RACE AND THE DISTRIBUTION OF SOCIAL AND PHYSICAL ENVIRONMENTAL RISK: A Case Example from the Detroit Metropolitan Area

Linking environmental injustices in Detroit, MI to institutional racial segregation through historical federal redlining

OBJECTIVES

To identify the most pervasive environmental exposures driving environmental disparities today associated with historical redlining in Detroit.

METHODS

We overlaid Detroit's 1939 Home Owners' Loan Corporation (HOLC) shapefile from the Mapping Inequality project onto the EPA EJScreen and the DOT National Transportation Noise maps to analyze differences in current demographic and environmental indicators between historically redlined (D-grade) and non-redlined neighborhoods using simple linear regression and a boosted classification tree algorithm.

RESULTS

Historically redlined neighborhoods in Detroit experienced significantly higher environmental hazards than non-redlined neighborhoods in the form of 12.1% (95% CI: 7.2-17.1%) higher levels of diesel particulate matter (PM), 32.2% (95% CI: 3.3-69.3%) larger traffic volumes, and 65.7% (95% CI: 8.6-152.8%) higher exposure to hazardous road noise (LEQ(24h) >70 dBA). Historically redlined neighborhoods were situated near 1.7-times (95% CI: 1.4-2.1) more hazardous waste sites and twice as many (95% CI: 1.5-2.7) risk management plan (RMP) sites than non-redlined neighborhoods. The lifetime cancer risk from inhalation of air toxics was 4.4% (95% CI: 2.9-6.6%) higher in historically redlined communities, and the risk of adverse respiratory health outcomes from air toxics was 3.9% (95% CI: 2.1-5.6%) higher. All factors considered together, among the environmental hazards considered, the most pervasive hazards in historically redlined communities are proximity to RMP sites, hazardous road noise, diesel PM, and cancer risk from air pollution.

CONCLUSIONS

Historically redlined neighborhoods may have a disproportionately higher risk of developing cancer and adverse respiratory health outcomes from air toxics. Policies targeting air and noise pollution from transportation sources, particularly from sources of diesel exhaust, in historically redlined neighborhoods may ameliorate some of the impacts of structural environmental racism from historical redlining in Detroit.

An environmental justice analysis of air pollution emissions in the United States from 1970 to 2010

Over the last decades, air pollution emissions have decreased substantially; however, inequities in air pollution persist. We evaluate county-level racial/ethnic and socioeconomic disparities in emissions changes from six air pollution source sectors (industry [SO2], energy [SO2, NOx], agriculture [NH3], commercial [NOx], residential [particulate organic carbon], and on-road transportation [NOx]) in the contiguous United States during the 40 years following the Clean Air Act (CAA) enactment (1970-2010). We calculate relative emission changes and examine the differential changes given county demographics using hierarchical nested models. The results show racial/ethnic disparities, particularly in the industry and energy generation source sectors. We also find that median family income is a driver of variation in relative emissions changes in all sectors-counties with median family income >$75 K vs. less generally experience larger relative declines in industry, energy, transportation, residential, and commercial-related emissions. Emissions from most air pollution source sectors have, on a national level, decreased following the United States CAA. In this work, we show that the relative reductions in emissions varied across racial/ethnic and socioeconomic groups.

Backyard aerosol pollution monitors: foliar surfaces, dust enrichment, and factors influencing foliar retention

Air pollution is one of the leading causes of death from noncommunicable diseases globally, and in Arizona, both mining activities and abandoned agriculture can generate erodible dust. This dust is transported via wind and can carry high amounts of toxic pollutants. Industry-adjacent communities, or "fenceline communities," are generally closer to the pollution sources and are disproportionally impacted by pollution, or in this case, dust. The dust transported from the mine settles into nearby rivers, gardens, and homes, and increases the concentrations of elements beyond their naturally occurring amounts (i.e., enriched). This study was built upon previous community science work in which plant leaves were observed to collect similar concentrations to an accepted dust collection method and illustrated promise for their use as low-cost air quality monitors in these communities. This work investigated the concentration of Na, Mg, Al, K, Ca, Mn, Co, Cu, Zn, Mo, and Ba in dust from the leaves of community-collected backyard and garden plants (foliar dust), as well as if certain variables affected collection efficacy. This assessment evaluated (1) foliar concentration versus surface area for 11 elements, (2) enrichment factor (EF) values and ratios, (3) comparisons of foliar, garden, and yard samples to US Geological Survey data, and (4) what variable significantly affected dust collection efficacy. The EF results indicate that many of the samples were enriched (anthropogenically contaminated) and that the foliar samples were generally more contaminated than the yard and garden soil samples. Leaf surface area was the most influential factor for leaf collection efficiency (p < 0.05) compared to plant family or sampling location. Further studies are needed that standardize the plant species and age and include multiple replicates of the same plant species across partnering communities. This study has demonstrated that foliar dust is enriched in the participating partnering communities and that plant leaf samples can serve as backyard aerosol pollution monitors. Therefore, foliar dust is a viable indicator of outdoor settled dust and aerosol contamination and this is an adoptable monitoring technique for "fenceline communities."

