…and managed CRP’s Data
Source Neighborhood Data Access website. He also has
over ten years’ experience in child advocacy and policy
support with KidsOhio.org and Children’s Defense
Fund — Ohio. And prior to that, as a workshop instructor
and journal editor with the American Chemical Society.
David holds a master’s degree in public policy and management
from the Glenn School at the Ohio State University and
a bachelor’s degree in zoology from Ohio University. Now,
without further ado, Mr. Norris, you have the
floor, and we can begin. DAVID: Excellent. Thank
you, Maria, and good afternoon, everyone. Let me just get
my slides up here. Let’s see. Here we go. Alright. Well, this
afternoon, what I’d like to do is explore a little
bit with you the linkage between place and health, and specifically the
linkage between place and neighborhood health in
regards to infant mortality and some of the
things that you might encounter as you work as
peer educators with folks that you’ll be working with. Let me just say a little
bit about the Kirwan Institute for the Study of Race and
Ethnicity. As Maria said, we are located at the
Ohio State University in Columbus, Ohio. This
slide lays out just a few of the many subject
matter areas that we deal with. I’m not going to go into a
lot of details about what we do specifically, although
I do want to point out, on the left-hand side, that
graphic with the four circles and then the
larger gray circles. At the top of that,
you’ll see a phrase “structural racialization.” That phrase describes how
race and prejudice have been incorporated into the very
fabric of our society through our structures of government,
economics, through the neighborhoods that
we live in, and so on; the healthcare
systems that we all utilize. And that is primarily the area that we’re going to
be talking about today, when we talk about
the linkage between place and infant mortality. So here’s what I’d
like to do this afternoon. Just very briefly go
through infant mortality; the definition, just so
we’re all on the same page. I’m going to speak quite a
bit about some mapping work and some analysis
that we have done in Ohio around infant mortality.
But even though the work is specific to Ohio, the
concepts that we’ll discuss and discover together apply
in cities across the country. We’ll talk about specifically,
the linkages, or what we call the spatial correlates
between infant mortality and some of the social
determinants of health and neighborhood conditions
in three Ohio cities. And then we’ll talk about
how our neighborhoods came to be the places that they
are in terms of better or worse health outcomes
for their residents. Now, just briefly, and I
think you all know all of this, so let’s just go
through this really quickly. But infant mortality, in
terms of birth outcomes, is the absolute
worst birth outcome. It’s the death of an infant
within the first year of life. And you can see the
leading causes listed there. Some are things that
we may be able to do little about, such as birth
defects. Other things that preconception and that
prenatal interventions might be able to have some
influence over, like being born too small, being born too
early, and some of the maternal complications of pregnancy.
And then some of the causes of infant mortality
happen after the baby leaves the hospital and is living in
the home within the first year of the baby’s life. And we’ll
look at mostly those factors that happen after the baby
leaves the hospital today. Just real quickly, the infant
mortality rate, I’ll be using that phrase quite a bit today;
you’ll see it abbreviated as IMR. It’s the number of
infant deaths before age one per one thousand live
births. And you may have heard the phrase, the infant
mortality rate is the canary in the coal mine
for community health. If you see high rates of infant
mortality, that generally tends to signal that there
are other poor health outcomes happening in those
neighborhoods as well. So we’re actually
going to test that today. We’re going to look at,
not only infant mortality, but other health outcomes
that are linked to place. One of the reasons that we
are really concerned about infant mortality here in
Ohio is that our state doesn’t do very well in terms of
infant mortality. We’ll look at some statistics on that in
a second. But in fact, our entire nation doesn’t do well
in terms of infant mortality. When you look at the
infant mortality rate in the United States compared
with other advanced countries, you can see in that bar
chart to the right that, among those
countries displayed there, we are pretty close to the
bottom, if not the bottom. There are probably some
countries that are below us, but not among the
developed countries. And you’ll also notice
that the infant mortality rate tends to go up in that bar chart
or in that graph on the left, as we go from the prenatal
period; I’m sorry, the perinatal period to the postnatal period,
and then the postnatal period. So not only do we not
do well as a country, but there are also differences
in infant mortality that vary by the affluence of
the mother, essentially. And so you can see that here
in the United States, again, the infant mortality rate goes
up for both wealthy mothers and disadvantaged
mothers from one day to one year of birth. The gap widens quite
substantially between disadvantaged mothers and
mothers who have more resources. Now I want you to keep that gap
in mind as we look ahead here, because if you look
at where babies die in that neonatal period, one month after birth, versus
the post-neonatal period, you see that the location
of the infant’s death varies quite a bit
between those two periods. In the neonatal period,
overwhelmingly babies who die, die in the
hospital as inpatients. These are most
likely babies that have had congenital problems. They’re babies that have
struggled from the point of birth, and most likely,
these are largely babies that never leave the hospital. When you look at the
post-neonatal period, however, you see that the majority
of infants who die, either die in the home or in the emergency
room, probably because they were having trouble
at home and were brought to the emergency
room and never made it to inpatient status. And it’s
in that post-neonatal period when the socioeconomic status
issues [unintelligible] in how well a baby thrives. So I want you to keep that
in mind as we move forward and talk about place. Now, here’s Ohio, compared
to the rest of the states in the union, and you can
see in that graph on the left, Ohio is pretty far down in terms of overall infant
mortality for white babies. We rank probably, depending
on whose numbers you look at, between 42, 48 or so, for
overall infant mortality. The chart on the right shows
you the infant mortality rate for black babies, and you
can see that Ohio is really far down the list. Either at
the bottom, or again, depending on whose numbers you look
at, among the bottom five. Now I’d also like for you
to take a look at the x-axis across the bottom of both those
charts, because you’ll see that the difference in
rate between whites and blacks in terms of infant
mortality is pretty stark. In fact, if we
overlay the entire range of infant mortality rates across all 50 states for
