17
AMERICAN CITIES: GOOD AND BAD NEWS ABOUT PUBLIC HEALTH* MICHAEL GREENBERG, PH.D. Distinguished Professor of Public Health Rutgers University New Brunswick, New Jersey
IWAS BROUGHT UP ON 169th Street and College Avenue, three blocks from the Concourse in the Bronx. That once wonderful neighborhood is badly deteriorated. I shall return to my old neighborhood in my remarks about TOADS later in this talk. My talk will have two parts. The first part will be the good news, and the second part will be the not-so-good news. GOOD NEWS PERIOD
The good news period begins in the 1940s and ends in the late 1970s and the early 1980s. During the good news period a very long-standing "urban penalty" in public health gradually disappeared. In the 1930s and 1940s we find that urban areas, not just New York City, but most cities in the United States had considerably higher death and morbidity rates from the chronic diseases that cause most deaths-notably heart disease, cancer, diabetes. Cerebrovascular disease is an exception because the populous northeastern and midwestern cities did not have the highest rates. During this period, for example, respiratory, digestive, and urinary tract cancer rates in cities were 50-100% higher than in rural areas. But a change occurred. Beginning in the mid-1960s the chronic disease death rates in the populous cities of the Northeast and Midwest decreased in absolute terms, but also decreased relative to rates in cities in the South and West and in rural areas. For example, in cancer, differences in the 1940s and 1950s of 50-100% between cities and non-city areas decreased to 5 to 10% in the 1970s and 1980s. Briefly, one reason this happened is that cities are places where innovations occur. Unfortunately, not all public health innovations are good. When we examine cigarette advertising and cigarette smoking patterns from the frag*Presented in a panel, Health and the City-Renegotiating Roles and Responsibilities, as part of the Annual Health Conference, The Challenge ofHealth Care in the Nation's Cities, held by the Committee on Medicine in Society of the New York Academy of Medicine May 16, 1990.
Vol. 67, No. 1, January-February 1991
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M. GREENBERG
mentary data we have from the 1930s and 1940s we find that cities probably had about twice as much cigarette smoking per capita as nonurban areas. And we can say the same thing for a lot of other behavioral risk factors. In the 1950s and 1960s these not-so-good behavioral risk factors diffused to rural areas and cities in the West and South. Because cities tend to be innovative places, we see an increase in the recognition that these harmful behavioral risks should be stopped. So one key factor in the changing distribution of the geography of mortality-that is, city rates decrease both absolutely and relatively to rural areas is the diffusion of behavioral risk factors across the United States. I am guessing that the same pattern will happen in behavioral risks associated with AIDS and drug use in the United States. A second factor contributing to the relative decline of death rates in the populous cities in the United States is the diffusion of people and employment. There was once an American manufacturing belt: an area that began in Boston and neighboring New Hampshire, ran west to Milwaukee, south roughly to St. Louis, and then across to Baltimore. Some people now call the old American manufacturing belt the American rust belt. Industry declined in big cities, moved west, south, and out of the United States, especially hazardous industry. We now have a more even distribution of environmental and occupational risk in the United States. Much of it is no longer focused in northeastern and Midwestern cities; in fact, much of it is no longer focused in cities. Another major change is improved medical practices in rural areas. Diagnosis and record keeping is better in rural areas than it once was, so we now can more accurately compare mortality and morbidity in urban and rural areas. BAD NEWS PERIOD
I shall briefly discuss some of the not-so-good trends. Unfortunately, we think that the urban health penalty is beginning to reappear again. Dr. Glazer pointed out that residents of the cities are increasingly black and Hispanic. These populations, especially black men, are at much higher risk of a variety of diseases than are Americans of European and Asian heritages. The aging American population is not evenly distributed over the United States. Retirement areas and many cities continue to have a very large and increasingly elderly population. What we find through analysis of elderly populations is that those who tend to migrate to Florida, Arkansas, Texas, Arizona, and other retirement communities in the United States actually tend Bull. N.Y. Acad. Med.