Current practice and recommendations for advancing how human variability and susceptibility are considered in chemical risk assessment

A key element of risk assessment is accounting for the full range of variability in response to environmental exposures. Default dose-response methods typically assume a 10-fold difference in response to chemical exposures between average (healthy) and susceptible humans, despite evidence of wider variability. Experts and authoritative bodies support using advanced techniques to better account for human variability due to factors such as in utero or early life exposure and exposure to multiple environmental, social, and economic stressors.This review describes: 1) sources of human variability and susceptibility in dose-response assessment, 2) existing US frameworks for addressing response variability in risk assessment; 3) key scientific inadequacies necessitating updated methods; 4) improved approaches and opportunities for better use of science; and 5) specific and quantitative recommendations to address evidence and policy needs.Current default adjustment factors do not sufficiently capture human variability in dose-response and thus are inadequate to protect the entire population. Susceptible groups are not appropriately protected under current regulatory guidelines. Emerging tools and data sources that better account for human variability and susceptibility include probabilistic methods, genetically diverse in vivo and in vitro models, and the use of human data to capture underlying risk and/or assess combined effects from chemical and non-chemical stressors.We recommend using updated methods and data to improve consideration of human variability and susceptibility in risk assessment, including the use of increased default human variability factors and separate adjustment factors for capturing age/life stage of development and exposure to multiple chemical and non-chemical stressors. Updated methods would result in greater transparency and protection for susceptible groups, including children, infants, people who are pregnant or nursing, people with disabilities, and those burdened by additional environmental exposures and/or social factors such as poverty and racism.

A science-based agenda for health-protective chemical assessments and decisions: overview and consensus statement

The manufacture and production of industrial chemicals continues to increase, with hundreds of thousands of chemicals and chemical mixtures used worldwide, leading to widespread population exposures and resultant health impacts. Low-wealth communities and communities of color often bear disproportionate burdens of exposure and impact; all compounded by regulatory delays to the detriment of public health. Multiple authoritative bodies and scientific consensus groups have called for actions to prevent harmful exposures via improved policy approaches. We worked across multiple disciplines to develop consensus recommendations for health-protective, scientific approaches to reduce harmful chemical exposures, which can be applied to current US policies governing industrial chemicals and environmental pollutants. This consensus identifies five principles and scientific recommendations for improving how agencies like the US Environmental Protection Agency (EPA) approach and conduct hazard and risk assessment and risk management analyses: (1) the financial burden of data generation for any given chemical on (or to be introduced to) the market should be on the chemical producers that benefit from their production and use; (2) lack of data does not equate to lack of hazard, exposure, or risk; (3) populations at greater risk, including those that are more susceptible or more highly exposed, must be better identified and protected to account for their real-world risks; (4) hazard and risk assessments should not assume existence of a "safe" or "no-risk" level of chemical exposure in the diverse general population; and (5) hazard and risk assessments must evaluate and account for financial conflicts of interest in the body of evidence. While many of these recommendations focus specifically on the EPA, they are general principles for environmental health that could be adopted by any agency or entity engaged in exposure, hazard, and risk assessment. We also detail recommendations for four priority areas in companion papers (exposure assessment methods, human variability assessment, methods for quantifying non-cancer health outcomes, and a framework for defining chemical classes). These recommendations constitute key steps for improved evidence-based environmental health decision-making and public health protection.

Historic Redlining Practices and Contemporary Determinants of Health in the Detroit Metropolitan Area

Objectives. To examine how redlining, a historical racially discriminatory housing policy implemented by the Home Owners' Loan Corporation (HOLC), is associated with current neighborhood determinants of health in the Detroit Metropolitan Area. Methods. We analyzed associations between census tract‒level HOLC color grades (red = "hazardous"; yellow = "declining"; blue = "desirable"; and green = "best") and a developed neighborhood determinants of health index (DOHI) consisting of 8 indicators of economic, social, governance, and physical environment characteristics using spatial regression analysis and controlling for change in the census tract's percentage of White residents. Results. A total of 484 Detroit Metropolitan Area census tracts had HOLC grades. The mean redlining score across all census tracts was 3.02 (min = 1.0; max = 4.0). The mean contemporary DOHI was 19.11 (min = 8.0; max = 36.0). Regression models show significantly higher DOHI scores in yellowlined (b = 2.71; 95% confidence interval [CI] = 1.52, 3.91), bluelined (b = 5.33; 95% CI = 3.65, 7.01), and greenlined (b = 9.25; 95% CI = 6.86, 11.64) neighborhoods compared with redlined neighborhoods. Conclusions. Historical redlined neighborhoods experience contemporary determinants of health conditions that are less conducive to health compared with those in nonredlined neighborhoods. These differences also reflect the accumulation of resources essential for health in greenlined neighborhoods. Public Health Implications. Neighborhood development initiatives should consider the impacts of historical redlining on contemporary neighborhood conditions. (Am J Public Health. 2023;113(S1): S49-S57. https://doi.org/10.2105/AJPH.2022.307162).

HIV testing among transgender and nonbinary persons in Michigan, United States: results of a community-based survey

INTRODUCTION

Transgender (trans) and nonbinary people (TNB) are disproportionately impacted by HIV. HIV testing is critical to engage TNB people in HIV prevention and care. Yet, scant literature has examined social and structural factors associated with HIV testing among TNB people of diverse genders and in geographies with potentially lower trans acceptance. We: (1) characterized the prevalence of never having been tested for HIV; and (2) identified associated factors, among TNB people in Michigan, United States.

METHODS

Data were from a community-based participatory cross-sectional survey (n = 539 sexually experienced TNB people). The prevalence of never having had an HIV test was reported overall and compared across socio-demographic, clinical, social and structural factors using bivariable and multivariable logistic regression analyses.

RESULTS AND DISCUSSION

Approximately one-quarter (26.2%) of participants had never had an HIV test (20.8% transfeminine; 30.0% transmasculine; 17.8% nonbinary assigned male at-birth; and 32.0% nonbinary assigned female at-birth). In a multivariable socio-demographic model, older age (adjusted odds ratio [aOR] for 1-year increase: 0.93, 95% CI: 0.90, 0.96, p<0.001) and Black/African American race (vs. White) (aOR: 0.28, 95% CI: 0.09, 0.86, p<0.05) were associated with increased odds of HIV testing (aORs for never testing). In separate multivariable models controlling for socio-demographics, ever experiencing sexual violence (aOR: 0.38, 95% CI: 0.21, 0.67, p<0.001), not accessed sexual/reproductive healthcare in the past 12 months (aOR: 4.46, 95% CI: 2.68, 7.43, p<0.001) and reporting a very/somewhat inclusive primary care provider (PCP) (aOR: 0.29, 95% CI: 0.17, 0.49, p<0.001) were associated with HIV testing (aORs for never testing).