white babies on the rates for black babies, you can see
that with the exception of Washington up there at the
top, the absolute lowest rates of infant mortality for
black babies are higher than the highest
rates for white babies. So there are some real
issues there that we have to unpack a little bit about why
it is that infant mortality is so much worse for black babies
than it is for white babies. Now we’re going to be
talking about Ohio quite a bit, so if you’ve never been to
Ohio, this slide will just help to orient you. We are firmly in
the Midwest, in the Rust Belt. We’re a Great Lakes state. Lake
Erie is to the north of us. And we’re going to talk
specifically about research that we’ve done in Columbus,
Cleveland, and Toledo. This is a map that we prepared
for the Ohio Equity Institute to help inform their work on infant
mortality across the state. And what you’re looking at is a
density map of infant mortality. This is where babies have
died in the greatest numbers, in this case. And you read this just
like you would a weather map. The hot spot areas are
the areas that are red. Those are the areas with
the highest concentration of infant death. And it’s not surprising,
I think, to most folks, that the highest
concentrations of infant death are gonna be in the
urban centers of the state, simply because that’s
where the most people live. But you can see, even
across a particular city, there are
variations across the city. And so it’s those
variations across the city that we want to talk
about for the most part today. This is just a brief map to
show you what you’re looking at when you look at a dot density
map. It literally is showing you where the dots are the most
dense. Each point on that map represents one infant death
from the period 2007 to 2011 in Franklin County. That’s
the county where Columbus is located. It’s where
The Ohio State University is. And there are 770 dots
on that map. Seven hundred and seventy infants who died
before their first birthday over that period
in Franklin County. Now we have top-notch
medical facilities here, and so one of the things that is
really a mystery and a question that we need to answer is why is
it in the midst of such wealth and such great healthcare
resources are we still seeing infant mortality as such
a dire problem in our state and across the nation? So when
we look across an urban area like Columbus, we
see, obviously, that there are
different neighborhoods, and so we want to
be able to tease out the characteristics of
those different neighborhoods to see if we can find patterns
that will help us address this problem of
infant mortality. Now one other
thing to point out about these maps is that
even though there are areas on the map that don’t have
any color overlay on them, that doesn’t mean there
weren’t any infant deaths in those areas. We’ve just
chosen to show areas that have more than one infant death per
square mile, because the point, here again, was to
find those areas that have the highest concentration
of infant deaths in the city of
Columbus, Franklin County. Once we identify those
areas using hot spot mapping, we then overlay the
census tracts for those areas because what we want to do is
understand the characteristics of those neighborhoods. We
know where babies are dying, now we need to take a closer
look at those neighborhoods to see if we can find patterns.
And to do that, we use largely census data, or data
that’s linked to census tracts, because that’s the geography
that a lot of people work with. Now, the names of
these specific neighborhoods aren’t important. They’re
important, obviously, to us here in Columbus, because
they identify areas that we are familiar with. But what’s
more important is just to notice that we’re describing different
areas of the city that have a similar problem. They all have
high rates or high incidences of infant mortality. In fact, when we look at
all of those areas together, what we see is that each one of
those areas, not surprisingly, has a higher rate
of infant mortality than the county as a whole. In fact, those areas taken all
together have only nine percent of the county’s population, only
about 12 percent of the county’s births, and yet when we look
at infant deaths, 22 percent of all infant deaths and 30 percent
of all non-white infant deaths occur in those hot spot areas. So if we can address infant
mortality in those areas, we’ll be taking a substantial
step toward solving or addressing infant mortality
for our county as a whole. Now a moment ago, we saw that
you could overlay census tracts on these hot spot areas, and in
essence, that’s what we’ve done with this map as well. Each dot on that map represents
one census tract, and in this case, the size of each
dot represents the incidence of STDs, a measure or
proxy for safe sex practices, in each one of
those census tracts. The larger the dot, the more
cases of chlamydia and gonorrhea per thousand population. And when you look
at a map like this, you start to see that there
are definitely some overlaps between what you might consider
not safe sex practices, using this as proxy,
and infant mortality. Now it’s not 100 percent
alignment, as you can see. There are some areas
that have high rates of STDs that don’t have high
infant mortality rates. And conversely, there
are areas that do have high infant mortality rates
that don’t necessarily have high STD rates. You can
see that on the west side of the city, for example;
I’ll circle it over here with my cursor. Not
terribly high STD rates, and yet that’s a hot
spot for infant mortality. Another factor we can
look at is teen births. There is some correlation
or some linkage, at least, that we can see in the
overlap of the incidence of teen births and the
infant mortality rates. Now again, not 100
percent, and we’re really just doing a visual correlation. We’re not doing any
mathematics or statistics in order to say that
this is a specific linkage. Nevertheless, when
you look at the overlap, you can see that for
most of those hot spot areas, we have an increased
number, an increased percentage of teen births in those areas. We can also look at some
of the social determinants of health; socioeconomic
factors. In this case, what we’re looking at is
the percentage of households receiving SNAP benefits,
that’s food assistance. And again, the size of the
dot represents the percentage of households
receiving SNAP benefits. Again, some rough
alignment. In particular, in the northwest
corner of the city, you see very low rates
of infant mortality and also very low rates
of SNAP benefit usage. Out here on the west
side, where we saw low rates of STDs, over this particular
hot spot, we see that there’s a fairly high
incidence of households receiving SNAP benefits. So again, we’re
starting to tease out here that even though these
neighborhoods experience the same problem, infant
mortality, they’re different neighborhoods in terms of
their socioeconomic status and other aspects
of their composition. And that’s going to
inform them what kind of strategies we might want to
use in addressing this problem in those neighborhoods. So let me just kind of
cut to the chase here. We see differences in
the racial composition of those neighborhoods.
