How Neighborhoods Make Us Sick Restoring Health and

Wellness to Our Communities

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I
n the race toward health equity, we have embraced many models in an
effort to close gaps in health disparities for underserved and indigent
populations. We know there is no one-size-fits-all solution. I submit that we
must keep working toward health equity and embrace models that empower
the communities we serve and move toward an all-inclusive policy and
integrated care resolutions.
I personally believe that health equity is achieved when all levels of the
socioecological model are addressed, but more specifically, the outer
realms. We have spent so much time trying to change behavior that we
forget once the behavior changes it is met with resistance at the institutional
and policy levels. How can one be expected to maintain a positive change
when met with obstacles at various levels? Once we embrace having
everyone at the table—communities, housing, safety, urban planning, faith-
based organizations, health systems, workforce development, legislators,
and so forth, then we will move the needle on health equity. Collaborative
partnerships are the most important tool along with policy change. That is
how we win at health equity!
The real and lived experiences of Veronica and Breanna are indicative
of how where you live impacts your mental and physical health, regardless
of your socioeconomic status. They are dedicated servant leaders who have
a heart toward health equity and made it their purpose to immerse
themselves in communities with the greatest needs. I urge readers to forget
the race of these women and do not liken them to well-to-do women who
volunteer in disparate communities and leave it at donations and daytime
exchanges with poor folks. This was no ethnographic study; this was the
heart of Christ in two professional women who embedded themselves in
walking the walk. Two professional women who now understand the
communities they serve more than ever and who advocate for change even
when it means challenging the status quo.
As a public health professional with over sixteen years of experience
working in disparate and vulnerable communities throughout the United
States and its territories, I compel you to see how models of health equity
should begin to expand and encompass cultural humility and servant
leadership and revisit community-based participatory programs. We can
look to foundational initiatives, like the East Side Village Health Workers
Partnership, and the local efforts highlighted in this book, such as the Good
Samaritan Health Center and King County’s Office of Equity and Social
Justice, to find models that need replicating throughout our communities
and will finally bridge the gap.
 CHAPTER 1

TWO JOURNEYS TO THE INNER

But if I could turn life on its side

JENN BOSTIC, “SNOWSTORM”