CONCLUSIONS

Findings contribute to scant literature about gender-based differences in HIV testing inclusive of transmasculine and nonbinary people. Lack of statistically significant gender differences suggests that broad TNB interventions may be warranted. These could include training healthcare providers in trans-inclusive practices with sexual violence survivors and PCPs in trans-inclusive HIV prevention and care. Findings showing Black participants were less likely to have never had an HIV test suggest the promise of culturally tailored services, though further investigation is needed. Findings identify social and structural factors associated with HIV testing and can inform multi-level interventions to increase TNB person's HIV testing.

Toxic Substances Control Act (TSCA) Implementation: How the Amended Law Has Failed to Protect Vulnerable Populations from Toxic Chemicals in the United States

Exposures to industrial chemicals are widespread and can increase the risk of adverse health effects such as cancer, developmental disorders, respiratory effects, diabetes, and reproductive problems. The amended Toxic Substances Control Act (amended TSCA) requires the U.S. Environmental Protection Agency (EPA) to evaluate risks of chemicals in commerce, account for risk to potentially exposed and susceptible populations, and mitigate risks for chemicals determined to pose an unreasonable risk to human health and the environment. This analysis compares EPA's first 10 chemical risk evaluations under amended TSCA to best scientific practices for conducting risk assessments. We find EPA's risk evaluations underestimated human health risks of chemical exposures by excluding conditions of use and exposure pathways; not considering aggregate exposure and cumulative risk; not identifying all potentially exposed or susceptible subpopulations, and not quantifying differences in risk for susceptible groups; not addressing data gaps; and using flawed systematic review approaches to identify and evaluate the relevant evidence. We present specific recommendations for improving the implementation of amended TSCA using the best available science to ensure equitable, socially just safeguards to public health. Failing to remedy these shortcomings will result in continued systematic underestimation of risk for all chemicals evaluated under amended TSCA.

“I do the she and her”: A qualitative exploration of HIV care providers’ considerations of trans women in gender-specific HIV care

Objectives:

Women of all genders, including cisgender (cis) and transgender (trans) women, experience social and structural drivers of HIV inequities and pervasive barriers to HIV care. Yet, little is known about how HIV care providers address gender diversity in health care. Through a critical feminist lens informed by intersectionality theory, medical anthropology, and critical sociology, we explored (1) how do HIV care providers describe women living with HIV’s care needs and barriers; (2) what are their perspectives on optimal HIV care for women; and (3) to what extent do these conceptualizations include/exclude trans women.

Methods:

Utilizing a community-based exploratory qualitative study design, we conducted 60–90 minute semi-structured individual interviews from March 2019–April 2020 with eight HIV care providers (n = 4 social service providers; n = 4 physicians) practicing across seven counties representative of rural, suburban, and urban Michigan, United States. Data were analyzed utilizing a reflexive thematic approach.

Results:

Three overarching themes emerged: (1) Emphasis on (different) clinical needs: key considerations in cis and trans women’s HIV care; (2) Recognition of the structural: barriers to HIV care affecting women of all genders; and (3) Proposed solutions: piecing together individual, social, and organizational interventions to increase access to HIV care that may benefit women living with HIV of all genders but are disproportionately framed as being for cis women. While HIV care providers recognized both cis and trans women living with HIV’s clinical care needs and structural barriers to care, they rarely envisioned optimal HIV care inclusive of gender affirmation and structural interventions.

Conclusions:

Findings suggest that HIV care providers can avoid reducing gender to biology and making assumptions about reproductive care needs, endocrinological care needs, caregiving responsibilities, and other life circumstances; provide gender-affirming medical care; and address structural barriers to HIV care to enhance intersectional and structurally focused gender-affirming—that is, trans-inclusive—women-centered HIV care.

Revealing the racial and spatial disparity in pediatric asthma: A Kansas City case study

Black and other socially disadvantaged children are disproportionately burdened by high rates of pediatric asthma. Intraurban variation in environmental risk factors and limited access to high-resolution health data make it difficult to identify vulnerable patients, communities, or the immediate exposures that may contribute to pediatric asthma exacerbation. This article presents a novel, interdisciplinary health disparities research and intervention strategy applied to the problem of pediatric asthma in Kansas City. First, address-level electronic health records from a major children's hospital in the Kansas City region are used to map the distribution of asthma encounters in 2012 at a high spatial resolution. Census tract Environmental Justice Screening Method (EJSM) indicators are then developed to scan for patterns in both the population health risks and vulnerabilities that may contribute to the burden of asthma in different communities. A Bayesian Profile Regression cluster analysis is used to systematically explore the complex relationships between census tract EJSM indicators and pediatric asthma incidence rates, helping to identify population characteristics and risk factors associated with both high and low rates of pediatric asthma throughout the region. The EJSM scanning exercise and BPR analysis demonstrate that each community faces a distinct set of risks and vulnerabilities that can contribute to the rate of acute pediatric asthma acute care encounters, providing targets for research and intervention. It is clear, however, that different forms of social disadvantage are driving high rates of pediatric asthma, which is closely tied to uneven development patterns and racial residential segregation. The results provide a starting point for designing place-based health disparities research and intervention strategies catered to the unique needs of vulnerable patients and communities; disparities-focused research and intervention strategies that leverage local knowledge and resources through community-based practices.

