Life and Death From Unnatural Causes
Health and Social Inequity in Alameda County
The Alameda County Public Health Department 1May2008
This executive summary was produced by The Alameda County Public Health Department
Tony Iton, M.D., J.D., MPH Health Officer and Director
Sandra Witt, Dr.PH, Deputy Director of Planning, Policy, and Health Equity
Authors: Matt Beyers • Janet Brown • Sangsook Cho • Alex Desautels • Karie Gaska • Kathryn Horsley • Tony Iton • Tammy Lee • Jane Martin • Neena Murgai • Katherine Schaff • Sandra Witt • Sarah Martin Anderson, Policy Consultant
Alameda County Public Health Department Reviewers : Julie Garcia •
Tamiko Johnson • Brooke Kuhn • Mia Luluquisen • Mona Mena • Kelly Nanney
Liz Maker • Kimi Watkins-Tartt • Pam Willow • Diane Woloshin
Other Reviewers: Bob Allen, Urban Habitat • Juliet Ellis, Urban Habitat • Amie Fishman, East Bay Housing Organizations • Adam Gold, Just Cause Oakland • Dana Harvey, Mandela Marketplace • Greg Hodge, Oakland Unified School District Board • Sonia Jain, West Ed • Yvette Leung, Alameda County Health Care Services Agency • Jennifer Lin, East Bay Alliance for a Sustainable Economy • Molly Mauer, Education Trust-West • Guillermo Mayer, Public Advocates • Carli Paine, Transportation and Land Use Coalition • Anthony Panarese, ACORN • Swati Prakash, Pacific Institute • Bob Prentice, Bay Area Regional Health Inequities Initiative • Mildred Thompson, PolicyLink • Junious Williams, Urban Strategies Council • Heather Wooten, Public Health Law and Policy • Wendi Wright, Alameda County Behavioral Health Care Services Agency
Comments, questions, and requests for additional copies can be directed to:
Community Assessment, Planning, Education, and Evaluation (CAPE) Unit
Alameda County Public Health Department
1000 Broadway, Suite 500
Oakland, California 94607
David Kears, Director Health Care Services Agency
Full report will soon be available at www.acphd.org.
Compared with a White child in the Oakland Hills, an African American born in West Oakland is 1.5 times more likely to be born premature or low birth weight, seven times more likely to be born into poverty, twice as likely to live in a home that is rented, and four times more likely to have parents with only a high school education or less.
As a toddler, this child is 2.5 times more likely to be behind in vaccinations. By fourth grade, this child is four times less likely to read at grade level and is likely to live in a neighbor- hood with twice the concentration of liquor stores and more fast food outlets. Ultimately, this adolescent is 5.6 times more likely to drop out of school and less likely to attend a four- year college than a White adolescent.
As an adult, he will be five times more likely to be hospitalized for diabetes, twice as likely to be hospitalized for and to die of heart disease, three times more likely to die of stroke, and twice as likely to die of cancer.
Born in West Oakland, this person can expect to die almost 15 years earlier than a White person born in the Oakland Hills.
“Achieving equity in health is ultimately a political process based on a commitment to social justice rather than to survival of the fittest.”
— Barbara Starfield2
Certain groups of people in Alameda County are getting sick and dying prematurely from “unnatural causes.” In Alameda County, access to proven health protective resources like clean air, healthy food, and recreational space, as well as opportunities for high quality education, living wage employment, and decent housing, is highly dependent on the neighborhood in which one lives. These inequities cluster and accumulate over people’s lives and over time successfully conspire to diminish the ultimate quality and length of life in these neighborhoods. Some of the social inequities that are associated with poor health are:
- A retail salesperson would need to work nearly 100 hours per week to afford fair market rent for a two-bedroom apartment.
- Households earning less than $20,000 per year spend over half of their income on transportation.
- A teacher of poorer students in Oakland Unifi ed School District makes $14,000 less than a teacher of wealthier students in Piedmont Unifi ed School District.
- West Oakland residents breathe air that contains three times more diesel particles than in the rest of the Bay area.
