Winston Vargas

Brownsville, Brooklyn, 1972. The neighborhood's current health problems can partly be traced to economic trends and policy decisions that harmed it decades ago.

Though only about nine miles apart, Brownsville and Battery Park have over 10 years between them in the average life expectancy of their residents. In Brownsville—a neighborhood consistently ranked among the poorest and most dangerous in the city — life expectancy, at 74.4 years, was at a citywide low in the most recent Summary of Vital Statistics released by the city’s Department of Health and Mental Hygiene. In the predominantly white, upper middle class Battery Park, meanwhile, the rate was 85.9 years — over four years above the city’s average.

Over the past decade, life expectancy has risen citywide, and disparities across race have narrowed — but between 2004 and 2013, the gap in life expectancy between very high and low poverty areas widened, suggesting persisting, if not increasing, inequality across income levels.

When comparing the city’s poorest neighborhoods to its wealthiest ones, disparities are difficult to boil down to one factor, reflecting everything from crime to chronic conditions. In Hunts Point and Longwood in the Bronx, where 43 percent of residents live under the Federal Poverty Level, rates of diabetes, for example, were five times as high as in Greenwich Village and Soho, according to 2015 Community Health Profiles released by the health department. In Mott Haven and Melrose, the asthma hospitalization rate among children was 14 times as high as the same rate in the Financial District. Infant mortality and new HIV diagnoses, too, were concentrated in neighborhoods with high poverty levels. And back in Brownsville, the rate of non-fatal assault hospitalizations was the highest reported in the city, over 10 times the same rate on the Upper East Side.

For David Sandman, president and CEO of the New York State Health Foundation, Brownsville “exemplifies the problems” for low-income neighborhoods when it comes to health inequality in the city. “There’s a history of disinvestment, and it will take time to reverse that,” he says.

Sandman emphasized that social ills afflicting the city’s poorest neighborhoods — such as housing issues, joblessness, lack of public safety — are all reflected in health outcomes. Health systems need to go beyond simply ensuring access to health care, he said, and invest in projects that address unemployment, incarceration, lack of educational opportunities, limited access to healthy food, and other factors often defined as social determinants of health.

But getting people and programs to recognize that broader health story can be difficult.

Linking health to violence, violence to jobs

Aiming to address the fuller health context in which neighborhoods exist, this past February Mayor de Blasio announced the opening of three new Neighborhood Health Action Centers in Brooklyn – seven are planned overall around the city — that will provide space for primary care and non-clinical social services in neighborhoods with high rates of excess morbidity and premature mortality. The goal of the neighborhood health action centers is to provide space for health care, wellness, assistance with issues such as housing and food, as well as a space for community organizing and mobilizing.

Then there’s Take Care New York 2020, an initiative launched by the health department in October 2015 that calls for greater focus on “non-traditional indicators” when working towards health equity across neighborhoods, according to a DOHMH press release. Along with addressing broader issues like disparities in premature mortality, the plan also calls for a higher citywide high-school graduation rate and a reduction in the jail population.

Through TCNY 2020, the city is also working with eight community-based organizations to create neighborhood health action plans addressing local priorities, as part of a larger effort for more community involvement. At a community health forum held by one of these partner organizations—the Northwest Bronx Community and Clergy Coalition in the Fordham section of the Bronx—this past October, attendees voted that decreasing violence in the community should be neighborhood’s main health priority. At a subsequent meeting in December, community members voted again on which area the organization should focus on in working to curb rates of violence, settling on workforce development efforts.

Shen’naque Sean Butler, an organizer with the coalition’s health justice committee, reflected on how this choice relates back to health outcomes, saying, “Jobs with dignity, jobs where people can earn a living wage, would improve the economy, bring in better food, bring in better options, raise the standard of living—all of that directly affects health.”

But he said it’s a challenge getting the community to understand the importance of these factors and “realize that a large part of what will make you healthy or unhealthy are external forces.” In his experience, many people see poor health outcomes in their community and feel guilty, attributing it entirely to personal choice.

Money chases symptoms, not causes

While the importance of social determinants in health outcomes has been long known in health circles, allocating funding to address those factors has been an ongoing challenge, says Amanda Parsons, vice president of community and population health for the Montefiore Health System.

“The lens on the marginal contributions of clinical care, compared to health risk behaviors and social determinants of health and your environment, is at least 15 to 20 years old,” she says. “What has always been a difficulty is that the payer world—like the insurance companies—have never agreed to pay for this kind of stuff in the past, and they don’t currently pay for much of it still now.”

Medicaid dollars, she noted, can’t be used for things like housing or pest control. If a child’s asthma is being triggered by roaches in his apartment, for example, and he ends up in the emergency room every two weeks, Medicaid cannot pay to get rid of the roaches, but “will pay for every single admission that kid has, all of the controllers, all of the nebulizers,” Parsons explained. “And so there’s been a very frustrated sentiment among providers, who know what the patient needs most of the time, but are unable to pay for it.”