Quantifying the Distribution of Environmental Health Threats and Hazards in Washington State Using a Cumulative Environmental Inequality Index

Background: Environmental racism, community stressors, and age-related susceptibility play a significant role in environmental inequality. The goal of this article was to use an inequality index (II) to assess the level of equality in environmental threats and hazards based on race, poverty, and age in Washington State. Methods: Using the Washington Environmental Health Disparities Map, we quantified the level of disproportionate burdens on communities with greater populations of people of color, people in poverty, children younger than 5, and people older than 65 using 3 cumulative environmental indices and 10 individual environmental indicators. Results: Census tracts with a higher proportion of people of color and those with people living below 185% federal poverty levels were found to be disproportionately burdened by environmental threats (II = -0.175 and II = -0.167, respectively, p < 0.001). Individual environmental indicators were found to disproportionately burden communities of color and low-income communities. Children younger than 5 were also disproportionately burdened by cumulative environmental indices (II = -0.076, p < 0.001) and individual indicators. Our analysis did not show disproportionate burden of environmental health threats based on the proportion of people older than 65 (II = 0.124, p < 0.001). Discussion: The disproportionate burden of the cumulative environmental threats on communities of color and low-income communities in this study corroborates similar analyses. These findings can be applied in policy and regulatory actions to correct the distributive environmental disparities. Conclusion: We found much higher burdens among historically marginalized communities and children who are more susceptible to environmental threats and hazards.

Assessing perceptions and priorities for health impacts of climate change within local Michigan health departments

Climate change affects Michigan's public health in several primary ways, including increased incidences of vector-borne, waterborne, heat-related, and respiratory illness. Because local health departments (LHDs) play a central role in surveillance and preventative health services, they are among the first institutions to contend with the local impacts of climate change. To assess current perceptions among Michigan public health officials, an online survey was conducted in partnership with the Michigan Association for Local Public Health (MALPH). Most of the Michigan respondents (62%, n = 34) agreed that their jurisdictions have experienced climate change in the last 20 years, and 77% agreed that climate change will impact their jurisdictions in the coming 20 years. However, only 35% (n = 34) of Michigan officials agreed that climate change is a priority in their departments. About one quarter (25%, n = 34) of Michigan LHD respondents did not know about the level of expertise of either the state and federal agencies, responsible for assisting them with information and programs related to climate change and health. Uncertainty regarding the resources available to them may hinder LHDs from developing necessary preparedness, so meeting this need could bolster the public health response to climate change.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s13412-021-00679-0.

Racial/ethnic disparities in the association between fine particles and respiratory hospital admissions in San Diego county, CA

Ambient air pollution exposure is associated with exacerbating respiratory illnesses. Race/ethnicity (R/E) have been shown to influence an individual's vulnerability to environmental health risks such as fine particles (PM 2.5). This study aims to assess the R/E disparities in vulnerability to air pollution with regards to respiratory hospital admissions in San Diego County, California where most days fall below National Ambient Air Quality Standards (NAAQS) for daily PM 2.5 concentrations. Daily PM 2.5 levels were estimated at the zip code level using a spatial interpolation using inverse-distance weighting from monitor networks. The association between daily PM 2.5 levels and respiratory hospital admissions in San Diego County over a 15-year period from 1999 to 2013 was assessed with a time-series analysis using a multi-level Poisson regression model. Cochran Q tests were used to assess the effect modification of race/ethnicity on this association. Daily fine particle levels varied greatly from 1 μg/m³ to 75.86 μg/m³ (SD = 6.08 μg/m³) with the majority of days falling below 24-hour NAAQS for PM 2.5 of 35 μg/m³. For every 10 μg/m³ increase in PM 2.5 levels, Black and White individuals had higher rates (8.6% and 6.2%, respectively) of hospitalization for respiratory admissions than observed in the county as a whole (4.1%). Increases in PM 2.5 levels drive an overall increase in respiratory hospital admissions with a disparate burden of health effects by R/E group. These findings suggest an opportunity to design interventions that address the unequal burden of air pollution among vulnerable communities in San Diego County that exist even below NAAQS for daily PM 2.5 concentrations.

Participatory Research for Environmental Justice: A Critical Interpretive Synthesis

BACKGROUND

Environmental health risks are disproportionately colocated with communities in poverty and communities of color. In some cases, participatory research projects have effectively addressed structural causes of health risk in environmental justice (EJ) communities. However, many such projects fail to catalyze change at a structural level.

OBJECTIVES

This review employs Critical Interpretive Synthesis (CIS) to theorize specific elements of participatory research for environmental health that effectively prompt structural change in EJ communities.

METHODS

Academic database search was used to identify peer-reviewed literature describing participatory research with EJ communities to address environmental health. Synthetic constructs were developed iteratively related to study characteristics, design elements, and outcomes; and data were extracted for included records. Statistical analyses were performed to assess correlations between study design elements and structural change outcomes. Through critical, comparative, and contextual analyses of the "structural change" case study group and "non- structural change" group, informed by relevant theoretical literature, a synthesizing argument was generated.

RESULTS

From 505 total records identified, eligibility screening produced 232 case study articles, representing 154 case studies, and 55 theoretical articles for synthesis. Twenty-six case studies resulted in a structural change outcome. The synthesizing argument states that participatory research with EJ communities may be more likely to result in structural change when a) community members hold formal leadership roles; b) project design includes decision-makers and policy goals; and c) long term partnerships are sustained through multiple funding mechanisms. The assumption of EJ community benefit through research participation is critically examined.

DISCUSSION

Recommended future directions include establishing structural change as a goal of participatory research, employing participatory assessment of community benefit, and increased hiring of faculty of color at research institutions. The power, privilege, and political influence that academic institutions are able to leverage in partnership with EJ communities may be as valuable as the research itself. https://doi.org/10.1289/EHP6274.

