Deborah Wallace

Socioeconomic determinants of health: community marginalisation and the diffusion of disease and disorder in the United States.

Abstract This article describes the cascading diffusion of “inner city problems” of disease and disorder in the United States–from the huge marginalised inner city communities of the largest municipalities, first along national travel routes to smaller cities, and then from central cities into surrounding more affluent suburbs–following the pattern of the daily journey to work. Public policies and economic practices which increase marginalisation act to damage the “weak ties” of the community social networks which bind central city neighbourhoods into functioning units. Spreading disease and disorder can be interpreted as indices of the resulting social disintegration, which is driven by policy. This “failure of containment” in the United States should serve as a warning for cities in Europe against reducing the municipal and other services that they provide to “unpopular” subpopulations.

U.S. apartheid and the spread of AIDS to the suburbs : a multi-city analysis of the political economy of spatial epidemic threshold

We compare mechanisms of AIDS diffusion at the county level from five U.S. central city epicenters into their associated metropolitan regions. Four of the five show an expanding hollowed out center of physically and socially devastated, politically and economically abandoned high density minority neighborhoods, surrounded by rings of relatively affluent majority suburban populations. From these centers AIDS diffuses into the suburbs as a single, spatially extended disease ecosystem. The exception, San Francisco, has not yet experienced the hollowing out process and is, we conclude, a major AIDS epicenter markedly less coupled to its suburbs because of that fact. This may constitute one of the few empirical observations of spatial threshold in epidemiology. Our empirical results contradict the conclusions of a recent National Research Council report that AIDS will be largely confined within marginalized urban populations. In reality U.S. urban apartheid, particularly its continuing disruption of minority social structures, has markedly accelerated the diffusion of AIDS into suburban communities. A widespread program of reform, which rebuilds minority physical and social community structures within both city and suburb, is an essential, but largely unrecognized, component to any serious strategy for the control of AIDS in the United States.

The Coming Crisis of Public Health in the Suburbs

A process of urban decay, coupled with forced displacement and behavioral problems, affecting an increasing number of neighborhoods in large U.S. cities. The resulting social disintegration has intensified a nexus of deviant behaviors and conditions, including substance abuse, that are related to transmission of HIV and resurgence of other contagious diseases. These diseases will diffuse, or are already diffusing, along the transportation hierarchy from larger into smaller central cities, and radially from the central cities into the surrounding areas. A widespread program of urban reform is a critical precondition for the control of contagious disease in the United States. It also is important for housing, social services, housing-related public services, and public health across urban and suburban jurisdictions.

The hierarchical diffusion of AIDS and violent crime among U.S. metropolitan regions : Inner-city decay, stochastic resonance and reversal of the mortality transition

Census data on migration within and between the 25 largest U.S. metropolitan areas-containing more than 113 million people-permit construction of a probability-of-contact matrix corresponding to a particular Markov process dominated by the nations largest cities, a hierarchical structure. Regression models based on vectors associated with that process find the large-scale diffusion of AIDS in the U.S.A. depends strongly on national patterns of contact with the original AIDS outbreaks in New York City and San Francisco as modulated by the violent crime rate, a local index of social disintegration resulting from the marginalization of minority ethnic urban communities. Violent crime is itself undergoing a recognizably similar hierarchical diffusion from the largest U.S. cities into smaller metropolitan regions. Further analysis suggests that continuation of public policies of benign neglect and planned shrinkage directed against marginalized urban populations may trigger a strong stochastic resonance which can significantly degrade public health and public order for much of the three-quarters of the U.S. population living in or near cities, in effect reversing the mortality transition of the last century.

Urban Systems during Disasters: Factors for Resilience

Urban neighborhoods form the basic functional unit of municipalities. Socioeconomically, they consist of social networks and interlocking layers of social networks. Old, stable neighborhoods are blessed with large social networks and dense interlocking layers. Both social control and social support depend on these complex structures of tight and loose ties. Public health and public order depend on these structures. They are the basis of resilience of both the neighborhood itself and of the municipality that is composed of neighborhoods. In New York City in the 1970s and later, domain shift occurred because of the disruption of the socioeconomic structure by the massive destruction of low-rental housing. A combined epidemic of building fires and landlord abandonment of buildings leveled a huge percentage of housing in poor neighborhoods and forced mass migration between neighborhoods. Social relationships that had existed between families and individuals for decades were destroyed. Community efficacy also greatly diminished. Drug use, violent crime, tuberculosis, and low-weight births were among the many public health and public order problems that soared in incidence consequent to the unraveling of the communities. These problems spilled out into the metropolitan region of dependent suburban counties. The ability of a municipality and its dependent suburban counties to weather a disaster such as an avian flu pandemic depends on the size of social networks in its neighborhoods and on the interconnection between the social networks. Diversity such as gained by social and economic integration influences the strength of the loose ties between social networks. Poor neighborhoods with extreme resilience conferred by a dense fabric of social networks must also maintain connections with mainstream political structure or they will fail to react to both good and bad impacts and communications.