T
he drive to the clinic in the morning is usually dark, the sun just
starting to emerge over the heart of West Atlanta. Near the clinic, the
roads become lined with abandoned houses and closed businesses. There
are several corner shops and a few gas stations. Despite the early hours,
there is always foot traffic and kids in uniform waiting at bus stops.
Occasionally stray dogs wander along the road, and someone holding a sign
is asking for money. Shortly before the clinic opens, the local jail
procession drives past taking prisoners to work duty for the day. The
landscape fits the story of urban poverty: unemployment, crime, and
abandonment.
Yet, having worked and lived in the neighborhood for nearly a decade,
we are aware of another story as well. The neighborhood is filled with
vibrant church communities offering fellowship, meals, and social services
in addition to weekly sermons. There is an urban garden movement with
fresh produce hiding behind many rundown buildings. Several clinics, like
the one we work in, offer health care services and health education.
Progressive and creative learning communities like BEST Academy and
KIPP are just blocks off the route to work. The neighborhood is filled with
engaged community members with deep passion for their community and
strong family ties. Yet the neighborhood is suffering.
When the Virginia Commonwealth University released their Mapping
Life Expectancy project, we saw numbers that confirmed what years of
clinical and community development experience had revealed. Life
expectancy in this West Atlanta zip code is thirteen years less than life
1
expectancy on the more affluent side of town. A twenty-minute drive
within the perimeter of Atlanta creates a life expectancy gap of thirteen
years. This finding wasn’t unique to Atlanta. From a sixteen year gap in
Chicago to twelve years in St. Louis and twenty years in Philadelphia, life
expectancy gaps persist throughout US urban areas. How is it possible that
people living within the same city could have such drastic differences in life
expectancies? How can residents in neighboring zip codes have such
distinct differences in mortality?
Similar questions have plagued us since starting our careers. Breanna is
a family nurse practitioner who has worked in nonprofit clinics since
graduating in 2008. In order to better understand the health care system, she
obtained a master’s degree in public health and focused her doctoral study
on social determinants of health and programs to improve clinical care for
vulnerable populations. In 2010, Breanna started working at the Good
Samaritan Health Center (Good Sam), a nonprofit clinic providing
comprehensive care to people without health insurance or adequate
financial resources to afford health care. The clinic, now in its twentieth
year, offers primary care, dental services, health education, behavioral
health, and some specialty care in West Atlanta with a mission of
“spreading Christ’s love through quality health care to those in need.”
Veronica joined the Good Sam team in 2015. Veronica’s career prior had
focused on nonprofit fundraising and development. As a Christian
Community Development practitioner, she lived in Southwest Atlanta years
before working in a similar neighborhood.
We found that despite our career differences, we shared a deep concern
for the health of the neighborhood and questioned whether our work,
personally and professionally, was making any difference. Breanna had
spent the first few years of her career learning the limitations of clinical
medicine in restoring health to underresourced communities. She had met
countless motivated patients who sacrificed to afford their medications and
make it to appointments on foot in the rain because they had no other
transportation. Yet even with their motivation and the best medical care she
could provide, she saw the direct health impact of poverty and faced the
sobering reality that health care simply wasn’t enough. Veronica moved to
Southwest Atlanta with her family in hopes of improving her community
through youth development, civic engagement, and fundraising for capital
expansion projects. Yet she and her family found the neighborhood was
making them sick far faster than their efforts were improving the
neighborhood.
Over our years of working together, we have had many long
conversations about what is making the neighborhood sick. We have
watched in frustration as patients face insurmountable barriers to good
health and have recognized our limitations in dismantling such barriers.
This book is our response to the question, What is making our
neighborhood sick? It is also a discussion of the programs, policies, and
community efforts that are bringing wellness and confronting the systems of
oppression that allow such life expectancy gaps to exist. We also hope this
book will be a catalyst for change and offer practical applications in part
two for how you, the reader, can make a difference.
 In the chapters that follow, we use our personal experiences along with
the shared experiences of friends, neighbors, colleagues, and community
partners to illustrate the ways social determinants affect health. We
recognize that because we are white women from a middle-class
background, we can never fully understand the challenges our neighbors
and patients have experienced. We cannot identify with the complex layers
of historical discrimination and generational poverty faced by many within
our communities. Yet despite these limitations, we chose to write this book
to illustrate the power and pervasiveness of social determinants such as
poverty, homelessness, environment, and education to impact health status.
The currently available literature on social determinants is often academic.
We come with personal, real-life language to describe what these
determinants are and how they can negatively impact health,
disproportionately so in low-income communities. Our aim is not to point a
finger and judge these communities for being sick. Rather, we are affirming
the very real obstacles that exist for these residents and calling for large-
scale change to heal their neighborhoods. We hope this is evident
throughout the remainder of the book. We have tried to keep an attitude of
humility, listening to and learning from our neighbors and patients about
interventions most helpful to them. We also recognize that while this book
focuses on experiences and issues in urban Atlanta, poverty, like a disease,
spares no geographical region or race. Social determinants of health impact
rural areas in different yet equally important ways.
A few years back a childhood friend of Breanna’s was coming to
Atlanta for work. In route to Breanna’s house, he called her to say he was
lost. “I think my GPS is trying to kill me!” he explained. In an attempt to
reroute him, she quickly discovered he was just a block from the Good Sam
clinic. His sentiment reflected the culture shock of driving through urban
poverty, but the statement holds an element of truth. The neighborhood is
deadly, but her lost friend passing through isn’t the one who is at risk. For
those living within the neighborhood, poverty, unemployment, racism, the
built environment, and systems of oppression are literally making them
sick.

