From the west-facing windows of the New York Academy of Medicine we can look across Central Park to the affluent Upper West Side of Manhattan, where boys who reach the age of 15 have about an 80% probability of living to the age of 65; for their sisters, the probability is even higher. Looking north and east we can see much of East and Central Harlem, where boys who reach the age of 15 have about a 40% chance of living to the age of 65; the probability for their sisters is about 65%.1 The urban setting has always provided an ironic interplay of extremes such as these, with areas of substantial wealth bordering on slums, major health care institutions adjacent to communities with preventable and inadequately treated diseases, and families whose relatives arrived in America over a century ago living next to recently arrived immigrants.2 These extraordinary disparities between communities only blocks apart require understanding of the impact of socioeconomic stratification on disease risk, incidence, course, and outcome, and reflect a major challenge for the evolving field of urban health.3 That challenge will continue to grow; approximately 80% of Americans live in cities or immediately adjacent communities, and worldwide it is predicted that 75% of the population will reside in urban areas by the year 2030.4
Urban health as a framing paradigm is of recent vintage.5,6 It reflects major and ongoing shifts in populations in this country and in the developing world, and offers a perspective on health and disease that, while based in clinical medicine and traditional public health activities, also includes powerful social, economic, psychologic, and political forces that affect to a significant degree life expectancy and health across the life trajectory. The urban health concept draws on the expertise of urban planners, architects, political philosophers, policy analysts, social scientists, community members, and the corporate world, and recognizes the critical importance of their contributions. Indeed, formulation of approaches to resolve the health problems of urban dwellers by government and the clinical and public health enterprises requires their inclusion.
The articles in this issue of Academic Medicine consider urban health from the perspective of understanding and affecting the health of poor, mostly minority populations, among whom the determinants of ill health are concentrated and where the introduction of effective interventions is most challenging. The urban health construct has proven especially useful in epidemiologic and related social science and health services research, but its utility and importance in medical education are relatively underdeveloped. Teaching about urban health in medical education not only examines the special health problems of the urban poor, but also allows a particularly sharp view of the convergence of clinical and public health perspectives and highlights for students important aspects of cultural sensitivity and social responsibility.
The health status and outcomes of urban minority populations are largely determined by the consequences of poverty, social and economic inequalities, and racism. In 1990, McCord and Freeman7 revealed that in Central Harlem, where 96% of the people are black and 41% live below the federal poverty line, age-adjusted mortality from all causes was more than double that of U.S. whites and 50% higher than that of the general population of U.S. blacks. For deaths under the age of 65 in Harlem, standardized age-adjusted mortality ratios compared with those of the U.S. white population were 2.91 for men and 2.70 for women. These data led the authors to comment that black men in Harlem who survive into adolescence are less likely to reach the age of 65 than are men in Bangladesh.
The increase in death and chronic illness among poor minority populations is not primarily related to the consequences of urban epidemics of drugs and violence; rather, the excess mortality and burden of chronic illness are due to the increased prevalence and severity of common diseases, including asthma, cardiovascular disease, diabetes, and kidney disease. Such differences may result from deterioration of health in early adulthood as a result of a “weathering” effect, an accumulation of physical, psychologic, and social stresses—not unlike the effect on houses exposed to unrelenting wind and rain—in this context created by long-standing exposure to poverty, social exclusion, and deprivation among many living in dense urban settings.8 Measures of neighborhood deprivation and neglect, including abandoned buildings, trash in the streets, infestations of vermin, and few parks and open spaces, correlate with poor health status. In Central Harlem, there are three times as many bars and one-quarter as many supermarkets as in more affluent adjacent areas, and fewer safe green spaces to enjoy. These structural factors have a profound impact on the quality of life and subjective well-being, as well as the behavioral choices, of the people who live there.
Looking out our windows we can also see several academic medical centers, community hospitals, and clinics that serve the inner-city poor. Access to health services is a major factor determining health status and health outcomes in the urban setting. Paradoxically, many working poor families who live in East and Central Harlem, in the shadow of world-renowned hospitals, cannot reap the benefits of these facilities because of lack of health insurance. But even with health insurance provided through government programs such as Medicare, Medicaid, and Child Health Plus, families frequently choose to seek care at institutions that may provide lower-quality care in perhaps more culturally comfortable environments.
Institutional and professional cultural competency are important aspects of health outcomes, as revealed by a recent report of the Institute of Medicine (IOM).9 That report confirms decades of research that has found that disparate care and health outcomes in racial and ethnic minority patients are the results not only of lack of health insurance, but also of discriminatory practices in health care institutions and by health professionals. The IOM report specifically considers disparities in health care as “racial or ethnic differences in the quality of health care that are not due to access-related factors or clinical needs, preferences, and appropriateness of interventions.” Differential quality of care has been noted in varying areas, including diagnosis and treatment of cardiovascular disease10–13 and cancer,14 pain management,15,16 and antiretroviral therapy for patients infected with HIV.17 There is increasing empirical evidence to support the notion that provider bias affects the quality of care for minorities and influences diagnostic and treatment decisions based on patient race or ethnicity.16,18,19 Thus, sensitizing institutions and educating physicians who practice in the multicultural context of the urban environment about differences in health beliefs and health behaviors among people of various racial, ethnic, and cultural backgrounds has the potential to positively affect the quality of health care and health outcomes.20
Among other factors inherent in urban life that affect health, studies of the effect of social processes on biology indicate that an individual's continual experience of stress, along with the perception of relative deprivation as compared to others, are associated with significant changes in adrenal hormone secretion, emotional distress, and psychologic symptoms.21 There is a relationship between these changes and the prevalence of stroke, prematurity, hypertension, alcohol abuse, illicit substance use, and domestic violence.22
Recent work suggests that stressful events may be even more significant if the individual experiencing deprivation observes substantial inequities between the environment of his or her peer group and that of others. Economic inequality and its extent have been shown to contribute significantly to health outcomes in various populations.23 This goes beyond the relationship between absolute deprivation and health; such correlations also reflect the role of social gradients in health.24 Social hierarchies are nearly universal among human social groups and have profound effects on the psychological and physiological processes that appear to influence biologic susceptibility and response to disease.
The impacts of race and racism on health have also been examined.25 Racial and ethnic differences in health outcomes persist after adjustment for socioeconomic status, suggesting that race/ethnicity independently influences health status. While socioeconomic status is a confounder of the relationship between race and health, it is also part of the causal pathway by which race affects health.26 Race is a social construct that determines, to some extent, socioeconomic status and educational level. Thus, race affects employment opportunities that can result in health risks associated with working in less desirable occupations.
Since overt and subconscious racial discrimination plays a role in decreasing access to the most appropriate treatments available for various disorders, and since recent studies show that individual patients may be subject to discrimination in treatment due to stereotypical generalizations about group beliefs, attitudes, or behaviors, attempts to ameliorate these misconceptions have been integrated into cultural competency education programs for health professionals at all levels.27 Such efforts must be extended and linked across undergraduate and graduate education and training.
It is clear that the health of urban dwellers represents a convergence of powerful biologic, social, and contextual forces. A comprehensive approach to urban health problems will require engagement of the clinical and public health communities, along with others interested in the environment, social services, housing, education, and information dissemination, to translate increasing knowledge about the social determinants of health in urban populations into enhanced health status and outcome.28 The articles in this issue of Academic Medicine reflect a growing realization that leaders in medical education and health care delivery ought to look out their windows and pay careful attention to the populations that surround them and the impact of urbanization on health, in order to more appropriately prepare physicians and institutions for the challenge of caring for all the residents of our cities.
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