AMERICAN CITIES
19
to be healthier and live longer than those elderly who stay in city environments. In general, those who remain in the cities are not very affluent, and the cost of their medical care is rising very rapidly. I shall summarize this problem by noting that about eight days ago I had a conversation with our family physician, who told me that she would not accept any patients dependent on Medicare because payment for her services did not cover her costs. This means that local and state governments are facing an increasing population that votes for and wants health services. Black and Hispanic populations are even more concentrated in cities than are the elderly. We are now doing a research project on 94 counties in the United States, 94 out of more than 3,000 counties. These 94 counties have at least 50,000 black residents. Sixty-one percent of the black population live in these 94 counties; about 30% of the white population lives in these 94 counties. The problems of black and Hispanic populations as measured by mortality and morbidity are much greater than that of the white population. I shall give a few numbers to give you a sense of the difficulty this population faces. Margaret Heckler, former Secretary of Health and Human Services, commissioned a study on minority health in the United States. The numbers from that study are for the American population 70 years of age or younger. Here are comparisons of various causes of death of the black and white populations. For black males compared to white males: homicide rate, 6.5 times as high; diabetes 2.2 times as high; infant mortality twice as high; cirrhosis death rate twice as high; cancer 60% higher; and cardiovascular diseases 50% higher. The age-adjusted mortality rate for black males was 70 percent higher than it was for white males for total causes of death during 1979 to 1981. The health problems of cities such as New York, Baltimore, Cleveland, Detroit, and many others are increasingly the health problems of the elderly, blacks, and Hispanics.
EPICENTERS OF PUBLIC HEALTH PROBLEMS
Furthermore, health problems of blacks, Hispanics, and elderly populations are disproportionately found in a few parts of cities that also suffer both physical deterioration and economic deterioration. One of these areas is the South Bronx, the neighborhood where I was raised. We have coined an expression, TOADS, to describe physical aspects of the environment. TOADS stands for Temporarily Obsolete, Abandoned, Derelict Sites. TOADS are abandoned factories, stoops, schools, and houses. We studied TOADS in 14 of the 15 most populous cities in the United states. (Detroit refused to cooperate.) We asked city officials about TOADS. They all had Vol. 67, No. 1, January-February 1991
20
M. GREENBERG
TOADS, including Phoenix, San Francisco, and Los Angeles. This is just not a Northeastern and Midwestern phenomenon. They identified economic problems (financial decline, very few jobs, closed businesses, decreased investment). But the most troubling part was that vacant buildings were occupied by the homeless, were used for drug sales, and were torched. City governments, some said, exacerbated the problem by withdrawing police and fire services from the deteriorated areas which in turn increased the catastrophic destruction of the buildings. More people were forced to leave the areas. Those people migrated to adjacent areas because they were poor minorities or they were poor elderly, and the TOADS cycle started again in the neighboring areas. In short, TOADS became the epicenter for economic decline, job loss, and major public health problems. The public health problems are substantial increases in tuberculosis, substantial increases in infant mortality, high rates for AIDS from intravenous drug use, suicide, and homicide. In other words, what we have found on the microgeographic scale is the worst of the worst-places in the major cities where there are massive physical destruction and major public health problems, and these problems interact and spread. ABANDONING PUBLIC HEALTH PROBLEMS IN THE INNER CITIES
American federal policy has changed during the last two decades, and is partly responsible for these clustered inner city health and economic land problems. Policy has swung over the years in a pendulum-like arc between the federal government dominating and controlling and the federal government backing off and leaving policy and funding to state and local governments. Toward the end of the Carter administration, certainly in the Reagan administration, now in the Bush administration, states are responsible for more health services. Some areas of the United States do not need the federal government to take control, the federal government to set the policies, the federal government to provide most of the money. States such as New Jersey, Connecticut, Massachusetts, Florida, Wisconsin, and Minnesota typically are able to do much of what they need on their own. In fact, the federal government often gets in their way. But other states in the United States, many with large cities and many without such large cities, are incapable of handling the extra responsibility that they must assume when the federal government backs away from what it had once assumed as its responsibility. Many states have responded to the federal government by cutting money. So, although New York City provides many services, many other states and cities in those states provide few services and will probably provide fewer as Bull. N.Y. Acad. Med.
AMERICAN CITIES
AMERICAN CITIES
21 21
budgets tighten. For example, a study was done on state policies for cancer prevention. States such as New York, New Jersey, and Massachusetts had six-nine cancer prevention programs. Many other states had zero-two cancer preventive programs. In short, many cities with increasing minority and elderly populations and the health problems associated with these problems offer few preventive programs and cannot provide adequate health services. Summarizing, during the 1940s to the late 1970s the urban penalty in death gradually disappeared. But major changes in urban demography have brought serious public health problems to cities at a time when the federal government is doing as little as it can to provide funds for these problems and many states are unable or unwilling to support their major cities. In short, while I am optimistic about public health improvements in the United States, I am pessimistic about public health in poor, elderly, and minority communities in inner city areas of America's cities. These areas need help.
