SAKE OF ALL A report on the health and well-being

SAKE OF ALL A report on the health and well-being
FOR THE
SAKE
OF ALL
A report on the health and well-being
of African Americans in St. Louis and
why it matters for everyone
May 30, 2014 | St. Louis, Missouri
TABLE OF CONTENTS
Acknowledgments................................................................................................................................................................................. 02
Executive summary.............................................................................................................................................................................. 04
Goals and process................................................................................................................................................................................... 06
1 Introduction: Why consider economics, education, and health together?................................. 10
2 Past and present: African Americans in St. Louis ................................................................................................ 16
3 Place matters: Neighborhood resources and health ......................................................................................... 26
4 Education and health: A foundation for well-being ........................................................................................... 34
5 A health profile of African Americans in St. Louis ............................................................................................. 46
5.1
Chronic diseases .................................................................................................................................................................. 47
5.2
Lifestyle risk and protective factors ................................................................................................................... 51
5.3
Health insurance and access to primary care ..........................................................................................55
5.4
Maternal and child health .......................................................................................................................................... 56
5.5
Mental health ......................................................................................................................................................................... 60
5.6
Violence and injury .......................................................................................................................................................... 62
5.7
HIV/AIDS and other STDs ........................................................................................................................................ 65
6 Recommendations ............................................................................................................................................................................... 68
Glossary.............................................................................................................................................................................................................. 71
Resources ........................................................................................................................................................................................................ 72
References ......................................................................................................................................................................................................73
Washington University in St. Louis and Saint Louis University 01
Acknowledgments
Many individuals and organizations
contributed to this publication, to the
series of policy briefs that preceded
it, and to the overall For the Sake of
All project. We are very grateful for
their assistance and support.
Report
Conceptualization, Production, and Editing
> J ason Purnell, PhD, MPH, For the Sake of All
Principal Investigator
> Gabriela Camberos, MPH, For the Sake of All
Program Coordinator
> Robert Fields, MPH, For the Sake of All
Data Analyst
Research Assistance
>R
ebecca Gernes, Research Assistant
>C
harles Turner, Research Assistant
Personal Interest Stories
> S t. Louis Public Radio (formerly St. Louis Beacon)
– Robert Joiner, Health Reporter
Design
> jager boston (www.jagerboston.com)
Printing
>T
he Advertisers Printing Company
Photography
> Nanette Hegamin (identified with NH symbol)
> Missouri History Museum, St. Louis
(identified throughout)
Policy Briefs
“How can we save lives—and save money—in St. Louis?
Invest in economic and educational opportunity”
by Jason Q. Purnell, PhD, MPH, Assistant Professor,
George Warren Brown School of Social Work, Washington
University in St. Louis
“How does health influence school dropout?”
by William F. Tate IV, PhD, MPE, Edward Mallinckrodt
Distinguished University Professor in Arts & Science &
Chair, Department of Education, Washington University
in St. Louis
02 For The Sake Of All
“How can we improve mental health in St. Louis?
Invest in our community and raise awareness”
by Darrell L. Hudson, PhD, MPH, Assistant Professor,
George Warren Brown School of Social Work, Washington
University in St. Louis
“Segregation: Divided cities lead to differences in health”
by Melody S. Goodman, MS, PhD, Assistant Professor,
Division of Public Health Sciences, Washington University
School of Medicine; and Keon L. Gilbert, DrPH, MA, MPA,
Assistant Professor, Department of Behavioral Science &
Health Education, College for Public Health & Social Justice,
Saint Louis University
“Chronic disease in St. Louis: Progress for better health”
by Bettina F. Drake, PhD, MPH, Assistant Professor,
Division of Public Health Sciences, Washington University
School of Medicine; and Keith Elder, PhD, MPH, MPA,
Professor & Chair, Department of Health Management
& Policy, College for Public Health & Social Justice,
Saint Louis University
Community stakeholders and policy brief advisers
Beyond Housing
> Chris Krehmeyer, President/CEO
> Jillian Guenter, Chief Community Building Officer
> Caroline Ban, Special Assistant to the President/CEO
ChildCare Aware of Missouri
> L. Carol Scott, PhD, CEO
George Warren Brown School of Social Work,
Washington University
> Derek Brown, PhD, Assistant Professor
> Ross Brownson, PhD, Professor & Director, Prevention
Research Center
> Tim McBride, PhD, Professor
> Molly Metzger, PhD, Assistant Professor
> Michael Sherraden, PhD, George Warren Brown
Distinguished Professor & Director, Center for
Social Development
> Vetta Sanders Thompson, PhD, Professor
Maternal, Child, and Family Health Coalition
> Kendra Copanas, Executive Director
> Lora Gulley, Director of Programs, Healthy Mothers
and Babies
Metropolitan St. Louis Equal Housing Opportunity Council
> Will Jordan, Executive Director
> Elisabeth Risch, Education and Research Coordinator
Places for People
> Joe Yancey, Executive Director
Missouri Department of Mental Health
> Roy C. Wilson, MD, Medical Director
>L
aurent Javois, Regional Executive Officer
St. Louis Integrated Health Network
> Robert Massie, MD, Board Chair
St. Louis Mental Health Board
> S erena Muhammad, Senior Project Director —
Strategic Partnerships
St. Louis Regional Early Childhood Council, Executive Committee
> J eanine Arrighi, Health Services Manager,
City of St. Louis Department of Health
> S. Wray Clay, Vice President, United Way of Greater
St. Louis
> Elizabeth George, Senior Consultant, The Rome Group
> Elizabeth Hoester, Research Coordinator, Vision for
Children at Risk
> Anne Kessen Lowell, Executive Director, Southside
Early Childhood Center
> Rich Patton, Director, Vision for Children at Risk
Project
Community Partner Group
> S ally J. Altman, MPH, Manager, News Partnerships,
St. Louis Public Radio
> Dolores J. Gunn, MD, Director, Saint Louis County
Department of Health
> Ronald L. Jackson, Chairman, St. Louis Black
Leadership Roundtable
> Jade D. James, MD, MPH, Immediate Past President,
Mound City Medical Forum, Director of Research
and Medical Services, Saint Louis County Department
of Health
> Bethany Johnson-Javois, MSW, Chief Executive Officer,
St. Louis Integrated Health Network
> Sandra M. Moore, JD, President, Urban Strategies, Inc.
