A foe more than a friend: law and the health of the American urban poor.

• Author: Papke, David Ray

ABSTRACT

Social epidemiologists insist fundamental social conditions play a large role in the health problems of the American urban poor, but these well-intentioned scholars and practitioners do not necessarily appreciate how greatly law is intertwined with those social conditions. Law helps create and maintain the urban poor's shabby and unhealthy physical environment, and law also facilitates behaviors among the urban poor that can result in chronic health conditions. Then, too, law shapes and configures the very poverty that consigns the urban poor to the inner city with its limited social capital and political clout. Overall, law creates and perpetuates the health problems of the urban poor more than it eliminates or ameliorates them. Social epidemiologists and others concerned with improving the urban poor's health might therefore approach law as a foe more than a friend.

TABLE OF CONTENTS Introduction 2 I. Physical Environment 3 II. Social Environment 13 III. Poverty 22 Conclusion 30 INTRODUCTION

Social epidemiology emerged as a major subfield in public health during the final quarter of the twentieth century. (1) Social epidemiologists maintained that consideration of a broader historical and social context should be essential in understanding the health of a population sector, (2) and they noted in particular "the tendency of health outcomes to line up on a steady slope from the have-leasts to the have-mosts." (3) For groups such as the urban poor, they insisted, one had to "travel upstream" to the true sources of poor health. (4) One had to appreciate that collective health "is shaped to a significant degree by fundamental social conditions." (5)

In the contemporary United States, law is intimately intertwined with the urban poor's fundamental social conditions, and its functions are virtually uncountable. As subsequent discussions in this Article will illustrate, law provides for zoning, licensing, inspecting, and warning, and it also separates, regulates, polices, and penalizes. Then, too, law prohibits, bans, and deters, while it also supports, pays, compensates, and reimburses. When the sociologist Austin Sarat conducted his now-classic study of the legal consciousness of the "welfare poor," a sub-set of the urban poor, he found "the law is all over" the welfare poor's lives. (6) Law was not a "distant abstraction" but rather "an irresistible and inescapable presence." (7)

But is it possible to capture the dominant or most important role of law in the fundamental social conditions that lead to the urban poor's health disparities and to their relative health inequity vis-a-vis the middle and upper classes? Our answer to the question might be surprising in light of the way Americans usually cast law as a positive force in social life. Throughout the nation's history, political leaders and government officials in the United States have unreflectively placed law on an ideological pedestal and assumed it is used for good things. (8) Imbued with this assumption, one well-intentioned health scholar has even produced a winning but naive "legal toolkit for reducing health disparities." (9) Yet law need not be placed on a pedestal or packed up in a useful toolkit when it comes to its role in the fundamental social conditions of the urban poor. We argue that law in general is central in the creation, development, and extension of the very social conditions that result in the urban poor's health problems.

This Article has three parts. Part I explores the unhealthy physical environment in which the urban poor live, especially in the urban poor's neighborhoods and housing, and underscores law's role in maintaining this environment. (10) Part II examines law's facilitation of unhealthy behaviors within the urban poor's physical environment." Part III considers the actual poverty of the urban poor and law's importance in the nature and configuration of that poverty. (12)

Overall, laws are not intentionally used to oppress the urban poor, and laws might be, and often are, changed in hopes of improving the urban poor's collective health. However, these self-styled progressive laws are often woefully ineffective. Additionally, the courts often toss out efforts to use law to effect positive change, citing to constitutional principles and endorsing the relatively unbridled consumption of goods and services. (13) Law is much more important in creating and perpetuating the urban poor's unhealthy social conditions than it is in ameliorating them. Those seeking to improve the health outcomes and relative health status of the urban poor should realize law supports unhealthy social conditions more than it corrects them. The social epidemiologist committed to health equity for the urban poor might recognize law as a foe more than a friend.