- African Americans are sentenced to prison for drug offenses at a rate 34 times that for Whites even though they use illicit drugs at about the same rate.
- Latinos are four times as likely as Whites to lack health insurance.
The full report on which this executive summary is based 1) documents the health disparities found in Alameda County by neighborhood, income level, and race/ethnicity; 2) illustrates the links between these disparities and existing economic and social inequities; and 3) suggests goals and cross-sectoral policies that can lessen the inequities in our county.
Tackling the Challenge of Health, Race, and Place
Health, disease and death are not randomly distributed. The evidence in this report demonstrates that illness concentrates among low-income people and people of color residing in certain geographical places. In Alameda County, this phenomenon is particularly stark among low-income African Americans in certain neighborhoods within Oakland. A just society does not consign whole populations to foreshortened and sicker lives based on skin color and bank account size. If we are a just society, we must tackle the challenge of poor health and its linkage to race, social class and place. Our goal is health equity.
Health inequity is related both to a history of overt discriminatory actions, as well as present-day practices and policies that perpetuate diminished opportunity for certain populations. Inequities in economic, social, physical and service environments continue to create and maintain clear patterns of poor health in Alameda County, statewide, and nationally. Social inequity causes health inequity.
Inequities in health are related to much more than access to health care. Although health care is important, a narrow focus on curative medical services will fail to eliminate health inequities. David Satcher, former Surgeon General of the United States, recently stated that “Although critical to eliminating disparities, access [to health care] only accounts for 15% to 20% of the variation in morbidity and mortality that we see in different populations in this country.”1 To change the factors that account for the other 80% to 85%, we will need to look far beyond the health and medical sectors of society and focus on the root causes of poor health.
Deliberate public and private policy helped create the inequitable conditions and outcomes that confront us today. Consequently, deliberate new policy is needed to unmake inequitable neighborhood conditions and decouple health from race and place. Examples of such action might include formal legislative policies to encourage mixed-income housing, universal preschool, and equitable transportation funding.
Local, state and federal governments must mandate and fund cross-sectoral and interagency collaboration focused on clear and measurable health equity outcomes. New partnerships of health departments working across disciplines and sectors with a range of government agencies and community organizations with experience working in these diverse areas must emerge.
Learning From Community, Learning From Research
Voices from the community
When Alameda County community residents, youth, community partners, local politicians, and Public Health Department staff were asked what makes communities healthy, they answered with remarkable consistency. Elements of economic, social, and physical environments, as well as community services, were all considered necessary to health. Having access to good jobs, home ownership, safety, trust, good relationships with police, being free of racism, having social supports, clean air, water, safe places to walk and play, access to healthy foods, and quality affordable housing, were all put on the list. In terms of services, people mentioned health care, health information, excellent schools, and convenient transportation. When economic, social, physical, and service environments are weak, the health of people suffers. When policies create inequitable environments, the result is profound and persistent disparities in community health based on place, race, and class.
Alameda County Mortality Rate
Life expectancy is years at birth. Alameda County overall life expectancy = 79.9 years.
Rate is age-adjusted all-cause mortality per 100,000.
Alameda County overall rate = 704.3/100,000
Evidence from health equity research
Though there is a large amount of research literature on the social determinants of population health, relatively little is helpful for prioritizing actions and policies to eliminate inequities. Nevertheless, a few generalizations in a recent review article point to some promising approaches and can therefore set the stage for action in Alameda County.3
- There is no basis for assuming a single community characteristic or set of characteristics is the most influential in causing inequities in health. We should look at influences at all levels—neighborhood, local, state, and national.
- Interventions outside the health sector are likely to have relatively greater impact on the occurrence of illness in the fi rst place, whereas health care policies—especially those directed at early detection and stopping progression of illness—are likely to have strong impacts in reducing disparities in the severity of illness.
- Early childhood is when the basis for many health inequities is established. Social disadvantage is hazardous at any stage of life, but is especially damaging when experienced early. Priority should be given to policies that influence the lives of infants, children, and adolescents.
