Neighborhoods and Health
Disparities
2004 Summer Public Health Research Institute
and Videoconference on Minority Health
Gilbert C. Gee, PhD
University of Michigan
Copyright 2004, Gilbert C. Gee, PhD
U.S. Life Expectancy by Race, 1930-1999
Life Expectancy from Birth (years)
90
80
70
60
50
White
Black
40
30
20
10
0
1930
1940
1950
1960
1970
1980
1990
1999
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
Copyright 2004, Gilbert C. Gee, PhD
Per Capita Expenditures on Health Care, Top Five
Countries, 1999
U.S.A.
$4,358
Switzerland
$2,794
Norway
$2,425
German
$2,424
Canada
$2,313
$0
$1,000
$2,000
$3,000
$4,000
$5,000
Copyright 2004, Gilbert C. Gee, PhD
Health Care Expenditures, As Percent of Gross
Domestic Product, 1999
U.S.A.
13
Switzerland
10.4
Germany
10.6
9.6
France
9.5
Canada
0
2
4
6
8
10
12
14
% GDP
Copyright 2004, Gilbert C. Gee, PhD
Life Expectancy at Birth
Women
1. Japan
82.9
2. France
82.6
3. Switzerland 81.9
Men
1. Japan
2. Sweden
3. Israel
76.4
76.2
75.3
19. U.S.
20. Cuba
25. U.S.
75.0
72.5
78.9
Copyright 2004, Gilbert C. Gee, PhD
• 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)
Copyright 2004, Gilbert C. Gee, PhD
Health Disparities
• Racial disparities are a marker of the
health of race relations.
• Explanations
– Genetics/Biology (?)
– Social Class
– Culture
– Discrimination
– Geography
Copyright 2004, Gilbert C. Gee, PhD
Political-Economic System
Stratification
National &
State Policies
Social Networks
Community and
Occupations
Health
Behaviors
Health
Care
Genetics
Copyright 2004, Gilbert C. Gee, PhD
Convergent perspectives
• “Ecological model”
– Bronfenbrenner
• Proximal-Distal
– Amick
• Fundamental / root causes
– Link & Phalen
• Ecosocial theory
– Krieger
• Multi-level perspective
– Diez-Roux
Copyright 2004, Gilbert C. Gee, PhD
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.
Copyright 2004, Gilbert C. Gee, PhD
Race varies by geography
Copyright 2004, Gilbert C. Gee, PhD
Copyright 2004, Gilbert C. Gee, PhD
Copyright 2004, Gilbert C. Gee, PhD
Source: U.S. Census, 2000
Copyright 2004, Gilbert C. Gee, PhD
Copyright 2004, Gilbert C. Gee, PhD
Copyright 2004, Gilbert C. Gee, PhD
Copyright 2004, Gilbert C. Gee, PhD
Copyright 2004, Gilbert C. Gee, PhD
Copyright 2004, Gilbert C. Gee, PhD
Copyright 2004, Gilbert C. Gee, PhD
Copyright 2004, Gilbert C. Gee, PhD
Copyright 2004, Gilbert C. Gee, PhD
Copyright 2004, Gilbert C. Gee, PhD
At a more local level of
geography
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Copyright 2004, Gilbert C. Gee, PhD
Copyright 2004, Gilbert C. Gee, PhD
• 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
Copyright 2004, Gilbert C. Gee, PhD
• 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
Copyright 2004, Gilbert C. Gee, PhD
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
Copyright 2004, Gilbert C. Gee, PhD
Residential Patterns of Whites & African Americans,
Detroit, MI, 1990
Whites
African Americans
D=89
Copyright 2004, Gilbert C. Gee, PhD
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
Copyright 2004, Gilbert C. Gee, PhD
Why should public health
people care?
Copyright 2004, Gilbert C. Gee, PhD
http://137.187.213.155/
Copyright 2004, Gilbert C. Gee, PhD
Copyright 2004, Gilbert C. Gee, PhD
Copyright 2004, Gilbert C. Gee, PhD
Standardized Lynching Rate for 7 Groups of
Mississippi Counties by Percent Black
-- JS Reed, 1972
Lynching Rate
3
2.5
2
1.5
1
0.5
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
% Black
Copyright 2004, Gilbert C. Gee, PhD
Source: Polednak, 1997
Copyright 2004, Gilbert C. Gee, PhD
Age-adjusted CVD Mortality, by Birthplace
and Gender, NYC, 1988-1992
Fang, et al., 1996
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Potential Mechanisms
• Environmental Justice
• Community stressors
• Concentration of poverty
• Clustering of resources
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Environmental Justice
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Source: Lopez, 2002
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Source: Lopez, 2002
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Source: Pastor, 2001
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Community stress as an
analogue of individual stress
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Stress Process
McEwen, 1998
Copyright 2004, Gilbert C. Gee, PhD
Examples
• Crowding
• Social disorganization
• Crime
• Fear
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Source: Frankenhauser, et al., 1978
Copyright 2004, Gilbert C. Gee, PhD
Source: Davison, et al., 1986
Copyright 2004, Gilbert C. Gee, PhD
Source: Davison, et al., 1986
Copyright 2004, Gilbert C. Gee, PhD
Copyright 2004, Gilbert C. Gee, PhD
Street noise or traffic present am ong
hom eow ners, by social status
Street noise or traffic present am ong
renters, by social status
0.35
0.45
0.4
0.3
0.35
0.25
0.3
%
%
0.2
0.25
0.2
0.15
0.15
0.1
0.1
0.05
0.05
0
0
Total
Black
Below poverty
Source: 1999 American Housing Survey
Total
Black
Below poverty
Copyright 2004, Gilbert C. Gee, PhD
Copyright 2004, Gilbert C. Gee, PhD
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
Copyright 2004, Gilbert C. Gee, PhD
Figure 2. Interaction between Traffic Stress and Vehicular Burden
73.