> Melba R. Moore, MS, CPHA, Commissioner of Health,
City of St. Louis
> Valerie Patton, MSW, Vice President, Economic
Inclusion & Executive Director, St. Louis Business
Diversity Initiative, St. Louis Regional Chamber
> Louise Probst, MBA, BSN, Executive Director, St. Louis
Area Business Health Coalition
> Will Ross, MD, MPH, Associate Dean for Diversity,
Associate Professor of Medicine, Washington University
School of Medicine
> Don Senti, PhD, Executive Director, EducationPlus
> Yvonne S. Sparks, MPA, Community Development
Officer, Federal Reserve Bank of St. Louis
> Donald M. Suggs, DDS, Publisher and Executive
Director, St. Louis American
George Warren Brown School of Social Work, Washington
University in St. Louis
> Edward F. Lawlor, PhD, Dean & the William E. Gordon
Distinguished Professor
> Patricia Anagnos, Assistant Director of Communications
> Ann Kittlaus, Assistant Dean of Communications
> Nancy Mueller, Assistant Dean for Evaluation
& Planning
> Liz Valli-Hall, Grant & Contract Coordinator
> Freddie Wills, Assistant Dean for Strategic
Implementation
Policy Forum, Brown School
– Sue Stepleton, PhD, Director
– Hillary Frey, Coordinator
enter for Social Development, Brown School
C
– Michael Sherraden, PhD, Director
– Lissa Johnson, Director of Administration
– Katherine Stalter, Communications Coordinator
Office of Public Affairs, Washington University in St. Louis
> Ellen Rostand, Assistant Vice Chancellor
> Leslie McCarthy, Senior News Director
> Brittaney Bethea, Graduate Student Assistant
Institute for Public Health, Washington University in St. Louis
> William Powderly, MD, Director, J. William Campbell
Professor of Medicine, & Co-Director of Division of
Infectious Diseases, Washington University School
of Medicine
> Victoria Anwuri, Associate Director
> Kimberly Singer, Communications Manager
Department of Education, Washington University in St. Louis
> Brittini D. Jones, Doctoral Student
> Kelly Harris, Doctoral Student
Saint Louis University
> Enbal Shacham, PhD, MPE, Associate Professor,
College for Public Health & Social Justice
> Nancy Solomon, Director, Medical Center
Communications
Missouri Department of Health and Senior Services,
Bureau of Health Care Analysis and Data Dissemination
> Andrew Hunter, Bureau Chief
> Becca Mickels, Research Analyst IV
> Whitney Coffey, Research Analyst II
Missouri Foundation for Health
> M. Ryan Barker, Vice President, Health Policy
> Sarah Morrow, Health Policy Officer
Washington University in St. Louis and Saint Louis University 03
Executive summary
Health is about more than what happens in a doctor’s
office or a hospital room. Health allows us to engage fully
in the activities of our daily lives and to make meaningful
contributions to our communities. It is fundamental to
human well-being, but it is not equally distributed across
our community.
Since March of 2013, scholars from Washington University
in St. Louis and Saint Louis University have been exploring
how this unequal distribution of health in the St. Louis
region is related to what are called social determinants
of health — factors like education, income, the quality and
composition of neighborhoods, and access to community
resources like healthy foods and safe public spaces.
In one year alone, the loss of life
associated with low levels of education
and poverty among African Americans
was estimated at $3.3 billion.
African American health and well-being has been at the
center of this work because of the particular history and
demographic make-up of the City of St. Louis and St. Louis
County, which make up the project’s targeted geographic
area. Differences in social and economic factors by race
play a significant role in explaining the differences in health.
There are very real ways in which these differences in
health and life outcomes affect everyone in the St. Louis
region. Of course, the most important and immediate
impact is the loss of our neighbors, co-workers, family,
friends — our fellow St. Louisans — to early deaths that
could have been prevented. The economic costs of that loss
of life are staggering as well. In one year alone, the loss of
life associated with low levels of education and poverty
among African Americans was estimated at $3.3 billion.
Other economic impacts:
1
More than 2,000 African American students
dropped out of high school in 2012. They are likely
to earn about $7,000 less per year than high school
graduates. Their lifetime earnings loss (ranging
from $347,000 to $739,410) reduces purchasing
power at regional businesses, lowers tax receipts,
and adds to the costs of social services and
unemployment assistance. Using earnings alone,
St. Louis leaves $694 million to $1.5 billion “on
the table” when we let dropouts occur.
2
Eliminating racial and ethnic differences in
mental health could save as much as $27 million
in inpatient hospital charges. Other economic
impacts associated with poor mental health
include crime, imprisonment, reduced earnings
and employment, and family disruption.
3
If we reduced the disparity in chronic diseases
like heart disease, cancer, and diabetes, St. Louis
could save $65 million a year in inpatient hospital
charges, which would be a significant cut in the
$1.1 billion on just these three diseases.
These are just some of the costs and potential savings
associated with the social and economic factors that are
linked to health. We cannot afford to continue like this.