We see differences in the percentage of
foreign-born persons in those neighborhoods,
differences in crime rates, and differences of
housing vacancies. When we take those
all together, the graph that you see there on
the left just represents six of those factors and you
can think of each vertical line there as being a
ranking from low to high. And so, for example, when
you look at, let’s just follow the red line. The red
line is for an area of town we call Franklinton. And it’s
got an infant mortality rate about halfway between
the highest and the lowest infant mortality rates
for those hot spot areas. Looking further to the right,
the percentage of pre-term births is about 75 percent,
and then when you look at the percentage of
non-white and foreign-born, very low percentages of both. Looking at these different
arrays of characteristics, let’s characterize these
neighborhoods so that we can make some conclusions
about the folks who live there and the types of interventions
that might work in those areas. And strategies
for doing outreach. And so, when you look
at Franklinton Hilltop, this is a low-income,
predominantly white community, a lot of urban
Appalachian influence, and there’s significant
neighborhood distress. You can see that
by the vacant housing rate and the violent crime rate. Kind of at the other
end of the spectrum, these three communities all again
track pretty closely together on those indicators
that we show on the chart, and these are
immigrant communities. A lot of Hispanic Latino
families, African-born blacks. We have a very large
Somali community in Columbus. And relatively less
neighborhood distress. And you can see very high
percentages of both non-white and foreign-born. And then finally,
these three neighborhoods that go through the north-south
axis of the central part of the city are predominantly
African-American communities; low-income with significant
neighborhood distress. These are South Linden,
Near East, and Near South. And it’s these neighborhoods
that the Columbus Infant Mortality Task Force chose
as their pilot neighborhoods to begin to work on interventions
to address infant mortality. And their choices were
based in part on the research that we did for them
through these mapping efforts. Now we just looked at infant
mortality, but if you look at the other end of the spectrum,
the end of the life course, look at life expectancy from
birth, you see that there are also similar patterns
with life expectancy. The central city portions have
the lowest life expectancies and the outlying suburbs have
very high life expectancies. The key here is the place seems
to be the common denominator. In fact, when you look at
the range there, the span of life expectancy is almost 20
years from zip code to zip code across Franklin County.
It’s a pretty stark difference, and we’ve seen similar
differences through our research and through the
research of others, in cities all across the country. So let’s talk about
the foundation here. Let’s talk about place as a
determinant of health outcomes. We’re gonna talk some
about our historical policies that shape neighborhoods,
and we’re gonna shift away from Columbus for a moment and talk a
little bit about another city, Toledo. That’s the one on the
map that was in the upper left corner of the state.
It’s a moderate-sized city. It’s a little bit smaller than
both Cleveland and Columbus, a little bit larger than a town.
I guess the population there is probably around
250,000 in the central city. So let’s talk about
place a little bit, and urban development. It’s important to keep in
mind that the way our cities are structured is not a
result of natural processes. The way our cities are
structured are the result of policies and practices that
human beings have implemented. And so we need to talk about
the role of racial and social exclusion, and frankly,
exploitation, as driving forces in shaping the
cities that we live in. Now we’re not going to
have time to talk about all of these different
drivers of racial segregation in the structuring of our
cities. I’ll just mention very quickly some of the
ones on the right there. For example, zoning
and land use practices. Zoning is just designating,
municipalities designating particular land uses and
requirements for buildings on different parcels of
land. And so for example, one way that a city could
have a discriminatory practice of zoning would be, if you think
about the outlying suburbs, saying that, requiring
that parcels in those areas have to have very large lots;
the homes have to have a minimum of three bedrooms. Things
like that that would price out lower income buyers
from that housing market. Urban renewal was a
practice in the 50s and the 60s that attempted to
provide affordable housing. We won’t go into any of
that, other than to say that I’ll give you some references
at the end that will kind of walk you through some of
the steps of urban renewal and how those policies kind
of both misjudged the social structure of the
country, and also actually were discriminatory
in their practices. On the right there, you
can see another program that significantly
affected our cities, the building of
the interstate system. This happens to be Interstate 71
as it was being built through Columbus. It follows the
north-south trajectory through the middle of the city, and
if you think back a few slides, it slices right through a good
portion of the African-American community in Columbus. And
I think if you, as you drive in your own city down an
interstate and look to your left and look to your right and
imagine what was in the place of that interstate before
the highway arrived, I think you’ll get a sense of just how
divisive and how destructive the interstates were to particular
neighborhoods in our cities. Remember that the folks
who created the interstates and created the policy
listened to their constituents and they also listened to
the folks with political power. And if you think about a typical
low-income neighborhood that doesn’t have a lot of
organization or a lot of resources, not a lot of
political clout there either. And so it’s not surprising
that those neighborhoods, in particular, were
devastated by the interstate. And then of course, there are
the kinds of explicit racial discrimination and intimidation
practices that I think most of us are most familiar
with, because they’re the interpersonal kinds of
things. For example, a realtor may show a black family fewer
properties than a white family. Or they may show black
and white families properties in different parts of the
city. Those are discriminatory practices and the further
segregation in our cities. But I want to go over to
the left there and talk about redlining and investment
practices, and we’re gonna spend a little bit of time on
this, because of all of these, these are the ones that are
probably the most universal practices and the ones that
probably had the most effect overall on shaping our cities to
be the way that they are today. Now before we talk about
redlining specifically, and I’ll define that
term in a second; I do want to also
point out that one practice that was used to prevent
the, as they say, at the infiltration of undesirables,
as they defined them. And undesirables at this point
were blacks, Asians, people of Eastern European
descent. In essence, anybody who wasn’t what, in
the language of the day, they called a natural-born
white, which is an odd phrase, but it was the way that
whites in those days referred to folks who were white
and were well-established. One of the structures that were
utilized were racial covenants inserted into deed
documents or incorporated into subdivision bylaws and
property owners associations. You can see an example of
one of those here on the right. “None of the said
lands interest therein or improvements thereon shall
be sold, resold, conveyed, leased, rented to, or
in any way used, occupied, or acquired by any
person of Negro blood or to any person of the
Semitic race, blood, or origin, which racial description shall
be themed to include Armenians, Jews, Hebrews,
Persians, or Syrians.” Now this language might
have actually been inserted into the deed document itself,
and when a person purchased that home, this was, at
the time it was written, a binding contract saying
that if they agreed to purchase the home, then they also were
agreeing not to sell the home to any of these folks
that were listed here. Those have long since been
determined to be unenforceable, but if you have an older home,
say built in the 20s or before, or maybe a little bit later, take a look at your
deed and see if it includes some of that language.
