Helping the Doubly-Disadvantaged: The Role of Neighborhoods in Health

Posted November 2, 2011

In collaboration with the John D. and Catherine T. MacArthur Foundation’s How Housing Matters Initiative, Spotlight on Poverty and Opportunity will be running a series of commentaries for the next two months exploring the relationship between housing and three topics: health, economic opportunity, and education. Please be sure to read Michael Stegman’s “An Introductory Note to learn more.

This commentary is the first installment in the series, which is entitled “How Housing Matters to Families and Communities.”

One of the most striking features of urban life in America today is the degree to which our neighborhoods are so starkly segregated by race, ethnicity, and economic status. Two of us work or live in Hyde Park on Chicago’s south side. The neighborhood is home to the University of Chicago and formerly President Barack Obama. 

Fewer than one in five Hyde Park residents are poor. Right across Cottage Grove Avenue to the west is Washington Park, a neighborhood where 98 percent of residents are black and 52 percent are poor.

Just as striking is the correlation between neighborhood segregation and life outcomes—including health. The overall mortality rate in Washington Park is about 1.5 times that in Hyde Park. 

These sorts of disparities across neighborhoods have generated long-standing concern that poor families living in high-poverty neighborhoods might be “doubly-disadvantaged”—both poor and living in a high-poverty environment that may be harmful to their health. This is an important consideration for policymakers, because social policy - including housing policy - helps shape the geography of poverty in America.

There are several common hypotheses for how neighborhood or residence affects health, including differential access to grocery stores that sell healthy foods, opportunities for physical activity, or availability of medical treatment. Neighborhoods could also vary in their social norms around health-related behaviors, or in the psychological stress arising from rates of crime and violence. Some research even suggests that the physical appeal or aesthetic of a neighborhood may also influence health and well-being.

While there has been no shortage of theories, empirically isolating the causal effects of neighborhood environments on health has been challenging for social scientists and medical researchers because most families have at least some degree of choice over where they live.

On average, people in Hyde Park have better health than people in Washington Park. Is that due just to differences in the characteristics of people living in the two areas, including individual attributes that are hard to measure? Or is at least part of the difference in average health outcomes we see between places like Hyde Park and Washington Park also due to something about the neighborhood environments themselves?

We recently published a paper in the New England Journal of Medicine that provides the first test from a real randomized experiment of how social and physical environments affect health outcomes. Drawing on data from the U.S. Department of Housing and Urban Development’s (HUD) Moving to Opportunity (MTO) experiment, we found that providing low-income women the opportunity to move from high-poverty to lower-poverty urban neighborhoods was associated with about a one-fifth reduction in rates of extreme obesity and diabetes.

Our study suggests that, over the long term, investments in improving neighborhood environments may be an important complement to medical care when it comes to preventing obesity and diabetes and improving the health outcomes of poor families.

We also found that environmental influences on health are big. In comparing the MTO impacts to those from other studies, it is important to keep in mind that most clinical trials in medicine usually enroll study samples that are more socioeconomically advantaged than that of MTO, and that different studies often use slightly different outcome measures. With those qualifications in mind, we saw health effects in MTO that are comparable in size to the long-term impact on diabetes that can result from targeted lifestyle interventions or from providing people with medication that can prevent the onset of diabetes. This suggests that investments in improving neighborhood environments may be an important complement to medical care when it comes to preventing obesity and diabetes and improving the health outcomes of poor families.

While our research could help policymakers utilize housing policy to improve life for low-income Americans, it may also shed some light on why the prevalence of obesity and diabetes has more than doubled in the U.S. since about 1980. Over this same time period, the likelihood that poor Americans live in economically disadvantaged neighborhoods has also increased. We’re not yet certain how well our findings generalize to other populations, but these results suggest the possibility that the growing exposure of Americans to distressed neighborhoods could be one reason why obesity and diabetes have been on the rise in the US. They may even help explain an even more unsettling phenomenon—the disparity in obesity and diabetes rates that we see in America between minorities and whites, given that minorities are more likely than whites to live in high-poverty areas.

Economic and racial segregation is something visible to people who live in America’s urban areas every day. What’s less visible is the long-term health toll of such segregation. We’re hopeful our research is an important first step in helping inform policy decisions in housing and social policy more generally that can help America’s “doubly-disadvantaged” poor.

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Greg J. Duncan is a distinguished professor in the department of education at the University of California, Irvine.

Stacy Tessler Lindau is an associate professor of obstetrics, gynecology, and medicine-geriatrics at the University of Chicago.

Jens Ludwig is the McCormick Foundation Professor of Social Service Administration, Law, and Public Policy in the School of Social Service Administration and the Harris School and director of the University of Chicago Crime Lab at the University of Chicago.     

Robert Whitaker is professor of public health and pediatrics at Temple University.