Where you live can affect how long you live

POSTED: 9:14 a.m. EDT, September 12, 2006

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WASHINGTON (AP) -- The longest-living Americans can expect to survive decades longer than the worst off -- and the explanation is far more complex than poverty, says a startling report on the nation's health disparities.

It turns out that where you live, combined with race and income, plays a huge role in whether you die young, says a study issued Monday that contends the differences are so stark it's as if there are eight separate Americas instead of one.

Worse, the gaps in lifespan have persisted over 20 years, despite efforts to tackle them, concluded Dr. Christopher Murray of the Harvard School of Public Health.

"That's pretty devastating," said Murray, who published the exhaustive analysis in the online science journal PLoS Medicine. "Whatever it is that we're doing isn't working. That's a wakeup call."

Leading the nation in longevity are Asian-American women who live in Bergen County, New Jersey, and typically reach their 91st birthdays, concluded Murray's county-by-county analysis.

On the opposite extreme are American Indian men in swaths of South Dakota, who die around 58.

Millions of the worst-off Americans have life expectancies typical of developing countries, lamented Murray. The Asian-American women can expect to live 13 years longer than low-income black women in the rural South. That's like comparing women in wealthy Japan to those in poverty-ridden Nicaragua.

Compare those longest-living women to inner-city black men, and the life-expectancy gap is 21 years. That's similar to the life-expectancy gap between Iceland and Uzbekistan.

Health disparities are widely considered an issue of minorities and the poor being unable to find or afford good medical care. But Murray's government-funded study shows the problem is far more complex, and that geography plays a crucial role.

"Although we share in the U.S. a reasonably common culture ... there's still a lot of variation in how people live their lives," he explained.

The longest-living whites weren't the relatively wealthy, which Murray calls "Middle America." They're edged out, by a year, by low-income residents of the rural Northern Plains states, where the men tend to reach age 76 and the women 82.

Yet low-income whites in Appalachia and the Mississippi Valley die four years sooner than their Northern neighbors.

"If it's your family involved, these are not small differences in lifespan," Murray said. "Yet that sense of alarm isn't there in the public.

"If I were living in parts of the country with those sorts of life expectancies, I would want ... to be asking my local officials or state officials or my congressman, 'Why is this?"'

This more precise measure of health disparities will enable federal officials to better target efforts to battle inequalities, said Dr. Wayne Giles of the Centers for Disease Control and Prevention, which helped fund Murray's work.

The CDC has some county-targeted programs -- like one that has cut in half diabetes-caused amputations among black men in Charleston, South Carolina, since 1999, largely by encouraging physical activity -- and the new study argues for more, Giles said.

"It's not just telling people to be active or not to smoke," he said. "We need to create the environment which assists people in achieving a healthy lifestyle."

Murray analyzed mortality data between 1982 and 2001 by county, race, gender and income. He found some distinct groupings that he named the "eight Americas:"

NEW ORLEANS, Aug. 26 — At one edge of this city’s future are the extravagant visions of its boosters. Awash in federal cash, the New Orleans they dream of will be an arts-infused mecca for youthful risk-takers, a boomtown where entrepreneurs can repair to cool French Quarter bars in ancient buildings after a hard day of deal making.

At the other extreme are the gloomy predictions of the pessimists. New Orleans will be Detroit, they say, a sickly urban wasteland abandoned by the middle class. A moldering core will be surrounded by miles of vacant houses, with wide-open neighborhoods roamed by drug dealers and other criminals. The new New Orleans will be merely a grim amplification of its present unpromising self, the pessimists say.

Somewhere between these unrealistic visions lies a glimpse of the city’s real future a year after Hurricane Katrina, say many planners, demographers and others here who have been deeply involved in rebuilding. Like a half-completed drawing in a child’s coloring book, the picture is starting to fill in. There are shadows and firmer outlines, a few promising, some of them menacing.

New Orleans will almost certainly be smaller than it was. Repopulation has slowed to a trickle, leaving the city with well under half its prestorm population of 460,000. It will probably have fewer poor people; its housing projects remain essentially closed, and many poorer neighborhoods are still devastated. With inexpensive housing scarce and not being built, partly because of the paralysis in recovery planning, it is easier for the middle class than the poor to return.

New Orleans, the demographers think, has begun to shrink back to its historic dimensions, the ones that existed before a post-World War II expansion through the back swamps, and the ones that visitors know best. Life in the smaller city will be concentrated in the mostly middle-class districts closer to the Mississippi River that bounced back after the storm. Some of these districts were unaffected by flooding; already they bustle with commerce.

No area is officially off the table for redevelopment. But the silence and emptiness of outlying neighborhoods near Lake Pontchartrain and in east New Orleans appear to be harbingers of the future.

“I think people will get discouraged, and some of those areas will not be rebuilt,” said Pres Kabacoff, a leading developer here.

Within these more concentrated neighborhoods, it will be somewhat whiter, though still mostly black over all. The electorate was 57 percent black in last spring’s mayoral runoff; before the storm it was typically in the low 60’s.

Neighborhoods ruined now will probably shrivel further, planning experts say.