It might be a little bit surprised at what you
might find in your deed. Well, let’s talk about
suburban growth and race. Specifically, we’re
gonna talk a little bit about the
development of the suburbs. You may have heard the term
“white flight,” and so this is gonna describe how, basically,
whites left the central cities for the suburbs, leaving the
central city, the central core, without an adequate tax base.
And therefore, kind of set it on the course to
decline. But there were some other factors involved,
and we’ll go into those. If you look at the
prime suburb-shaping years, from 1930 to 1960, fewer than one percent of
all African Americans were able even to obtain a mortgage. They
were entirely closed out of the housing market. And if that phrase
“formation of white America” sounds a little strange to you;
again, I’ll have a resource listed at the end that helps to
explain exactly what that means. In essence, what it means is
that the concept of white and the concept of race overall
is essentially just that. It’s a social construct.
It’s not a genetic reality. And that social construct has
shaped policies and practices that have led to
discrimination and segregation. And just to put a fine point
on this, the kinds of things I described earlier about
realtors showing homes and those sorts of things, those
are interpersonal, one-on-one types of discrimination.
But I want to point out on the
right-hand of this slide some text from the
FHA underwriting manual. This is from 1947, but this text
remained in the manuals until the 60s. “If a neighborhood is to retain
stability, it’s 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.” This reflects kind of an
overarching conceptual framework that said that neighborhoods
progress in a certain way. When neighborhoods are
first built, they’re pristine. They have nice facilities.
The homes are all new. And as the
infrastructure declines, and as some people move
out, and other people move in, the decline is hastened. And one of the things that it
was believed hastened decline was the influx of blacks
and immigrants and other folks that were deemed to
be, again, undesirable. Again, federal policy.
This is part of that structural racialization that I pointed out
on the slide at the beginning. This is prejudice. This is
discrimination that’s built into federal policy. Now, you might have heard
the term “redlining’ before. It’s a term that’s reached kind
of general use, but this is where the term originated. What
you’re looking at here is a map of the city of Toledo
from, I believe, 1938 or somewhere thereabouts. This map and maps for about 240
other US cities were produced in the 1930s by the
Homeowners Loan Corporation. This was a federal office that
was set up in the wake of the Great Depression. The purpose
was to insure refinanced loans for homeowners who were
struggling to keep their home. So the idea was, the Homeowners
Loan Corporation, it did issue some loans, but its main
purpose was to insure the loans on mortgages for folks who
needed to refinance in order to keep their homes. In order
to protect taxpayer dollars, the Homeowners Loan
Corporation had local realtors, real estate professionals, and
bankers assess the neighborhoods in their cities
for the perceived risk of insuring a loan. So when you look at the
map, the assessors ranked neighborhoods from A to D and
used color codes to represent those, green being the
highest value and red being the lowest value. In other
words, green being the lowest risk for insurance and red being
the highest risk for insurance. So if you wanted to write a
mortgage loan for one of those red areas, one of those redlined
areas, if the loan defaulted and you were the one
who issued the mortgage, federal government
essentially wouldn’t insure it. It’s a very large disincentive
to pour money into those redlined areas and to put any
kind of investment in place. Now the thing that was
different about the way that those assessors evaluated the
properties around their cities and the way we do
property appraisals today is that the appraisers of
those days didn’t just assess the neighborhoods on
the basis of the properties and the land that were
present in those neighborhoods. They also assessed the
neighborhoods on the basis of the folks who lived
in those neighborhoods. Because remember that general theory that said cities
decline in a certain way, and one of the ways that leads
to decline of neighborhoods is through the influx of folks
who are going to lower your property values. So this is a copy of
one of the documents. Each one of those areas that
you saw on the map; red, green, yellow, blue; also had assessor
notes associated with it. You can get these for
some cities from the National Archives, or you can do some
web searches and find these. This happens to be a grade
A area description from one of those greenlined
areas in the city of Toledo. And what’s really interesting
about these, if you look at the upper right, there’s
a space specifically for the percentage of Negro
population in that area. And in this case, there were
no blacks living in the area. The availability of mortgage
funds for home purchase and home building was ample.
And if you read the clarifying remarks, you see things like
“This is a somewhat older but very fine
high-type neighborhood; pride of
ownership, well-planned homes soundly constructed within
short distance to University of Toledo. Abutment to
cemetery and lower-grade areas should not jeopardize
our ability for several years.” So, you know, cemetery,
obviously a fixed use. And so you were
pretty much guaranteed that nobody was
going to move in next to you if you
lived in this area. Now let’s take a look at
a grade D area description. Again, it’s from Toledo.
Factory and common laborers, about 20 percent black.
Availability of mortgage funds for home purchase very limited;
for home building, very limited. And in the clarifying remarks,
“Now rapidly being run down through influx of colored
and low-income group of whites. Heavy relief load,
high vacancy ratio.” Another grade D
area description, “about 95 percent black,” and look at that; availability
of mortgage funds for home purchase and home building,
just flat-out no.There was just gonna be no mortgage
investment in this area at all. And the only difference
between this area and the preceding one was
the percentage of black. So we talk about the
life course of individuals, this chart here really
summarizes more the life course of a redline neighborhood.
Now the redlining maps, when they were created,
reflected the discrimination and the segregation that was
already present in our cities at that time. And it’s
questionable whether folks actually used the redlining
maps to make case-by-case mortgage decisions, but
what we do know is that because local
appraisers were used in the process of
creating the redline maps, that’s how those
folks viewed their city. And those are the ones
who made the decisions on whether or not to issue
mortgages, based on whether they could get them insured or not. So the redline maps, we know,
do very specifically reflect where there would be
greater or lesser investment by the folks who
created them. In other words, a redlined area wasn’t going to
get a whole lot of investment in terms of mortgage funding. So you have disinvestment.