- Policies that are directed to structural changes in society and systems tend to be more effective than interventions targeted at individual behavior.
Public Policies to Correct the Course in Alameda County
This report examines relationships between health and social inequities in income, employment, education, housing, transportation, air quality, access to healthy foods, opportunities for physical activity, criminal justice and crime, social support and cohesion, and access to health care. The report also identifi es a spectrum of policies that can make a difference in decreasing premature death and health inequities. Listed below are several policy principles that provide guidance for how and with whom Alameda County takes on the challenge of addressing root causes of health inequities.
- Understanding the historical forces that have left a legacy of racism and segregation is key to moving forward with the structural changes needed to provide living wages, affordable housing, excellent education, clean air, and other social conditions in neighborhoods that now experience disadvantage.
- Working across multiple sectors of government and society is key to making the structural changes necessary. Such work should be in partnership with community advocacy groups that continue to pursue a more equitable society.
- Measuring and monitoring the impact of social policy on health to ensure gains in equity is essential. This will include instituting systems to track governmental spending by neighborhood and tracking changes in measures of health equity over time and place to help identify the impact of adverse policies and practices.
- Groups that are the most impacted by inequities must have a voice in identifying policies that will make a difference as well as in holding government accountable for implementing these policies. Meaningful public participation is needed with attention to outreach, follow-through, language, inclusion, and cultural understanding. Government and private funding agencies should actively support efforts to build resident capacity to engage.
- Acknowledging the cumulative impact of stressful experiences and environments is crucial. For some families, poverty lasts a lifetime and is perpetuated to next generations, leaving its family members with few opportunities to make healthful decisions.
CHART Life Expectancy at Birth, Alameda County, 1960-2005
- The developmental needs and transitions of all age groups should be addressed. While infants, children, youth, adults, and elderly require age-appropriate strategies, the largest investments should be in early life because important foundations of adult health are laid in early childhood.
- Changing community conditions requires extensive work on land use policy to address the location of toxic sites, grocery and liquor stores, affordable housing and transportation, the primacy of the automobile, access to opportunities for physical exercise and building social supports, and overall quality of life.
- The social fabric of neighborhoods needs to be strengthened. Residents need to be connected and supported and feel that they hold power to improve the safety and well-being of their families. All residents need to have a sense of belonging, dignity and hope.
- While low-income people and people of color face age-old survival issues, new challenges brought on by the global economy, climate change, U.S. foreign policy, and the need for immigration reform and energy alternatives are also relevant and should be addressed in the context of equity.
- Because of the cumulative impact of multiple stressors, our overall approach should shift toward changing community conditions and away from blaming individuals or groups for their disadvantaged status. Eliminating inequities in Alameda County is a huge opportunity to invest in community. Inequity among us is no longer politically and morally acceptable and we all stand to gain by eliminating it.
The policy goals and implications that follow are grouped into two arenas consistent with a new report, Reaching for a Healthier Life: Facts on Socioeconomic Status and Health in the U.S.: a) policies that impact opportunity for increasing income and wealth, educational attainment and occupational mobility and b) policies that address adverse community conditions.4
Matthews vs. Andrade, 1946, Alameda County Superior Court
Policies that impact income, wealth, education, and work
A main way that place is linked to health is through geographic concentration of poverty. People clustered in low-income neighborhoods struggle with public and private disinvestment, fewer job opportunities, lower-quality housing and schools, toxic contamination, higher levels of crime, and more social isolation—all of which take their toll on health. The combined impact of these socio-economic and physical realities limits the quality of life and life chances for residents of such neighborhoods.
In Alameda County the highest poverty areas are in parts of North Oakland, West Oakland, and East Oakland. This geographic distribution of poverty is strikingly consistent with the geographic patterns of death and disease. African Americans and Latinos are highly concentrated in these high poverty areas, a result of racist institutional policies that led to physical separation of races in most of U.S. cities. From racial restrictive covenants to redlining to racial steering, U.S. policies systematically denied people of color homeownership opportunities while simultaneously expanding them for lower income Whites.