on Health Status
0
72.2
G
e
n
e
r
a
l
H
e
a
l
t
h
71.4
70.6
69.8
69.0
68.2
67.4
Vehicular Burden
66.6
Lower Quintile
Upper Quintile
65.8
65.0
-1.56
LOW
-0.85
-0.14
0.58
TRAFFIC STRESS
1.29
2.00
HIGH
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
& Gilbert
Taekuchi,
2004
Copyright
2004,
C. Gee,
PhD
Concentration of economic
deprivation
Copyright 2004, Gilbert C. Gee, PhD
Ethnic Composition of High Poverty Neighborhoods,
1990 Census (Adapted from Jargowski, 1997)
White
23%
Hispanic
24%
Other
4%
Black
49%
Copyright 2004, Gilbert C. Gee, PhD
High Job Growth Areas
Hispanic
31%
White
52%
Asian
12%
Ethnic composition of
Low and High Job
Growth Areas,
Los Angeles, 1990
(Adapted from
Pastor, 2001)
Black
5%
Low Job Growth Areas
White
28%
Hispanic
48%
Black
12%
Asian
12%
Copyright 2004, Gilbert C. Gee, PhD
• Median family net worth, 2001
– Homeowners
– Renters
Source: Federal Reserve,
2001 Survey of Consumer Finances
$171,700
4,800
Copyright 2004, Gilbert C. Gee, PhD
Homeownerhip rates by Ethnicity of
Householder, 2000 Census
White Non-Hispanic
American Indian & Alaskan Native
Asian and Pacific Islander
Two or more races
Black
Hispanic
0
10
20
30
40
50
60
70
80
%
Copyright 2004, Gilbert C. Gee, PhD
Copyright 2004, Gilbert C. Gee, PhD
Housing Appreciation between
1967-1988, by Race and Housing
Value
60000
50000
Thousands $
40000
White
30000
Black
20000
10000
0
Less expensive
homes
More expensive
homes
Copyright 2004, Gilbert C. Gee, PhD
Source: Winkleby and Cubbin, 2002
Copyright 2004, Gilbert C. Gee, PhD
• Alcohol & tobacco advertising (USDHHS,
1998)
• Pharmaceuticals (Morrison, 2000)
• Food stores (Morland, et al., 2001)
Copyright 2004, Gilbert C. Gee, PhD
Clustering of resources & the
potential of resistance
Copyright 2004, Gilbert C. Gee, PhD
Segregation
Resource Depletion
Resource Accumulation
Employment
Education
Networks
Municipal Services
Environmental Toxins
Employment
Language, Tutoring
Refuge from Overt Racism
Legal Assistance
Foods
Negative Outcomes
Positive Outcomes
Copyright 2004, Gilbert C. Gee, PhD
• “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
Copyright 2004, Gilbert C. Gee, PhD
• “The ethnic enclave is an attempt … to
create social and cultural ecological
conditions for ease in survival and
adaptation.”
• Munzamar, et al., 2000
Copyright 2004, Gilbert C. Gee, PhD
• Black political power (Laveist, 1993)
• Social capital (Sampson, 1997; Kawachi,
et al., 1998)
Copyright 2004, Gilbert C. Gee, PhD
http://sf.indymedia.org/news/2003/08/1635306.php
Copyright 2004, Gilbert C. Gee, PhD
Environmental Racial Disparities Framework
Race/Ethnicity
Residential segregation
Residential
Location
Community
Stressors
Gee & Payne-Sturges
Environmental
Level Vulnerability
Neighborhood
Resources
Environmental
Toxins
Community
Stress
Exposure
Individual
Stress
Internal
Dose
Health
Effect
Individual
Level Vulnerability
Copyright 2004, Gilbert C. Gee, PhD
A woman walks past a homeless person sleeping on the sidewalk
on Mission Street in downtown San Francisco.
Copyright 2004, Gilbert
Gee,Times
PhD
NewC.York
Women sit in a coffee shop as a homeless man panhandles for money outside
on Market Street in downtown San Francisco.
Copyright
Gilbert C.York
Gee,Times
PhD
Monica2004,
Almeida/New
Copyright 2004, Gilbert
Gee,Times
PhD
NewC.York
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
Copyright 2004, Gilbert C. Gee, PhD
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
Copyright 2004, Gilbert C. Gee, PhD
Copyright 2004, Gilbert C. Gee, PhD