Because there’s no investment, then it becomes kind of
a self-fulfilling prophecy that the housing
stock would decline there, and then in later days, we
also see predatory lending in those areas and
property value loss. Again, a self-fulfilling
prophecy because if you’re not investing in those
neighborhoods, you’re going to see some decline. Some results that
come out of that: foreclosures and
vacancy. You also have crime and safety and health
problems because the tax base is declining in those
areas. And then you also, if you are a homeowner in
those areas, your property values have gone down,
and so you see a loss of the equity that you’ve built up in
the home that you’ve purchased, if you’ve been
able to purchase one. Well, let’s see if that bears
out. Again, this is Toledo. The upper map there is
just to remind you that’s the redlined area. The
lower maps are from 2013. These are residential parcels;
in other words, each little space on that map represents one
residential or one home parcel. And you can see, largely,
in the areas that correspond to the areas that were redlined,
most of the residential properties were built before
1950, so there hasn’t been a whole lot of new construction
at all in those areas. Some neighborhoods
have seen absolutely none. And also the property values in
those areas are very depressed. Well, let’s look at some
health correlates as well. We said earlier that
place makes a difference in health outcomes. And so
if you look at the risk of lead poisoning in those
areas, and let me go back here for a second.
These two factors together, low property value and
homes built before 1950, or even homes in
yellow built before 1970, those two factors combined
to create a pretty high risk of lead poisoning, because
of lead-based paint dust in the homes. And in fact,
we’re doing some of that work in Toledo now with some of the
legal aid agencies up there. And not surprisingly, if
you look at the redline map, you think about the current
valuation of those properties and the age of those properties;
again, it’s not surprising that the disinvestment
in those properties has led to a high risk of lead
poisoning, as shown on the map on the right. We can
also overlay other things on the redline map; again,
remembering that the redline map correlates pretty highly
with lead poisoning risk. We also see that, in the
2000s, if you look at those neighborhoods that
were previously redlined, there’s a pretty high proportion
of those neighborhoods that were also targeted
with high-cost mortgage loans. We think of this as actually
being reverse redlining. In the redlining days, it was
a lack of information about the lending practices that got
folks into trouble when they actually tried to obtain
a mortgage for those areas. In the era of the high-risk,
high-cost mortgage loans, it was actually an
overabundance of information. People were given way more
information than they could absorb, and simply signed
on the basis of, essentially, trust, to get a
high-cost mortgage loan. And not surprisingly, a lot of
those loans went into default. The effect being that what
little equity was left in those areas that had been
previously disinvested, was more or less
sucked out of those areas, further depressing them. Well, let’s look
at health outcomes. Here we go. The infant
mortality hot spot map is shown overlain on
Toledo. It’s a little difficult to see, but if you look
in the upper right there you can see just the
lip of Lake Erie dipping in to the city there. So that’ll
orient you a little bit. These are the hot spots,
and overlaid on those hot spots are the outlines of the
census tracts that we used to analyze those neighborhoods.
And if we overlay those census tracts that correspond
with infant mortality, I think you can see that
here again, for the most part, except in the
northwest corner of the city, those previously-redlined
neighborhoods are also the areas where we see high
incidences of infant mortality. Again, disinvestment in
the central neighborhoods has led to conditions that
are rife for creating poor health outcomes. And it’s
not just those two cities that we’ve looked at here. Just
to kind of put a final point on this. This happens to be
Cleveland. This is the redline map from 1940s
Cleveland. Lake Erie is up here to the left, right along here. The Cuyahoga River
comes down through here, the river that caught
fire a few years ago. And when you look at
the redline map compared to current health outcomes,
in those previously redlined areas, you see infant mortality
rates five to six times higher than the
non-redlined areas. You have higher rates of
lead exposure, just as you have in Toledo. Higher exposure
to toxic waste release sites. You have the highest
vacant property rates. You have more than one
half of all residential loans subprime. And there’s a 15-year
difference in life expectancy between those previously
redlined areas and areas in the rest of the city.
And again, let me just toggle between these two,
just so you can see. Redline, infant mortality.
Again, for the redline, it’s both red and yellow
areas that were disinvested. The redlined areas
primarily, but the yellow areas were seen as being in
decline, and so there was very low tendency to
invest in those neighborhoods as well. The red and
yellow areas, and again, infant mortality
current outcomes. And again, if we look at
more contemporary things, the neighborhoods that
receive the most high-cost mortgage loans; again,
very high visual correlation between the areas that received
high-cost mortgage loans and those areas that
were previously redlined. Now I want to point
out that a neighborhood’s being redlined was not
necessarily a death sentence for that neighborhood.
We do see exceptions where some of the previously-redlined
neighborhoods have turned around and
actually become very nice areas of town. And the
question we need to ask when we see those
kinds of transformations is whether it was a straight
line progression between being a redlined area
and kind of a nicer area. In other words, the area picked
itself up by its bootstraps. Or did we see some other
things happening in those neighborhoods? Things
like gentrification, where the neighborhood declined to a
point that folks either left or were forced out, and
new construction and new neighborhoods took their
place, displacing the folks who lived in those
neighborhoods previously. A lot of history happened
between 1930 and current day; almost 80 years. But again,
the fact that these areas were redlined led to a
lot of disinvestment in those areas and more often
than not, those areas subsequently didn’t prosper. Well, why is this
history relevant today? This is kind of
bringing everything together. There is a direct
relationship between historical patterns of systemic
discrimination and today’s community-based
health challenges. Because of the way
that our cities developed and the practices and
policies that were in place, you saw what we described
earlier as white flight. Whites tended to leave
the central cities for the suburbs, because
they could afford to. And what you were
left with were folks who didn’t have the
means to move elsewhere being concentrated
in the central cities and segregated racially. Now if you happen to be somebody who’s living in
one of those areas, then you lack access
to adequate healthcare and other
necessary assets to thrive. For example,
healthy foods. Now again, that’s not to say
that these areas should be written off, certainly
not. It’s also not to say that these areas
don’t have resources. One of the things that
we do when we work with a neighborhood is not
only to help them identify the areas of need, but
also to identify the assets that are present in those
neighborhoods that can be marshalled to address
the problems and the needs of those neighborhoods.