Something has to change in order for everyone in the
St. Louis region to be able to thrive and contribute to its
growth and vitality. For the Sake of All is a project with
just that purpose in mind.
The four project goals were to:
1.Inform the general public about the social determinants
of health as they impact African Americans, as one of
the populations most impacted by health disparities.
2.Present the regional economic and health consequences
of intervening (or failing to intervene) on social
determinants of health.
3.Provide evidence of the impact of persistent disparities
on all members of the region, regardless of race or
socioeconomic status.
4.Influence the policy agenda on health disparities
by broadening the conversation beyond personal
responsibility and the delivery of medical care alone.
04 For The Sake Of All
Accomplishing these goals involved a vital partnership
with community stakeholders across multiple sectors
in the St. Louis region. A Community Partner Group
with representatives from public health and health care,
education, business, community and economic development,
media, and civic engagement offered guidance and input
on the project. Five policy briefs were released between
August and December of 2013, each describing a different
aspect of health and well-being for African Americans in
St. Louis. Also included with each brief was a set of policy
and programmatic recommendations for addressing the
social and economic factors driving differences in health.
In March of 2014, members of the St. Louis community were
asked to provide their feedback on these recommendations
along with other elements of a final report, including new
information not contained in the original five briefs. That
feedback was incorporated as much as possible in this report.
Key findings from the report:
> Differences in health and life outcomes between African
Americans and whites in St. Louis can be understood
within the context of larger national trends in death
and life expectancy.
> Social and economic factors are strongly linked to health
outcomes like disease, disability, and death. In fact, this
set of relationships is so strong and consistent that there
is a term for it: the socioeconomic gradient in health.
> Addressing social and economic factors is the most
powerful means of tackling differences in health outcomes.
This will require regional effort from multiple sectors in
our community.
> There are historical trends that help to explain social,
economic, and health differences, including long-standing
gaps in educational attainment, poverty, and unemployment.
Current demographic figures reflect this history and point
to ongoing challenges in these areas.
> Where you live in St. Louis has a powerful impact
on your health. Residents of zip codes separated by
only few miles have up to an 18-year difference in
life expectancy. Because of considerable residential
segregation in St. Louis, many areas with high African
American populations are also areas with concentrated
poverty and poor health. These neighborhoods often
lack resources like healthy foods, safe green spaces for
recreation, and convenient access to medical care.
> Education is one of the strongest and most consistent
predictors of health, and gaps in life expectancy between
those with low and high levels of education are widening.
That makes differences in academic achievement and
educational attainment for many African American
students in St. Louis particularly troubling. One in 10
African American in grades 9 – 12 dropped out of school
in 2012, and poor performance in key subjects at critical
points in their education place many others at risk.
> Poor health can also act as a barrier to education,
particularly when chronic childhood illnesses like asthma
and mental health challenges go untreated.
> These social and economic patterns help provide necessary
context for understanding differences in mental and
physical health outcomes between African Americans and
whites in the St. Louis region. African Americans are more
likely to experience chronic disease, violence and injury,
emergency mental health treatment and hospitalization,
sexually transmitted disease, adverse pregnancy and
birth-related outcomes, and risk factors for disease like
obesity and high blood pressure. The lack of resources
and amenities in neighborhoods where many African
Americans live also makes it more difficult to engage in
healthy lifestyle behaviors like physical activity and eating
a healthy diet.
Recommendations:
1
I nvest in quality early childhood development
for all children.
2 Help low-to-moderate income families create
economic opportunities.
3 Invest in coordinated school health programs
for all students.
4
I nvest in mental health awareness, screening,
treatment, and surveillance.
5 Invest in quality neighborhoods for all in
St. Louis.
6 Coordinate and expand chronic and infectious
disease prevention and management.
Washington University in St. Louis and Saint Louis University 05
Goals and process
With funding from the Missouri
Foundation for Health, scholars
from Washington University
and Saint Louis University have
collaborated with community
partners and key stakeholders
to produce a series of briefs on
A
topics related to the health and
well-being of African Americans in the City of St. Louis
and St. Louis County. That same group of academic and
community partners helped to inform this final report
to the community, which we release in this year of several
important anniversaries: the 50th anniversary of President
Lyndon Johnson’s
signing of the Civil
Rights Act of 1964, the
60th anniversary of the
landmark Supreme Court
decision in Brown v. Board
of Education, and the
B
250th anniversary of the
founding of St. Louis. Each of these anniversaries reminds
us of the significant progress made over the past several
decades, and indeed, several centuries. But they also force
us to reflect on what more can be done to ensure the health
and well-being of all residents in the St. Louis region.
Four goals for the project:
1
To inform the general public about the social
determinants of health as they impact African
Americans, as one of the populations most
impacted by health disparities.
2 To present the regional economic and health
consequences of intervening (or failing to
intervene) on social determinants of health.
3 To provide evidence of the impact of persistent
disparities on all members of the region,
regardless of race or socioeconomic status.
4
To influence the policy agenda on health
disparities by broadening the conversation
beyond personal responsibility and the delivery
of medical care alone.
A: Attorneys George Hayes, Thurgood Marshall, and James Nabrit, Jr. celebrate Brown victory.
B: President Johnson hands Dr. Martin Luther King, Jr. ceremonial pen from Civil Rights Act signing.
Images Courtesy of the Library of Congress, NYWTS
06 For The Sake Of All
Overview of process
Community Partner Group
One of our first tasks was identifying a Community
Partner Group (CPG) that was regional in its scope,
represented key sectors in the community, and brought
expertise relevant to the topics covered in the briefs
and final report. It was important that the group
include not only leaders in public health and health
care, but also education, community and economic
development, business, media, and civic engagement.