While such policies are no longer sanctioned and the federal government has taken some affi rmative steps to end residential segregation, inequalities associated with this shameful history persist. To help those who have been oppressed to rise out of poverty and gain access to a higher quality of life, sound economic and educational policies are needed.
Income, wealth, employment
- Raise incomes of the poor, especially those with children: Increase enrollment in income support programs; expand access to earned-income tax credits; raise the state minimum wage; implement local living wage ordinances.
- Assist poor people to accumulate assets: Provide education and fi nancial counseling to increase access to savings accounts and investment programs; expand home ownership and micro-enterprise opportunities.
- Support job creation and workforce development: Negotiate community benefi ts agreements, preserve industrial land for goodpaying jobs, and expand local green-collar jobs; increase access to education, training, and career ladders; fund job readiness and skill-building programs especially for African Americans, Latinos, and youth.
- Invest in early childhood: Provide high quality and affordable child care and preschools; ensure equitable distribution of and access to preschools and provide subsidies.
- Reform school funding: Finance to equalize access to quality education in K-12; create incentives for teachers to work in disadvantaged schools; ensure accountability, adequate facilities and highly qualified teachers and administrators.
- Invest in recruiting, training and retaining child care providers and teachers for K-12.
- Provide supports to schools and students and parents in need: Provide positive interventions for at-risk middle and high school students; invest in youth development programs; create greater support for low-income parents of color to participate in their child’s education.
Policies that address adverse community conditions
Segregation and systematic exclusion from decisionmaking venues paved the way for inequitable community conditions. Continued power imbalances at the individual and community levels are the legacy of these conditions and affect health through many pathways. Residents must be given more power and support to improve their community conditions.
The physical design as well as social and business structures of neighborhoods determine some health pathways. Our choices are oft en limited by our environments. For example, where there is a high concentration of “unhealthy” goods and services, such as liquor stores and fast food restaurants, people’s health behaviors and perceptions about the neighborhood are shaped accordingly. Similarly, the locating of pollution- releasing facilities (diesel bus depots, hazardous waste sites) in residential areas reveals land use decisions that disproportionately burden low-income communities with an excess of air toxics that, in turn, result in serious health problems. Good housing, health-conscious zoning, and strong crime prevention can make communities healthier and safer. Access to health care, reliable and affordable transportation, social supports and a fair criminal justice system will help buffer the impacts of living in poorer neighborhoods. A broad range of policies can shape much better community conditions.
- Increase affordability and stability: Ensure affordable housing for all by protecting existing stock, increasing production, and funding the EveryOne Home Plan. Protect affordable housing stock including enhanced rent control laws, just condominium conversion policies, and funding for single room occupancy hotels. Increase production including increasing the redevelopment tax increment for affordable housing and affordable housing bond measures.
- Support housing polices to build wealth: Use policies such as establishing community land trusts, increasing funds for and utilization of fi rst time home buyer programs, and establishing inclusionary zoning ordinances.
- Decrease foreclosure and displacement: Utilize strategies such as increasing funding for emergency housing assistance, partnering with community organizations to target preventative outreach to at risk households, and implementing Just Cause for Eviction ordinances.
- Increase affordability: Utilize policies such as free bus passes for students 17 and under and low-income bus passes.
- Improve accessibility and reliability: Strategies include equalizing public transit subsidies and expanding bus service in the Metropolitan Transportation Commission identified communities of concern by implementing and funding community- based transportation plans.
- Decrease driving: Policies include equitable roadpricing strategies and transit-oriented development. Decrease pedestrian and bicyclist Injuries: Utilize tools such as fully funded regional, countywide, and citywide pedestrian and bicycle strategic plans.
- Reduce exposure to diesel particulates by eliminating diesel trucks in residential neighborhoods; enforcing the no-idling law near schools, requiring the use of clean technology in new ships and trucks; reducing emissions in existing fl eets; and implementing existing state and federal emissions reductions regulations.
- Study trucking and shipping operations, including expanded monitoring such as school sites, of the impact on low-income and vulnerable populations.