Vol. 67, No. 1, January-February 1991
AMERICAN CITIES: GOOD AND BAD NEWS ABOUT PUBLIC HEALTH* MICHAEL GREENBERG, PH.D. Distinguished Professor of Public Health Rutgers University New Brunswick, New Jersey
IWAS BROUGHT UP ON 169th Street and College Avenue, three blocks from the Concourse in the Bronx. That once wonderful neighborhood is badly deteriorated. I shall return to my old neighborhood in my remarks about TOADS later in this talk. My talk will have two parts. The first part will be the good news, and the second part will be the not-so-good news. GOOD NEWS PERIOD
The good news period begins in the 1940s and ends in the late 1970s and the early 1980s. During the good news period a very long-standing "urban penalty" in public health gradually disappeared. In the 1930s and 1940s we find that urban areas, not just New York City, but most cities in the United States had considerably higher death and morbidity rates from the chronic diseases that cause most deaths-notably heart disease, cancer, diabetes. Cerebrovascular disease is an exception because the populous northeastern and midwestern cities did not have the highest rates. During this period, for example, respiratory, digestive, and urinary tract cancer rates in cities were 50-100% higher than in rural areas. But a change occurred. Beginning in the mid-1960s the chronic disease death rates in the populous cities of the Northeast and Midwest decreased in absolute terms, but also decreased relative to rates in cities in the South and West and in rural areas. For example, in cancer, differences in the 1940s and 1950s of 50-100% between cities and non-city areas decreased to 5 to 10% in the 1970s and 1980s. Briefly, one reason this happened is that cities are places where innovations occur. Unfortunately, not all public health innovations are good. When we examine cigarette advertising and cigarette smoking patterns from the frag*Presented in a panel, Health and the City-Renegotiating Roles and Responsibilities, as part of the Annual Health Conference, The Challenge ofHealth Care in the Nation's Cities, held by the Committee on Medicine in Society of the New York Academy of Medicine May 16, 1990.
Vol. 67, No. 1, January-February 1991
18
M. GREENBERG
mentary data we have from the 1930s and 1940s we find that cities probably had about twice as much cigarette smoking per capita as nonurban areas. And we can say the same thing for a lot of other behavioral risk factors. In the 1950s and 1960s these not-so-good behavioral risk factors diffused to rural areas and cities in the West and South. Because cities tend to be innovative places, we see an increase in the recognition that these harmful behavioral risks should be stopped. So one key factor in the changing distribution of the geography of mortality-that is, city rates decrease both absolutely and relatively to rural areas is the diffusion of behavioral risk factors across the United States. I am guessing that the same pattern will happen in behavioral risks associated with AIDS and drug use in the United States. A second factor contributing to the relative decline of death rates in the populous cities in the United States is the diffusion of people and employment. There was once an American manufacturing belt: an area that began in Boston and neighboring New Hampshire, ran west to Milwaukee, south roughly to St. Louis, and then across to Baltimore. Some people now call the old American manufacturing belt the American rust belt. Industry declined in big cities, moved west, south, and out of the United States, especially hazardous industry. We now have a more even distribution of environmental and occupational risk in the United States. Much of it is no longer focused in northeastern and Midwestern cities; in fact, much of it is no longer focused in cities. Another major change is improved medical practices in rural areas. Diagnosis and record keeping is better in rural areas than it once was, so we now can more accurately compare mortality and morbidity in urban and rural areas. BAD NEWS PERIOD
I shall briefly discuss some of the not-so-good trends. Unfortunately, we think that the urban health penalty is beginning to reappear again. Dr. Glazer pointed out that residents of the cities are increasingly black and Hispanic. These populations, especially black men, are at much higher risk of a variety of diseases than are Americans of European and Asian heritages. The aging American population is not evenly distributed over the United States. Retirement areas and many cities continue to have a very large and increasingly elderly population. What we find through analysis of elderly populations is that those who tend to migrate to Florida, Arkansas, Texas, Arizona, and other retirement communities in the United States actually tend Bull. N.Y. Acad. Med.