Urban HEART Detroit: the Application of a Health Equity Assessment Tool

The Urban Health Assessment Response Tool (Urban HEART) was developed by the World Health Organization. In 2016, the Urban HEART was adapted and used by the Healthy Environments Partnership, a long-standing community-based participatory research partnership focused on addressing social determinants of health in Detroit, Michigan, to identify health equity gaps in the city. This paper uses the tool to: (1) examine the geographic distributions of key determinants of health in Detroit, across the five Urban HEART specified domains: physical environment and infrastructure, social and human development, economics, governance, and population health, and (2) determine whether these indicators are associated with the population health indicators at the neighborhood level. In addition to the Urban HEART matrix, we developed various tools including graphs and maps to further examine Detroit's health equity gaps. Although not required by Urban HEART, we statistically analyzed the associations between each indicator with the health outcomes. Our results showed that all the domains contained one or more indicators associated with one or more health outcomes, making this an effective tool to study health equity in Detroit. The Urban HEART Detroit project comes at a critical time where the nation is focusing on health equity and understanding underlying determinants of health inequities in urban areas. A tool like Urban HEART can help identify these areas for rapid intervention to prevent unnecessary burden from disease. We recommend the application of the Urban HEART, in active dialog with community groups, organizations, and leaders, to promote health equity.

Weathering in Detroit: Place, Race, Ethnicity, and Poverty as Conceptually Fluctuating Social Constructs Shaping Variation in Allostatic Load

Policy Points Despite 30 years of attention to eliminating population health inequity, it remains entrenched, calling for new approaches. Targeted universalism, wellness-based local development, and Jedi Public Health approaches that are community informed, evidence based, and focused on improving everyday settings and diverse lived experiences are important policy directions. State and federal revenue transfers are necessary to mitigate the harms of austerity and assure greater equity in fiscal and population health in places like Detroit, Michigan.

CONTEXT

US population health inequity remains entrenched, despite mandates to eliminate it. To promote a public health approach of consequence in this domain, stakeholders call for moving from risk-factor epidemiology toward consideration of dynamic local variations in the physiological impacts of structured lived experience.

METHODS

Using a community-based, participatory research approach, we collected and analyzed a unique data set of 239 black, white, and Mexican adults from a stratified, multistage probability sample of three Detroit, Michigan, neighborhoods. We drew venous blood, collected saliva, took anthropometric measurements, and assayed specimens to measure allostatic load (AL), an indicator of stress-mediated biological dysregulation, linking participants' AL scores and survey responses. In a series of nested Poisson models, we regressed AL on socioeconomic, psychosocial, neighborhood, and behavioral stressors to test the hypothesis that race/ethnicity and poverty-to-income ratio (PIR) are conceptually fluctuating variables whose impacts on AL are sensitive to structured lived experience.

FINDINGS

White and Mexican Detroit participants with PIR < 1 have higher AL than counterparts nationally; black participants in Detroit and nationwide had comparable AL. Within Detroit, disparities by PIR were higher in whites than blacks, with no significant difference by PIR in Mexicans. The size of estimated effects of having PIR < 1 for whites is 58 percentage points greater than that of Mexicans and twice that of blacks.

CONCLUSIONS

Structurally rooted unobserved heterogeneity bias threatens the validity of independent main effects interpretations of associations between race/ethnicity, socioeconomic characteristics, or place and health. One-size-fits-all analytic or policy models developed from the perspective of the dominant social group insufficiently address the experiences of diverse populations in specific settings and historical moments; nor do they recognize culturally mediated protective resources residents may have developed against material and psychosocial hardship.

Social and spatial distribution of soil lead concentrations in the City of Santa Ana, California: Implications for health inequities

BACKGROUND

Lead (Pb) exposure is a problem that disproportionately impacts low-income communities and communities of color. We applied a community-based participatory research approach to assess the distribution of soil Pb concentrations and related social vulnerabilities across Census tracts in Santa Ana, CA.

METHODS

Soil Pb samples (n = 1528) were collected by the ¡Plo-NO! Santa Ana! Lead-Free Santa Ana! partnership in 2018 across Santa Ana, CA, at a high spatial resolution and measured using XRF analysis. Pb concentrations were mapped and spatial interpolation was conducted to generate a continuous smoothed map of soil Pb concentrations across the city. American Community Survey data was used to examine Pb across Census tracts based on social and economic factors, and to allow for the development of a Cumulative Risk Index to identify areas at high risk of health impacts.

RESULTS

Soil Pb concentrations varied by landuse type and socioeconomic factors. Census tracts with a median household income below $50,000 had over five times higher soil Pb concentrations than high-income Census tracts. Soil samples collected in tertiles with the highest percent children, residents without health insurance, renter-occupied housing units, and lowest percent college educated residents had 90.0%, 96.1%, 75.2%, and 87.0% higher Pb concentrations on average, respectively, compared to their counterparts. Overall, 52.7% of residential samples had Pb concentrations in excess of the 80 ppm California EPA recommendation, and 11 Census tracts were characterized as high risk according to our Cumulative Risk Index.

DISCUSSION

This study underscores the need for precautionary measures relating to disturbances of the soil, particularly for areas where children play outside, given children's higher absorption of lead. It also informs environmental justice initiatives and identifies vulnerable subpopulations at greater risk of Pb exposure, thus warranting community-driven recommendations for policies and initiatives to remediate soil Pb and protect public health and health equity.

Independent and joint contributions of economic, social and physical environmental characteristics to mortality in the Detroit Metropolitan Area: A study of cumulative effects and pathways

OBJECTIVE

Previous studies have demonstrated associations between race-based residential segregation, neighborhood socioeconomic and physical environmental characteristics, and mortality. Relatively few studies have examined independent and joint effects of these multiple neighborhood characteristics and mortality, including potential mediating pathways. In this study we examine the extent to which associations between race-based residential segregation and all-cause mortality may be explained by multiple socioeconomic indicators and exposure to air pollutants.

