In 1967 Nathan
Goldman wrote in the Annals of American Academy of Political and
Social Science wrote
"Although problems of family breakdown, drug and
alcohol addiction, mental disorder, suicide, and sexual deviation
appear to be increasing, the available data are either so deficient
or so incomplete that accurate appraisal of the situation is
impossible. However, some of these problems seem to be more or less
socially sanctioned adjustments to strains in the social system
rather than maladjustments in themselves. To achieve our goal of
maximizing the social health of American society, we must consider
these problems as indicators of strain, and focus our national
resources on the reduction of these strains. We need to improve the
collection of data on these indicators, and to devise new ones, in
order to identify and locate those situations which interfere with
the ideal functioning of our social system. A significant aspect of
social breakdown is seen in the inability of the society to
mobilize for an attack on situations which it has defined as
undesirable. Our concern should be with the identification of these
processes as well as the underlying social strains of which social
problems are overt indicators. We must establish standard
definitions or criteria of social problems and increase the scope
and accuracy of our data- collection. Information-gathering on the
local or state level would need to be co-ordinated on a nationwide
basis to provide a useful set of indicators of the social state of
the nation".
The issue of
urbanization is not just one of larger numbers of persons gathered
into urban geopolitical units. The geographic size of a city makes
a difference as well. For example, in central New York City
(Manhattan), there are 52,419 people per square mile; in Cook
County, Illinois (Chicago), 5,398; in Los Angeles County,
California, 2,183; and in Dade County, Florida (Miami), 996.1. In
contrast, the overall United States population density is 70.3
people per square mile; and in 1790 the nation had a population
density of 4.5 people per square mile. The less concentrated
population of today's sprawling urban areas present challenges of a
different kind, such as the difficulties of organizing public
transportation. Lack of mass transportation may mean increased
pollution from individual use of internal combustion engines, and
it may mean that individuals lacking a personal car may have
difficulty reaching health services.
From an economic
perspective, urban populations experience some of the extremes of
income inequality, with large differences in income between the
highest- and lowest- earning segments of the population. Income
inequality has been increasing in the United States over the last
twenty-five years, and, for the low- earning segment, can have a
significant negative impact on health. Areas with high income
inequality and a low average income have been reported as
experiencing nearly 140 deaths per 100,000 people, compared with a
rate of 64.7 per 100,000 in other areas. This impact is greater for
infants and those between 15 and 64 years of age. A study of thirty
large metropolitan areas revealed that when poverty is concentrated
within a geographic area, mortality is significantly elevated.
Conversely, a concentration of affluence is associated with lower
mortality, at least in the elderly.
Urban populations in
the United States include large ethnic and racial minority
populations. The combination of segregation and discrimination felt
by minority groups in urban areas can also have an impact on
health, whether due to limitations in access to health services,
education, and jobs; or the increase in stress due to the tensions
of being a minority population. Urban areas have been cited often,
for example, for the failure of their police forces to respond
equitably to members of minority populations. This has included
disproportionate targeting of minorities as potential offenders
(racial profiling), a lower level of response to complaints or
requests for assistance, or outright disrespect or brutality. While
none of these issues is uniquely urban, the concentration of
population and the media visibility in a metropolitan area make
this an even greater issue of concern.
As already
identified, placing a large number of people in a small area
increases the risk of health and illness problems. The closer
proximity and higher rate of face-to-face contact has a direct
impact on the rates of transmissible diseases such as tuberculosis
and other respiratory infections. It is no surprise that the
resurgence of tuberculosis experienced in the United States in the
late 1980s and early 1990s began in New York. The high population
density, and the use of large, poorly ventilated spaces as
overnight sleeping accommodations for the homeless provided an
ideal environment for the transmission of the bacillus. The fact
that the public health resources were being strained by the arrival
of another condition, HIV/AIDS (human immunodeficiency
virus/acquired immunodeficiency syndrome), compounded the problem
and meant that drug- resistant organisms were being shared. Health
concerns as much as concerns for recreation space have been
involved in the development of at least limited open spaces such as
parks within concentrated urban areas.
The
interrelationships of central urban areas to their surrounding
suburbs has been the focus of study and attention from several
perspectives. The decreased population density of suburban housing
may mitigate some problems that are encountered in older urban
settings. For example, there may be more open spaces for recreation
or sport, and access to more remote areas is simpler. On the other
hand, suburbs mean more widely dispersed individual homes, each
needing access to utilities and transportation, and constructed in
such a way that neighborhood cohesion may be difficult or
impossible to develop. The availability of individual automobile
transport in the United States has undoubtedly contributed to
suburban sprawl, as have issues of social discrimination. These
areas have also grown because of what has been labeled "urban
flight": the movement out of cities of the more affluent as new
waves of immigrants, often from different ethnic or racial groups,
moved in. The apparent cost of maintaining or advancing a standard
of living within the urban core was seen as too great. This flight,
however, leaves older housing stock to be occupied by those of
lower income levels, with less generation of taxes to support
services, and the beginning of a downward spiral. When combined
with the movement of industry because of restrictions on pollution,
search for a cheaper labour pool, or simple displacement due to
competition from elsewhere, the result can be a severe, area-wide
depression. The cities of the so- called Rust Belt of the
northeastern United States provide many vivid examples of this
cycle.
Some of the health
concerns in urban areas are the result of a loss of individual
control. When a person is dependent on either walking or using a
private vehicle on a seldom-used two lane road, there is much less
need to be concerned about the behaviour of others than if the
person uses public transportation or walks or drives in a busy
urban environment. In addition to the difficulties related to the
increased numbers of encounters, there is an increased level of
stress, which is known to increase the risk of illness. The density
of urban populations and the associated stresses have also been
associated with increased rates of violence and, in the second half
of the twentieth century, an increase in crime associated with an
increase in the distribution, sale, and use of illegal drugs. Some
of the crime directly involved the drug distribution networks, as
they competed with one another for turf; other crimes were
committed by those who became addicted as they attempted to find
the resources to support their addictions. For example, one
occupational risk that has been studied is the risk of violence to
convenience store employees. Of 1,835 robberies of convenience
stores in eastern metropolitan areas in 1992 and 1993, 63 percent
involved the use of a firearm, and 12 percent were associated with
an injury to at least one employee. All five reported fatalities
were firearm- related.
A major news story
of the late twentieth century was the dramatic success of many
urban areas in reducing violent crime. While observers are
consistent in saying that no single action can be credited with
bringing this about, it may have been the result of a combination
of much more sophisticated and targeted policing and a demographic
shift that meant a smaller population of young adults, the group
most likely to be involved in crime.
Finally, cities are
a centre of immigration, both from rural areas (as evidenced by the
population shift of the last century) and from other countries.
Port cities (which may not be coastal in this age of airport
travel) experience a constant influx of people from other cultures
and climates. This may add to the health challenge in a number of
ways. For example, during the period following the end of the
Vietnam War in which a large number of refugees from Southeast Asia
were arriving in the United States, many health care providers had
to learn about an entirely new range of parasitic diseases that
were endemic in these people's countries of origin. Beyond specific
diseases, immigrants bring different expectations of the health
care system, and a different understanding of the range of
interventions appropriate to various disease states. Some immigrant
health practices have moved toward the mainstream, as in the
increasing use of acupuncture, once seen as an odd practice of the
Chinese immigrant community. And the increasingly popular herbal
remedies are an echo of the role the botanica plays in
Hispanic cultures.