The Lower Ninth Ward, still a barren wasteland, is unlikely to be rebuilt anytime soon, if at all. Gentilly, a classic 1920’s and 30’s New Orleans neighborhood of Arts and Crafts-style stucco houses with wide overhanging eaves, is coming back only fitfully, with a few trailers visible in front yards of once-flooded houses. Tremé, with its 19th-century Creole cottages and shotgun houses, across Rampart Street from the French Quarter, is being reclaimed, but abandonment alternates with revival, as is the case throughout the city.

These uncertain indicators yield to a more hopeful one: a wave of citizen activism in the wake of the storm that is chipping away at some of this city’s unhealthy institutions. It has already toppled some of the old structures that helped cement prestorm New Orleans in poverty and despair.

The schools, a dysfunctional catastrophe before the storm, have been removed from the control of a corrupt district office; just under two-thirds are now in the hands of parents and community activists as charter schools. (Students not admitted to charters, however, will have to attend a state-run school district rife with problems.)

The City Council is under the influence of impatient newcomers pledging reform and pushing for tighter ethics. They are threatening to dismantle a feudal means of resolving everyday planning disputes, long discarded elsewhere. The crippling fiscal structure, long a hurdle to raising adequate revenue in this impoverished city, is under assault. Voters will soon decide whether to throw out the balkanized system of seven district property assessors.

‘There’s a Lot of Uncertainty’

With government a light or invisible presence since the storm, citizens have taken matters into their own hands, whether to overhaul institutions, clean streets or resurrect the city’s parks. If there is to be a new New Orleans, its seeds are to be found in this low-intensity citizens’ revolution that has some people here credibly claiming to find promise among the ruins.

“There was a wall against ideas in New Orleans for years,” said William Borah, a veteran civic activist who helped defeat a proposed riverfront expressway here in the mid-1960’s. “That wall has been broken down.”

Still, under present conditions, hope requires faith. “Over all, it’s scary,” said Tim Williamson of the Idea Village, a local nonprofit organization that supports small business. “There’s a lot of uncertainty.”

Oppressed by the midsummer heat, this city is now traversing a bleak trough: the planners are still squabbling a year after the storm, forests of uncut weeds grow in the medians, and measurable progress is difficult to detect. St. Charles Avenue on a summer evening has an eerily empty feel; one plausible recent population count, based on Postal Service data, put the figure at 171,000, well below City Hall’s claim of 250,000. The population is thought to be roughly what it was around 1880.

From the living zone near the river, a trip north of any distance is sobering: blocks of sagging houses not so much empty as dead, and heaps of rubble and garbage with dogs and rats among them. At odd intervals, the occasional householder can be spotted on a porch, looking out with a furrowed brow, trying to make a go of it in the ruins.

New Orleans now, often rudderless, filthy and still deeply scarred by the storm, is hemorrhaging some of the people it can least afford to lose. In the professional classes, nearly half the doctors and three-fourths of the psychiatrists have left, the largest synagogue says its congregation is down by more than 10 percent, and a big local moving company reports a “mass evacuation.”

Tens of thousands in the African-American working-class backbone remain unable to return. They have been replaced by hundreds of Hispanic workers who have done much of the heavy lifting in the reconstruction, and live in rough conditions. In the meantime, the only thriving industry is the back-street drug trade, pessimists note.

The outside world is scared by New Orleans. Banks, for instance, are insisting on unusually high collateral in real estate deals, and for good reason, given a homicide rate that is double its prehurricane level and no guarantee that neighborhoods will return to life. Basic services — water, electricity, garbage pickup — are intermittent.

“Look at what we’re getting in terms of services,” said Janet Howard, of the Bureau of Governmental Research, an independent nonprofit group in New Orleans. “It’s basically a nonfunctioning city.”

City Hall, meanwhile, has settled back into its habitual easygoing rhythms; a well-placed insider there reported, with alarm, no sense of urgency among its officials. Mayor C. Ray Nagin was recently set to attend an opening at a French Quarter gallery of an exhibit of photographs — of himself, taken by his personal photographer. A public outcry this month forced him to cancel plans for a fireworks display and a “comedy show” to commemorate Hurricane Katrina’s first anniversary tomorrow.

Lacking a Master Plan

With little direction from the top, long-term planning for the city’s future remains incoherent. A year after the storm, there are no plans for large-scale infrastructure and redevelopment in the city. One group of official planners took the step of attacking a second group in a full-page advertisement in The Times-Picayune this month, even warning citizens to stay away from its rivals.

The absence of a plan has forced developers, who might otherwise be building housing for the displaced, to the sidelines. “The developers, they want to know what the plan is,” said Andy Kopplin, executive director of the Louisiana Recovery Authority.

The latest notion, after earlier false or incomplete starts, is to turn planning over to the citizens, allowing neighborhoods to choose from a list of planners, with the hope that at the end it can all be folded into one giant framework. It was pushed by state officials holding the redevelopment purse strings who grew impatient this summer with the city’s abortive planning efforts.

In the neighborhoods, New Orleanians are skeptical. “Why does it seem that every time someone swoops in to help us, it winds up being a mess?” asked Jenel Hazlett, of the Northwest Carrollton Civic Association, a neighborhood group. “They keep moving the players around, and we as citizens keep getting jerked around.”

