Perusing the San Francisco apartment ads on Craigslist (Ingleside, Sunset, Lower Nob Hill, Panhandle, Cow Hollow…), it’s evident that people care about defining their neighborhoods. But oftentimes even residents can’t agree on the size and shape of their own neighborhoods. When research subjects are asked “What do you think of as your neighborhood?” their answers vary from “my block” to “a 20-minute walk from my home,” with no single option receiving a majority vote.
“The problem is there’s no one answer we all agree on,” says Assistant Professor of Epidemiology Jennifer Ahern PhD ’07, MPH ’00, who has been studying neighborhood level determinants of health since she was a graduate student at the School of Public Health. “In terms of studies and interventions, we have to match what we’re doing to the best possible guess. We hope we’re getting it right.”
In the early days of community research, people relied on zip codes as neighborhood markers. “No one was arguing it was optimal, but early on it was something,” says Ahern. Later, researchers preferred to use census units like blocks or tracts, because they are pre-defined, replicable, and come with secondary source socioeconomic and health data. In the past decade or so, defining neighborhoods in increasingly sophisticated ways—both for commercial and research purposes—has become a body of study in and of itself.
But no matter how neighborhoods are defined, health researchers agree: Neighborhoods matter for health. One study finds that disparities in neighborhood background account for 35 percent of the variation in health status among men in mid-life. Just as there are huge variations in living conditions in the United States, there are also shockingly large health disparities between—and even within—local communities. In San Francisco, residents of Hunters Point can expect to live, on average, 10 years less than their counterparts on Russian Hill. In Los Angeles County, 33 percent of children in the 10 poorest cities are obese, while in the 10 richest cities it’s only 6 percent.
You might conclude from these statistics that neighborhood health follows the social gradient, i.e., the more wealth people have, the longer they are likely to live. But the neighborhood effect on health extends beyond poverty and safety to cultural factors—family, lifestyle, diet—all of which can help or hinder someone’s ability to weather the hardships of life.
Much of the inequality of communities in America has a historical basis in events and factors that shaped the composition of our nation. One example is the Industrial Revolution of the nineteenth century, which led to both urbanization and the creation of wealth. Another is the transfer of many factory jobs overseas in the 1970s; this resulted in communities of working-class families becoming isolated and devoid of economic opportunities beyond basic service industry jobs.
“With the Industrial Revolution, all of a sudden people are living a lot closer together than they used to and some people have a lot more than others,” says Ahern. “There are real juxtapositions created by those conditions in our major cities.” Ahern recalls working in East Harlem, very close to the Upper East Side of Manhattan. “You walk out of public housing projects and a block later you’re in the middle of ladies with furs,” she says. “You think, ‘What is going on in this place?’ It plays out in a very dramatic way.”
Segregation and racism also loom large in this country’s past and continue to play a role in the homogeneous nature of the majority of U.S. communities. Associate Professor Amani Nuru-Jeter, who has spent years looking at race and socioeconomic inequalities in health, explains: “Studies show that the history of racial discrimination, specifically with respect to real estate, socially and economically marginalizes blacks into racially segregated communities. Historically, banks systematically pulled out of those neighborhoods, did not lend to people in those neighborhoods, and, in fact, told whites in adjacent neighborhoods to move or they too would not receive loans because they were too close to the ‘black’ neighborhoods. As a result, those neighborhoods became dilapidated, businesses didn’t want to move there—so the result was and remains economic disinvestment in terms of jobs and other opportunities.”There is some freedom for residents to move away from bad neighborhoods, although this choice comes with its own set of problems and can prove elusive for many. “People think they have more control over their environments than they actually do,” says Nuru-Jeter. “It’s not always about, ‘I want to live in this community, in this environment, with these people, etc.’ People can be selected into neighborhoods because of much broader social and political factors.”