And sometimes those assets aren’t physical. Sometimes
the assets that are strongest in a community are
the community’s cohesion, its social linkages. Or the
third places, as we call them, where folks meet to
discuss and organize and plan. So assets aren’t necessarily
physical but they are definitely important
in these neighborhoods. Another thing I just
want to briefly mention is that the folks who live
in a disadvantaged neighborhood don’t spend
their entire lives in a disadvantaged neighborhood. They also interact
with society at large. And if you are black,
growing up in America, you are under pressure 24/7; what we call micro-aggressions,
or the little slights that blacks are
subject to when they interact with mostly whites. This
creates some stress levels in addition to the stress of
living in an impoverished area. And as biologically-focused
folks as you are, you understand that if any
creature is stressed 24/7, there are physiological
responses, hormonal changes that can lead to permanent
or oftentimes very long term effects on the
physiology of that organism, and that organism
includes human beings. And the reason we know
this is because when you look at health outcomes for
blacks compared to whites, even when you allow for
all other factors being equal, so black families and
white families of the same socioeconomic status, living
in the same types of housing, the same kinds of
neighborhoods. When you look at health outcomes
between whites and blacks, blacks still have worse
health outcomes than whites. So there’s something
else going on there besides socioeconomic status. It’s
not that that’s not important, but it’s also not the
only factor that figures into poor health outcomes for blacks. So I guess in terms of
recommendations, and I don’t know specifically how much
involvement a preconception peer educator has with folks
that you’re interacting with, if they happen to become
pregnant, and throughout the pregnancy and throughout
the first year of birth. But what I would advise is that
if you have the opportunity, then by all means, make all
attempts to connect the folks that you’re working with
with resources that will buoy them up through
pregnancy, through delivery, through that postnatal
period, and especially that post-neonatal period,
that two to twelve months. Because that’s where, in
terms of infant mortality, again, we tend to see those
socioeconomic status factors really impinging on the health
and the ability to thrive of infants. Well, I said throughout
that I had some resources that I wanted to put up
here for you, and here are a few that I’ve found
really helpful as I’ve thought through some of these problems. The first one up there
to the left is a website. It’s from the California
Newsreel organization. They create films for
social equity, social justice. There’s one series in
particular that lays out specifically the things
that I spoke about with place and a lot more. It actually
goes into some of those other factors, like
zoning and urban development and white flight, and
explains the linkage between race and location
in a very engaging and very informative way. You
can actually; you used to have to buy the series, the film
series. It’s a four-part series. But you can now rent it on
Vimeo. I think it’s $4.99 for — and it’s a
three-part series, not four. The one that I
would recommend watching; if you can’t watch all of
them, I recommend watching all of them; but the
third episode in the series is called Race,
the House We Live In. And it goes through this
history of development and real estate practice
from the turn of the century up through present day,
and really lays out in a very clear and concise
manner the linkage between real estate practice,
federal policy, and inequity. Off to the right there is a
talk that I highly recommend you listen to. Nadine
Burke Harris is a pediatrician in Oakland, California.
If you’ve read the book How Children Succeed,
she figures prominently in that book. Her work in Oakland
in a distressed neighborhood there led her to discover
the resource down at the lower left, The Adverse
Childhood Experiences Study. And again, you might want to
take a look at the ACE Study. If you haven’t heard of
that before, what the ACE Study does is, it posits a series
of questions, and you can take the ACE Study as an adult,
because what it asks you about is adverse experiences
that you had during childhood. And the number of adverse
experiences that you had directly correlates with
health outcomes in adults. In other words, the more
adverse childhood experiences you had, the greater is the
likelihood that you’ll have health problems as an adult. Again, Dr. Harris
explains that very well. It’s an engaging talk.
It’s about 20 minutes. They’ll give you kind of a
brief overview of the ACE Study and its use and the
correlations between childhood trauma and
adult health outcomes. The one other thing I would
mention, and it’s not on the resource page here though,
is that one of the reasons I’m mentioning the ACE
Study and Dr. Harris’s talk is that if you are working with,
if you’re counseling folks who grew up in one of
these distressed neighborhoods, or if you’re counseling
minority folks, or black folks, then you should keep in
mind that these adverse experiences and the
experience of living in a distressed neighborhood may
be part of their background, of their growing up. And so
it’s essentially important to, again, connect them with
resources that can help them through this
period of their lives. I’d be remiss if I claimed
credit for all of the work that I just described to you. In fact, there have
been several staff here at the Kirwan Institute who
have worked on this research. Some of them are listed there
and in addition to those folks, probably about half a
dozen more graduate students have assisted us with this
work as they’ve gone through the Kirwan Institute. And that brings me
to the end of my talk. My email address is
there. Again, I’m David Norris, senior researcher at
the Kirwan Institute, and if you’d like to
reach me with questions, you can do that.
