William A. Vega, Ph.D.
Director of MRPI

Issue

When cities decline there is a deterioration of physical and mental well being of the population. The vitality of community institutions and neighborhood relations are fundamental assets in promoting health. A recent Harvard School of Public Health study found that the level of neighborhood trust and reciprocity reported by community residents across the nation was closely tied to their respective morbiditiy and mortality levels. 1

Two contemporary challenges are facing San Antonio: inner city regeneration and protecting the health of a large low income population. Both challenges are based on overlapping goals. However, there are inadequate linkages between two sets of vital stakeholders who are key to local urban regeneration strategies, public institution and non-profit agency directors, neighborhood associations, lending and investment institutions, and health institutions such as public hospitals, managed care organizations, and public health providers. The world-wide Healthy Cities Movement, which includes San Antonio, promotes active partnerships across sectors for balanced development.The rationale for inter sector integration in San Antonio is examined below.

Methods and Results

The survey items for Figure 1 were derived from the MRPI – Department of Community Initiatives population survey of San Antonio adults. Both English and Spanish language versions of the questionnaire were created. Calls were completed Monday through Thursday evenings from 5:00 PM – 9:00 PM and Saturdays and Sundays from noon until 6:00 PM. These times optimize availability of employed people. In addition, the initial screen excluded anyone answering the phone who was not eighteen years or older. Actual telephone prefixes were paired with four random digits to produce the phone numbers. This process insures that all necessary phone prefixes are included, and that unlisted numbers are part of the sampling frame. As is typical of most telephone surveys, results for the Community Initiatives telephone survey slightly over-represent women in all race and ethnic groups compared to their demographic representation in the community. To compensate, a weight variable was created using 1990 U.S. Census data for each sex by race and ethnic category. The random sampling process as well as the size of the sample combine to produce findings representative of the San Antonio adult population. The completed sample size of 1,223 San Antonio residents allowed for precise estimates of citywide public opinion (±3%) of adult individuals living in San Antonio, Texas in March and April 1999. Results report attitudes and self-reported needs of respondents.

Figure 1 illustrates the clear relationship between self-reported excellent health and quality of neighborhood. The essential message is that better health is most likely to be found where people feel good about living in their neighborhoods, and least likely to be found where they dislike them. The most plausible explanation is that neighborhood quality of life is tied to individual health. There are many qualities that make neighborhoods good, including cohesiveness, history of organization and problem solving, sound infrastructure and recreational facilities, quality of housing, schools, etc. The indicators of good, sustainable communities are also indicators of good public health. Although there is certainly a relationship between bad neighborhoods and poverty, most respondents who reported living in good neighborhoods are not from upper income levels.

Source: MRPI-DCI Survey, Juanita Firestone, Principal Investigator.

Discussion

It is a fundamental assumption of public health practice and demonstrated historical fact, that well organized communities deter physical deterioration of their environments using advocacy and the political process. Communities that fall into serious deterioration have fragmented social and commercial networks, ineffective institutions, and rapidly become breeding grounds for disease, crime, and personal risk behaviors. Any systematic effort to prevent disease and lower disease burden without heeding environmental factors will be inefficient. Stable, cohesive communities increase the likelihood of producing healthy people and the feasibility of long term planning and public and private partnerships that lower the disease burden.

Stakeholders in urban development have similar needs. They must have confidence that communities possess requisite human resources and a web work of organizations to make their investment position rational. Today there is an increased understanding among institutional stakeholders that decisions to invest in low income communities cannot be based solely on standard risk criteria. There is growing recognition that “social investment” takes into account community assets such as history, identity, sense of place, and leadership as qualitative indicators of social cohesiveness correlated with investment risk. Parenthetically, these are prime assets public health experts have long identified as requisite elements of community organization and advocacy.

Urban planners have argued for some time that suburban growth and sprawl must be controlled because they undermine the natural environment and weaken the core city as a viable commercial and residential center. Losing tax revenues, encouraging limitless suburban subdivision and strip mall development, and fostering dense traffic congestion are inherently bad things for cities. These are also bad things for the health of inner city residents, as their neighborhoods are left behind with depleted resources and decaying housing, and cash starved educational systems.

We have no national policy to discourage this. Regrettably, the public health and human services stakeholders have not fully appreciated the importance of policies controlling land use, tax incentive mechanisms, and inner city economic development. These issues have been the purview of business interests, financial institutions, and political and regulatory bodies that are often unfamiliar with public health principles. The lack of shared information, vision, and strategic planning produces inefficiencies.

Low income urban communities, according to John McKnight, are best served by an asset based approach rather than a deficit approach.2 Human services providers, including the public health and medical care sectors, have shown limited success in identifying tangible community assets and transforming them into resources that improve low income communities. However,they are major stakeholders. In San Antonio, health care and research represents the area’s largest sector, estimated at over 7.5 billion dollars annually.

Private sector stakeholders and grassroots organizations are focused on outcomes. To rebuild communities they require capital and a political-administrative environment that engenders investment, and return on that investment. In turn, this activity builds confidence and momentum for community revitalization. New and in-fill housing, commercial development, job creation, and improved public safety and school quality are key elements for urban regeneration. These assets are tangible and create momentum for further investment, strengthening of community institutions and schools, and neighborhood self improvement. The health sector should participate in these opportunities by forming urban partnerships to position themselves as community assets. There are resources available for financing partnerships around specific projects, such as hospital community benefit funds and philanthropic foundations formed by hospitals and health care networks. Leadership and creativity for better and healthier communities will increase with inter sector cooperation.

Recommendations

As it becomes more evident that stakeholders, including the health sector, face similar benefits and risks accruing from the status of low income communities, attention must be given to how effective linkages, reciprocity, financing, and policy development across sectors can be fostered. There are obvious steps that should be taken immediately. Advisory boards should be inclusive of multi sector interests, for example bankers on hospital-community boards, or health care representatives on housing boards. Improved communication is needed for development of a common framework of quantitative and qualitative indicators for assessing community well-being and policy evaluation. Promoting inter sector initiatives often requires cooperative financing and identifying specific organizational connection points for higher efficiency. Special inter sector coordinators may be required to overcome bureaucratic impediments, and to increase cooperation among partners.

1. Ichiro Kawachi and Lisa Berkman, Social Cohesion, Social Capital, and Health, in Social Epidemiology by Lisa F. Berkman (Editor), Ichiro Kawachi (Editor).
2. John L. McKnight, Two Tools for Well-Being: Health Systems and Communities, in Community Organizing & Community Building for Health by Meredith Minkler (Editor).