Social issues
In 1967 Nathan Goldman wrote in the Annals of American Academy of Political and Social Science wrote
"Although problems of family breakdown, drug and alcohol addiction, mental disorder, suicide, and sexual deviation appear to be increasing, the available data are either so deficient or so incomplete that accurate appraisal of the situation is impossible. However, some of these problems seem to be more or less socially sanctioned adjustments to strains in the social system rather than maladjustments in themselves. To achieve our goal of maximizing the social health of American society, we must consider these problems as indicators of strain, and focus our national resources on the reduction of these strains. We need to improve the collection of data on these indicators, and to devise new ones, in order to identify and locate those situations which interfere with the ideal functioning of our social system. A significant aspect of social breakdown is seen in the inability of the society to mobilize for an attack on situations which it has defined as undesirable. Our concern should be with the identification of these processes as well as the underlying social strains of which social problems are overt indicators. We must establish standard definitions or criteria of social problems and increase the scope and accuracy of our data- collection. Information-gathering on the local or state level would need to be co-ordinated on a nationwide basis to provide a useful set of indicators of the social state of the nation".
The issue of urbanization is not just one of larger numbers of persons gathered into urban geopolitical units. The geographic size of a city makes a difference as well. For example, in central New York City (Manhattan), there are 52,419 people per square mile; in Cook County, Illinois (Chicago), 5,398; in Los Angeles County, California, 2,183; and in Dade County, Florida (Miami), 996.1. In contrast, the overall United States population density is 70.3 people per square mile; and in 1790 the nation had a population density of 4.5 people per square mile. The less concentrated population of today's sprawling urban areas present challenges of a different kind, such as the difficulties of organizing public transportation. Lack of mass transportation may mean increased pollution from individual use of internal combustion engines, and it may mean that individuals lacking a personal car may have difficulty reaching health services.
From an economic perspective, urban populations experience some of the extremes of income inequality, with large differences in income between the highest- and lowest- earning segments of the population. Income inequality has been increasing in the United States over the last twenty-five years, and, for the low- earning segment, can have a significant negative impact on health. Areas with high income inequality and a low average income have been reported as experiencing nearly 140 deaths per 100,000 people, compared with a rate of 64.7 per 100,000 in other areas. This impact is greater for infants and those between 15 and 64 years of age. A study of thirty large metropolitan areas revealed that when poverty is concentrated within a geographic area, mortality is significantly elevated. Conversely, a concentration of affluence is associated with lower mortality, at least in the elderly.
Urban populations in the United States include large ethnic and racial minority populations. The combination of segregation and discrimination felt by minority groups in urban areas can also have an impact on health, whether due to limitations in access to health services, education, and jobs; or the increase in stress due to the tensions of being a minority population. Urban areas have been cited often, for example, for the failure of their police forces to respond equitably to members of minority populations. This has included disproportionate targeting of minorities as potential offenders (racial profiling), a lower level of response to complaints or requests for assistance, or outright disrespect or brutality. While none of these issues is uniquely urban, the concentration of population and the media visibility in a metropolitan area make this an even greater issue of concern.
As already identified, placing a large number of people in a small area increases the risk of health and illness problems. The closer proximity and higher rate of face-to-face contact has a direct impact on the rates of transmissible diseases such as tuberculosis and other respiratory infections. It is no surprise that the resurgence of tuberculosis experienced in the United States in the late 1980s and early 1990s began in New York. The high population density, and the use of large, poorly ventilated spaces as overnight sleeping accommodations for the homeless provided an ideal environment for the transmission of the bacillus. The fact that the public health resources were being strained by the arrival of another condition, HIV/AIDS (human immunodeficiency virus/acquired immunodeficiency syndrome), compounded the problem and meant that drug- resistant organisms were being shared. Health concerns as much as concerns for recreation space have been involved in the development of at least limited open spaces such as parks within concentrated urban areas.
The interrelationships of central urban areas to their surrounding suburbs has been the focus of study and attention from several perspectives. The decreased population density of suburban housing may mitigate some problems that are encountered in older urban settings. For example, there may be more open spaces for recreation or sport, and access to more remote areas is simpler. On the other hand, suburbs mean more widely dispersed individual homes, each needing access to utilities and transportation, and constructed in such a way that neighborhood cohesion may be difficult or impossible to develop. The availability of individual automobile transport in the United States has undoubtedly contributed to suburban sprawl, as have issues of social discrimination. These areas have also grown because of what has been labeled "urban flight": the movement out of cities of the more affluent as new waves of immigrants, often from different ethnic or racial groups, moved in. The apparent cost of maintaining or advancing a standard of living within the urban core was seen as too great. This flight, however, leaves older housing stock to be occupied by those of lower income levels, with less generation of taxes to support services, and the beginning of a downward spiral. When combined with the movement of industry because of restrictions on pollution, search for a cheaper labour pool, or simple displacement due to competition from elsewhere, the result can be a severe, area-wide depression. The cities of the so- called Rust Belt of the northeastern United States provide many vivid examples of this cycle.
Some of the health concerns in urban areas are the result of a loss of individual control. When a person is dependent on either walking or using a private vehicle on a seldom-used two lane road, there is much less need to be concerned about the behaviour of others than if the person uses public transportation or walks or drives in a busy urban environment. In addition to the difficulties related to the increased numbers of encounters, there is an increased level of stress, which is known to increase the risk of illness. The density of urban populations and the associated stresses have also been associated with increased rates of violence and, in the second half of the twentieth century, an increase in crime associated with an increase in the distribution, sale, and use of illegal drugs. Some of the crime directly involved the drug distribution networks, as they competed with one another for turf; other crimes were committed by those who became addicted as they attempted to find the resources to support their addictions. For example, one occupational risk that has been studied is the risk of violence to convenience store employees. Of 1,835 robberies of convenience stores in eastern metropolitan areas in 1992 and 1993, 63 percent involved the use of a firearm, and 12 percent were associated with an injury to at least one employee. All five reported fatalities were firearm- related.
A major news story of the late twentieth century was the dramatic success of many urban areas in reducing violent crime. While observers are consistent in saying that no single action can be credited with bringing this about, it may have been the result of a combination of much more sophisticated and targeted policing and a demographic shift that meant a smaller population of young adults, the group most likely to be involved in crime.
Finally, cities are a centre of immigration, both from rural areas (as evidenced by the population shift of the last century) and from other countries. Port cities (which may not be coastal in this age of airport travel) experience a constant influx of people from other cultures and climates. This may add to the health challenge in a number of ways. For example, during the period following the end of the Vietnam War in which a large number of refugees from Southeast Asia were arriving in the United States, many health care providers had to learn about an entirely new range of parasitic diseases that were endemic in these people's countries of origin. Beyond specific diseases, immigrants bring different expectations of the health care system, and a different understanding of the range of interventions appropriate to various disease states. Some immigrant health practices have moved toward the mainstream, as in the increasing use of acupuncture, once seen as an odd practice of the Chinese immigrant community. And the increasingly popular herbal remedies are an echo of the role the botanica plays in Hispanic cultures.