Assistant Professor of Epidemiology Mahasin S. Mujahid points out that certain groups of people living together is not a bad thing in and of itself. “We’re finding that some communities that are predominately one race or ethnic group have a lot of benefits: shared resources, social support, and networks of information sharing,” she says. “The fact that people may want to have a kindred network of support, that’s a wonderful thing. But when it comes with poor schools and no grocery stores and limited infrastructure and these other things we know cluster with certain ethnic compositions, then that’s the problem.”
When it comes to neighborhood environments, Ahern is especially interested in how they relate to mental health and health behaviors, including substance abuse, sexual risk behavior, and violence. Growing up in Baltimore, she was exposed to the impact that crime can have on a community. “We got broken into several times. People were mugged outside my house all the time,” she recalls. “It wasn’t until I left that I was like, ‘Wow, that’s crazy!’ No wonder my mom was always saying we have to move.”
Her childhood experience illustrates how certain characteristics of neighborhoods can quickly become normative, even if they are not desirable. As an epidemiologist, Ahern now studies social cohesion and social norms and how they can enforce or derail efforts to change communities.
”There’s a body of research that addresses the idea of social cohesion or social capital—how much members of a neighborhood trust and look out for each other and act on behalf of the collective good of the community. And there’s a move to build these things in communities,” she says. “I became interested in how there’s this focus on cohesiveness, but we’re not thinking as much about the normative environment.”
It’s not just an academic consideration, because it means interventions to build community cohesion may not have the intended effect. To illustrate, Ahern points to the issue of adolescence and substance use, such as smoking. “If you have a cohesive neighborhood but norms are very permissive about smoking, if you increase the cohesiveness in the community you actually see more smoking,” says Ahern. “When you think about people being cohesive with their peers, it’s clear that whether or not that is good or bad depends on what those peers are doing. In terms of substance abuse, just being close with your group doesn’t necessarily lead to better health.”
Ahern is increasingly interested in assessing the impact of large-scale policies and interventions that may not be implemented for health reasons, but may have substantial health impacts. For example, violence interventions that follow what’s called the Ceasefire model have been carried out in major cities across the country (Chicago, New York, Boston, Baltimore, and Los Angeles) over the past decade. These interventions typically address some of the key elements that lead to violence: lack of economic opportunities, lack of social controls, and the development of norms that permit violence as a way of solving conflicts. “We know these kinds of interventions succeed in reducing the level of violence for some period of time,” says Ahern. “But does that affect health more broadly and, more importantly, does it help reduce health disparities?”
Beyond the reduction of preventable death and injury, Ahern believes that curbing violence has great potential to start closing the gap on health disparities. A few recent studies suggest violence has an impact on birth outcomes (e.g., preterm deliveries), asthma, mental health, and health behaviors. With regard to disparities, she cites a biomarker study that found stronger effects of violence on stress biomarkers for African American women who are pregnant than for women of other ethnicities.
“African American women throughout the country have twice the risk of having preterm babies, which is pretty dramatic,” says Ahern.“Violence is one thing that African American communities are disproportionally exposed to, and if at the same time they’re disproportionally affected by the exposure, that’s a doubling of the impact. It’s suggested by the literature, but we don’t really know.”
Why might African American women be disproportionately impacted by neighborhood factors such as violence? Nuru-Jeter is looking to answer that question and more. “How is the social experience of being a black woman in America embodied psychologically and biologically?” she asks. “We’re looking at the experience of racial discrimination across the life course.”
With the help of a team of students and alumni, Nuru-Jeter is canvassing Bay Area cities— Oakland, San Francisco, Berkeley, San Leandro, and Richmond—to recruit black women between 30 and 50 years of age to participate in the African American Women’s Heart and Health Study. The study has three components: a survey; anthropometric assessment including height, weight, waist and hip circumference, blood pressure, body fat percentage, and BMI; and blood samples to measure neuro-hormonal and other activity in the body. With this data, she hopes to examine the feasibility of associations between racial discrimination and both subclinical cardiovascular risk and overall physiologic aging, which Nuru-Jeter describes as the “weathering hypothesis,” a term coined by Arline Geronimus at the University of Michigan.