Thank you very much. MARIA: Alright. Thank you
very much, Mr. Norris. That was a fantastic presentation. We
did have one question regarding your sources, but
since you’ve answered it with one of the slides, I
will read the second part of that question, which was
if you know of resources that our county or specific city,
if there’s that kind of data for a particular county or
particular city. For example, the person asking is
from Rochester, New York. DAVID: Uh-huh. What
kind of data specifically? The birth certificate data, or? MARIA: The question was
regarding examples of historical drivers of segregation
and exclusion policies. DAVID: Okay. I’m not sure
about Rochester, specifically. I do know that you can find
several resources on the web that will point you to
some of the redlining maps. It really is kind of a
case-by-case search when you do this kind of work. For
example, we’re working in Kansas City now on
something somewhat related. We’re looking at
emergency department usage, and we just happened
to find a book that was specifically about
real estate development and the development of
Kansas City, Missouri. So there may be some
local historians who have done similar research
around your city. And again, if you or any of
you would like some assistance in locating some
of those resources, just drop me an email. In the
course of doing our research, we’ve come across resources
all across the country, and we can certainly help
to point you in the direction of some of the data
that you might want. MARIA: Alright. Our next question is
if you’ve looked into the Flint, Michigan lead issues,
and have you found similarities in the Flint crisis that
relates to your own research? DAVID: Well, we haven’t
looked at Flint specifically, and the lead research
that we’ve done in Toledo is really around lead paint
rather than the kind of issue that they had in Flint,
which was lead in the water. And my understanding of Flint
was that when the City of Flint switched from the
Detroit water system over to taking water directly
out of the Flint River, they also failed to add
a chemical that conditions the pipes and then
keeps the pipes from leaching toxic minerals and substances. So it’s really kind of a
one-two punch for the citizens of Flint. Not only were they
getting toxins in the water itself, but they were
also getting lead leaching out of the pipes that were
part of the infrastructure of their water system. Now having said that, I think
that Flint is not an outlier. I think we’re going to
see a lot more examples, not necessarily of
the magnitude of Flint, but I think people are going to
be paying a lot more attention to the way their
water is treated; and also, the infrastructure
of the pipes through which the water is passing. You
know, lead was a common agent in piping through most
of the twentieth century and so I think we’re
going to see a lot more cities that are going to come to an
awareness that they’re sitting on top of this
crisis waiting to happen. In terms of similarities to
the kinds of things we’ve done in Toledo with lead,
the dosages for paint lead tend to be a little bit
less acute than the ones you’re seeing in Flint, simply
because the concentration of lead in the water was
so high there and it was such a toxic hit to the
system, so you saw some really, really terribly
elevated lead levels and other toxins as well in Flint. If you think about a similar
situation with, let’s say compare Detroit with
New Orleans and Katrina. You saw similar things
happening to the destruction of both of those cities.
It’s just that in one case, one was a man-made situation; the other was a combination
of man-made failures of the levees and nature. But the result was
essentially the same. One happened rapidly;
the other happened slowly over time. But the
end result was the same, and it’s the same
with Toledo and lead paint versus Flint and
lead in the water. Basically the same result.
You have a lot of children who were poisoned and
adults as well, who never should have been
and it was a policy and a government failure. MARIA: Oh my god. Wow. We
suddenly got a whole bunch of questions here at the end.
One moment, please while I parse through this.
DAVID: Sure. MARIA: Someone is asking
if you’ve conducted similar research in other areas. She
is asking if there have been similar results in urban
areas in the North versus urban and rural areas in the South. DAVID: That’s a great question.
To do this research is fairly time intensive. And to
do the specific things around infant mortality we’ve done,
that work has been in progress for a couple of years now
and we’re drawing directly from the birth and death certificate
database of the State of Ohio. We had to go through an
institutional review board to get that data. It’s
very tightly constrained. So in terms of infant mortality,
specifically, we haven’t done that outside
Ohio yet. We have looked at the redlining linkages
in some cities outside Ohio, and specifically, we’re
looking again at Kansas City right now. We have done
some work in Birmingham and also in Dallas, and
that work is still in progress. We’re actually curious ourselves
to see what kind of differences we’ll see, specifically
in the documentation, those assessor
notes that go along. One of the things that we
saw in Birmingham, for example, that differed from the
redline maps that I showed you for Ohio cities, was
that, in the maps you saw in my presentation; for the most
part, the city was parsed out into A, B, C, and D areas.
In Birmingham, what we saw on the redline map was, there
were A, B, C, and D areas, and then there were
entire swaths of the city that were completely
crossed off as black, or Negro, in the vernacular of the day. And so, they weren’t even
considered to be on the radar in terms of any
kind of investment for mortgages whatsoever. They simply were
not even in the game, in terms of mortgages. So that’s one interesting
difference that we saw. But again, that work is in
progress and we’re really hoping to learn a lot more. So
we’re asking the same question, we just don’t have a whole
lot of answers to it just yet. Now, having said that,
there are folks who have done similar research in other
cities. Richmond, Virginia, I believe, has a website
where they’ve actually overlaid a digitized redline map
on current-day conditions and you can compare those. If you just do a Google
search on redlining maps, you’ll come upon a Slate page.
This is the online magazine, Slate, and they have a webpage
that I think specifically the title is Where to Find
Redlining Maps for Your Area. You can certainly find those.
