Martine Hackett, PhD, MPH, Assistant Professor of Health Professions, Hofstra University
in the Spring 2015 edition of Hofstra Horizons
During the late summer of 2014, news from Ferguson, MO, dominated the headlines:
“Ferguson Unrest Shows Poverty Growing Fastest in Suburbs”
— Bloomberg News
“Politics Counts: Ferguson, Mo., Among Shifting Suburbs”
— The Wall Street Journal
“Hit by poverty, Ferguson reflects the new suburbs”
— CBS News
“The death of America’s suburban dream“
— The Guardian
The tragic events in Ferguson identified a new reality: the problems of the city are the problems of the suburbs. These “shifting” suburbs are now home to a more diverse population in terms of age, ethnicity, household size, and poverty status. By 2008 the number of poor people living in suburbs exceeded the number of poor people in primary cities by 1.5 million (Kneebone & Berube, 2013). This reality lies in stark contrast to the historic portrayal of suburban areas as wealthy and healthy enclaves, far removed from urban problems.
The contemporary field of public health originated from the consequences of urbanization during the 19th century and focused on controlling the spread of communicable diseases, cleaning up toxic environments and managing poor urban residents. Today, public health problems are still seen as urban problems: think HIV rates in marginalized populations, food deserts that contribute to obesity, and the legislative efforts of former Mayor Bloomberg in New York City. Overall, higher income suburbs do have better health outcomes. The national County Health Rankings report in 2014 ranked suburban Nassau County on Long Island sixth for health outcomes for all counties in New York state. The Bronx was last, with the worst health outcomes in New York state. Those who work in public health view the problems of suburban populations as less significant than those in urban areas in their breadth, depth, and urgency.
However, public health problems do not stop at the city line. The same changing realities of race, class, and power in the suburbs that sparked protests last summer in the Midwest also influence the health of the people who live here on Long Island.
Hidden Health Problems in the Suburbs
Suburban health is strongly influenced by geography. In a 2013 Nassau County Department of Health Community Needs Assessment, health outcomes were examined by ZIP code: 12 ZIP codes where the majority of non-Hispanic black and Hispanic populations live in Nassau County were combined and compared to all the other ZIP codes that are majority white.
Comparing the differences between these two sets of ZIP codes demonstrates wide disparities and inequality. The hospitalization rate for asthma and Type 2 diabetes is two and a half times higher for select communities compared to the rest of the county; the case rates of syphilis and chlamydia are five times higher; and the teen pregnancy rate is 47 per 1,000 in select communities compared to less than 10 in the rest of Nassau County.
Zooming more closely into Nassau County we see large disparities in health outcomes —communities of color invariably fare much worse than communities that are majority white. Consider the differences between two adjacent communities: Uniondale’s infant mortality rate is 11.5 per 1,000 births and East Meadow has just 0.9 per 1,000 births; childhood asthma discharge rates are higher in Uniondale than in East Meadow; and the teen pregnancy rate in Uniondale is six times higher than in neighboring East Meadow (NYS Department of Health, 2011). Overall in Nassau County, black and Hispanic residents are twice as likely as white residents to die prematurely.
Certain health outcomes are worse for blacks in Nassau County than in New York City. For example, the infant mortality rate among blacks in Nassau is one and a half times higher than for blacks in New York City.
This is also true for some rates of cancer and coronary disease. How do we explain these stark health differences that belie the image of what the suburbs are supposed to be?
Compared to other countries, the United States spends more on health care than any other nation, yet we are among the least healthy among peer countries by most measures of health. One of the key contributors to this discrepancy is the inequitable distribution of health outcomes across populations. Those who are poor, less educated, and minorities in the United States generally have a higher burden of illness, premature death, and disability compared to those who are more advantaged. Even when there is financial and geographic access to care, studies have documented that minorities often receive a lower quality of care for the same conditions. In addition, the very same factors that public health research has identified as affecting health – community design, housing, employment, environmental pollutants, and access to healthy foods – are worse in lower-income communities across the country.
