The Suburban Myth of Health and Wealth
Houses line the street in Mineola, a village in Nassau County, N.Y.(Krisanne Johnson for USN&WR)
GARDEN CITY, N.Y. – On the surface, Nassau County is a wealthy and thriving suburban enclave in New York City's backyard.
Home to 1.4 million people and one of two independent counties on Long Island, it's the picture of community well-being: The area is relatively safe, the unemployment rate is fairly low and most people have health coverage. In U.S. News' 2019 Healthiest Communities rankings – a project evaluating nearly 3,000 counties across myriad measures of health, housing, economy and more – Nassau County places 96th overall.
That's the Nassau County many residents know. But further scrutiny reveals stark disparities at the ZIP code level, making it clear that health challenges traditionally thought of as city problems – like pollution, poverty and access to care – can transcend city limits and spill over into suburban rings.
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"From the 20,000-foot level, we have one of the wealthiest and healthiest suburbs in America," says Lawrence Levy, executive dean of Hofstra University's National Center for Suburban Studies. "But the closer you get to the ground, the more you realize the unrecognized disparities.
"I am in a community where quality and outcomes in health care are terrific, whereas there are neighborhoods and villages cheek to jowl where you could be in the inner city," Levy says. "Much of the country (has) fallen victim to this myth of wealth and wellness in the suburbs."
This longstanding dichotomy can also be found elsewhere: Among America's 100 most populous metro areas in 2015, more people lived in poverty in the suburbs than in the major cities nearby, according to an analysis presented to Congress by Elizabeth Kneebone, then a senior fellow with the Brookings Institution. A lack of mass transit and fragmented government resources can exacerbate the issue.
But Nassau County – sometimes called the birthplace of post-World War II suburbia – offers a clear example of how a sweeping area assessment can mask neighborhood problems. For example, while census estimates say just 6.2 percent of residents live in poverty, the county's cost of living is significantly higher than in most of the country, and those struggling to make ends meet have largely been relegated to a handful of neighborhoods.
Community boundaries draw visible lines. In the county hamlet of Merrick, about 88 percent of the approximately 22,000 residents are white, and the median household income is $147,572, according to census estimates. But in neighboring Roosevelt, a 1.77-square-mile hamlet that's home to a little over 16,000 people, roughly half of public school students are eligible for free or reduced-price lunch, a marker of community poverty. About 98 percent of residents are black or Hispanic.
Half a century after redlining and racial discrimination in housing were banned in the U.S., Nassau County remains one of the most racially segregated of America's large communities, Healthiest Communities and other data indicate. The legacy of such practices has been documented across the country: Affected communities often lack access to quality housing, jobs, schools and health care, resulting in poorer health outcomes.
"Racial residential segregation is a fundamental cause of health disparities across the board," says Martine Hackett, an assistant professor and public health researcher at Hofstra University. "If you take that concept – of the outside environment playing a role in the differences on a population level – then the way that looks and presents as the health outcomes of people in suburban areas is going to have a different flavor."
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For example, in Nassau County, black babies are about 3.5 times as likely as white babies to die before their first birthday – a slightly harsher disparity than in New York City, where the poverty rate and uninsured rate are higher. Infant mortality serves as a strong indicator of the health of a population overall, public health experts say, since it's tied to socioeconomic status, health care access and health care quality – all factors that can be influenced by the structural racism shown to exist in health care.
A community health assessment conducted by the Nassau County Department of Health in 2016 identified nine of the county's communities, including Roosevelt, as areas where "population pockets are disproportionately burdened with a poorer health status," which can be borne out by shorter life expectancies, higher disease prevalence and less accessible health care. Some problems vary by neighborhood and demographics, but taken together, the nine communities generally have significantly higher rates of asthma, type 2 diabetes, liver disease and chronic obstructive pulmonary disease than the rest of the county, according to the assessment.
Sexually transmitted infections also are more prevalent in the nine communities, and Nassau County, combined with neighboring Suffolk County, is one of the only suburban areas in the country to receive federal funding through the Ryan White HIV/AIDS program, authorized in 1990 to provide access to health care for low-income people living with HIV.
Local funding to address such health problems is scarce, however, and while underserved communities in Nassau County have advocated for more attention and resources in recent years, progress has come slowly in some arenas and been stagnant in others.
For example, the county helped pay for programs that supported pregnant teenagers and teenage parents in the village of Westbury for decades. But within the last few years, the county has stopped funding all but one such program – Good Beginnings for Babies – which has seen its funding reduced while need has grown, says Nellie Taylor-Walthrust, who leads the initiative for the North Shore Child & Family Guidance Center, a local counseling agency.
Good Beginnings is now the only program to receive discretionary funding through the health department, which saw its budget slashed by roughly $39 million between 2009 and 2018.