Lisa David, is president and CEO of Public Health Solutions, a non-profit organization that conducts public health research and offers neighborhood services around the city. Despite barriers to better healthcare delivery for providers all over the health system, she feels there are reasons to be optimistic. She praised the recent work of the health department, particularly under health commissioner Mary Bassett, and said she thinks the city has finally been paying long overdue attention to neighborhoods that have historically been in the worst shape. “I think the distribution of resources is changing in a way that should allow there to be greater impact where the need is greatest,” she said. “But most things cannot get solved in a year or two or two-year grant. There needs to be a long-term commitment.”

Brownsville’s medical history

With 88,000 residents, Brownsville is not a big neighborhood, but its problems are outsize for its population. More than a third of its residents are living below the federal poverty line, almost a third, 32 percent, are obese and nearly a third, 29 percent, of its residents are under the age of 18.

These factors, taken together, have created a confluence of negative factors bearing on people’s health. “It’s a very young population and so many lack the basic skills in food preparation, and we know that unhealthy food is a major contributor in terms of the chronic disease we see in our practice,” says Harvey Lawrence, executive director of the Brownsville Multi-Service Family Health Center.

The problems of poor nutrition are being compounded by a host of factors: low or no paychecks, which has made it difficult for the neighborhood to attract exercise gyms; rising crime, which makes people reluctant to travel around the neighborhood; lack of open spaces to exercise or just play: and bad schools, which are cutting off young people’s future income, at the door.

“It’s the combination of things – housing, the lack of many different options for healthy food, lack of opportunity to have green space, or space where you could pursue outdoor activities and do it in a leisurely way,” all these things add up to a confluence of stressors that just become overwhelming, says Lawrence.

It wasn’t always that way. In the late 1940s and the early 1950s, Brownsville’s public housing was staunchly middle class, the neighborhood was almost evenly divided among black and white residents and in 1962, a coalition of white and black hospital workers successfully fought for the right to unionize at then Beth El (now Brookdale) hospital, according to a history of the neighborhood prepared by the Center for Court Innovation.

But problematic undercurrents were already starting to flow: The city’s ‘urban renewal’ program of the 1950s that removed low-income residents from wealthier neighborhoods, placing many of them in neighborhoods like Brownsville; the flight of middle-class black families out of the neighborhood, and the bitter racial fights over the desegregation of the Ocean Hill-Brownsville school district, which was supposed to improve educational outcomes for black students, but instead, many community activists believe, led to the wholesale abandonment of the education of minority children in New York City for decades to come.

In the intervening decades, as wages have stagnated or disappeared, as schools have lost money and resources, the concomitant effect of all these stressors has had a huge impact on health care, and the health of the neighborhood, say community activists.

It’s not difficult to trace the health effects of these broader social changes. In 1967, there was a 15 percent literacy rate among high school graduates in Brownsville, according to social activist and then school teacher Charles S. Isaacs: flash forward to today, that graduate is 67 years old. How does someone who had trouble reading high-school textbooks decode their medicine bottle, and understand or know to ask how different medicines they take interact with one another. At the same time, advances in medicine have reduced hospital stays, putting a greater onus on patients to manage their care at home.

Feedback effects

For Lawrence, the physical distances his patients have to travel for health care are dwarfed by the psychic distances they have to cover, distances compounded by high-density housing, low access to fresh food, neighborhood blocks carved out by gangs, all of which, says Lawrence, put “an extra set of gravity on people (that) they walk through and carry with them.”

“All this stuff that we call social determinants of health,” says Lawrence, “it’s not happenstance that they are all here as the result of Robert Moses’ urban renewal and planning to relocate people to certain areas and concentrate them in others.” Lack of green space, deeply dense housing, lack of jobs and economic opportunity, “all of these elements impact on one’s sense of well being,” says Lawrence.

Which loops back to how people can or will take care of themselves. “There is evidence that at some level the stress affects your health and affects some of the choices you make.” And that tension gets released in ways that are unhealthy. For a diabetic, it may be indulging in sugary drinks – Brownsville has the highest self reporting of sugary drink consumption for any neighborhood in New York City; it’s not healthy, but the rationalization may easily be “this is my escape when I am depressed. This is my little small piece of satisfaction, escape from the reality I’m dealing with,” suggests Lawrence.

As Roger Green, executive director of the DuBois-Bunche Center for Public Policy at Medgar Evers College, sees it, a key factor that has exacerbated Brownsville’s underlying economic disadvantages was the 2007 global financial crisis, which set housing in a tailspin, stagnated wages and forced people out of work.

“I think if you look at what happened almost 10 years ago, with the collapse of the global financial markets, Brownsville and East New York were hit with local economic depression—people losing their housing . . . not being able to aggregate assets, not being able to save money, to do the things that other folks do in order to achieve economic mobility, these are all stressors,” says Green.

Read Part 3: Hospital Closures and Medicaid Shifts Took Toll on Health