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Death, Violence, Health, and Poverty in Chicago

Fredrick, Earl III, MD, MBA

doi: 10.1097/01.EEM.0000552785.67628.84
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Dr. Fredrick is an emergency physician who has been practicing for 28 years mostly in community hospitals on Chicago's southwest and southeast sides. He is currently the medical director for a Cook County-managed care organization, and was the medical director at Advocate Trinity Hospital from 1993 to 2001, at Holy Cross Hospital from 2002 to 2004, and at Jackson Park Hospital from 2015 to 2018.

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I noticed about a decade ago that Chicago's South Side communities had extremes of chronic disease and their complications. The intensity of chronic disease morbidity and mortality was higher in community hospitals on Chicago's South Side than in the university referral centers in which I had previously worked and trained.

A couple years ago, I began to review Medicare discharge data by zip code in Chicago and found clusters of zip codes on Chicago's south and west side that had the highest concentrations of cardiovascular, renal, endocrine, neurologic, and HIV disease in the entire city. The same neighborhoods with extremes of chronic disease also had extremes of poverty, racial-residential segregation, and gun violence. There was an incontrovertible link between poverty, poor education, poor health, early death, racial residential segregation, and gun violence in Chicago.

Gun violence in Chicago is a public health emergency. It is driven by poverty and inequity. Chicago is famously known as a city of neighborhoods. The neighborhood affects life expectancy, wealth, health, and likelihood of encountering gun violence. Segregation drives the persistence of poverty, premature death, and violence in Chicago's neighborhoods. An epidemiologic approach to assessment and a public health approach to policy and mitigation are desperately needed to address violence in Chicago's most challenged neighborhoods.

The neighborhood in which a person lives determines his health, wealth, life expectancy, and whether gun violence will directly affect him, and it is clear that segregation is the core prevailing influence that perpetuates conditions that sustain and ensure ongoing violence in some Chicago neighborhoods.

Guns caused 36,252 deaths in the United States in 2016, according to the Centers for Disease Control and Prevention. (National Vital Statistics Reports 2017;66[6]; http://bit.ly/2OD2G4R.) The majority of these deaths (excluding mass shootings) occur in economically-challenged communities with high rates of individuals living at or below the poverty line. Growing up in certain Chicago neighborhoods is a guarantee of poverty and exposure to violence. Massey and Denton in their seminal treatise found that poverty is concentrated in nonwhite neighborhoods not by coincidence but through systematic segregation. (American Apartheid: Segregation and the Making of the Underclass. Cambridge, MA: Harvard University Press, 1993.) Racial segregation magnifies poverty's influence on communities of color in particular. (Am Social Rev 2012;77[3]:354.) The Chicago neighborhoods with the highest concentrations of poverty from 2005 to 2009 also had the highest homicide rates citywide based on age-adjusted data per 100,000 persons.

Among these neighborhoods, Fuller Park is currently 90 percent African American, 5.4 percent Hispanic, and 4.2 percent white. The median annual household income there is $22,400, while the U.S. poverty level in 2017 was $24,858. (U.S. Census; http://bit.ly/2PYtxJq.) Englewood is currently 94.6 percent African American, 2.5 percent Hispanic, and 1.2 percent white with a median annual household income of $25,200. Washington Park is 95 percent African American, 0.9 percent Hispanic, and 0.4 percent white with a median annual household income of $24,600. West Englewood is 90 percent African American, 7.6 percent Hispanic, and 0.7 percent white with a median annual household income of $31,000. Burnside is 99 percent African American and 0.4 percent white with a median annual household income of $32,800. (Statistical Atlas; http://bit.ly/2PmziTZ.)

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Race and Violence

The level of residential segregation is directly related to the level of violence, particularly gun violence. African American-white segregation is especially problematic in Chicago. One homicide occurred in each of the three predominantly white neighborhoods in Chicago (Lakeview 80% white; O'Hare 77% white, and Near North 72% white) while the remaining predominantly white neighborhoods had none during 2015. Homicides in Chicago's predominantly black neighborhoods ranged from three in Riverdale (96% black) and Burnside (98% black) to 23 in Chatham (97% black). Racial segregation also affects mortality, life expectancy, and infant mortality. Reductions in exposure to racial residential segregation are associated with reductions in systolic blood pressure. (JAMA Intern Med 2017;177[7]:996.)

