grow, rejoice, reinvigorate, and recommit.
Rev. Forbes pointed out that the Prodigal son’s older brother is an important person in the story. He stands for all of those who support the status quo and oppose change. The father did not let that child’s petulance stop him from welcoming his lost son home. We can anticipate massive resistance to restoring wholeness in our cities, but we should not let it stop us. By eliminating this fundamental cause of disease, we open the door to a healthier future for all.