“A lot of work on discrimination and health has focused on racial discrimination as a stressor,” says Nuru-Jeter. “If we believe that discrimination is a stressor and we want to model it as a stressor, then we should also be looking at two other key, but often neglected, components of the stress process, threat appraisal and coping style.”
Her study uses validated measures of these processes, as well as original measures assessing what she terms “culture-specific threat appraisal and coping style.” She says, “In addition to the environment itself, how people perceive and cope with these environments is also important.”
Because the Heart and Health study is a pilot project with a small budget, Nuru-Jeter can’t afford to do probability sampling. She and her team have adopted a grassroots neighborhood strategy to capture as wide a range of subjects as possible, including socioeconomic diversity. They canvassed the streets in targeted neighborhoods, frequenting flea markets, farmer’s markets, and other community events. They posted flyers in soul food restaurants in Fruitvale and theaters in Temescal, downtown Oakland, and Berkeley. They visited churches, beauty shops, and nail shops—places where black women congregate across socioeconomic lines. They recruited from community organizations like sororities. Their goal is to reach a sample size of 200 women, more than enough to convince the NIH to fund a larger study in the fall.
“Our recruitment motto is, ‘Don’t expect them to come to you. Go where the people are,’” says Nuru-Jeter. “Go to their safe places.”
An epidemiologist at heart, Nuru-Jeter is drawn to the sheer amount of data. “We have health behaviors in the survey, we have substance abuse, physical activity, diet, mental health outcomes, depressive and anxiety symptomatology, and a scale of psychological distress,” she enthuses. “We have BMI, body fat, blood pressure, and numerous biological markers. There is going to be a ton to look at!”
Nuru-Jeter believes the outcome of this study and others like it could have long term political and policy implications. “From a policy perspective, we’re able to say that it’s not necessarily people’s own doing in that they’re in the predicaments that they’re in,” she says. “The traditional interventions have been behavioral, urging people to eat the right food or stay active. But those may not be effective if there’s something about the larger social environment that affects our health beyond anything we have control over.”What kind of interventions would Nuru-Jeter like to see instead? She is full of ideas, from medical to space planning to social. “I don’t know how economically feasible it is, but I would recommend that some of these stress markers—cortisol, C-reactive protein, interleukin-6—become part of the normal clinical encounter, in terms of early risk identification,” she says. “When we go to the doctor, they can evaluate, for example, a glucose or lipid panel and tell us if we’re at risk for diabetes and/or cardiovascular disease. Why not also assess stress markers, which we know have long term health implications down the road?”
She then sees a role for the health care delivery system in developing support programs. For instance, HMOs like Kaiser Permanente already offer classes on diabetes and hypertension management, and it might make sense for them to offer classes on coping with stress as well.
“There are community-based organizations that could use this kind of evidence to get money to support program development for these types of interventions,” says Nuru-Jeter. “So I think there is a role for intervention across multiple levels.”
Whether you think of your neighborhood as your block or your side of town, social factors have affected your health. Possibly unbeknownst to you, your personal choices as an adult have been influenced by the neighborhood in which you grew up. Mujahid explains, “Research has found that there are certain aspects of where you live that affect your well-being without your awareness; there are social norms and cultural practices in areas that shape your own personal decision making. For example, you may think, “Oh I just prefer this kind of food,’ but actually, growing up that was all that was available at the corner store, and that’s what your parents and the families around you used. It became your own personal choice, but you didn’t realize that the environment shaped that choice.”
Social norms may play a large role in what we choose to eat, but convenience of acquisition matters as well—hence the rise of the fast food industry. “There was a study that showed that for every new grocery store that was immersed into a low-income community of color, African Americans’ consumption of fresh fruits and vegetables increased by close to 30 percent,” cites Nuru-Jeter.