The CPG met 5 times between June of 2013 and May
of 2014 and was available for consultation and feedback
between scheduled meetings. Members offered invaluable
guidance on the overall structure of the project and its
goals; substantive feedback on each policy brief, including
identifying key stakeholders to engage and vetting policy
and programmatic recommendations; and input on this
final report. The CPG also leveraged resources within their
organizations to publicize For the Sake of All among their
networks and in the broader community. This was especially
true of our two media partners, the St. Louis American and
the St. Louis Beacon (now merged with St. Louis Public
Radio), who published news stories, editorials, and
commentaries related to each of the briefs and the overall
project. These stories added an essential human dimension
to the data presented in the briefs.
Origins of For the Sake of All
The origins of this project’s
title rest with one of St. Louis’s
most famous African American
residents, the “King of Ragtime,”
Scott Joplin (pictured right).
The 1915 composition, “For the
Sake of All,” was among the
unpublished works that Joplin’s
widow shared with the public
after his death in 1917. Though
the title was jotted down by
writers researching Joplin’s life and music, no trace of the
musical score remains. That is fitting. A composition thought
to have been written nearly one hundred years ago in
St. Louis with the title “For the Sake of All” seems a poignant
reminder that our work to achieve the lofty goal that the title
suggests is also unfinished.
Part of our unfinished work involves the stark differences
in health and other life outcomes experienced by the African
American population in St. Louis. For the Sake of All is a
multi-disciplinary, multi-sector project to provide information
on the social and economic factors that contribute to
those disparities and to suggest policy and programmatic
recommendations for improving community health and
well-being.
Policy Briefs
The first of five policy briefs was released on August
28, 2013, exactly 50 years after the historic March on
Washington for Jobs and Freedom and Dr. Martin Luther
King’s iconic “I Have a Dream” speech. Entitled, “How
can we save lives—and save money—in St. Louis? Invest
in economic and educational opportunity,” the first brief
estimated the number of deaths attributable to low levels
of education and poverty among African American adults
in 2011 along with the economic impact of that loss of
life. The second brief, “How does health influence school
dropout?” was released in September and described
how the health of children and youth can impact their
educational outcomes. We released the third brief in
October: “How can we improve mental health in St. Louis?
Invest in our community and raise awareness.” This brief
detailed the social and economic impact of poor mental
health and disparities in the use of hospitals for mental
health treatment by African Americans in the region.
“Segregation: Divided cities lead to differences in health”
was the fourth brief released in November. It described
the relationship between racial and economic residential
segregation and health outcomes such as chronic disease
mortality. The fifth and final brief was titled, “Chronic
disease in St. Louis: Progress for better health.” It explored
the progress made by African Americans in reaching some
of the national Healthy People 2010 goals for reductions
in death rates for diabetes, cancer, and heart disease.
Community Engagement
Along with our partners, we recognized the need for
significant community engagement to ensure the success of
the project. In addition to inviting comment on each of the
briefs using the project’s website (forthesakeofall.org), we
also utilized social media such as Facebook and Twitter to
share information. More than 50 community organizations
and individual leaders were also engaged through meetings
and presentations about For the Sake of All. Online
engagement with the project has been considerable, with
over 10,000 views of forthesakeofall.org by 3,600 visitors
in the United States and 46 other countries.
On March 18, 2014, we hosted a Community Feedback
Forum, where community members were invited to
share their feedback on draft elements of this final report.
Over 90 individuals representing a broad cross-section
of the community joined us at the Forest Park Visitor &
Education Center.
While we could not directly respond to every comment,
the dominant themes from the Community Feedback Forum
are summarized below along with our responses:
Theme: Need to address social determinants of health for all
racial and ethnic groups.
Response: As the purpose of the For the Sake of All project is
to report on the health and well-being of African Americans,
this population was necessarily at the center of our analyses
and discussion. Where appropriate, we do compare African
American social, economic, and health status to the most
populous racial group in the region other than African
Americans, namely whites. We follow the conventions of
our data sources in labeling and identifying these racial
groups, without endorsing any particular classification scheme.
We also address the health and economic impact of social
and health disparities with reference to the entire region,
regardless of race. Our policy recommendations are broadly
applicable to all racial and ethnic groups in the region.
Theme: Need for incorporation of issues related to lesbian, gay,
bisexual, and transgender (LGBT) communities.
Response: We certainly appreciate the specific health
needs of individuals who are lesbian, gay, bisexual, and
transgender and the special barriers to optimal health
at the intersection of sexual and racial minority status.
Unfortunately, the publicly available data upon which we
relied for this project does not identify sexual orientation,
and gender identity is assessed only in the binary male vs.
female. Including information on sexual orientation and
gender identity at the local level would have required original
data collection beyond the scope of this project. However,
we would recommend that those interested in LGBT health
issues consult the August 2012 publication in the Missouri
Foundation for Health’s Health Equity Series entitled,
“Responding to LGBT Health Disparities” available at
https://www.mffh.org/mm/files/LGBTHealthEquityReport.pdf.
Theme: Explain sources, limitations, and methodology for
analyzing and reporting data.
Response: Please see “Data Sources and Limitations” on
pages 08-09.
Theme: Focus on HIV/AIDS
Response: HIV/AIDS was not presented in the Community
Feedback Forum posters, but it was always our intent to
include data and discussion on this topic in the final report.
Because of the feedback we received, we have expanded our
coverage. Please see the presentation of HIV/AIDS data on
pages 65 – 67.
Washington University in St. Louis and Saint Louis University 07
Theme: Clarity of data presentation and definitions
Response: We have addressed specific concerns about the
clarity of graphs, data tables, and other elements of the report
on display at the Community Feedback Forum. The terms
used to describe various factors and conditions have also
been clarified and a Glossary of Terms is included.