Life and death in Upper Manhattan and the Bronx: toward an evolutionary perspective on catastrophic social change

During the 1970s, poor neighborhoods of New York City lost significant proportions of housing and associated community structure to a policy-driven process of contagious fire and building abandonment. The south Bronx was among the most heavily damaged areas. Here we analyze and compare the interrelationships between socioeconomic factors, housing, demographics, and two health outcomes (low-weight birth rate and homicide rate) in the southwest Bronx and in Upper Manhattan (Harlem, Washington Heights, Inwood), using standard statistical methods as well as the Ives amplification factor employed by ecologists. Upper Manhattan showed much stronger and less ‘resilient’ relationships between these factors than the southwest Bronx, that is, a system of tight ties which amplifies external perturbations. It indicates vulnerability to impacts such as economic decline, changes in municipal service provision, and ‘welfare reform’. We hypothesize that the looser, and more resilient, system of the southwest Bronx and the brittle system of Upper Manhattan arose from their different histories of catastrophic urban decay, a highly ‘path dependent’ evolutionary process affecting a social system, subjecting it to extreme selection pressures on the underlying social network structure. The difference has profound policy implications.

Will AIDS be contained within U.S. minority urban populations

Recent empirical research, and a simple stochastic modeling exercise, suggest that affluent suburban communities are at increased risk for the diffusion of HIV from present inner city epicenters, while the core group construct of sexually transmitted disease theory suggests, somewhat counter-intuitively, that the hypercongregated and strongly self-interacting nature of affluent heterosexual elites in the U.S. places them at significant and increasing risk as well. In turn, a growing body of work strongly associates high HIV prevalence in minority urban populations with the processes of coupled physical and social disintegration which have produced the now-common and politically-generated hollowed out pattern of U.S. cities. We conclude that a return to the principles of the Great Reform Movement, which first brought public health and public order to U.S. urban areas, is a necessary, but at present largely unrecognized, component to any successful national program to control AIDS in the United States, and particularly to stem the diffusion of HIV into heterosexual populations outside present diseases epicenters.

Roots of increased health care inequality in New York

During the 1970s, New York city experienced an epidemic of housing destruction by contagious fire and building abandonment. This epidemic was triggered by reductions in municipal services, especially fire control, in the poor areas of high population density and aging housing. The rapid loss of low rent housing led to a wave of forced internal migration of the poor within the city and overcrowding of areas adjacent to the burned out ones. The spread of overcrowding spread the high fire incidence. The massive upheaval resulted in destruction of social networks and in degraded living conditions. Public health, as measured by many indices such as disease incidence, substance abuse incidence, infant mortality, and incidence of homicide, deteriorated. This deterioration caused increased demand for hospital health care, especially emergency service. The data on average stay length in the poorest areas in comparison with wealthier areas hints that the overloading of the voluntary hospitals in the poorest areas has caused care rationing and greater inequality in access to care.

Toward Cultural Oncology: The Evolutionary Information Dynamics of Cancer

AbstractRacial disparities among cancers, particularly of the breast and prostate, are something of a mystery. For the US, in the face of slavery and its sequelae, centuries of interbreeding has greatly leavened genetic differences between ‘Blacks’ and ‘Whites’, but marked contrasts in disease prevalence and progression persist. ‘Adjustment’ for socioeconomic status and lifestyle, while statistically accounting for much of the variance in breast cancer, only begs the question of ultimate causality. Here we propose a more basic biological explanation that extends the theory of immune cognition to include an elaborate tumor control mechanism constituting the principal selection pressure acting on pathologically mutating cell clones. The interplay between them occurs in the context of an embedding, highly structured, system of culturally-specific psychosocial stress. A rate distortion argument finds that larger system able to literally write an image of itself onto the disease process, in terms of enhanced ‘risk behaviour’, accelerated mutation rate, and depressed mutation control. The dynamics are analogous to punctuated equilibrium in simple evolutionary systems, accounting for the staged nature of disease progression. We conclude that social exposures are, for human populations, far more than incidental cofactors in cancer etiology. Rather, they are part of the ‘basic biology’ of the disorder. The aphorism that ‘culture is as much a part of human biology as the enamel on our teeth’ appears literally true at a fundamental cellular level.

Community stress, demoralization, and body mass index: evidence for social signal transduction

Quantification of the relationship between community-level chronic stress from neighborhood conditions and individual morale has rarely been reported. In this work, pregnant women were recruited at the prenatal clinics of Harlem Hospital and Columbia Presbyterian Medical Center in the USA, and given an initial questionnaire that included all 27 questions of the Dohrenwend demoralization instrument, as well as questions about household economics and health. An index of chronic community stress (ICCS) was compiled for each of the health areas of the study zone by standardizing and weighting each stressor significantly associated with low birthweight rate and summing the standardized, weighted values. Health areas were divided into ICCS quintiles. The graph of the quintile weighted averages of the index vs. the quintile averages of the demoralization score was an asymmetric inverted U shape that fitted well to a stochastic resonance signal transduction model (adjusted R2=0.73). On average, the women in the worst three quintiles were much heavier than those of the two best quintiles. Women reporting household economic deprivations were significantly more demoralized than the others. Median health area rents were strongly negatively associated with the ICCS. The worst average demoralization score occurred in the middle quintile, a state of coping with both poor community conditions and an economically strained household. Rents bridge community conditions and household economics.