Like others, Ms. Hazlett professes bewilderment at a planning process, now stretching out for nearly a year, that involves an ever-shifting cast of characters, embraces and then swiftly rejects differing visions, and calls for repeated consultations with the citizens — and still produces no plan.

The longer the city is without a master plan, the shakier the fate of the ruined neighborhoods, some planners say. The need will become even greater in a few days, when $7.5 billion in federal housing aid begins putting up to $150,000 in the hands of thousands of homeowners hoping to rebuild.

“It is highly probable that there would be many neighborhoods, with block after block of one or two houses restored, surrounded by vacant abandoned houses, no police stations, no services, low water pressure, an unsafe and unhealthy environment,” said John McIlwain, a senior planner at the Urban Land Institute, the Washington research group whose early plan for a shrunken city was rejected by the politicians here.

Publicly, Mr. Nagin insists the city will come back stronger than ever, saying its repopulation is ahead of schedule even while more cautious demographers suggest it is lagging. Rejecting the idea that New Orleans must shrink, he says City Hall will not dictate where citizens can live.

“You can’t wait on government,” Mr. Nagin said at a news conference here this week. “You have to figure out a way to partner with your neighbors.”

Mr. Nagin has endorsed the current version of the planning process, in which neighborhoods map out their own future — so far only a tiny handful of the city’s 73 districts have done so — and the individual plans eventually merge into a larger one. This week the mayor blamed unnamed “powers that be” for a flow of recovery dollars he deemed “painfully slow.”

A Fervor for Change

The one constant is the determination of people to rebuild. For good and ill, it has been demonstrated over and over since the earliest days after the catastrophe. It was present last month at a meeting of citizens in Broadmoor, packed into a church for the unveiling of the neighborhood’s reconstruction plan.

“Nobody is going to tell Broadmoor what to do except the people who live and work in Broadmoor!” one organizer, Harold Roark, said to great applause. Yet the citizens had to walk past piles of fly-covered garbage bags spilling out their contents just to enter the building.

The mix of reaching and realism was typical of present-day New Orleans. Crime, blight, abandonment: none of it was ignored. At the same time there was a call for “an educational and cultural corridor” in the neighborhood’s heart, a scene about as easy to imagine in that battered district as Versailles in the middle of the grimy 4200 block of South Galvez Street in the Broadmoor neighborhood.

Yet reaching high is critical to the collective survival strategy being worked out here. It is a way of pushing beyond the often grim quotidian reality. The psychology was evident in the grass-roots-driven insurgency that put a handful of self-proclaimed reformers on the seven-member City Council in last spring’s elections. Three incumbents were defeated.

Two newcomers, in particular, have already stirred things up, asking probing questions during sleepy Council meetings where rhetoric has traditionally predominated over substance. Shelley Midura, a former Foreign Service officer, has pushed for an inspector general and a board of ethics in City Hall, to combat endemic corruption. A majority appears to be in favor.

Stacy Head, a youthful lawyer also elected this spring, has been as high-profile in her central New Orleans district as the woman she defeated was invisible. (The incumbent she defeated, a protégé of the scandal-plagued Representative William J. Jefferson, is herself under federal investigation.) Ms. Head is now a ubiquitous presence in the city, asking questions of citizens and, unusually for a New Orleans politician, appearing at crime scenes, fires and community meetings.

A big test will come soon when the Council considers overhauling the day-to-day planning process, taking most decisions out of political hands — their own — and putting them under the purview of professional planners. That change was accomplished a century ago in most other places. But the old system has held on in New Orleans, with serious implications for orderly reconstruction of the ruined neighborhoods and equitable preservation of those that are not.

“I don’t want this power,” Ms. Head said. “This is horrible. I don’t like that responsibility. I think it should lie with the planners.”

Ms. Midura said she intended to champion the proposal, made by the Bureau of Governmental Research, and so far had not heard opposition to it.

Mr. Borah, the citizen activist, said, “Unless you get that right, nothing else is going to work.”

For years, a similar argument has been made about the disastrous public schools here, the worst performing in a state of underachievers, relentlessly preyed on by a corrupt district office. Hurricane Katrina upended the school landscape. Of 56 schools set to open this summer — there were 128 before the storm — 34 will be self-governing charter schools, a development that has given hope to parents and principals for the first time in years.

Parents and teachers throughout New Orleans worked feverishly to get a handful of schools up and running earlier this year; at the charters, parents control the money, taking charge of contracts, an area ripe for abuse when they were under school district control. Beneath the stagnant surface of daily life here, so discouraging to residents and astonishing to visitors, there is unmistakable pressure for change.

“I see more movement in a positive direction than I had seen for many years before Katrina,” said Una Anderson, executive director of the New Orleans Neighborhood Development Collaborative, which is focused on housing, and long a reform member of the school board.

Whether this movement will be enough to stave off the pessimists’ grim perspective is uncertain. Repeatedly, observers in and out of the city said the present juncture was critical to the city’s future. If the ferment stops, if the hopes of citizens dry up, the outlook for New Orleans could be dire indeed.