In order to understand the reasons suburban areas like Nassau County have such stark differences among neighborhoods, there is an important concept that needs to be understood: the relationship between place and health. Researchers have identified that the environment in which people live plays a significant role in their health and well-being. Access to health care (Kirby and Kaneda, 2005), exposure to environmental hazards (Brown, 1994; Pais et al., 2014), higher rates of diabetes (Gaskin et al., 2013) and stroke (Brown et al., 2007; Balamurugan et al., 2013), and even shorter life expectancy (Geronimus et al., 1996; Davids et al., 2014) can be predicted, in part, by where people live. These neighborhood effects can profoundly influence the trajectory of health over a lifetime (Menec et al., 2010). Unequal distribution of physical activity resources in high-minority communities is associated with higher BMI (Carroll-Scott et al., 2013). Lower income neighborhoods also have fewer healthy food choices for children (Galvez et al., 2009; Larson et al., 2009; Norman et al., 2010). Neighborhoods with unsafe surroundings increase the likelihood of children being obese or overweight (Singh et al., 2010).
The growing significance of the association between where we live and our health outcomes can be summarized by a phrase promoted by the Robert Wood Johnson Foundation: “Your ZIP Code May Be More Important to Your Health Than Your Genetic Code.”
ZIP codes matter in a suburb like Nassau County, which is one of the most racially segregated areas in the United States (Logan & Stults, 2011). Logan and Stults used an index that measures the integration of the 50 largest minority communities on a scale from 0 to 100, with any number 60 or higher considered very segregated. The study found that the segregation between whites and blacks on Long Island is 74.1, according to tract estimates from 2005 to 2009 from the Census Bureau American Community Survey. That number is up from 73.6 in 2000. Well over a century of racial segregation in Nassau County through land-use planning, restrictive housing covenants, and red lining and block busting by the real estate industry has inscribed residential segregation into the county’s culture. Today those who are black non-Hispanic live in just a few ZIP codes, concentrated in spaces that are separate from whites. This rigid segregation locks African American and Hispanic children into low-performing school districts: more than half of African American and Hispanic children are concentrated in just 13 of Long Island’s 124 school districts, and nine of the 10 Long Island school districts with poverty levels greater than 40 percent (measured by the number of students eligible for free or reduced-price lunches) have 60 percent or more students who are African American or Hispanic (Hartigan, 2002).
What does this have to do with health? Residential segregation is considered a “fundamental cause” of racial health disparities (Williams & Collins, 2001). In part this is due to fewer resources for healthy lifestyles, but minority neighborhoods also often have fewer businesses, fewer services, higher unemployment, worse performing schools, and inadequate transportation, and are more isolated than white neighborhoods. Segregated black neighborhoods have been found to have two to three times as many fast food outlets and up to three times fewer supermarkets, and are three times as likely to lack recreational facilities as comparable white neighborhoods (Landrine & Corral, 2009). Conditions linked to segregation can constrain the practice of health behaviors and encourage unhealthy ones.
Place does matter – the deliberate spatial concentration of poverty and race has led to persistent problems in Nassau County. So what do we do about it? To begin, we must acknowledge and explain the relationship between place and the geographical distribution of health disparities.
Telling Stories, Connecting the Dots
This story of the hidden health disparities in the suburbs and the complex causes has intrigued me since I moved to Long Island from New York City four years ago. As a public health professional and a sociologist, I was trained to observe my surroundings and how structural systems within society influence communities. Looking at the suburbs through a sociological and public health lens, I realized that I was seeing the consequences of residential segregation show up in the poor health outcomes of residents in communities of color on Long Island. However, as a researcher, I was stuck on where to start. There was so much to know, so many unanswered questions and such a great need to do something. I began with the National Center for Suburban Studies at Hofstra University, so that I could better understand the background and context of the suburbs.
Let’s Move Roosevelt!
Since 2012, the National Center for Suburban Studies at Hofstra University and NuHealth (Nassau County’s public health system), in collaboration with the Roosevelt Union Free School District, established a community-based model to address the issue of pediatric obesity. After registering with the national Let’s Move! initiative that first lady Michelle Obama established, we partnered to sponsor health fairs and create healthy eating and physical activity events open to the community, and we collaborated on school wellness policy changes and educated students in the classroom. In addition, we collected data to assess the scope of the problem of childhood obesity. We measured height and weight and calculated the Body Mass Index (BMI) of Roosevelt Middle School students. The BMI data in 2013 showed that 57 percent of sixth grade students were overweight or obese, with prevalence of 26 percent and 31 percent, respectively, as compared to national prevalence of 17 percent and 15 percent, and NYC prevalence of 21 percent and 22 percent in this age group.
Through surveys, we found that desire to lose weight and poor diet and exercise behaviors were more prevalent in the obese and overweight groups than the normal weight groups and were statistically significant. Many students are taking unhealthy steps to try to lose weight (i.e., fasting and skipping breakfast). Most students watch more television than recommended and do not participate in team sports. We have used these data to target changes within the school and larger community and have established a trusting and productive working relationship throughout.