- Engage communities in decision-making about locally wanted and unwanted land use.
- Incorporate public health input on air pollution impacts in local land use planning and development decisions.
Food access and liquor stores
- Limit number and density of fast food restaurants, especially in low-income areas.
- Increase healthy food availability: Retain and attract supermarkets and full-service grocery stores through tax write-offs and other incentives. Encourage neighborhood stores through tax incentives, streamlined permitting and zoning variances, and local government support. Strengthen alternative sources of fresh produce such as farmers’ markets and community- and school-based produce stands.
- Establish and enforce regulations to restrict the number of liquor stores in census tracts with an over-concentration of off -sale premises. Enforce regulations to limit nuisance activity (litter, prostitution, drug dealing) in and around stores. Limit the hours of operation and restrict the sale of cheap, fortified alcohol products.
Physical activity and neighborhood conditions
- Develop and promote venues for active recreation— parks, playgrounds and school facilities— especially in low-income communities. Improve access to public facilities for physical activity, such as facilitating aft er-hour use of school facilities. Promote regular physical activity in schools such as physical education programs and increasing funding for teachers and equipment in lowincome communities.
- Engage policy makers, law enforcement agencies, residents, and community organizations in the development of zoning laws and general plans to improve safety of parks and other recreational facilities in high crime and low-income communities.
- Increase land use mix in urban and suburban areas as a strategy to promote walking and biking to work, entertainment, shopping, and schools. Increase public transport access and improve walking and biking routes to schools.
- Reform crime laws: Decriminalize addiction and implement community programs for drug offenders in lieu of prison. Eliminate three strikes laws.
- Address the root causes of disproportionate incarceration rates for African-Americans, Latinos, and low-income people.
- Support re-entry programs and combine probation with social services, health, and other programs to ensure a support system for probationers.
Access to health care
- Support state and local legislative proposals for universal access to quality health care.
- Streamline public health insurance enrollment and improve affordability of services within existing public programs such as Medi-Cal.
- Support legislation to improve affordability of critical prevention services such as childhood immunization.
- Promote culturally-appropriate cancer screening programs for specific populations—for example, Asian women for cervical cancer—and support implementation of targeted breast and prostate cancer screening programs among low-income and lower literacy groups.
Social support and social cohesion
- Strengthen community capacity building efforts using a place-based approach.
- Build social capital in vulnerable communities by empowering residents to take action in partnership with city and county governments and community-based organizations to improve their neighborhood conditions.
- Facilitate neighborhood-level strategies to address unfavorable neighborhood social conditions, increase protective and resiliency factors.
People’s health cannot be separated from the environment in which they live. A toxic mixture of conditions such as poverty, pollution, poor education, substandard housing, a shortage of grocery stores, cheap fast food, violence, unemployment, and racism combine to make people sick. Residents of Alameda County must work together with public officials to correct the course, all the while remembering these ten points from the documentary series, Unnatural Causes.5
Health is more than health care.
Health is tied to the distribution of resources.
Racism imposes an added burden.
The choices we make are shaped by the choices we have.
High demand + low control = chronic stress.
Chronic stress can be deadly.
Inequality—economic and political—is bad for our health.
Social policy is health policy.
Health inequities are not natural.
We all pay the price for poor health.
1. Satcher D, Higginbotham EJ. The public health approach to eliminating disparities in health. American Journal of Public Health, 2008; 98 (3):400-403.
2. Starfield B. State of the art in research on equity in health. Journal of Health Politics, Policy and Law, 2006;31(1):14.
3. Ibid. pp. 14-17.
4. Adler NE, Stewart J, et al. Reaching for a Healthier Life: Facts on Socioeconomic Status and Health in the U.S. The John D. and Catherine T. MacArthur Foundation Research Network on Socioeconomic Status and Health, 2007, page 43
5. The California Endowment and NACCHO. Unnatural Causes: A Documentary Series and Public Impact Campaign. Produced by California Newsreel with Vital Pictures. 2008. www.unnaturalcauses.org.
Alameda County Public Health Department
1000 Broadway, Suite 500