AMERICAN CITIES
19
to be healthier and live longer than those elderly who stay in city environments. In general, those who remain in the cities are not very affluent, and the cost of their medical care is rising very rapidly. I shall summarize this problem by noting that about eight days ago I had a conversation with our family physician, who told me that she would not accept any patients dependent on Medicare because payment for her services did not cover her costs. This means that local and state governments are facing an increasing population that votes for and wants health services. Black and Hispanic populations are even more concentrated in cities than are the elderly. We are now doing a research project on 94 counties in the United States, 94 out of more than 3,000 counties. These 94 counties have at least 50,000 black residents. Sixty-one percent of the black population live in these 94 counties; about 30% of the white population lives in these 94 counties. The problems of black and Hispanic populations as measured by mortality and morbidity are much greater than that of the white population. I shall give a few numbers to give you a sense of the difficulty this population faces. Margaret Heckler, former Secretary of Health and Human Services, commissioned a study on minority health in the United States. The numbers from that study are for the American population 70 years of age or younger. Here are comparisons of various causes of death of the black and white populations. For black males compared to white males: homicide rate, 6.5 times as high; diabetes 2.2 times as high; infant mortality twice as high; cirrhosis death rate twice as high; cancer 60% higher; and cardiovascular diseases 50% higher. The age-adjusted mortality rate for black males was 70 percent higher than it was for white males for total causes of death during 1979 to 1981. The health problems of cities such as New York, Baltimore, Cleveland, Detroit, and many others are increasingly the health problems of the elderly, blacks, and Hispanics.
EPICENTERS OF PUBLIC HEALTH PROBLEMS
Furthermore, health problems of blacks, Hispanics, and elderly populations are disproportionately found in a few parts of cities that also suffer both physical deterioration and economic deterioration. One of these areas is the South Bronx, the neighborhood where I was raised. We have coined an expression, TOADS, to describe physical aspects of the environment. TOADS stands for Temporarily Obsolete, Abandoned, Derelict Sites. TOADS are abandoned factories, stoops, schools, and houses. We studied TOADS in 14 of the 15 most populous cities in the United states. (Detroit refused to cooperate.) We asked city officials about TOADS. They all had Vol. 67, No. 1, January-February 1991
20
M. GREENBERG
TOADS, including Phoenix, San Francisco, and Los Angeles. This is just not a Northeastern and Midwestern phenomenon. They identified economic problems (financial decline, very few jobs, closed businesses, decreased investment). But the most troubling part was that vacant buildings were occupied by the homeless, were used for drug sales, and were torched. City governments, some said, exacerbated the problem by withdrawing police and fire services from the deteriorated areas which in turn increased the catastrophic destruction of the buildings. More people were forced to leave the areas. Those people migrated to adjacent areas because they were poor minorities or they were poor elderly, and the TOADS cycle started again in the neighboring areas. In short, TOADS became the epicenter for economic decline, job loss, and major public health problems. The public health problems are substantial increases in tuberculosis, substantial increases in infant mortality, high rates for AIDS from intravenous drug use, suicide, and homicide. In other words, what we have found on the microgeographic scale is the worst of the worst-places in the major cities where there are massive physical destruction and major public health problems, and these problems interact and spread. ABANDONING PUBLIC HEALTH PROBLEMS IN THE INNER CITIES
American federal policy has changed during the last two decades, and is partly responsible for these clustered inner city health and economic land problems. Policy has swung over the years in a pendulum-like arc between the federal government dominating and controlling and the federal government backing off and leaving policy and funding to state and local governments. Toward the end of the Carter administration, certainly in the Reagan administration, now in the Bush administration, states are responsible for more health services. Some areas of the United States do not need the federal government to take control, the federal government to set the policies, the federal government to provide most of the money. States such as New Jersey, Connecticut, Massachusetts, Florida, Wisconsin, and Minnesota typically are able to do much of what they need on their own. In fact, the federal government often gets in their way. But other states in the United States, many with large cities and many without such large cities, are incapable of handling the extra responsibility that they must assume when the federal government backs away from what it had once assumed as its responsibility. Many states have responded to the federal government by cutting money. So, although New York City provides many services, many other states and cities in those states provide few services and will probably provide fewer as Bull. N.Y. Acad. Med.
AMERICAN CITIES
AMERICAN CITIES
21 21
budgets tighten. For example, a study was done on state policies for cancer prevention. States such as New York, New Jersey, and Massachusetts had six-nine cancer prevention programs. Many other states had zero-two cancer preventive programs. In short, many cities with increasing minority and elderly populations and the health problems associated with these problems offer few preventive programs and cannot provide adequate health services. Summarizing, during the 1940s to the late 1970s the urban penalty in death gradually disappeared. But major changes in urban demography have brought serious public health problems to cities at a time when the federal government is doing as little as it can to provide funds for these problems and many states are unable or unwilling to support their major cities. In short, while I am optimistic about public health improvements in the United States, I am pessimistic about public health in poor, elderly, and minority communities in inner city areas of America's cities. These areas need help.
Vol. 67, No. 1, January-February 1991
