Links between the social and physical environments.

This article proposes a model for understanding the links between children's health and the social and physical environment. School is the principal setting explored as a way of illustrating the issues. Three case examples of school-related problems are presented and actions that pediatricians and others may take are outlined.

Root shock: the consequences of African American dispossession.

Urban renewal was one of several processes that contributed to deurbanization of American cities in the second half of the 20th century. Urban renewal was an important federal policy that affected thousands of communities in hundreds of cities. Urban renewal was to achieve "clearance" of "blight" and "slum" areas so that they could be rebuilt for new uses other than housing the poor. Urban renewal programs fell disproportionately on African American communities, leading to the slogan "Urban renewal is Negro removal." The short-term consequences were dire, including loss of money, loss of social organization, and psychological trauma. The long-term consequences flow from the social paralysis of dispossession, most important, a collapse of political action. This has important implications for the well-being of African Americans. It also raises important questions about the strength and quality of American democracy.

The influence of geopolitical change on the well-being of a population: the Berlin Wall.

OBJECTIVES: Social cohesion is recognized as a fundamental condition for healthy populations, but social cohesion itself arises from political unity. The history of the Berlin Wall provides a unique opportunity to examine the effects of partition on social cohesion and, by inference, on health. METHODS: This ethnographic study consisted of examination of the territory formerly occupied by the Wall, formal and informal interviews with Berlin residents, and collection of cultural documents related to the Wall. Transcripts, field notes, and documents were examined by means of a keyword-in-context analysis. RESULTS: The separation of Berlin into 2 parts was a traumatic experience for the city's residents. After partition, East and West Germany had divergent social, cultural, and political experiences and gradually grew apart. CONCLUSIONS: The demolition of the Wall--the symbol and the instrument of partition--makes possible but does not ensure the reintegration of 2 populations that were separated for 40 years. The evolution of a new common culture might be accelerated by active attempts at cultural and social exchange.

Black-white inequalities in mortality and life expectancy, 1933-1999: implications for healthy people 2010.

OBJECTIVES: Optimistic predictions for the Healthy People 2010 goals of eliminating racial/ethnic disparities in health have been made based on absolute improvements in life expectancy and mortality. This study sought to determine whether there is evidence of relative improvement (a more valid measure of inequality) in life expectancy and mortality, and whether such improvement, if demonstrated, predicts future success in eliminating disparities. METHODS: Historical data from the National Center for Health Statistics and the Census Bureau were used to predict future trends in relative mortality and life expectancy, employing an Autoregressive Integrated Moving Average (ARIMA) model. Excess mortality and time lags in mortality and life expectancy for blacks relative to whites were also estimated. RESULTS: Based on data for 1945 to 1999, forecasts for relative black:white age-adjusted, all-cause mortality and white:black life expectancy at birth showed trends toward increasing disparities. From 1979, when the Healthy People initiative began, to 1998, the black:white ratio of age-adjusted, gender-specific mortality increased for all but one of nine causes of death that accounted for 83.4% of all US mortality in 1998. From 1980 to 1998, average numbers of excess deaths per day among American blacks relative to whites increased by 20%. American blacks experienced 4.3 to 4.5 million premature deaths relative to whites in 1940-1999. CONCLUSIONS: The rationale that underlies the optimistic Healthy People 2010 forecasts, that future success can be built on a foundation of past success, is not supported when relative measures of inequality are used. There has been no sustained decrease in black-white inequalities in age-adjusted mortality or life expectancy at birth at the national level since 1945. Without fundamental changes, most probably related to the ways medical and public health practitioners are trained, evaluated, and compensated for prevention-related activities, as well as further research on translating the findings of prevention studies into clinical practice, it is likely that simply reducing disparities in access to care and/or medical treatment will be insufficient. Millions of premature deaths will continue to occur among African Americans.

Motor-vehicle occupant injury: strategies for increasing use of child safety seats, increasing use of safety belts, and reducing alcohol-impaired driving.

The Task Force on Community Preventive Services has conducted systematic reviews of interventions designed to increase use of child safety seats, increase use of safety belts, and reduce alcohol-impaired driving. The Task Force strongly recommends the following interventions: laws requiring use of child safety seats, distribution and education programs for child safety seats, laws requiring use of safety belts, both primary and enhanced enforcement of safety belt use laws, laws that lower the legal blood alcohol concentration (BAC) limit for adult drivers to 0.08%, laws that maintain the minimum legal drinking age at 21 years, and use of sobriety checkpoints. The Task Force recommends communitywide information and enforcement campaigns for use of child safety seats, incentive and education programs for use of child safety seats, and a lower legal BAC for young drivers (in the United States, those under the minimum legal drinking age). This report provides additional information regarding these recommendations, briefly describes how the reviews were conducted, and provides information to help apply the interventions locally.