Theme: Focus on youth violence
Response: In response to feedback, we have expanded our
coverage of violence prevention and intervention. Please
see the presentation of violence and injury data on pages
62 – 65. We also refer interested readers to the Community
Plan developed with extensive community input by the Regional
Youth Violence Prevention Task Force (see Resources).
Theme: Highlight positive examples and sources of hope
Response: Throughout this report, and in our previously
released briefs, we have focused on local and national
examples of promising and proven strategies, policies, and
programs. We believe these exemplars offer many reasons
to be optimistic about our ability to positively impact
community health and well-being.
In addition to feedback on the presentation and content
of the report, there were specific community comments
on the recommendations. We respond to this feedback
in the Recommendations section of the report.
Engagement of policy makers
We have also had the opportunity to brief several regional
and state policy makers on the initial findings. In March,
representatives from the For the Sake of All project team
briefed City of St. Louis Mayor Francis Slay and members
of his Cabinet, including the leaders of several City departments;
members of Governor Jay Nixon’s staff; and the Missouri
Legislative Black Caucus. In May, briefings were held for
City of St. Louis Treasurer Tishaura Jones and the Health
and Human Services Committee of the City of St. Louis
Board of Aldermen. Efforts to engage additional policy
makers are ongoing.
Final report
This final report is the culmination of more than 14 months
of intensive work to uncover the social, economic, and other
factors that contribute to differences in health outcomes for
African Americans in the St. Louis region—and the extent
to which those differences impact everyone, regardless
of race or socioeconomic status. This report contains
the most current data available on the educational and
economic status of African Americans in addition to
08 For The Sake Of All
comprehensive health data. Where possible, we have drawn
lines of connection between these social factors and health
outcomes within the specific geographies of the City of
St. Louis and St. Louis County. The examination of these
issues is intentionally broad in both subject matter and
geographic coverage. Issues of health and health disparities
in the St. Louis region are complex, and a full understanding
requires the perspectives of multiple disciplines and sectors
as well as a regional scope.
Data sources
This report uses data previously collected by other
organizations and entities (i.e., secondary data sources).
It aims to provide a comprehensive snapshot of these data
and to provide the most current data available whenever
possible. However, there were several instances where
updated data was released after analysis.
Demographic, social, and economic data were primarily
drawn from the U.S. Census Bureau’s American Community
Survey (ACS) and Decennial Census. Education data were
drawn from the Missouri Department of Elementary and
Secondary Education (DESE) and ACS. Health data were
drawn from the Missouri Department of Health and Senior
Services (MODHSS), Centers for Disease Control & Prevention
(CDC), and previous St. Louis reports. Other sources include
data from scientific studies published in journals, reports,
and books. Education and health data were derived from
various surveys and other data collection programs. Nearly
all of the data in this report are publicly available.
Education data from DESE about student performance
are derived from the Missouri Assessment Program (MAP).
Health data from MODHSS were extracted from MICA
(Missouri Information for Community Assessment) and
Community Data Profiles (Profiles). MICA data are derived
from vital statistics (e.g., death records, birth records) and
the Patient Abstract System (e.g., inpatient hospitalizations,
emergency room visits). Most of the health data from the
Profiles used in this report are derived from the 2011 CountyLevel Study (CLS). Data drawn from all sources were extracted
at the aggregate-level, meaning no individual or personally
identifiable data were directly analyzed for this report.
Steps were taken to reduce errors in data extraction, analysis,
and reporting. Some data extracted from secondary sources
were recoded or categorized differently than in the original
assessment. It is possible that errors could have occurred
during these processes. The methods and descriptions
for each of the main data sources can be accessed online
(see Resources).
Limitations
them. Its focus on the links between economic resources,
neighborhood conditions, and health also are taken up in this
report. Another notable report, the St. Louis Regional Health
Commission’s Decade Review of Health Status, points to areas
of progress in chronic disease mortality and other indicators
of health in the region between 2000 and 2010, while also
noting areas of continuing disparity. The City of St. Louis
Department of Health has embarked on implementation of
an ambitious Community Health Improvement Plan based
on its Understanding Our Needs — City Health Assessment. It
places a clear emphasis on factors like education, poverty,
and public safety as key influences on the health of City
residents. These themes and many others are also addressed
in the City of St. Louis Sustainability Plan. In St. Louis County,
similar work is being done through the Health Department’s
Community Health Needs Assessment as well as Imagining
Tomorrow for St. Louis County, the County’s recently released
strategic plan. There have also been important regional
reports that include health and well-being among their
considerations, like the East-West Gateway Council of
Governments’ OneSTL regional plan. These reports are
among the many that have informed our work and upon
which For the Sake of All has built.
There are several limitations to using secondary data sources
and analysis. Because we used data that had been previously
collected, our report can only analyze variables that were
available in these secondary sources. There were many
instances where data were not available or limited in scope,
particularly at the local level. This report is also primarily
descriptive in nature rather than explaining or predicting
trends using statistical tests. This would have been beyond
the scope and intent of the project. We have relied on
published scientific studies to support interpretation of the
data presented, but chose to maintain accessibility for as
broad an audience as possible.