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Many school districts also have been hesitant to address mental health and substance use issues among students, Taylor-Walthrust says. "Working with our local community leaders, it's almost like you have to navigate: Who will listen to what I have to say?" she says. "I think there needs to be a meeting of the minds."
If historical policies and a clouded view of communities in need have perpetuated some health disparities, Nassau County's sheer number of villages and public school districts – ۵۶ for roughly 201,000 students – has further fragmented the region, isolating communities that are wealthier, healthier and typically whiter and preventing them from seeing their neighbors' challenges.
"In my experience, when I point it out to people, they are surprised – all the time – because they had no idea, no realization, even living in these neighborhoods," Hackett says. "If people don't know that it's happening, nobody is going to do anything about it."
Awareness is a key first step to improving the health of underserved communities, local advocates say, but it's hardly sufficient.
Northwell Health, the largest hospital system in New York and a major employer in the area, started deploying community interventions to improve health equity in Nassau County in recent years, including by offering "prescriptions" for healthy food to hospital patients who have a diet-related health issue and training community health workers, who are then employed by local organizations and help residents navigate the web of care and services they may need.
"We've been seeing there is a gap between where the community is and where social services and health care providers are," says Nuzhat Quaderi, who manages Northwell's community health worker program. "We recognize that we're not the expert in this grassroots, in-the-community work. So how do we build this bridge and create liaisons within the community?"
Dr. Lawrence Eisenstein, Nassau County's health commissioner, says his health department seeks to provide information and ensure access to services that are available through the region's many community-based groups, federally qualified health centers, hospitals, school districts and other organizations. The health department also works with the Long Island Health Collaborative – which has roughly 100 community partners across Nassau and Suffolk counties – to compile data, share resources and promote best practices to improve health. The Nassau County Department of Health does not provide clinical services itself.
"It's all about communication and identifying ways to level the playing field where we see these disparities," Eisenstein says. "When possible, we try and gear our initiatives toward impacting at-risk communities."[
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Still, some advocates have expressed concern about county leaders' willingness to take on the area's broader health disparities – and their underlying causes – in a timely and adequate manner. With so many levels of oversight between the county and its dozens of villages, school districts and even water districts, it can be difficult to know who's responsible for certain issues, creating a "disconnect" between community members and their government leaders, says Jacob Dixon, a community organizer who was born and raised in Roosevelt.
"It's not to say there's not the best intentions," Dixon says. "I think it's more so: Who is leading the work and who is on the ground to identify there needs to be a larger response? (They) shouldn't have to come to you to tell you what the problem is, if your job is to come to the people."
Dixon's nonprofit organization, Choice for All, was instrumental in having several polluted properties cleaned up in Roosevelt, and worked with the county health department to conduct air and water testing in nearby homes. Now, he is focused on increasing the availability of healthy, affordable food in the area and on improving Roosevelt's high school graduation rate, which sits at 64 percent.
He also employs two community health workers who were trained through Northwell's program.
"We have all these different pieces in place, but the concern is sustainability of funding," Dixon says. Like many community-based groups, many of Choice for All's initiatives are grant-funded, so when the money dries up, programs can, too.
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In the past, Dixon and others have not been able to rely on funding from Nassau County, which is cash-strapped and under the authority of a state financial oversight board despite having one of the highest property tax rates in the state. A report from the county's comptroller shows Nassau County had more than $3 billion in outstanding long-term debt in 2017, and indicates its financial position was weakened during former County Executive Edward Mangano's tenure, which ran from 2010 to 2017. (Mangano and his wife recently were convicted on corruption charges.)
County Executive Laura Curran, who took office in 2018, has worked to revamp the county's property tax system – which a Newsday investigation last year found had disproportionately burdened many property owners under Mangano – and highlighted her plan to regain public trust and ensure financial responsibility during her State of the County address earlier this month.
"We are now on the road to fairness, equity and accuracy," Curran said during the speech.
Ensuring Nassau County is truly an equitable place to live will require a more targeted focus on health, advocates say. The county is growing more diverse by the year, with census estimates showing an influx of roughly 25,000 Asian and Hispanic immigrants since 2010. Advocates say the county must be willing to change with the population in order to improve health for the people of Nassau County – all of Nassau County.
"Without the ability to dictate from the top, like you can in a city, often these problems are solved one village at a time," Hofstra's Levy says. "That's very inefficient, and not very effective … To break that cycle of dysfunction is very difficult, and it is really the challenge of our time in suburban America."
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Gaby Galvin, Staff Writer
Gaby Galvin is a staff writer at U.S. News & World Report, covering public health issues for … Read more
Tags: public health, poverty, New York, New York City
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