METHODS

Drawing on data from multiple sources, we assessed bivariate associations between race-based residential segregation (operationalized as percent non-Hispanic Black), education (percent with graduate equivalency degree), poverty (percent below poverty), income inequality (GINI coefficient) and air pollution (ambient PM2.5) and age adjusted all-cause, all race mortality (henceforth all cause mortality) at the census tract level in the Detroit Metropolitan Area. We used inequality curves to assess the (in)equitable distribution of economic and environmental characteristics by census tract racial composition. Finally, we used generalized estimating equations (GEE) to examine independent and joint associations among percent NHB, education, income inequality, and air pollution to all-cause mortality, and test for mediating effects.

RESULTS

Bivariate associations between racial composition, education, poverty, income inequality, PM2.5 and all-cause mortality were statistically significant. Census tracts with higher concentrations of NHB residents had significantly lower educational attainment, higher poverty, and greater exposure to PM2.5. In multivariate models, education, income inequality and PM2.5 fully attenuated associations between racial composition and all-cause mortality.

CONCLUSIONS

Results are consistent with the hypothesis that race-based residential segregation is associated with heightened all-cause mortality, and that those effects are mediated by education, income inequality, and exposure to air pollution at the census tract level. Public health and cross-sector interventions to eliminate race-based residential segregation or to eliminate the maldistribution of educational and economic resources, and environmental exposures, across census tracts could substantially reduce regional inequities in all-cause mortality.

Toxic structures: Speculation and lead exposure in Detroit's single-family rental market

Foreclosure sales permitted investors to purchase large volumes of low-cost residential properties after the last financial crisis, reshaping patterns of property ownership in low-income housing markets across the US. This study links post-foreclosure property acquisitions by investor landlords to subsequent lead poisoning cases among children under age six living in Detroit, Michigan. We find that the odds of exhibiting elevated blood lead levels (≥5 μg/dL) are higher for children living in investor-owned homes purchased through tax foreclosure sale. These findings highlight the potential for property speculation in post-foreclosure housing markets to exacerbate severe and racialized burdens of excess lead toxicity in low-income communities.

Mobilizing for Community Benefits to Assess Health and Promote Environmental Justice near the Gordie Howe International Bridge

Transportation infrastructure decisions contribute to social, economic, and health inequities in the U.S. Health Impact Assessments (HIAs) may improve understanding of potential strategies to mitigate adverse effects on quality of life from planned developments. We use the Gordie Howe International Bridge (GHIB), currently under construction in southwest Detroit, MI, as a case study to examine 15 years of community mobilization, which resulted in community benefits that included an HIA. We describe community engagement processes, household survey methods, and select findings of the baseline HIA, with a focus on their application to inform recommendations to promote quality of life. Baseline HIA results indicated significantly higher self-reported asthma rates among children living within 500 feet of trucking routes. Residents reported substantial economic (e.g., decreased home values), health (e.g., adverse outcomes, lack of health care access), and environmental (e.g., air pollution) concerns related to the GHIB. We discuss specific recommendations, based on HIA results, to reduce adverse impacts of the GHIB. These recommendations will inform ongoing community benefits negotiations. This case study provides lessons for community, academic, and government partners conducting HIAs, especially during building and operation of major infrastructure, and discusses their potential role in improving community engagement opportunities towards environmental justice.

MI-Environment: Geospatial patterns and inequality of relative heat stress vulnerability in Michigan

Heat stress causes morbidity and mortality and is increasing with climate change. Heat stress can pose particular challenges in northern regions not well adapted to heat. To assist decision makers, we identified the relative vulnerability of census tracts within Michigan to factors that increase exposure to heat stress or reflect susceptibilities in the population based on a California heat vulnerability index. In the MI-Environment assessment, we used a Geographic Information System (GIS) to combine future ensemble climate model projections to create a total of 9 geospatial and demographic variables. As part of a broader planned cumulative environmental exposure assessment, the statewide heat vulnerability index (HVI) maps display the location and relative magnitude of exposure on three metrics: built environment (Place), future expected long-term temperature averages (Temperature), and population susceptibility (People). We observed varied and distinct patterns for each of the three component indices. We assessed how equitably those exposures are distributed by racial and socioeconomic factors. This analysis showed that each of the component indices and the aggregate HVI are disproportionately distributed along racial and socioeconomic lines in Michigan. Census tracts with higher percentages of people of color had larger exposure to HVI factors with a deviation from equity of -0.115 [95% CI -0.108, -0.122]. Similarly, for census tracts with higher percentage of people experiencing poverty, the deviation from equity was -0.101 [95% CI -0.094, -0.107]. The MI-Environment visualization tool can help communities prepare for climate change and resolve inequities by identifying census tracts with the most vulnerable residents and highest potential exposures.

Health and Environmental Justice Implications of Retiring Two Coal-Fired Power Plants in the Southern Front Range Region of Colorado

Despite improvements in air quality over the past 50 years, ambient air pollution remains an important public health issue in the United States. In particular, emissions from coal-fired power plants still have a substantial impact on both nearby and regional populations. Of particular concern is the potential for this impact to fall disproportionately on low-income communities and communities of color. We conducted a quantitative health impact assessment to estimate the health benefits of the proposed decommissioning of two coal-fired electricity generating stations in the Southern Front Range region of Colorado. We estimated changes in exposures to fine particulate matter and ozone using the Community Multiscale Air Quality model and predicted avoided health impacts and related economic values. We also quantitatively assessed the distribution of these benefits by population-level socioeconomic status. Across the study area, decommissioning the power plants would result in 2 (95% CI: 1-3) avoided premature deaths each year due to reduced PM2.5 exposures and greater reductions in hospitalizations and other morbidities. Health benefits resulting from the modeled shutdowns were greatest in areas with lower educational attainment and other economic indicators. Our results suggest that decommissioning these power plants and replacing them with zero-emissions sources could have broad public health benefits for residents of Colorado, with larger benefits for those that are socially disadvantaged. Our results also suggested that researchers and decision makers need to consider the unique demographics of their study areas to ensure that important opportunities to reduce health disparities associated with point-source pollution.

