Sabrina Oliver looked forward to good schools and safer streets when she moved her family from her crime-ridden and trash-strewn West Baltimore neighborhood to the suburbs, but was surprised to discover another benefit as well — a dramatic improvement in their health.
The asthma that afflicted daughter Nyla, 9, and frequently kept her out of school just about disappeared when the family relocated to Parkville, and most recently to Orchard Beach, where there were no roaches and mice, and less dust because the houses were more modern. Although chronic depression had once mentally paralyzed Oliver — keeping her out of work and on disability — the 38-year-old no longer takes antidepressants and has a job sitting with severely ill patients at hospitals.
"I feel transformed," Oliver said. "I feel like I moved to a whole other world."
Sociologists and public health officials have long thought a ZIP code is at least as important as race, age and genetics in determining a person's health. Now, a growing body of more advanced research is bringing the issue to the forefront once again and opening up the debate about how the nation looks at health care.
In one recent study, researchers at the Johns Hopkins Bloomberg School of Public Health found racial disparities normally associated with hypertension, diabetes and obesity weren't as strong when they took into account where people lived.
The researchers looked at racially integrated, working-class neighborhoods, including in Southwest Baltimore, and found that blacks and whites had similar health outcomes. They also compared health outcomes in the neighborhoods to national health surveys. Across the country, blacks are more likely to suffer from hypertension, but when looking at the Baltimore neighborhood, the disparity declined by 29 percent. Blacks and whites in the neighborhood also showed similar odds of being obese.
The researchers attributed the difference to whites in the neighborhood having higher rates of disease than whites on average nationwide. "When whites are exposed to the health risks of a challenging urban environment, their health status is compromised similarly to that of blacks, who more commonly live in such communities," the researchers wrote.
"When people are living in a similar type of environment and they behave similarly, they tend to have similar health outcomes," said Thomas LaVeist, director of the Center for Health Disparities Solutions at Hopkins and lead author of the study, which was released last month in Health Affairs.
A different social experiment started by the U.S. Department of Housing and Urban Development in the 1990s is now also showing evidence that women in five cities, including Baltimore and Los Angeles, had a lower risk for diabetes and extreme obesity when they moved to better neighborhoods.
Under the program, HUD looked at the health impact a ZIP code played in the lives of 4,500 families, some who were given vouchers that allowed them to move out of neighborhoods with poverty rates of 40 percent or more. The other families stayed. Researchers revisited the families who moved over two years beginning in 2008, testing their blood levels, checking body mass index levels and having the families take a survey. They compared the results to a group of families who hadn't moved.
The study, published last month in the New England Journal of Medicine, found that the longer people lived in a lower-poverty neighborhood, the more their body mass index and diabetes symptoms improved.
People who stayed in the old neighborhoods had a prevalence rate of 18 percent for extreme obesity, while women who left were one-fifth less likely to suffer from extreme obesity. They were also one-fifth less likely to have diabetes than women who didn't move.
Jens Ludwig, a professor at the University of Chicago and lead author of the HUD study, said he hopes results like this will help the health industry see improving neighborhoods as a form of preventive care.
"The standard way we tend to do things is we have these low-income families living in these incredibly distressed neighborhoods, and we sit back and wait until someone comes to the doctor's office to say, 'I'm feeling bad, and have got this ailment and that ailment,'" Ludwig said. "People in the health system might think harder about intervention and preventive care by addressing the community-level risk factors that contribute to these adverse health outcomes."
Oliver was able to move to a better neighborhood under a federal program administered by the American Civil Liberties Union of Maryland that relocates low-income Baltimore families to what they call "opportunity neighborhoods" in the city or suburbs, where they have access to better schools and employment, less exposure to crime and more reliable transportation services. More than 1,500 families under the program have been moved from areas where the median income was $24,182 to neighborhoods with median incomes of $48,318.
Administrators of the program, which was not part of the Hopkins or HUD studies, soon began noticing anecdotally that many of the families that moved had seen their health improve as well. Most noticeable was the improvement in asthma among children.
"Our kids were in and out of the emergency room, and now that they're out of the city, their emergency room visits are down," said Barbara Samuels, managing attorney for ACLU of Maryland's Fair Housing Project. "It's important because asthma is a huge problem. It's one of the main reasons kids miss school in Baltimore."
Oliver walked around her old neighborhood recently and recalled that she once was afraid to send her kids outside. Drug dealers would sit on her front steps. Houses were boarded up all around her, and people's yards were littered with trash. She couldn't get rid of the roaches and mice that lived in the walls of her house.
Oliver felt like she was under a tremendous amount of stress as she constantly worried about the well-being of her family.
Nicole Davis also saw improvement in her son's asthma when she moved under the ACLU-administered program. Before their move to Laurel two years ago, Davis and her four kids lived in a corner house on Bentalou Street in West Baltimore that was badly maintained. People hung out on the corners, and the children couldn't play outside.
One of Davis' sons was in the emergency room every other week, sometimes for a few days at a time, because of asthma. He often missed school for doctor appointments. But now his asthma is under control, and the occasional attacks are eased by medication.
"He is definitely healthier," Davis said of her son." That was one good thing about moving."
The most recent studies didn't address why community matters, but public health officials and past research have found that a variety of factors may make a difference.
Old housing stock in some neighborhoods can contain mold, dust and other bacteria that can cause asthma and other respiratory ailments to flare up. When families can't go for walks because their neighborhoods are dangerous and can't buy healthful food because there are no nearby grocery stores, it can lead to weight gain. The stress of living in neighborhoods with violence can also lead to mental health problems, such as depression.
Some poor neighborhoods also don't have access to good jobs, which can be a problem because most Americans get health insurance through their employers. Some neighborhoods also aren't near hospitals, although that is less true in Baltimore, where health care is a major industry.
Much of the debate and policy surrounding health has been focused on medical care. Many in the field hope that as more studies are devoted to neighborhood disparities, social issues will foster more attention.
Dr. Michelle Gourdine, a Maryland physician and health consultant, said creating healthier communities can be accomplished through policy changes as simple as creating tax incentives to attract grocery stores to poor neighborhoods or as controversial as implementing fast-food bans in poor neighborhoods. Planning boards can require new developments to have features such as walking paths and parks.
Better health outcomes can lead to other improvements in life. When the HUD program was first implemented, one of the main goals was to improve participants' chances at finding a job, said Erika Poethig, a deputy assistant secretary in HUD's Office of Policy. The agency wasn't looking at health outcomes, but it figured out the two go hand-in-hand.
"By improving people's health, you are improving their employment opportunities," Poethig said. "They can sustain a long work day and people are able to keep a job. While that is not the outcome we thought we'd get or the reason for the initial study, we realize health can create better outcomes in many ways."