Abstract
Sustainability and environmental issues have become hot topics as the public recognizes that U.S. consumerist lifestyles cannot be environmentally, socially, or economically sustained indefinitely. However, the connection between environmental health, social inequality, and place is often absent from discussions about sustainability. Kevin Fitzpatrick and Mark LaGory’s book, Unhealthy Cities: Poverty, Race, and Place in America, makes those important connections. This is an essential source for policymakers, public health practitioners, and those who research and teach about social stratification, and urban, environmental, and/or medical sociology. With this work, the authors clearly tie together social theory, empirical work in psychology and sociology, and analyses of public health programs to construct a sociology of health that is place-based.
If there is one “take-home” message here, it is that “place matters.” In particular, it matters when assessing health inequities in the United States and globally. While globalization has seemingly connected people and ideas all over the world, people are anchored to place, and often cannot or choose not to leave unhealthy environments. Weaving throughout the text the example of a 1987 Birmingham, Alabama ecological disaster in which a warehouse fire released over 5,000 gallons of the chemical Dursban into the surrounding air and water of Village Creek, Fitzpatrick and LaGory illustrate how health is less a matter of individual choice (choosing a healthy lifestyle over an unhealthy one) than a state constrained by race, gender, social class, and other social inequities. In the case of Village Creek, the area most affected by the Dursban spill (which can cause breathing problems, nausea, and birth defects) were poor African American communities along the creek. Not surprisingly, the state was very slow to respond to the disaster and little was done to stem the damage until the chemicals were discovered in wealthier neighborhoods downstream.
This example is but one of many ecological disasters that have hit hardest those who can least withstand them. Locating dangerous facilities within poor neighborhoods is not accidental, but rather a product of conscious decisions by corporations and governments. It is part of the “ecology of disadvantage,” (p. 6) where place determines life chances. Fitzpatrick and LaGory argue, “For certain segments of the population, being in the wrong place is not a matter of timing or accident, but rather a function of the social structure” (p. 4). The “health penalty” that people pay in disadvantaged neighborhoods exceeds the placement of chemical spewing factories in the ghetto; it includes a lack of access to quality health care, dangerous, crowded, and dilapidated housing, community violence and gangs, rampant open-air drug markets, high rates of unemployment, limited access to healthy foods, crumbling infrastructure and schools, and a lack of public safety. In short, because of high levels of economic and racial segregation in the United States, inner city ghetto neighborhoods (the focus in the book) place the individuals residing in them at very high risk.
Instead of packing their text with facts and figures about the health inequities based on race and social class, the authors start with an exploration of the meaning of space and place and build to a sociology of health, explaining how certain groups are especially vulnerable and what policymakers and social institutions can do to ameliorate the health risks present in poor neighborhoods. The reader is given the opportunity to connect the philosophical aspects of what place means to humans and how humans become human through place. Using the framework of constrained choice, Fitzpatrick and LaGory explore what urban environments mean for humans and their health. Although transportation connects us to many parts of a city, our surrounding space has a larger effect on our cognitive map of options and resources.
Fitzpatrick and LaGory reject the individualistic “lifestyle” health perspective and argue that lifestyles are produced within the constraints of neighborhood resources available to residents. Unhealthy places produce unhealthy lifestyles, not the other way around: “These ecological circumstances (high density, high segregation, low access to health-promoting resources, presence of illegitimate institutions, presence of deviant role models) represent the spatial conditions that nurture high probabilities of health-compromising behaviors and health beliefs” (p. 99). Thus the disadvantage that residents in poor communities experience produces negative health outcomes that cannot be blamed on individual choice. Those choices have been constrained by lack of social capital and the structural conditions of the neighborhood.
In the latter half of the book, Fitzpatrick and LaGory explain the particular risks to vulnerable populations in the urban realm, using the metaphor of the city as a “mosaic of risk and protection” (p. 102). They discuss the health risks to those who live in high poverty ghettos and the informal and formal “blankets of protection” that can serve to lessen the health risks present, such as churches, a strong family structure, and school-based health clinics. Examples of health risks include high rates of HIV infection, lead paint poisoning, asthma, youth violence victimization, and mental illness. Four populations—the homeless, the poor, youth, and the elderly—are at special risk for the health disadvantage in general. Those who live in high poverty places are in “double jeopardy” for negative health outcomes.
Fitzpatrick and LaGory argue that in order to alleviate health risk and unhealthy outcomes, any health promotion strategy must be infused with “place.” If unequal places produce health inequities, then social institutions should focus on making places more equal, rather than treating health as an individual problem. The authors offer many excellent examples of community-based programs that have intervened in neighborhoods to lessen health risk and improve life chances. While programs that explicitly work to promote health in poor communities are necessary to alleviate health inequality, the authors emphasize that “…they cannot succeed without simultaneously implementing comprehensive, place-sensitive strategies for healthy communities. Such an approach must include programs to promote both social capital as well as the human and physical capital contained in the community” (p. 188). With this book, Fitzpatrick and LaGory have created a more holistic approach to public health by connecting place inequities to wellness.