The State of Public Health Lead Policies: Implications for Urban Health Inequities and Recommendations for Health Equity

Although lead has been removed from paint and gasoline sold in the U.S., lead exposures persist, with communities of color and residents in urban and low-income areas at greatest risk for exposure. The persistence of and inequities in lead exposures raise questions about the scope and implementation of policies that address lead as a public health concern. To understand the multi-level nature of lead policies, this paper and case study reviews lead policies at the national level, for the state of California, and for Santa Ana, CA, a dense urban city in Southern California. Through a community-academic partnership process, this analysis examines lead exposure pathways represented, the level of intervention (e.g., prevention, remediation), and whether policies address health inequities. Results indicate that most national and state policies focus on establishing hazardous lead exposure levels in settings and consumer products, disclosing lead hazards, and remediating lead paint. Several policies focus on mitigating exposures rather than primary prevention. The persistence of lead exposures indicates the need to identify sustainable solutions to prevent lead exposures in the first place. We close with recommendations to reduce lead exposures across the life course, consider multiple lead exposure pathways, and reduce and eliminate health inequities related to lead.

Utilization of the Maryland Environmental Justice Screening Tool: A Bladensburg, Maryland Case Study

Maryland residents' knowledge of environmental hazards and their health effects is limited, partly due to the absence of tools to map and visualize distribution of risk factors across sociodemographic groups. This study discusses the development of the Maryland EJSCREEN (MD EJSCREEN) tool by the National Center for Smart Growth in partnership with faculty at the University of Maryland School of Public Health. The tool assesses environmental justice risks similarly to the U.S. Environmental Protection Agency's (USEPA) EJSCREEN tool and California's tool, CalEnviroScreen 3.0. We discuss the architecture and functionality of the tool, indicators of importance, and how it compares to USEPA's EJSCREEN and CalEnviroScreen. We demonstrate the use of MD EJSCREEN through a case study on Bladensburg, Maryland, a town in Prince George's County (PG) with several environmental justice concerns including air pollution from traffic and a concrete plant. Comparison reveals that environmental and demographic indicators in MD EJSCREEN most closely resemble those in EPA EJSCREEN, while the scoring is most similar to CalEnviroScreen. Case study results show that Bladensburg has a Prince George's environmental justice score of 0.99, and that National Air Toxics Assessment (NATA) air toxics cancer risk is concentrated in communities of color.

Urban HEART Detroit: a Tool To Better Understand and Address Health Equity Gaps in the City

The Urban Health Equity Assessment Response Tool (Urban HEART) combines statistical evidence and community knowledge to address urban health inequities. This paper describes the process of adopting and implementing this tool for Detroit, Michigan, the first city in the USA to use it. The six steps of Urban HEART were implemented by the Healthy Environments Partnership, a community-based participatory research partnership made up of community-based organizations, health service providers, and researchers based in academic institutions. Local indicators and benchmarks were identified and criteria established to prioritize a response plan. We examine how principles of CBPR influenced this process, including the development of a collaborative and equitable process that offered learning opportunities and capacity building among all partners. For the health equity matrix, 15 indicators were chosen within the Urban HEART five policy domains: physical environment and infrastructure, social and human development, economics, governance, and population health. Partners defined the criteria and ranked them for use in assessing and prioritizing health equity gaps. Subsequently, partners generated a series of potential actions for indicators prioritized in this process. Engagement of community partners contributed to benchmark selection and modification, and provided opportunities for dialog and co-learning throughout the process. Application of a CBPR approach provided a foundation for engagement of partners in the Urban HEART process of identifying health equity gaps. This approach offered multiple opportunities for discussion that shaped interpretation and development of strategies to address identified issues to achieve health equity.

Racial and Ethnic Disparities in Treatment Outcomes of Patients with Ruptured or Unruptured Intracranial Aneurysms

OBJECTIVE

The aim of this study is to examine how health outcomes varied by treatment selection and race/ethnicity among hospitalized US patients with ruptured or unruptured IAs.

METHODS

A retrospective cohort study was conducted using a sample of 62,224 hospital discharges from the 2002-2012 Nationwide Inpatient Sample. Logistic regression models evaluated treatment selection as predictor of in-hospital survival (IHS: "yes," "no") and length of stay (LOS ≤ 7 days, > 7 days), overall and across racial/ethnic groups, taking hospital- and patient-level confounders into account, while stratifying by IA rupture status.

RESULTS

Compared to surgical clipping, endovascular coiling was associated with better IHS, after controlling for confounders. Compared to surgical clipping, LOS ≤ 7 days was less likely in patients with combination of treatments and more likely among patients with endovascular coiling as well as balloon- or stent-assisted coiling. Observed relationships varied significantly by race and ethnicity for IHS, but not for LOS ≤ 7 days. Whereas combination of treatments were associated with worse IHS than surgical clipping among Blacks alone, endovascular coiling was associated with better IHS than surgical clipping among White and Other racial/ethnic subgroups. These relationships were for the most part consistent among patients with and without IA rupture.

CONCLUSIONS

Racial and ethnic subgroups of IA patients experienced differential IHS by treatment selection, irrespective of IA rupture status. Prospective cohort studies are needed to further elucidate these racial and ethnic disparities, while collecting data on IA size, location, and morphology as well as Hunt and Hess grade for ruptured IA.