And again, if you want some assistance with interpreting
those, looking at those and correlating them
with current conditions, drop me a line and
we’ll work with you. MARIA: Alright. Another
question. We’re getting this one more than once, which is,
have you done similar research or do you know of someone
who’s doing similar research with regarding
Latino communities? DAVID: Not specifically
Latino communities. I focused pretty much on African-American
communities because that’s where we see the most health
disparities, the most glaring health disparities. Again,
in Kansas City; Kansas City has a very large Latino population,
primarily due to its historic linkages
with the railroads. There’s a very large
Latino community that settled pretty much around the
central railyards of the day. We’re getting into some
of that. We’re limited with the data that we have because
we’re using hospital records in that case. And even though
the city has a very large Latino population, when you
look at the way the data was collected on patients when they
were taken into the hospitals, there wasn’t a place for
people to indicate they were Hispanic or Latino. So we’re
pretty much having to go by assuming that Latino patients,
in the absence of the option to indicate they’re Latino,
probably either mark their race as white or other. And
doing a demographic overlay with the census tracts to
try to ferret out which parts of the city are specifically
the Latino population and the Latino patients. But I think, even given the
lack of our research on that, I think the same thing
holds in that when you look at these distressed neighborhoods
and lower-income folks, they tend to be concentrated
in these areas that also experience these other
poor health outcomes as well. MARIA: Another question we have
is in regards to, it’s sort of a two-parter regarding
this research. Number one, do you have any suggestions
on how people can improve their health outcomes, or
do you feel that because they were born or grew up in these
distressed areas that they’re more or less doomed
to bad health outcomes? And the other is, has
this gentrification been, is gentrification still
being purposefully coordinated to continue to exist, and
was is purposefully done? Was it purposefully
coordinated back then? DAVID: Okay. Let me see if I can address
the first question first. Could you remind me again
what the first question was? MARIA: Sure. How people
can improve their outcomes. DAVID: Okay. Okay. Yeah, so
I think one of the messages that we like to communicate
when we present this work is that because our cities
were formed largely through the workings of policy; you
know, policy is informed by people’s values. And so
one of the ways to change the situation,
because again, remember, it’s not a
naturally-occurring situation; it’s the result of, again,
purposeful policy choices and purposeful policy decisions. So I know it sounds a little
bit weak, I guess, to say this, but I think our current
primary situation really is also pointing to the need
to be politically involved, the need to be
advocates for your own area, for your own city, for
your own neighborhood. But I think it also, you know,
calls to account the folks who have power. The
folks who have power are the ones that can move the
levers. And so you really need to be in contact with those
folks and hold them to account. Now in terms of the
other question about whether folks are doomed. No, I
don’t think folks are doomed. In fact, when you look
at the research around microaggressions and
around chronic stress, it is possible to reverse
some of those physiological effects, which is why I said
that they may be long-term, but they’re not permanent. There are therapies and
other interventions that can help individually with
reversing the effects of chronic stress. So those
are available if you can find those resources. I think the other thing
to say about this is that one of the reasons we like
to look at multiple factors, when we look at
these neighborhoods. So we look at things
like the racial composition, certainly. But we also
look at access to jobs. We look at access
to transportation. We look at the
quality of schools. We do an exercise we
call opportunity mapping, where we roll together
about 20 of these different indicators, and we
didn’t look at that today. But the point of doing
that is to bring multiple stakeholders to the
table. One of the questions we get is, “Well, you
know this map that you’ve just shown me looks an
awful lot like a poverty map. Why don’t you just
show me a poverty map?” Or, “You’re not telling
me anything I don’t know about my city.” Well, if we put just
a poverty map up there, then we’ve defined
the problem as poverty. And poverty is a
problem. But if you tell people the problem is
poverty, then it falls to the poverty advocates to
solve it, and everybody else can just sit back and
wait until that happens. But if you can show that
in a given neighborhood, that neighborhood has
undergone decline because of historic disinvestment.
And because of that historic disinvestment resulting
from policy, you also have deficits in transportation,
in jobs, in school performance, in public places for kids
to play, in access to food. You show that all of these
factors are at work at once. It gives everybody a little
bit of responsibility in having created the problem,
but also it gives everybody a piece of the solution.
And it really does have to be a multi-pronged solution for
these neighborhoods in order to lift them up. The other
think I would say about that is that, as you just
saw from this presentation, these neighborhood conditions
didn’t develop overnight. We looked at the 1930s redlining
maps, and keep in mind that those redlining maps
represent the segregation that was already in
place in those cities. These folks were
describing them, regardless of their specific
intents and methods. They were describing
real segregation that already existed in those cities. Redlining didn’t create the
segregation and discrimination, but it did give us a
point in time where we can say specifically, yeah,
that existed even then. These neighborhoods
have been developing over long periods of time, and
so in order to correct these problems, we’ve got to
have multi-factor solutions that are also going to take
a long time to have effect. What that says is that if you’re
looking for political solutions, you really need to frame the
problem, frame the solutions, as, these are things that have
to outlast election cycles. These are issues and
problems that we have to tackle using multiple stakeholders
at the table over a very long term. Again, not to
say that there’s no hope; there is hope, but the solutions
aren’t going to be quick. MARIA: Thank you very much. We have now gone a little
bit overtime, so I’m afraid we will have to say
goodbye and goodnight for now. We want to thank Mr. Norris
for his wonderful presentation. If any of you folks still
out there have any further questions for him, number one,
the questions submitted via our chat box will be saved, so we
will be able to forward them to Mr. Norris. Those of you who
have not had a chance to send in questions, his email address
is Norris-dot-the number four-at O-s as in Sam-U-dot-edu. And
I believe he is moving forward on the slides to show you. Yes,
there it is. So you can send any further questions there
to him. To answer the most popular question of the
night, or of the evening, yes, it has been recorded. It
will go out in about one week, and the slides will also be
available. Send us an email to either Teddy Owusu or myself.
The information is there in your chat boxes and his email
should also be in the invite that you received. So if
you need those two things, just give us a call. You should get them
within one week, though. So again, to reiterate, thank
you very much, Mr. Norris. That was a fantastic, if a
bit harrowing, presentation, seeing all these horrible
things that have happened. I want to thank everyone
who stayed right here until the very end and all
the people who were with us from the beginning as well. So thank you very much
and we hope to see you at our next presentation. DAVID: Thank you.
MARIA: You’re welcome.

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Methew Wade

5 thoughts on “The Geography of Health”

  1. Roxanne Beye
    California Baptist University
    1. SES is lower for mothers who are single, less educated, and African American

    2. There is overlap between STDs and infant mortality rates
    3. Teen birth is a risk factor of infant mortality
    4. Less than 1% of African Americans were able to obtain a mortgage from 1930-1960

    5. Appraisers assessed neighborhoods on the basis of the people that lived in them

  2. Genesis Rivera, California Baptist University 
    1. Infant mortality is the death of an infant within the first year of life.
    2. The leading causes of infant mortality are a low birth weight, premature birth, sudden infant death syndrome, maternal complications of pregnancy, and injuries such as suffocation
    3. Areas with poor birth outcomes also exhibit shorter life expectancies and poor health outcomes such as asthma and diabetes.
    4. Homes were appraised not solely on the home itself, but also on those who lived in the home.
    5. The number of adverse childhood experiences an individual faces directly correlates with health outcomes as an adult.

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