Nicholas Freudenberg

Coming Home From Jail: The Social and Health Consequences of Community Reentry for Women, Male Adolescents, and Their Families and Communities

Each year, more than 10 million people enter US jails, most returning home within a few weeks. Because jails concentrate people with infectious and chronic diseases, substance abuse, and mental health problems, and reentry policies often exacerbate these problems, the experiences of people leaving jail may contribute to health inequities in the low-income communities to which they return. Our study of the experiences in the year after release of 491 adolescent males and 476 adult women returning home from New York City jails shows that both populations have low employment rates and incomes and high rearrest rates. Few received services in jail. However, overall drug use and illegal activity declined significantly in the year after release. Postrelease employment and health insurance were associated with lower rearrest rates and drug use. Public policies on employment, drug treatment, housing, and health care often blocked successful reentry into society from jail, suggesting the need for new policies that support successful reentry into society.

Cities and population health.

n Abstractn n A majority of the worlds population will live in urban areas by 2007 and cities are exerting growing influence on the health of both urban and non-urban residents. Although there long has been substantial interest in the associations between city living and health, relatively little work has tried to understand how and why cities affect population health. This reflects both the number and complexity of determinants and of the absence of a unified framework that integrates the multiple factors that influence the health of urban populations. This paper presents a conceptual framework for studying how urban living affects population health. The framework rests on the assumption that urban populations are defined by size, density, diversity, and complexity, and that health in urban populations is a function of living conditions that are in turn shaped by municipal determinants and global and national trends. The framework builds on previous urban health research and incorporates multiple determinants at different levels. It is intended to serve as a model to guide public health research and intervention.n n

Healthy housing: a structured review of published evaluations of US interventions to improve health by modifying housing in the United States, 1990-2001.

We sought to characterize and to evaluate the success of current public health interventions related to housing. Two reviewers content-analyzed 72 articles selected from 12 electronic databases of US interventions from 1990 to 2001. Ninety-two percent of the interventions addressed a single condition, most often lead poisoning, injury, or asthma. Fifty-seven percent targeted children, and 13% targeted seniors. The most common intervention strategies employed a one-time treatment to improve the environment; to change behavior, attitudes, or knowledge; or both. Most studies reported statistically significant improvements, but few (14%) were judged extremely successful. Current interventions are limited by narrow definitions of housing and health, by brief time spans, and by limited geographic and social scales. An ecological paradigm is recommended as a guide to more effective approaches.

Comparison of health and social characteristics of people leaving New York City jails by age, gender, and race/ethnicity: implications for public health interventions.

Objectives. We compared health and social needs by gender, age, and race/ethnicity of people leaving New York City jails and assessed the implication of these differences for the development of jail reentry programs. Methods. Surveys were completed with 1,946 individuals (536 men, 704 women, and 706 adolescent males) between 1997 and 2004. Structured questionnaires captured data on demographic, criminal justice, substance use, and health characteristics. Bivariate comparisons were performed to determine variations between men and women, men and male adolescents, and non-Latino black and Hispanic/Latino respondents. Results. The majority of participants were black and Hispanic/Latino, reported high levels of substance use, had high rates of recidivism, and experienced difficult living circumstances. Compared with men, women were more likely to be homeless, use illicit drugs, report drug charges at index arrest, have health problems, and be parents. Adolescent males were more likely than men to rely on illegal activities for income and to have used marijuana and alcohol recently, and were less likely to report homelessness or health problems. Ethnic/racial differences between black and Hispanic/Latino respondents within gender and age groups were smaller than differences among these groups. Conclusions. Jails concentrate individuals with multifaceted health and social problems, providing opportunities to engage at-risk populations in comprehensive reentry programs. Gender, age, and ethnic/racial differences among incarcerated populations require that interventions be tailored to the specific needs of these different groups.

BEYOND URBAN PENALTY AND URBAN SPRAWL: BACK TO LIVING CONDITIONS AS THE FOCUS OF URBAN HEALTH

Researchers have long studied urban health, both to describe the consequences of urban living and to design interventions to promote the health of people living in cities. Two approaches to understanding the impact of cities on health have been dominant, namely, urban health penalty and urban sprawl. The urban penalty approach posits that cities concentrate poor people and expose them to unhealthy physical and social environments. Urban sprawl focuses on the adverse health and environmental effects of urban growth into outlying areas. We propose a model that integrates these approaches and emphasizes urban living conditions as the primary determinant of health. The aim of the model is to move beyond describing the health-related characteristics of various urban populations towards identifying opportunities for intervention. Such a shift in framework enables meaningful comparisons that can inform public health activities at the appropriate level and evaluate their effectiveness in improving the health of urban populations. The model is illustrated with two examples from current urban public health practice.

The Impact of New York City’s 1975 Fiscal Crisis on the Tuberculosis, HIV, and Homicide Syndemic

In 1975, New York City experienced a fiscal crisis rooted in long-term political and economic changes in the city. Budget and policy decisions designed to alleviate this fiscal crisis contributed to the subsequent epidemics of tuberculosis, human immunodeficiency virus (HIV) infection, and homicide in New York City. Because these conditions share underlying social determinants, we consider them a syndemic, i.e., all 3 combined to create an excess disease burden on the population. Cuts in services; the dismantling of health, public safety, and social service infrastructures; and the deterioration of living conditions for vulnerable populations contributed to the amplification of these health conditions over 2 decades. We estimate that the costs incurred in controlling these epidemics exceeded 50 billion US dollars (in 2004 dollars); in contrast, the overall budgetary saving during the fiscal crisis was 10 billion US dollars. This history has implications for public health professionals who must respond to current perceptions of local fiscal crises.

Use of Comparative Case Study Methodology for US Public Health Policy Analysis: A Review.

Context: There is growing recognition that policies influence population health, highlighting the need for evidence to inform future policy development and reform. Objectives: This review describes how comparative case study methodology has been applied to public health policy research and discusses the methodologys potential to contribute to this evidence. Methods: English-language, peer-reviewed articles published between 1995 and 2012 were sought from 4 databases. Articles were included if they described comparative case studies addressing US public health policy. Two researchers independently assessed the 20 articles meeting review criteria. Main Outcome Measures: Case-related characteristics and research design tactics utilized to minimize threats to reliability and validity, such as the use of multiple sources of evidence and a case study protocol, were extracted from each article. Results: Although comparative case study methodology has been used to analyze a range of public health policies at all stages and levels, articles reported an average use of only 3.65 (out of 10) research design tactics. Conclusion: By expanding the use of accepted research design tactics, public health policy researchers can contribute to expanding the evidence needed to advance health-promoting policies.

Teaching Urban Health

This review has suggested priorities for the education of urban health professionals. First, researchers, practitioners and policy makers need to define the scope of the field of urban health and encourage the development of theories, models and concepts that bring together the diverse disciplines working to improve the health of urban populations. Second, universities and other training programs should broaden the diversity of the students they educate to be urban health professionals and the faculty who teach them. Third, teachers should continue to develop pedagogical strategies uniquely suited to developing the competencies that urban health professionals will need to master. Fourth, universities need to consider various organizational frameworks for teaching urban health and select the options that best match their resources and mission and meet the personnel needs of the region they serve. Finally, universities, health departments and accrediting agencies need to identify new opportunities for collaboration to create the health workforce needed to improve the health of urban populations in the 21st century.