My next step was to make a decision to start this research on the ground floor by understanding the lived experiences of the health consequences of residential segregation. Photos, maps and people’s individual stories are a particularly effective tool that can be used to create understanding, communicate the issues to other people in suburban communities, and make us feel that we are all in this together. I want us to use research as a tool for social change, and I want the change to be long lasting. Here is a description of some of the approaches I have taken and what we have found:
The first research I conducted was Photovoice projects with youth in communities of color in Nassau County. Photovoice is a participatory research method in which community members take photographs to record and reflect on their community’s strengths and concerns, promote critical dialogue and knowledge about important issues through group discussion of photographs, and reach policy makers (Wang and Burris, 1997). Over the last three summers, I have worked with youth in Roosevelt, New Cassel and Uniondale to visually explore where they live and how their environment may affect their health.
In Roosevelt, the Photovoice project identified through photographs the link between built environment and nutrition, and physical activity and childhood obesity, and ultimately reached policy makers with its assessments. One of the factors that contributed to the success of the project was involving the local youth in actively collecting and analyzing data about their community. Additionally, engaging the youth in conversations in which they critically assessed the built environment in Roosevelt and visually identified elements in the environment that benefited their health and those that were barriers to improved nutrition and physical activity was a powerful way for them to understand why suburban communities of color have much higher rates of childhood obesity than nearby white communities.
There were also unexpected findings that resulted from the Photovoice project in Roosevelt. One photo from the Photovoice project identified a known hazardous waste site – a former industrial laundry where a student’s mother used to work – as a community health concern. This photograph and the corresponding comments led to further investigation about the status of the site (originally thought to be a brownfield, but later identified as a Superfund site that was contaminating air and groundwater) by community-based organizations involved in the Photovoice project, as well as a graduate student in public health who worked on the project and grew up in Roosevelt. Based on the Photovoice project’s findings over the following year, we conducted focus groups (in partnership with Choice for All, a community-based organization) with community members. Also, community presentations were held with county and state environmental officials, the owner of the contaminated property, and regional environmental justice organizations. The research stimulated the establishment of the Roosevelt Environmental Justice Coalition – composed of community residents, community-based organizations, a local university, faith-based institutions, and the North Shore-LIJ Health System. The coalition has since applied for federal funding for community advocacy and capacity building.
Digital storytelling is a participatory ethnographic method useful in understanding people’s stories and sparking conversation. Participants create 3- to 5-minute visual narratives that synthesize images, video, audio recordings and text to create compelling stories (Lambert, 2012). Digital storytelling has been identified as an emergent method for health promotion research and practice (Gubrium, 2009); it can be used as a community development strategy (Marcuss, 2003). Digital narratives humanize health disparities often presented as statistics in public health and can be used as a tool for advocacy. I am implementing surveys to assess the effectiveness of these digital narratives to inform about health disparities in the suburbs; preliminary findings indicate that they are useful in changing viewers’ perceptions and knowledge.
Working with students and community members, I have created a series of digital narratives and have placed them on a map of Nassau County, along with discussion guides to understand the context of the issues raised in the videos and questions to consider. These materials appear online at www.phxli.com (Public Health Exchange Long Island); visitors to the site are welcome to submit their own stories of health inequity on Long Island.
Next Steps for Suburban Health Equity
The segregation of communities in Nassau County by race and class have created separate spheres where people living a mile away will attend different schools, play on different sports teams, attend different worship services, and shop in different stores. These patterns are not new, and these suburban contrasts resemble New York City. Whether it is the Upper East Side and East Harlem, or St. Albans and Forest Hills, social observers understand that this difference is fundamental to any great city.
But when these differences occur in suburban areas like the Village of Hempstead and Garden City, there is less interest both from those within the suburban communities and from those outside of them. Health inequities in the suburbs contradict the typical image of healthy and wealthy suburban spaces, and the real impacts of residential segregation on health outcomes in the suburbs are hidden from view in order to maintain the positive perceptions of suburban settings.
This is not just a local problem, unique to Nassau County and New York City. With over half of residents in the United States living in suburban areas, the growth of poverty in the suburbs and changing demographics, including larger immigrant populations and an increase in elderly residents, the health inequity by race/ethnicity is likely to present itself across different populations in suburbs across the country. The events in Ferguson last summer demonstrate that suburban areas such as Nassau County cannot sustain separation and its consequences for much longer. It is too expensive and no longer the reality, or the dream, in the 21st century.
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