Previous reports
Several previous reports on the St. Louis region offer
essential background and context for this report. We hope
that the final report on For the Sake of All is a useful extension
of this impressive body of work. For example, the North
St. Louis Health Care Access Study provides a compelling case
study of health care access in this predominantly African
American area of the region, giving voice to its residents
and the leaders of health care systems working to serve
Target Geography: St. Louis City and St. Louis County
N
Florissant
Bridgeton
Ferguson
Maryland
Heights
Olivette
Creve Coeur
Chesterfield
Black Jack
University
City
Clayton
Ladue
ST. LOUIS CITY
ST. LOUIS COUNTY
Wildwood
Des Peres
Webster
Kirkwood Groves
Valley Park
Fenton
Green Park
Eureka
Washington University in St. Louis and Saint Louis University 09
01
Introduction:
WHY CONSIDER
ECONOMICS, EDUCATION,
AND HEALTH TOGETHER?
Early deaths due to limited economic
and educational opportunity affect us all.
In St. Louis, the estimated cost of this loss
of life in one year is approximately $3.3 billion.
10 For The Sake Of All
Health is fundamental to human well-being. Health makes
it possible for us to engage fully in the activities of our
daily lives and make contributions to our communities.
Unfortunately, health is not equally distributed among
groups in society. In fact, there are fairly consistent patterns
of unequal health outcomes—like disease, disability,
and death—between people of different genders, races,
ethnicities, educational levels, and incomes.
Age in
years
85
White Female
African American Female
White Male
African American Male
Whites
1,500
Death Rate Per 100,000
Figure 1. Life expectancy at birth, by race and sex:
United States, 1970 – 2009
Figure 2. Death rates among St. Louis County
and St. Louis City residents of all ages
African Americans
1,200
900
2010
2005
2000
Rates are age-adjusted using the US 2000 standard population.
Source: Death MICA, Missouri Department of Health and Senior Services
70
65
60
1995
600
75
1990
80
1970
1975
1980
1985
1990
1995
2000
2005
2010
Year
Source: CDC/NCHS, National Vital Statistics System.
In Figure 1, we can see that despite overall improvements
in life expectancy at birth (i.e., how long we can project
that a baby born at a particular time will live), the gap
between races in the United States remains. Women in
general live longer than men, but within gender groups,
both white women and men live longer than African
American women and men.
A similar gap between outcomes for African Americans and
whites exists when we look at the St. Louis region. Figure 2
shows that overall death rates for St. Louis residents of both
races have declined over the past few decades, but African
American mortality rates continue to be higher.
Health is fundamental to human
well-being. Health makes it possible
for us to engage fully in the activities of
our daily lives and make contributions
to our communities.
We call gaps like these health disparities. They are differences
in health outcomes for specific groups within a population.
Why do we observe such different health outcomes among
racial groups both nationally and in the St. Louis region?
Washington University in St. Louis and Saint Louis University 11
What all of the factors outside of genetics have in common
is that they are unevenly distributed in society along social
and economic lines. Health differences are so consistently
tied to these factors that we have a name for the relationship.
It is called the socioeconomic gradient in health. Figure 4
illustrates the gradient by showing the relationship between
household income and premature death. The reason it is
called a gradient (which literally means something that goes
up or down at a regular rate) is because health improves
at every step up the socioeconomic ladder. In this case, the
more income households have, the less likely the members
of those households are to die early. Households with less
than $10,000 in income are more than 3 times more likely
to die early compared to households with $100,000 or more
in income.
Figure 4. Relative risk of premature death by family
income (U.S. Population)
3.5
NH
Figure 3. Factors Contributing to Premature Death
3
Relative risk
When most people think about health, their immediate
thoughts turn to health care. But as Figure 3 shows, medical
care only accounts for about 10% of premature deaths
(i.e., dying before expected) in the U.S. After accounting for
genetic differences between individuals (30%), most of the
contribution to premature death is made by behaviors like
diet, exercise, and smoking (40%), social factors like poverty,
education, and housing (15%), and exposure to physical
environments that are unhealthy because of toxins, disease
carrying agents, or unsafe structures (5%).
2.5
2
1.5
Social Circumstances
30%
40%
Behavioral Patterns
1
Environmental Exposure
10%
15%
Health Care
Genetic Predisposition
5%
Source: Schroeder, SA. We can do better-improving the health of the American people. New England
Journal of Medicine 2007;357:1221-8. Adapted from McGinnis, JM, Williams-Russo, P, Knickman, JR.
The case for more active policy attention to health promotion. Health Affairs 2002;21:78-93.
12 For The Sake Of All
0
<$10K $10 – 19K $20 – 29K $30 – 39K $40 – 49K $50 – 99K $100 + K
Family income in 1980 (adjusted to 1999 dollars)
*Age and sex adjusted relative risk of dying prior to age 65
Based on 9-year mortality data from the National Longitudinal Mortality Survey
While differences in health outcomes by income are stark,
an equally troubling trend is occurring when we look at
gaps between groups who have different levels of education.
Research has shown that the gap in expected years of life has
been widening for those with high vs. low levels of education.
Figure 5 shows that those with high school or less education
gained no years of life between 1990 and 2000, while those
with any college gained more than a year-and-a-half.
280 DEATHS
237 DEATHS
DUE TO POVERTY
DUE TO LESS THAN HIGH
SCHOOL EDUCATION
COMBINED THE NUMBER OF DEATHS COULD FILL ABOUT
7 METROLINK CARS
It turns out social and
environmental contexts matter
quite a bit for overall health.
So, we can see that a complex set of social and economic
factors accounts for a significant proportion of our health
outcomes. Even when we consider that behavior plays such
an important part in explaining chronic diseases like cancer,
heart disease, and diabetes, that behavior happens within
a context. It turns out social and environmental contexts
matter quite a bit for overall health. In our first brief, we
were able to estimate the number of deaths among African
American adults 25 and older in St. Louis City and County
in 2011 that were attributable to poverty and low levels of
education. Of the 3,101 deaths, 280 were due to poverty and
237 were due to obtaining less than high school education.
