There’s the achievement gap in schools. The income gap. The opportunity gap.
But have you heard of the life-and-death gap? A new report by the Spokane Regional Health District quantifies the morbid fact that people who live in Spokane County’s wealthy neighborhoods can expect to outlive those from poorer ones by years and years.
The difference between the longest-lived neighborhood in the county (Southgate) and the shortest-lived one (downtown) is about 18 years: an entire American childhood. But it is not simply a matter of extremes; neighborhood by neighborhood, there is a gradual rise in years of expected life that tracks the rise in neighborhood wealth. Life expectancy in East Central is 72.92 years; in Cliff/Cannon it’s 76.51; in Manito it’s 80.82; in Rockwood it’s 82.79.
That is the starkest example in the health district report, which details how differences in income, education, race and neighborhood are correlated with disparities in individual health.
The report, “Odds Against Tomorrow: Health Inequities in Spokane County,” reveals that incomes at the top of the scale increased the most in recent years, while those at the very bottom have dropped. It quantifies the long-term relationship between education and poverty, as well as the link between education and a healthier lifestyle. It demonstrates that white people live longer than everyone else.
“Health inequity is not only about extremes of wealth and poverty,” wrote Dr. Joel McCullough, district health officer, in the report’s introduction. “There is a continuous gradient in health status throughout society – even among the middle classes. The higher an individual’s social status, the healthier they are, and the longer they live. Whether we look at life expectancy or at the frequency of most causes of death and disability, health standards are highest among those nearest the top of the social ladder – whether measured by income, education or occupation – and lower as we look at each successive step down the ladder.”
Tale of two neighborhoods
Fifteen-year-old Megan Wallace has lived in the East Central neighborhood for a decade. When she was younger, she thought she lived in a dangerous “ghetto,” but her views on the place have softened. Still, she was shocked when she saw the figures on life expectancy: Someone living just up the hill from her, in the Comstock neighborhood, had a life expectancy that was 10 years longer than hers.
“Ten years is a big deal,” said Wallace, a sophomore at Ferris High School. “It was quite shocking and a scary thing, but it also makes you wonder what you can do.”
Wallace and her twin sister, Elizabeth, have become a case study in what you can do. Along with a friend, Dustin Schaefer, 16, they created a photographic comparison of alcohol and tobacco advertising in East Central and Comstock. The “PhotoVoice” project – sponsored by a health district program called Neighborhoods Matter – resulted in a presentation that the teens have given to the Spokane City Council and several community organizations.
Using mostly disposable cameras, they documented that the visible public advertising in East Central focused more heavily on alcohol and cigarettes. Beer ads tended to feature provocative images of bikini-clad women, while beer ads in Comstock featured military families. All told, they found twice as much alcohol advertising in East Central; they also found that beer was cheaper at comparable stores.
One startling comparison involved a pair of Conoco stations. The Comstock station has bushes and treed landscaping and a vintage Coke sign; the East Central station has not a single bit of greenery – not counting a stubborn weed or two – and an enormous red sign: “CHEAPEST BEER & CIGARETTES.”
“Same business, different message,” Schaefer said.
And when they did come across beer ads on the South Hill – “What do you know, everyone’s fully dressed!” Megan says in the PhotoVoice presentation.
Your neighborhood is not your fate, of course. The relationship among income, education, personal choices, cultural attitudes, services, transportation, parks and safety is so complex that oversimplifying cause-and-effect can be misleading.
But as the PhotoVoice project shows, some of the factors that make an environment conducive to health are easy to see. Seemingly simple things, such as access to healthy food, vary from neighborhood to neighborhood; wealthier neighborhoods have more grocery stores, and others have small markets focused heavily on marketing beer and cigarettes, offering lots of junk food.
For the Wallaces and Schaefer, these advertisements are not abstract. They are an expression of what others think about them.
“The project is very personal, and we wanted it to be that way,” Elizabeth Wallace said. “We wanted people to see that the neighborhood affects us.”
A web of factors
It’s tempting to view the new report as simply a more detailed expression of an old problem: poverty and its effects.
But health officials reject this notion. Poverty is a problem with deep ramifications, but they say no one “social determinant” explains these differences in health. When you try to simplify it – to put your finger on a solvable piece of the puzzle – you find several different characteristics entangled.
Take the issue of maternal smoking. It’s a classic modern health problem, in that its ill effects are well-known and educational campaigns and social programs have put a bull’s-eye on the practice for decades – and still it persists.
In Spokane County, the rate of smoking among pregnant women climbs steadily as you step up the socioeconomic grade of neighborhoods: More than 41 percent of pregnant women in West Central smoke, about twice the percentage as in the Cliff/Cannon neighborhood, about four times the state average – and 10 times the percentage of the Manito neighborhood.
The web of factors that might contribute to those differences is more than income or education – and more than simply a question of “educating” people.
A lot of that web is expressed in place and culture. In neighborhoods where smoking is more prevalent, people are more likely to see family and friends do it. The status – or lack thereof – associated with smoking differs by area. People may have seen their mothers smoke during pregnancy, with no fatal consequence. Some young women believe that smoking during pregnancy will help ease their labor, because the baby will be born smaller. And smoking is a tenacious addiction that people use to ease stress, and fighting tenacious addictions is harder when you have less support and less cultural disapproval.
The health district’s goal in producing the report – and in giving it a wide public airing – is to gather a communitywide effort.
McCullough said positive efforts will have to come from all quarters, not just the health district. He points to Priority Spokane – an effort led by a coalition of political, educational and community leaders that targets a range of community priorities. Raising the graduation rate is now the key priority – something that can have a long-term, positive effect on income and health.
But on its own, the health district has been targeting neighborhood influence for a few years. Neighborhoods Matter – the program that sponsored the PhotoVoice project – was set up in East Central in 2010. It’s a new approach to community health, one that aims to enlist neighborhood residents in identifying problems and finding solutions. It arose following an assessment of maternal and child health in the neighborhood.
“We realized that even though we had a very effective one-on-one program to address maternal and child health, we were only affecting a small number of families,” said Rowena Pineda, program manager for Neighborhoods Matter.
One initiative is the Community Café, a regular open house for neighbors where they discuss neighborhood health. Early on, organizers asked them to answer a simple question: What makes for a healthy community?
One answer: a place that’s safe for children.
“They said, ‘Our kids need a park that’s clean and safe,’ ” Pineda said. “So we did park cleanups.”
Another issue that arose was the number of streetlights that weren’t working. Neighbors did an inventory of the lights, and the program is in the process of working with the city and Avista to get them fixed. The teens involved in PhotoVoice are also taking on community cleanup efforts, organizing and promoting events at vacant lots and graffiti hot spots.
Pineda said one East Central resident told her: “Before I got involved, if I had seen garbage across the street, I would have said, ‘Why isn’t the city picking up that garbage?’ Now I would just go out and pick that garbage up.”
The program may expand into other neighborhoods. It’s just one tool in the larger effort of attacking what health workers call a “wicked problem.”
“It’s big,” Pineda said. “There are several layers to it. It’s a very complex issue. But if we’re going to resolve health inequities, we need to include community members and their voices. … It’s not a public health problem. It’s a community problem.”