Clearly, people want to eat their vegetables. Yet food deserts—defined as an area where a substantial number of residents have low access to a supermarket or large grocery store—persist in both low-income and middle-income neighborhoods. Even in the Bay Area, neighborhoods like West Oakland and South Berkeley have a very unbalanced proportion of liquor stores to grocery outlets, making it easier to buy beer than broccoli.
Why can’t we just open more grocery stores? It’s not as simple as it sounds. “In terms of advocating for larger grocery stores which offer fresh produce and other healthy food options to come into all the areas that could use them, research suggests that there are unintended consequences,” says Mujahid. “Policy, redlining, zoning issues, community debate all influence the decision-making process. Sometimes it can take ten years for a large grocery store to move into an area.”
Undaunted, Mujahid has partnered with Dr. Latetia Moore from the CDC, Division of Nutrition, Physical Activity, Overweight and Obesity, to take a look at the untapped potential of smaller stores as a source of healthier fare. Together they are assessing the potential of smaller stores in tri-county Detroit as well as seven Bay Area counties.
“California is a wonderful model for this, because we have bodegas and farmers markets and all these opportunities to provide healthy options,” says Mujahid. “We don’t have to rely exclusively on larger stores.”
Smaller stores may be more flexible and responsive to community needs than large grocery outlets, and supporting small business is also good for the neighborhood economies in general. The problem with smaller stores is that currently there is no reliable way to assess their food offerings. “Will it require going into these establishments and checking off ‘Does it have tomatoes?’ or ‘Does it have bananas?’” muses Mujahid. She and Moore are looking to find a surveillance system already in place that might provide a good proxy for in-person banana counting.
One such program is the USDA’s Women, Infants and Children (WIC) program, which provides supplemental nutritious foods, health care referrals, and nutrition education to low-income, nutritionally at risk women who are pregnant, breast feeding, or have children under the age of five. WIC already certifies stores nationwide based on prices of foods, the business integrity of the store’s owner, and the variety and quantity of foods available in the store. WIC also established the Farmers Market Nutrition Program (FMNP) in 1992. Farmers, farmers markets, and roadside stands also must be authorized to accept FMNP coupons. In 2011, coupons redeemed through the FMNP resulted in over $16.4 million in revenue to farmers and increased access to locally grown produce to low-income women.
“Advocating for more WIC-certified stores, farmer’s markets, and produce stands might be a great way to increase incentives for small stores to provide healthier food choices— thus increasing additional purchasing options,” says Mujahid.
The CDC is already launching a national surveillance system to monitor what’s available in communities and determine what kind of resources can support healthy food environments. Mujahid hopes to inform the larger initiative and help the CDC capitalize on the opportunity smaller stores can provide. “One of the nice things about working with the CDC is that this is their priority,” she explains. “If we can identify promising initiatives that help create local food resources for people in need, the CDC is committed to funding them.”
With wealth disparity increasing rapidly since the 1990s and communities continuing to remain largely segregated by ethnicity and income, neighborhood-based inequalities in health are unlikely to diminish in the United States without a concerted effort. Coming out of a nationwide recession with slow economic growth, deciding where to invest resources and how much to invest can be difficult, and can itself lead to disparities.
“When we’re operating in a scarce resource model, we don’t invest evenly,” Mujahid says. “We invest in the people who make the most noise, who have the most power—and they get a disproportionate share of limited goods, services, and other important resources. Ironically and unjustly those who are most vulnerable, those with the least power, usually don’t get any.”
Mujahid believes that people need to come together and support each other in order for our communities to thrive. “We say it’s personal choice; we say we can’t help that people have bad behaviors. But that’s actually an inaccurate excuse,” she says. “We’re not investing in the well-being of all people. Ideally, we need to invest not just in the powerful and influential, but in all people—and all communities and neighborhoods.”