The estimated cost of this loss of life (see Resources) was
approximately $3.3 billion. This is a clear, local example of
the impact that social and economic factors have on health.
Figure 5. Years of life remaining at age 25
by education level1
Any college
1.6 years gained in life
expectancy
High School or less
No years in life
expectancy gained
49.6
years
49.6
years
55.0
years
56.6
years
1990
2000
1990
2000
Source: Authors’ calculations using data on non-Hispanic blacks and whites in the National
Longitudinal Mortality Study (NLMS) and death certificate data from the Multiple Cause of Death
(MCD) files linked to census data.
THE ESTIMATED COST OF THIS LOSS OF LIFE IS APPROXIMATELY
$3.3 BILLION
To address these complex, population-wide relationships
between social and economic factors and health in St. Louis,
both policy and programmatic changes are necessary. In the
sections that follow we will present several lines along which
health and other aspects of well-being are unevenly distributed
in our region, but we will also point to activities already taking
place both locally and nationally that hold promise for better
outcomes. We will suggest a set of policy and programmatic
recommendations based on scientific evidence, community
partner and stakeholder input, and comments gathered
online and at the Community Feedback Forum.
Institutions, organizations, and
individuals from across multiple
sectors and segments of the region
must come together to act.
Of course a report and list of recommendations by themselves
will not result in progress. Institutions, organizations, and
individuals from across multiple sectors and segments of the
region must come together to act. Our hope is that the data
and analysis provided in this report will be a helpful guide
in focusing community-wide efforts to improve health and
well-being for the sake of all.
Washington University in St. Louis and Saint Louis University 13
Two Lives of Jasmine
A simplified story of a girl told from the perspectives of two different starting points in life.
What follows is an attempt to describe how the life outcomes of a little girl we’re calling “Jasmine” can be dramatically
different based on the circumstances into which she is born. We have simplified the story to highlight crucial features
of Jasmine’s context that influence her health and well-being. At each stage in Jasmine’s development, we also point to
various opportunities to intervene. Obviously, there are also multiple opportunities for Jasmine to make individual choices
about her life that will also impact her outcomes. The point is that those choices are shaped in important ways by both her
starting point in life and the resources available to her.
1
Home and neighborhood: The home and neighborhood environments affect health and shape current and future
opportunities for children.
Home &
Neighborhood
Jasmine is born to a single mother. Her mother works two jobs but struggles
to make ends meet. She wishes she could spend more time reading to and
interacting with Jasmine, but her work schedule makes it difficult. Jasmine’s
neighborhood doesn’t have many places to buy fresh and healthy foods. We
could help Jasmine by making college savings accounts available for
all children and investing in quality neighborhoods for all families.
Jasmine is born to college-educated parents, who have stable jobs and
income. When she is born, they start a college savings account to prepare
for her future. Jasmine grows up in a neighborhood that provides healthy
food options and safe places to play.
2
Early childhood: High-quality early childhood programs allow children to grow and develop in a nurturing environment.
This prepares them for future academic and job success and healthy adulthoods.
Early
Childhood
Jasmine’s parents pay for her to attend a high-quality early childhood
education center. She grows up in a nurturing environment, exposed
to many fun learning activities and opportunities to explore her world.
Jasmine stays with her grandmother during the day, and spends many
hours inside because her family worries that it is not safe to play outside.
Although her grandmother loves Jasmine very much, she also watches
other grandchildren and doesn’t have resources to do learning activities
with Jasmine. She is also limited in what she can do by her own health
problems. We could help Jasmine by investing in quality early
childhood education and development for all children.
3
School: School is a setting where children spend a large part of their childhood and adolescence.
The resources and quality of schools affect their learning and employment opportunities.
School
Jasmine is intellectually curious and wants to attend college but receives
little guidance. There is also no savings account to help her pay for college
and has not been given basic financial education. She also has health
problems that make it more difficult to learn in school. We could help
Jasmine by investing in coordinated school health programs.
Jasmine’s school district has many resources, like state-of-the-art
technology, tutoring and college counselors. Jasmine and her classmates
expect to attend college and get information and financial support from
their parents.
4
Work: Jobs are essential for bringing resources into households. They also offer many benefits beyond income that affect
health and well-being.
Work
Jasmine works in a mall as a sales associate. She works hard but is
often worried about losing her job. Her work schedule changes often and
makes it difficult for her to finish her degree at a local community college.
Jasmine doesn’t make enough money to save for retirement. We could
help Jasmine by creating economic opportunities like savings
programs and easily accessible financial services.
After college, Jasmine finds a job working for an engineering firm.
Jasmine’s job provides benefits like health insurance, sick leave, and
retirement savings.
5
Retirement Years: As people age, many decide to retire. Some do not have that option. Others find that poor health forces
them to leave work earlier than they expected.
Retirement
Years
Jasmine is able to retire at 67. She spends her time traveling and trying
new activities. Jasmine also spends time with her family, who will benefit
from the wealth she is able to leave behind.
*
In her older age, Jasmine still needs to work. She works at a neighborhood
grocery store as a clerk. Some days it is very difficult for Jasmine to work
because she has health problems. Jasmine worries that she has very little
to leave behind for her children. We can help Jasmine by investing in
chronic disease prevention and management.
The story of Jasmine provides a simplified illustration of complex realities. The stories of actual St. Louis residents facing similar challenges are included throughout
this report in the form of summaries of reporting by Robert Joiner, health reporter with our media partner, the St. Louis Beacon (now St. Louis Public Radio).
02
Past and Present:
AFRICAN AMERICANS
IN ST. LOUIS
By understanding a population’s demographics,
we are better able to identify and address areas
of need with targeted intervention and investment.
