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. Infor mation-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.