Independent and Joint Contributions of Fine Particulate Matter Exposure and Population Vulnerability to Mortality in the Detroit Metropolitan Area

Fine particulate matter is associated with adverse health outcomes. Exposure to fine particulate matter may disproportionately affect urban communities with larger numbers of vulnerable residents. We used multilevel logistic regression models to estimate the joint effects of fine particulate matter (PM_2.5) and population vulnerabilities on cardiopulmonary mortality (CPM). We estimated the health benefits of reductions in PM_2.5 across census tracts in the Detroit metropolitan area with varying levels of population vulnerability, using cluster-specific odds ratios scaled to reflect PM_2.5-attributable cardiopulmonary risk. PM_2.5 and population vulnerability were independently associated with odds of CPM. Odds of CPM and the number of deaths attributable to PM_2.5 were greatest in census tracts with both high PM_2.5 exposures and population vulnerability. Reducing PM_2.5 in census tracts with high PM_2.5 would lead to an estimated 18% annual reduction in PM_2.5-attributable CPM. Between 78–79% of those reductions in CPM would occur within census tracts with high population vulnerabilities. These health benefits of reductions in PM_2.5 occurred at levels below current U.S. reference concentrations. Focusing efforts to reduce PM_2.5 in the Detroit metropolitan area in census tracts with currently high levels would also lead to greater benefits for residents of census tracts with high population vulnerabilities.

Examining Joint Effects of Air Pollution Exposure and Social Determinants of Health in Defining "At-Risk" Populations Under the Clean Air Act: Susceptibility of Pregnant Women to Hypertensive Disorders of Pregnancy

Pregnant women are uniquely susceptible to adverse effects of air pollution exposure due to vulnerabilities and health consequences during pregnancy (e.g., hypertensive disorders of pregnancy [HDP]) compared to the general population. Because the Clean Air Act (CAA) creates a duty to protect at-risk groups, the regulatory assessment of at-risk populations has both policy and scientific foundations. Previously, pregnant women have not been specially protected in establishing the margin of safety for the ozone and particulate matter (PM) standards. Due to physiological changes, pregnant women can be at greater risk of adverse effects of air pollution and should be considered an at-risk population. Women with preexisting conditions, women experiencing poverty, and groups that suffer systematic discrimination may be particularly susceptible to cardiac effects of air pollutants during pregnancy. We rigorously reviewed 11 studies of over 1.3 million pregnant women in the United States to characterize the relationship between ozone or PM exposure and HDP. Findings were generally mixed, with a few studies reporting a joint association between ozone or PM and social determinants or pre-existing chronic health conditions related to HDP. Adequate evidence associates exposure to PM with an adverse effect of HDP among pregnant women not evident among non-gravid populations.

Disease and Health Inequalities Attributable to Air Pollutant Exposure in Detroit, Michigan

The environmental burden of disease is the mortality and morbidity attributable to exposures of air pollution and other stressors. The inequality metrics used in cumulative impact and environmental justice studies can be incorporated into environmental burden studies to better understand the health disparities of ambient air pollutant exposures. This study examines the diseases and health disparities attributable to air pollutants for the Detroit urban area. We apportion this burden to various groups of emission sources and pollutants, and show how the burden is distributed among demographic and socioeconomic subgroups. The analysis uses spatially-resolved estimates of exposures, baseline health rates, age-stratified populations, and demographic characteristics that serve as proxies for increased vulnerability, e.g., race/ethnicity and income. Based on current levels, exposures to fine particulate matter (PM_2.5), ozone (O₃), sulfur dioxide (SO₂), and nitrogen dioxide (NO₂) are responsible for more than 10,000 disability-adjusted life years (DALYs) per year, causing an annual monetized health impact of $6.5 billion. This burden is mainly driven by PM_2.5 and O₃ exposures, which cause 660 premature deaths each year among the 945,000 individuals in the study area. NO₂ exposures, largely from traffic, are important for respiratory outcomes among older adults and children with asthma, e.g., 46% of air-pollution related asthma hospitalizations are due to NO₂ exposures. Based on quantitative inequality metrics, the greatest inequality of health burdens results from industrial and traffic emissions. These metrics also show disproportionate burdens among Hispanic/Latino populations due to industrial emissions, and among low income populations due to traffic emissions. Attributable health burdens are a function of exposures, susceptibility and vulnerability (e.g., baseline incidence rates), and population density. Because of these dependencies, inequality metrics should be calculated using the attributable health burden when feasible to avoid potentially underestimating inequality. Quantitative health impact and inequality analyses can inform health and environmental justice evaluations, providing important information to decision makers for prioritizing strategies to address exposures at the local level.

Neighborhood Context, Homeownership and Home Value: An Ecological Analysis of Implications for Health

While homeownership has been linked to positive health outcomes there is limited evidence regarding the conditions under which it may be health protective. We present a conceptual model linking homeownership to health, highlighting key potential pathways. Using the Detroit Metropolitan Area as a case study, and data from the American Community Survey (2009-2013; 5-years estimates) and Michigan Department of Community Health, we tested the following questions: (1) Is neighborhood percentage non-Hispanic Black (NHB) associated with homeownership? (2) Is neighborhood percentage NHB associated with health? (3) Is the association between percentage NHB and health mediated by homeownership? (4) Does neighborhood housing value modify associations between percentage NHB and health, or between homeownership and health? Percentage NHB was associated with homeownership and health outcomes; Associations between percentage NHB and mortality, but not disability, were partially mediated by neighborhood homeownership. Neighborhood housing value modified associations between neighborhood homeownership and both disability and mortality, but not between percentage NHB and health outcomes. Findings are consistent with the thesis that health-promoting effects of homeownership may be contingent upon house values. These results add to a limited body of evidence suggesting that variations in homeownership may contribute to persistent racial and socioeconomic health inequities.