Living in some of Baltimore's poorest and most violent neighborhoods can significantly increase your risk of heart attack or stroke, according to a study by the Johns Hopkins Bloomberg School of Public Health. In the worst areas, the hazard is on a par with being a regular smoker.
The results confirm the suspicions of a small group of urban researchers who in recent years have come to believe that impoverished environments can seriously damage health, even for people not directly touched by violence or who do not have unhealthy eating and lifestyle habits.
Researchers suspect the culprit is the stress of living in communities where gunfire and dilapidated housing are common and where stress-reducing activities such as recreational walks can be dangerous.
"We think of health in terms of medicine and genes and lifestyle," says Dr. Thomas A. Glass, a researcher at the university's Bloomberg School of Public Health and the study's lead author.
"We need to think of it more in terms of environment."
The results held even after Glass made allowances for other risk factors, including high blood pressure, cholesterol levels, diabetes and smoking.
The study, which appears in the latest issue of the American Journal of Public Health, is among the first to look at the link between heart disease and neighborhood. It is the first to focus on Baltimore.
Many studies have found that chronic stress can lead to heart disease. And for many people, living in a bad neighborhood produces stress due to worries about personal safety and life in substandard housing amid blight.
Glass said: "Bad things are happening all the time. You have to be vigilant constantly."
Glass and his colleagues looked at 1,100 people, ages 50 to 70, spread across Baltimore from Guilford to Druid Heights. Glass' study did not look for a causal relationship between neighborhood and heart disease, only an association --- which it found.
Researchers rated 64 neighborhoods, ranking them on a "psychosocial hazards scale" that measured attributes such as rates of murder and other violent crimes, percentage of boarded-up and abandoned buildings, number of 911 calls and per-capita income.
"We measured the things that make these neighborhoods scary," Glass said.
Researchers then looked at the history of cardiovascular disease among study subjects. To be included in the research, the subjects had to have lived in their neighborhood for at least five years.
Glass examined four ailments: heart attack, stroke, transient ischemic attack - essentially a small stroke without permanent effects - and intermittent claudification, a peripheral artery disease that causes decreased blood flow in the legs.
All four illnesses were more common in neighborhoods that ranked highest on the psychosocial hazards scale.
Such conditions evoke significant stress. As associate director of the Johns Hopkins Urban Health Institute, Dr. Chris Gibbons, who did not participate in the study, runs several health programs in poor neighborhoods in East Baltimore. He said people living in the city's worst neighborhoods deal with "amazing" levels of stress.
"There are so many things beyond the control of these people that affect their health," he said.
For those who live in Baltimore's poorer areas, Glass' analysis was not surprising.
Joseph Lomax has lived in East Baltimore for all of his 42 years. It has been a stressful four decades, he says.
"There's always something you have to be leery of," said Lomax, a thin man with a salt-and-pepper beard and stylish white shoes. "You can't go outside and not be aware. Being unconscious at any point could get you in a dangerous situation."
Lomax, who now lives on Federal Street, was sitting on the stoop of an abandoned building near the corner of Ashland and Chester streets.
Even relaxing on a stoop can get you into trouble, Lomax said ruefully. Sometimes dealers stash drugs in the steps, he said, pointing to a hole in the marble block on which he sat. Police could come by, he said, or the dealer might take offense.
A floor installer and cleaner, Lomax said the neighborhood puts him under nearly constant stress. On the block where he lives, he is surrounded by drug dealing, and he, his wife and three kids hear gunfire every night.
"You get used to it," he said. "But you think about it constantly. You hear gunshots, you automatically duck." He says he gets what relaxation he can from his church.
Has all this affected his health? Lomax didn't know, but he does have high blood pressure.
Robert Goldman, who also lives in East Baltimore, on Monument Street, had a heart attack this spring. He says that his neighborhood is not an easy place to live. He also hears constant shooting, and he lives among abandoned buildings and drug dealing.
"It's a heavy burden," he says.
Goldman, who is 56, gets around by wheelchair - his left leg was amputated after an infection. He gets government disability payments, but sometimes he has to beg to make ends meet.
For Glass, the issue - in Baltimore and similar cities across the country - comes down largely to the economy: "Starting in the '50s, we lost the lower and middle rungs of the economic ladder. All the solid-paying union and manufacturing jobs that anchored people to these neighborhoods, those jobs left."
Baltimore City Health Commissioner Joshua M. Sharfstein said the study "adds to the growing body of knowledge that health is more than a collection of individual behaviors."
More than anything, he said, the study underlined the deep links between health, economy and culture. "Health is in the mix, even when we might not think it's in the mix," he said.
The Health Department is working to reduce violence through a program that pays community members to work with youths to head off confrontations and attacks, and it is trying to prevent heart disease through a community awareness program.
The problem, researchers say, is that bad neighborhoods can cause problems through so many mechanisms.
"There's not one single thing," said Dr. Ana V. Diez-Roux, director of the Center for Integrative Approaches to Health Disparities at the University of Michigan. "It's a whole lot of things that go together."
One of the few researchers besides Glass who study the interaction between neighborhood and health, she said that people who live in dangerous, unstable neighborhoods not only experience constant stress, they often can't get relief that people who live elsewhere might find.
"You might sleep less, and you're not going to take an evening walk," she said. "All of these things have consequences."