The Family to Family program: a structural intervention with implications for the prevention of HIV/AIDS and other community epidemics.

OBJECTIVES: To describe a case study of a community-based intervention located in the Harlem community of New York City, one of the oldest African-American communities in the United States. Although not specifically designed to prevent HIV infection, the program, 'Family to Family', exemplifies a 'structural intervention' that was created to strengthen family functioning and to strengthen the bonds that connect families to each other. By fostering strong relationships within and between families in a community with high rates of violence, drug abuse, and HIV infection, the program seeks to improve the quality of neighborhood life and influence the social determinants of individual risk behavior. SOCIAL CAPITAL: Family to Family was created specifically to develop the 'social capital' that is available to children and families in the Harlem community. Social capital refers to resources that result from social relationships, and that enhance an individual's or a group's ability to function and achieve a given set of goals and objectives. In addition to fostering closer relationships between children and their parents, this program also works to help participating families develop closer relationships with other participating families and with Columbia University student and faculty volunteers. Finally, Family to Family is sustained through the efforts of volunteers; it receives no grant support and is entirely self-supporting. CONCLUSIONS: Family to Family has the potential to change the social dynamics that promote HIV risk behavior in communities such as Harlem. Should it prove successful in improving the relationships between families and children, and in increasing the social capital available to all of its participants, it may become an important asset to public health prevention specialists concerned about preventing the spread of HIV.

Building momentum: an ethnographic study of inner-city redevelopment.

OBJECTIVES: One factor contributing to the decay of inner-city areas, and to consequent excess mortality, is the massive loss of housing. This report studied the effects of a redevelopment project on social functioning in an inner-city community. METHODS: This ethnographic study included the following elements: a longitudinal study of 10 families living in renovated housing, repeated observations and photographing of the street scene, focus groups, and informal interviews with area residents. The project was located in the Bradhurst section of Harlem in New York City and was focused on a redevelopment effort sponsored by local congregations. RESULTS: Those who were able to move into newly renovated housing found that their living conditions were greatly improved. Neighborhood revitalization lagged behind the rehabilitation of individual apartment houses. This uneven redevelopment was a visual and sensory reminder of "what had been." Residents missed the warmth and social support that existed in Harlem before its decline. CONCLUSIONS: Rebuilding damaged housing contributes greatly to the well-being of inner-city residents. The current pace and scope of rebuilding are insufficient to restore lost vitality.

Risk factors for excess mortality in Harlem. Findings from the Harlem Household Survey.

INTRODUCTION: In 1980, age-adjusted mortality rates in Central Harlem were the highest among New York City's 30 health districts. This population-based study was designed to describe the self-reported frequency of selected health conditions, behavioral risk factors, preventive health practices, and drug use in the Harlem community. METHODS: From 1992 to 1994, in-person interviews were conducted among 695 adults aged 18 to 65 years who were randomly selected from dwelling-unit enumeration lists for the Central Harlem health district. Descriptive statistics were computed for men and women separately, and compared to other population-based surveys. RESULTS: Self-reported medical insurance coverage in Harlem was unexpectedly high (74% of men, 86% of women) as was lifetime use of preventive health practices, e.g., blood cholesterol screening (58% of men, 70% of women). However, lifetime rates of substance use, e.g. crack cocaine (14%) and self-reported history of traumatic events, e.g., witnessing someone seriously injured or violently killed (49% of men, 21% of women) were also high in Harlem, especially in comparison to other populations. CONCLUSIONS: This study has identified important patterns of similarities and differences in risk behaviors between Harlem and other populations. Potential solutions to the health problems of Harlem may lie in the creation of strategies that operate at the community, municipal, and regional level, as well as at the level of individual behavior and risk-taking.

Stories of spiritual awakening. The nature of spirituality in recovery.

Substance abuse has had a devastating impact on the lives of millions. As substance use and abuse continues to ravage communities, researchers remain in the dark about what works to ensure successful recovery from addiction. In searching for the answers, researchers have often overlooked the role of religious and spiritual practices and beliefs in preventing use and relapse. The study reported here describes the process of spiritual awakenings experienced by some persons in recovery during their quest for sobriety. The data suggests that persons in recovery often undergo life altering transformations as a result of embracing a power higher than one's self, that is, a Higher Power. The result is often an intense spiritual journey that leads to sustained abstinence. Given how widespread substance abuse is, research on the nature, implications, and limitations of a spiritual approach to addiction might offer new options for treatment.

Injury and anomie: effects of violence on an inner-city community.