VERONICA’S JOURNEY
I first heard about community redevelopment during my freshman year at
Emory University a few months into joining the InterVarsity Christian
Fellowship chapter, a diverse witnessing community of believers on
campus. Having grown up in a small suburb outside of Orlando, Florida,
going away to school at Emory in Atlanta was my first introduction to a big
urban city. I fell in love with both.
As I became more involved in InterVarsity, I was encouraged to see my
life as having a mission and that I could be a “world changer.” I jumped in
with both feet. It was like I had finally been acquainted with the missing
link that made everything else in my life make sense—my helping
personality, my love for people, and my desire to see broken systems
restored to new life. Surrounding me were Christians acting as Jesus’ hands
and feet by caring about racial reconciliation, loving the poor, engaging
with those who mourn, and fighting for justice. I came alive as a Christian
and started devouring books by C. S. Lewis, Dietrich Bonhoeffer, Dorothy
Day, and Elisabeth Elliot. My list of spiritual heroes grew tremendously in
college.
It helped that in the larger InterVarsity network there were many
examples of individuals and families making radical decisions in service of
God and marginalized peoples. By the time my husband, Eric (we met in
InterVarsity), and I graduated four years later, we had been pricked by the
desire to live counterculturally as urban missionaries in Atlanta. We saw
countless biblical examples of God calling individuals and communities to
care for the poor, the widow, and the foreigner. It was clear that a big piece
of God’s heart, and the specific ministry of Jesus Christ, centered on
seeking out those society at large often neglects. This spiritual motivation
was combined with a deep sense of personal responsibility and desire to
live differently in order to help others and glorify God.
After graduation and marriage, we read John Perkins’s book Restoring
At-Risk Communities and Bob Lupton’s Theirs Is the Kingdom. We prayed
and dreamed about participating in Perkins’s three Rs of community
development—relocation (move to the inner city), redistribution (share
resources and invest in the neighborhood), and racial reconciliation. About
this time, we connected with another young married InterVarsity couple
who were also considering a missional move to the inner city. After one
year of shared weekly dinners, we decided to buy our first home together
and live a communal life in Southwest Atlanta. The purpose of the
communal approach was to have a built-in support network as well as save
resources through sharing so more finances could be invested in the
neighborhood.
Our first clue that this journey would be difficult came when we tried to
get a loan for our new home. Even though all four of us had good credit
scores and stable incomes, we had difficulty finding a bank that would
make a home loan in our Southwest neighborhood. We were experiencing
the lingering effects of redlining (neighborhoods marked “hazardous” in red
ink on maps drawn by the federal Home Owners’ Loan Corp. from 1935 to
1939) that still disproportionally affect low-income, minority
neighborhoods today. 2
But we finally got the financing, and in May of 2007, the four of us
filled two enormous U-Hauls and drove from Buckhead (the nicest side of
town) to Southwest Atlanta (one of the roughest zip codes). We didn’t know
it at the time, but as we drove just a few miles we were crossing through zip
codes that differed thirteen years in life expectancy. Buckhead is an affluent
area with high-end luxury housing and retail centers where 71 percent have
white collar jobs and 75 percent have a bachelor’s degree or higher. 3 Our
new neighborhood was plagued by high poverty levels (18 percent living at
the most extreme level of poverty as measured by the federal government),
55 percent unemployment, 48 percent without a high school degree, and
4
high rates of violent crime.
We arrived full of good intentions and community development
training, but had no concept or language yet for the structures affecting
lifespan and quality of life for our new neighbors. We stepped out of the
moving van and were greeted by, “Huh, we thought we ran white people out
years ago.” We didn’t even realize that two preceding generations ago our
neighborhood, and many other Atlanta inner-city neighborhoods, were
wealthy, white communities and had experienced white flight to the
suburbs. 5 Racial tensions and mistrust had been building for decades, and
here we were—the new and only white people in the neighborhood. Despite
the fact that we stuck out like a sore thumb, our neighbors generally
welcomed us and treated us with kindness.
But at first no one really understood why we were there. Speculation
abounded, and people assumed at first that we were undercover cops, which
put them on their best behavior when we were around. After months of our
insisting this was not the case, they labeled us as hippies and tried selling us
a variety of illicit drugs. When we didn’t buy the drugs, our home became a
primary site for stealing. In the first two years we experienced over eighteen
attempted break-ins, most of them occurring shortly after we left for work
in the morning. But more importantly, we observed two of the primary
neighborhood economies: drug trade and theft. Additionally, with high
unemployment and incarceration rates, there was an abundance of desperate
parents trying to earn a living. The first time we cut our grass the
lawnmower was stolen out of our front yard, and we had to buy it back
from the local flea market for $25. My uncle jokingly referred to this as a
“creative recycling program” in the community. But in reality there was a
lot of economic “creativity” going on because even low-wage jobs were out
of reach for most of my neighbors.
When we first moved in, we had vowed not to own a gun or have an
alarm system, trusting our neighbors indiscriminately up front and wanting
to live a “normal” existence in our new home. Over time we relented to add
an alarm system, window bars, and two large guard dogs. This was the
second scraping of our ideals against the harder realities of our chosen
neighborhood. Just the need for these protective measures changed the way
we viewed our home and our community. We didn’t know who was
breaking in, so we became suspicious of everyone.
I knew intellectually that we were putting ourselves at risk moving into
a high crime zip code, but our dedication to the move kept me from
internalizing how I would really feel living in this environment. The real
and perceived danger in the community quickly took its toll, and I spent
most of my time at home feeling anxious. Between negative monthly crime
reports at our community meetings and rumors of shootings, home
invasions, and car theft, I quickly passed the point of concern and went into
a chronic stress mode that kept me scared and ultimately sucked the joy out
of life. I remember every time I would hear gunshots at night (which was
frequent), I would bury my head under my pillow and cry, shivering with
fear and wondering if a tragic incident was simply a matter of time. Every
sound in the house was a potential intruder. One night I woke to a weird
flapping sound. Terrified, I shook my husband, Eric, and whispered that I
thought someone might be in our room. I bundled under the covers while he
bravely flipped on the light to discover it was simply a large moth throwing
itself at our overhead fan. Even after he told me it was fine, I didn’t come
out from under the pillows, and I didn’t feel better. I was so tired of being
afraid.
After experiencing this level of stress for a couple of years, I couldn’t
imagine the negative accumulation of stress for our neighbors who had been