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Name of Submitter:
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Naa Oyo Kwate
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Title of proposed idea:
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Health and the American City
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What is the major obstacle/challenge in the biomedical research field? What is needed to overcome this obstacle/challenge?
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Much of what we know about human health centers on individual behaviors, such as exercise, diet, substance use, and health care utilization. Because individuals can engage in behaviors that promote health and lessen the risk of disease, behavior change has been a fundamental focus in NIH funding. Indeed, the Common Fund has funded “The Science of Behavior Change”, which is designed to elucidate some of the basic mechanisms underlying the initiation and maintenance of a range of health behaviors. At the same time, researchers are asking how social factors affect health directly and indirectly, differentially placing populations and individuals at greater risk of health risks. We know that factors such as socioeconomic position, racism, inequitable distributions of power and resources, and physical environments are critically important in health status and health disparities. For example, it is well known that persons classified as Black in the United States face marked health disparities across a range of conditions, and these disparities are not attributable solely to individual behavior. Racial residential segregation has been described as the cornerstone on which Black-White disparities in health status have been built, with empirical studies documenting associations between segregation and adult and infant mortality, homicide, smoking, weight status, injection drug use, and self-reported health. These adverse health outcomes are thought to result, at least in part, from segregation’s negative effects on access to resources, exposure to stressors, and foreshortening of opportunity structures (e.g., economic and social capital). Importantly, the effects of segregation on health are heterogeneous across metropolitan areas. Neighborhood-level factors have also increasingly come into focus in predicting health disparities. For example, ethnographic social science research showed that Chicago’s North Lawndale neighborhood saw a disproportionate loss of life in the 1995 heat wave because the neighborhood infrastructure deterred people from utilizing public space. Public health studies have shown that the presence of physical disorder (e.g., litter and abandoned cars) is associated with decrements in mental health, and that the density of fast food restaurants is associated with obesity prevalence among youth.
Taken together, researchers who study social context and health are making important discoveries. But several key obstacles remain: First, much of the research we have uses a fairly limited scope of exposures. This is an obstacle because exposures are of critical importance in understanding health risk. Research has tended to study factors that are relatively easy to quantify proximally (e.g., number and types of stores, the number of streets with sidewalks, the number of times an individual perceives that they experienced racism in the past month). Less studied are more distal, structural factors (e.g., history, urban governance, policies), which are harder to quantify and also less likely to be positively reviewed in a typical NIH R01 application. Research is desperately needed to describe the means by which easily quantifiable exposures are distributed in the first place, how historical conditions shape the life trajectories and health chances of entire populations, and how institutional and policy climates produce and challenge inequities that harm health. Second, research on social context and health is informed by social science theory and basic research on social processes (e.g., stereotyping). However, almost all of that research has been conducted in psychology laboratories in university settings, with predominantly White undergraduate students serving as the basis from which to generalize to people in general. Research is needed to examine how these processes play out in the real-life contexts we are concerned about. Third, a significant amount of health research and intervention has focused on individual behavior change. As our knowledge continues to grow, we need to test structural interventions—where neighborhood resources, public policies, and physical infrastructures are the locus of treatment. Finally, researchers may have solid theories but they lack the technological skills to model relationships of interest. For example, Geographical Information Systems (GIS) is a central tool in mapping neighborhood exposures and disease incidence. It is an extremely useful tool, but one that requires significant investments of time and training, and even then, most researchers will only use a fraction of its capabilities. |
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What emerging scientific opportunity is ripe for investment by the Common Fund?
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The proposed Common Fund Project is “Health and the American City”, and is designed to push the field on social context and health research. Cities remain important residential locales for Americans and we are witnessing transformations in many that are going to have a sustained impact for years to come. For example, some U.S. cities are enacting changes to create sustainable transportation infrastructure, including bike-sharing programs and congestion pricing for auto traffic dense areas. In others, urban agriculture is blossoming. And in still others, such as Detroit, the very urban landscape appears imperiled as populations losses have left large portions of the city reverting to prairies, and city administration thinking how to reconstitute lived boundaries by discontinuing municipal services. Home foreclosures have created a crisis in many cities, exploding extant wealth disparities, and disrupting social ecologies. A Common Fund program on health and the American city is ideally positioned to look at how these changes are affecting population health at various scales, to look for and explain heterogeneity in health, and broaden the scope from proximal and individual to distal and structural.
Four initiatives conceptually and operationally located in American cities serve as the nexus within which to spur innovative research on social determinants of health.
1. Lab to Landscape: This initiative would fund research to conduct social science experiments on processes relevant to contextual effects on health in real-world settings. For example, university-based experimental studies have demonstrated the consequences of endorsing ideas about a just world (the idea that what happens to people is deserved), and have shown how stereotyping can be characterized by processes in which stereotyped populations are seen as combinations of warmth and competence. Scholars have argued that when inequalities can be rationalized as logical outcomes based on perceived intrinsic characteristics (like stereotypes), inequalities in wealth and health can be justified as well. The question remains, then, what can translating these lab studies to experiments in city contexts tell us about social processes and how they affect health?
2. Place, Policy, & Legacy: This initiative would fund research that interrogates broad, population-level determinants of health and health disparities. These determinants may be realized in institutional practice, policy, and laws, day-to-day social interaction, or physical infrastructure,. Research funded under this initiative centers on health consequences of quantifiable social determinants that are more challenging to identify than those currently studied, or determinants that, while quantifiable, are too distal or risky for traditional R01 mechanisms. These could include characteristics of place (e.g., political economy, urban design and aesthetics), policies (e.g., housing preservation, stop & frisk law enforcement), and historical legacies (e.g., Jim Crow laws, racial housing covenants, incarceration).
3. High Risk Structural Interventions: This initiative would fund research that tests the impact of place-based structural interventions in which city physical infrastructure, policy, or material resources are modified to change health. Structural interventions are inherently risky, but studies that take a broad lens in operationalizing health-relevant interventions would be particularly encouraged.
4. Spatial Technology: This initiative would create a shared resource for investigators who conduct spatial analyses of health. Without access to sophisticated mapping and data visualizing technologies, researchers will tend to conduct research that is delimited by their technical skills in GIS or by funding constraints that would be needed to pay skilled professionals. This initiative would create a community resource where investigators can employ a wide variety of spatial analytic tools and data visualization in a user-friendly interface by plugging in their data at a variety of scales. |
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What are the potential Common Fund investments that could accelerate scientific progress in this field?
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A Common Fund investment in the proposed program could accelerate scientific progress, particularly if an emphasis is placed on interdisciplinary collaboration. RFAs for the four initiatives should attract studies from epidemiologists, economists, psychologists, sociologists, historians, urban planners and more. |
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If a Common Fund program on this topic achieved its objectives, what would be the impact?
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The first three initiatives would have a significant impact on the knowledge base of social determinants of health in U.S. cities. By targeting fundamental social causes of health, the program is central to the NIH mission and would invite participation from institutes such as NHLBI, NIDDK, NIAAA, NCI, NIMH, NIMHD and NICHD. Research generated from the program would unpack multiple levels of factors that shape features in American cities that increase, or protect against health risk, and investigate the impact of structural, place-based interventions. The fourth initiative would contribute to the goal of transformative science on social determinants by creating a shared resource for the scientific community to use, which will not only improve the rigor and creativity of individual investigator’s projects, but will foster shared methodologies across studies. |
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