OBJECTIVES: Widespread violence affects individuals but also alters group life. This study was designed to examine the effects of violence on an inner-city community. METHODS: A qualitative study was undertaken that included field observations and semistructured interviews. The study took place in Washington Heights, a New York City neighborhood with a high rate of violence, largely secondary to the drug trade. RESULTS: The 100 people interviewed differed widely in their definitions of violence and in their likelihood of having experienced violent acts in the course of daily life. High, medium, and low violence microenvironments were identified; risk of exposure to violence, but not individual definitions of violence, differed by location. Violence in all parts of the neighborhood inhibited social interactions, but the intensity of this effect differed by microenvironment. CONCLUSIONS: In Washington Heights, violence has injured individuals and fractured social relationships, leading to the state of social disarray referred to as "anomie." The public health response to the violence epidemic should address anomie through community organizing efforts.

Promoting social cohesion to improve health.

The disintegration of communities places stress on the well-being of residents. This paper presents four case studies of efforts to strengthen community in four distinct US cities. They are based on interviews and observations made by the author, as well as on published accounts and reports in scientific and lay media. The case studies suggest that each community has a unique set of problems that require targeted interventions. The case studies suggest that interventions can promote social cohesion, thereby recreating the social foundation for good health. The implications for women's health are discussed.

Beyond stereotypes: stigma and counseling.

AIDS: Stereotyping a person predisposes the observer to an image of what a person is like, rather than understanding a person as an individual. It is important to understand the roots of stereotyping, and the ways that it is used, in order to prevent it from being employed in therapeutic situations. Four observations about how stereotypes are formed and used are discussed. First, everyone creates stereotypes about others, and should be able to recognize which stereotypes they endorse and to what extent these stereotypes interfere with getting to know other people. Second, assumptions are made based on values and cultural differences; therefore, sharing information among different cultures will increase understanding. Third, everyone should consider external circumstances which shape the responses and interactions of other people. Fourth, in order to identify with other groups, a person must be open-minded. Therapists must be mindful of these four observations when counseling people from different backgrounds, so as not to damage the therapeutic relationship.^ieng

Chaos, criticality, and public health.

Self-organized criticality offers more than a descriptive model or a doomsday forecast. We have tried to suggest that it is a paradigm for understanding the interconnections between apparently complex processes. At best, it suggests a method for finding the pressure points that can be used to bring unstable systems of public health services into greater levels of stability. The model enjoins us to understand that our goal is not to achieve equilibrium--that perfect match between the demand for health services and its delivery--but rather stability (or, more precisely, metastability). As is true of the sandpile, our systems of public health are constantly evolving. If we are correct, then the mechanism driving this ostensibly complex pattern of change and growth reflects the existence of simpler and, hopefully, more manageable processes. By monitoring these processes, it may be increasingly possible to adapt to change and even manage it effectively.

Psychiatric implications of displacement: contributions from the psychology of place.

OBJECTIVE: The purpose of this article is to describe the psychological processes that are affected by geographic displacement. METHOD: The literature from the fields of geography, psychology, anthropology, and psychiatry was reviewed to develop a "psychology of place" and to determine the manner in which place-related psychological processes are affected by upheaval in the environment. RESULTS: The psychology of place is an emerging area of research that explores the connection between individuals and their intimate environments. The psychology of place posits that individuals require a "good enough" environment in which to live. They are linked to that environment through three key psychological processes: attachment, familiarity, and identity. Place attachment, which parallels, but is distinct from, attachment to person, is a mutual caretaking bond between a person and a beloved place. Familiarity refers to the processes by which people develop detailed cognitive knowledge of their environs. Place identity is concerned with the extraction of a sense of self based on the places in which one passes one's life. Each of these psychological processes-attachment, familiarity, and place identity-is threatened by displacement, and the problems of nostalgia, disorientation, and alienation may ensue. CONCLUSIONS: As a result of war, decolonization, epidemics, natural disasters, and other disruptive events, millions of people are currently displaced from their homes. Protecting and restoring their mental health pose urgent problems for the mental health community.

Cognitive and emotional assessments of perceived risk for HIV among unmarried heterosexuals.

We examined perceived risk of contracting HIV using assessments of likelihood and worry in a probability sample of unmarried heterosexuals. Perceptions of the likelihood of contracting HIV and worry about HIV were only modestly correlated (r = .23), suggesting that they are different constructs. Far more respondents expressed worry (43%) than expressed the belief that they were at risk for HIV (9%). A significant proportion of the sample reported experiences that may have placed them at risk for HIV transmission. Demographic and psychosocial correlates of perceived likelihood and worry were examined in separate multivariate logistic analyses. Misconceptions about HIV transmission, a history of injection-drug-using sexual partners, and less education were associated with higher perceived likelihood of contracting HIV. Misconceptions, having multiple sexual partners in the past year, and a history of sexually transmitted diseases (STDs) were associated with high worry about HIV. Implications of the findings for correcting HIV-related misconceptions are discussed.