1. PHYSICAL ENVIRONMENT

   When social epidemiologists consider the collective health of a sector of the population, they sometimes observe that "place matters." (14) "Place" includes not only features of the physical environment, such as green space and housing, but also features of the social environment such as, alcohol consumption and interpersonal violence. (15) The physical and social aspects of place combine in countless ways, but it might nevertheless be helpful to address the two aspects separately. First, what are the most important features of the urban poor's physical environment, and how do these features relate to the urban poor's health?

   For many of the urban poor, the physical environment has taken the form of "depressed neighborhoods--those with at least 40 percent of residents below poverty line," at least since the 1990s. (16) Law and legal institutions have crucial roles in this physical environment, and laws and legal institutions routinely create or maintain many of the unhealthy features of the urban poor's neighborhoods.

   Urban parks and recreation areas are neighborhood features that are notoriously inadequate, especially in impoverished neighborhoods. (17) The problems with parks and recreation areas began to develop in the second half of the twentieth century, as cities began to deteriorate and middle and upper class Americans moved to the suburbs with their green subdivisions and manicured cul-de-sacs. (18) When city governments faced severe economic problems in the 1990s, mayors and city lawmakers addressed their budget woes by, among other things, slashing park-spending. (19) Even the federal government failed to sustain a professed commitment to urban parks and recreation areas. Congress enacted the Urban Park and Recreation Program ("UPARR"), but the program's annual funding declined and then stopped altogether in 2002. (20) As a result, inner-city residents lost facilities for much-needed exercise and opportunities for relieving stress. (21)

   In contrast to parks and recreation areas, the ubiquitous, trash-strewn vacant lots of the inner city, where buildings have collapsed or burned down, are among the physical "stressors" the urban poor encounter. (22) In fact, it makes a difference if vacant lots have been replanted. One study found that "in-view proximity to a greened vacant lot decreases heart rate compared with in-view proximity to a nongreened vacant lot," and the authors noted that consistently elevated heart rates over a lifetime can lead to heart problems caused by inflammation and damage to the cardiovascular system. (23) Had local government officials been more willing to police the lots or, at least, to insist on their rehabilitation as green spaces, they might have reduced stress and thereby contributed positively to the urban poor's health. (24)

   The commercial fabric of the inner city is often as shabby as its green spaces. Shops in the South Bronx or the inner cities of Chicago, Illinois and Milwaukee, Wisconsin--to cite three impoverished areas--are often small and cramped. The shops' actual number and variety of goods in the shops are also limited. Common businesses include barbers, hair salons, nail salons, discount tobacco outlets, and cheap cell phone stores. Some shops surprisingly sell only tobacco products and cell phones.

   Two particularly common types of businesses are (1) alcohol outlets in the form of bars and liquor stores and (2) corner grocery stores. Legally licensed and protected by law enforcement, the alcohol outlets obviously facilitate and benefit from alcohol use. Drinking too much over time can lead to not only alcoholism but also high blood pressure, stroke, fatty liver, cirrhosis, pancreatitis, and alcoholic hepatitis. (25) In addition, according to a study done in Boston, Massachusetts, interpersonal violence increased in and around alcohol outlets. (26) Poor neighborhoods with concentrations of bars and liquor stores have higher levels of violent crime. (27)

   Also legally licensed and legitimate, the corner grocery stores are convenient for daily shopping, but the stores do not offer the range of fresh fruit and vegetables, available in larger supermarkets. (28) Instead of healthy foods, the stores proffer less healthy food and beverage products, such as snacks, soft drinks, and canned or frozen foods. (29) Since the stores are often the only ones in their neighborhoods, this could have serious consequences for what residents buy and ultimately eat. (30)

   The inventory and practices of the inner-city convenience stores are major factors in what has been called the "food desert" of the inner city. (31) According to the United States Department of Agriculture, almost twenty-four million people live in areas without ready access to fresh, healthy, and affordable food, and the great majority of people living in these "food deserts" are poor or have low incomes. (32) The immediate environments may not be quite as barren as the "food desert" metaphor connotes, but local food environments vary tremendously in quality, with inner-city neighborhoods often offering relatively unhealthy food. As a result, the...