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Improve the Health of Urban Populations




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American Journal of Public Health 837 Time for a National Agenda to Improve the Health of Urban Populations June 2000, Vol. 90, No. 6 To achieve the vision of “healthy people in healthy communities” articulated in Healthy People 2010,1 the United States must do more to promote health and prevent dis- ease in urban areas. Despite some significant improvements in health status in the last decade, the failure to achieve more than 15% of the goals identified in Healthy People 20002 stems in large measure from the dispro- portionate burden of certain health problems in urban areas—HIV infection, asthma, vio- lence, substance abuse, and preterm delivery as well as heart disease, cancer, and stroke.3–7 Although rural areas also experience higher- than-average morbidity and mortality that de- mand attention, in the last 50 years, the excess mortality and morbidity experienced by the poor and by people of color have become in- creasingly concentrated in cities.8 More than 80% of the US population lives in metropolitan areas, which include both cities and their surrounding suburbs. In the last 25 years, cities and suburbs have become more similar, and the demographic and health profiles that were previously uniquely urban are now shared by “edge cities” and poor and minority suburbs. More than a quarter of the US population still lives in central cities. Moreover, after more than 5 decades of federal support for suburbanization, cities continue to be the economic engine of the US economy and the focal point for global interchanges of people, services, products, and money.9 Even though cities have a disproportion- ate impact on the nation’s economy and health status, the United States lacks a clearly articulated urban agenda. Equally disturbing, the public health community has not defined a research or action agenda for urban health. What explains these failures, and how can public health workers contribute to reducing the health disparities now concentrated in the nation’s cities? The lack of a political agenda for improv- ing social conditions in cities stems from sev- eral related phenomena. First, over the last half century, the political machines and social movements that won new resources for cities have declined.10,11 In many states, political power shifted to suburban regions, where elected officials pursued tax and spending policies that favored their areas at the ex- pense of cities. At the same time, the na- tional government, which during the New Deal and the post–World War II era had served as the protector of urban and other vulnerable populations, lost power both to the states and to multinational corporations. After 1980, more conservative state and na- tional governments began to cut back the safety net programs that had protected people in previous decades. Between 1970 and 1990, the number of people living in poor inner-city neighborhoods doubled.12 Public health emerged as a modern pro- fession in the late 19th and early 20th cen- turies, born out of popular and elite efforts to improve living conditions in US and Euro- pean cities.13,14 More recently, however, orga- ...





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