The leading causes of death in the United States are heart disease, cancer, chronic lower respiratory disease, unintentional injuries, and strokes. (National Center for Health Statistics, NCHS Data Brief No. 229, December 2015; http://bit.ly/2OKaJ3U.) Illinois's leading causes of mortality largely mirror national statistics except stroke tops unintentional injuries at the state level. Mortality data for Chicago generally mirror national and state data except that homicides are the leading cause of death for those aged 15-24 and 25-34; injuries are first for these age groups nationally. Coupling these age groups show that they suffer the burden of excessively high unemployment, under-education, community-based trauma and violence, and premature death due to homicide.

The question is are these relationships incidental or causal? Debate has raged over the influence of poverty on violence and homicide while the data on mortality, life expectancy, and chronic disease prevalence are more compelling. U.S. life expectancy for all races and ethnicities is 75.6 years for men, 80.6 years for women, and 78 years overall. (Prev Chronic Dis 2016;13:160088.)

Chicago life expectancy in 2010 was 79.8 years overall. Significant variance in life expectancy is associated with median household income in Chicago, which was $49,877 in 2010. The median income in Chicago's poorest neighborhoods was $22,234 and $90,000 in the highest income neighborhoods. Life expectancy was an average of 73.5 years in the lowest income neighborhoods and 86 years in high-income neighborhoods, a 12-year gap.

The neighborhoods with the lowest life expectancy in Chicago are West Garfield Park 69, Washington Park 69, Fuller Park 69, West Englewood 70, Englewood 71, Greater Grand Crossing 71, and West Pullman 72. Seventy percent of these neighborhoods with the lowest life expectancy were Park 72, Austin 72, and Burnside 72. Chicago also has the highest levels of gun violence. Obviously, it makes sense that high homicide and gun violence rates equate with low levels of life expectancy.

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Segregation and Poverty

Chicago experienced 58 percent more homicides and 43 percent more nonfatal shootings between 2015 and 2016. The incidence of violent crime and gun violence in Chicago is markedly disparate across neighborhoods. Sixty-four percent of 2017 homicides occurred in 20 percent of Chicago's neighborhoods. The Chicago metro area is the third most segregated after Milwaukee and New York City/Newark, NJ. Chicago is one of the most racially segregated cities in America, and its neighborhoods serve as placeholders for racial and economic groups. Segregation also concentrates poverty, low life expectancy, and high infant mortality.

Gun violence is a disease resulting from generations of neglect and concentrating racial and economic groups to the detriment of Chicago as a whole. Redirecting funds that isolate, segregate, and incarcerate toward community and individual development, education, and desegregation is urgently needed. We urgently need safer communities that are multicultural and racially diversified. We urgently need to lift all Chicagoans to at least the level of the average of the 100 most populous cities in America. Systematic desegregation, educational investment, and growth of jobs and incomes will improve the quality of life for Chicago. Gun violence in Chicago requires a massive public health response to remediate a predictably worsening crisis.

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Emergency physicians and trauma surgeons are the front line of the gun violence crisis. Education, community activism, and enormous compassion are needed to comprehend the impact of social determinants on the victims and perpetrators of gun violence. Each encounter is an opportunity to teach and show love that is otherwise absent from the landscape and policy affecting victims and perpetrators of gun violence. Our criminal justice system has predictably failed to redress gun violence on the individual or population level. Policymakers need education from first responders and emergency physicians who stand at the vanguard of gun violence.

The Means Matter campaign at the Harvard T. H. Chan School of Public Health addresses the availability of guns in relation to suicides, including children. In fact, Baxley found that 22 percent of children had played with a gun parents thought was hidden. (Arch Pediatr Adolesc Med 2006;160[5]:542.) Emergency physicians' advocacy for gun control is important to save lives. Just hours before the mass shooting in San Bernardino, CA, that killed 14 people and seriously wounded 22 in December 2017, a group of doctors in white coats brought a petition to Capitol Hill. More than 2,000 physicians from across the country petitioned Congress to lift the 20-year restriction on CDC funding for gun violence research.

Racial residential segregation in Chicago isolates individuals with limited means in areas rife with gun violence. Gun violence is a public health emergency in need of policy, advocacy, and epidemiologic research to develop real solutions. Powerful lobbying groups have effectively stifled research and have only offered law-enforcement solutions that clearly don't work and, in fact, exacerbate the core social determinants underlying gun violence.

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