Lifting boats without closing gaps: child health outcomes in distressed US cities from 1992-2002

Objectives. We compared cause-specific mortality and birth rates for children and youths aged younger than 18 years in 100 US cities from 1992 through 2002.Methods. We used 5 census indicators to categorize the 100 most populous US cities in 1990 as economically distressed or nondistressed. We used Poisson regression to calculate rate ratios for cause-specific mortality and birth rates, comparing distressed cities to nondistressed cities overall and by race/ethnicity from 1992 through 2002. We also calculated rates of change in these variables within each city over this period.Results. Despite improvements in health for the study population in all cities, disparities between city groups held steady or widened over the study period. Gaps in outcomes between Whites and Blacks persisted across all cities. Living in a distressed city compounded the disparities in poor outcomes for Black children and youths.Conclusions. A strong national economy during the study period may have facilitated improvements in health outcomes for children and youths in US cities, but these benefits did not close gaps between distressed and nondistressed cities.Substantial evidence has demonstrated that city residence in the late 19th and early to mid-20th centuries was associated with high rates of injury and infectious diseases.^1–6 Researchers have noted that cities have continued to impose a health penalty on their residents, with poorer outcomes among children and youth in cities than in the rest of the United States.^7–11Some have argued that this penalty was associated with the period of urban decline after 1970, during which physical infrastructures deteriorated and city government services shrank. Yet a number of scholars have noted that the decline from 1970 to 1990 set cities on different demographic and economic trajectories.^12–17 In this formulation, some cities suffered substantively different qualities of economic distress. One group of cities endured ongoing “White flight,” increasing crime rates, poorly performing schools, shrinking populations, an eroding tax base, and greater demand for health and social services.^18–22 A second group of cities experienced the same ills but less severely, and they were buoyed by new immigration.^23,24 These trajectories may have positioned cities differently to benefit from the economic prosperity that the United States experienced from 1992 through 2001.Surprisingly, even within the field of urban health, little attention has been paid to the ways in which economic and population differences among cities may be associated with poorer health outcomes and racial/ethnic health disparities among cities. To be sure, investigators have extensively studied the racial/ethnic disparities that persist despite overall gains in life expectancy and in specific health indicators in the last 15 years.^25–29 However, to our knowledge, health scholars have not investigated the different trajectories of city distress as a factor explaining health disparities and urban health. Several influential studies have demonstrated that health disparities exist between Blacks and Whites within cities,^30–32 and that the health of Blacks in cities is worse than that of Blacks in rural areas.^33,34 Much recent scholarship has demonstrated that neighborhoods of concentrated poverty in cities impose an additional health disadvantage beyond that explained by a resident''s individual poverty level.^35–39 The independent effects of neighborhood residence in urban areas have been documented across educational and social outcomes as well.^40–44We investigated the impact of different patterns of urban distress on selected mortality and birth outcomes for children and youths from 1992 through 2002. First, we assessed whether there were differences in health outcomes for children and youths in economically distressed versus nondistressed cities at the beginning of this period and whether there were racial disparities for these outcomes between different groups of cities in 1992. Next we asked whether, as the period of economic prosperity ended, all boats had risen to the same degree. That is, did improvements in health over this period narrow differences between economically distressed and nondistressed cities? Further, did disparities in health outcomes between Black and White children and youths residing in these 2 groups of cities decrease during this period? To address these questions, we investigated selected causes of mortality and birth rates for children and youths in 1992 and 2002 in 100 US cities. We also compared mortality and birth rates for Whites and Blacks in economically distressed cities versus nondistressed cities, to assess differences across this time period.