16 For The Sake Of All
NH
Historical perspective on African Americans
in St. Louis
As we look back on milestones like the Civil Rights Act of
1964 and the 1954 Brown v. Board of Education decision, it
is entirely appropriate to ask what progress has been made
in the St. Louis region. The picture that emerges is mixed.
Some measures of health and well-being have improved,
while others are worse than they were 50 or 60 years ago.
One important caveat to consider is that certain factors were
measured or understood in different ways several decades
ago. We have only reported trends where we believed the
data collection methods and definitions were similar enough
to warrant it.
NH
80%
64%
60%
53%
50%
40%
50%
36%
30%
10%
44%
37%
23%
17%
20%
23%
11%
9%
1960
1970
1980
1990
2000
2010
Source: Social Explorer Tables (SE), Census 1960, 1970, 1980, 1990, 2000, ACS 2010 (1-Year Estimates);
Social Explorer & US Census Bureau.
Notes: Educational attainment among population 25 years and older; 1960 estimate for African
Americans classified as “non-white” population
Figure 7. Unemployment rates in St. Louis County
and St. Louis City, 1970 – 2010
25%
Educational attainment
Whites
22%
African Americans
20%
Percent unemployed
Figure 6 shows that in the 50-year period between 1960
and 2010, the percentage of African Americans with some
college or higher education increased by over 5 times (9%
in 1960 vs. 50% in 2010). A sharp increase began in the
1970s. Opportunities opened up by the gains of the Civil
Rights Movement no doubt contributed to this marked
improvement in educational outcomes. However, even
these impressive gains did not close the gap with whites
in St. Louis. By 2010, the gap in attaining some college or
higher education was 20 percentage points (50% vs. 70%).
70%
African Americans
0%
One area of considerable progress is educational attainment,
particularly the percentage of African Americans in the
region who have completed at least some college.
Missouri History Museum, St. Louis
Whites
70%
African American population in the 1950s and 1960s
In 1950, there were a total of 170,350 African Americans
in St. Louis County and the City of St. Louis.2 The total
African American population grew to 233,384 (37% increase)
by 1960.3 It is important to note that most African Americans
(92%) during this time period lived in the City. As will be
noted later, a much larger proportion of the African American
population now resides in St. Louis County.
Missouri History Museum, St. Louis
Figure 6. Educational attainment in St. Louis County
and St. Louis City, 1960 – 2010
Percent with some college or higher
NH
16%
15%
10%
9%
5%
4%
15%
13%
8%
5%
4%
4%
1990
2000
0%
1970
1980
2010
Source: Social Explorer Tables (SE), Census 1970, 1980, 1990, 2000, ACS 2010 (1-year estimates);
Social Explorer & US Census Bureau
Notes: Unemployment rates are among those 16 years or older in the civilian labor force
Unemployment
African American unemployment rates have been roughly
twice that of whites in the United States for several decades.
Figure 7 shows the unemployment data for the St. Louis
region, where African American unemployment rates have
ranged from 2 to nearly 4 times higher than whites.
Washington University in St. Louis and Saint Louis University 17
Historical health outcomes
Next, we provide a snapshot of health data contained
in historical vital statistics reports from the 1950s, 1960s,
and 1970s. It is important to note that very different disease
classifications were used to record deaths in these time periods.
We do not report on chronic diseases like cancer and heart
disease because only crude mortality rates are available. This
means that they are not adjusted for the age composition of
the population, and rates likely underestimate the true risk
of death due to chronic disease for African Americans during
this time period.
What is clear from these data, though, is a consistently higher
rate of death among infants (see figure 9). As we will see
Missouri History Museum, St. Louis
in data on the present day, this is a disparity that continues
to characterize the St. Louis region. Also of note were the
Poverty
extremely high disparities in death by homicide. For example,
There is a notably persistent gap in the rate of poverty
African Americans had a homicide death rate (38 deaths per
in the past 30 years as well. Figure 8 shows that rates of
100,000) that was 10 times higher than whites (4 deaths per
poverty range from 4 – 6 times higher for African Americans 100,000) in the 1960s.4 Present-day disparities present
compared with whites in St. Louis. Concentrated areas of a similar challenge.
poverty that are the result of persistent racial and economic
segregation in the St. Louis region continue to have serious
Figure 9. Infant death rate in St. Louis County
health and other social consequences. We will address the
and St. Louis City, 1950s – 2000s
impact of poverty on the health of African Americans in
the following sections.
50
Figure 8. Poverty in St. Louis County and St. Louis City,
1980 – 2010
27%
30%
29%
25%
Percent in poverty
25%
Whites
20%
African Americans
15%
10%
5%
5%
5%
6%
8%
40
Whites
African Americans
30
27
22
20
17
20
13
10
15
5
5
1990s
2000s
0
0%
1980
1990
2000
2010
Source: Social Explorer Tables (SE), Census 1980, 1990, 2000, ACS 2010 (1-year estimates); Social Explorer
& US Census Bureau
Notes: Defined as individuals below poverty level among those for whom a poverty status was determined
18 For The Sake Of All
Infant death rate per 1,000
30%
41
40
1950s
1960s
1970s
Source: MODHSS, Vital statistics reports for 1950s, 1960s, & 1970s; MODHSS, Death MICA & Birth MICA
(1990s & 2000s)
Notes: Rates per 1,000 live births; deaths among infants under 1 year of age; 1950s-1970s rates for
African American infant deaths were classified as “non-white”; 1950s data years: 1954, 1955, 1958; 1960s
data years: 1960, 1963, 1965, and 1967; 1970s data years: 1970, 1972, 1975, and 1977; data not available
for 1980s; 1990s data years: 1990, 1993, 1996, 1999; 2000s data years: 2000, 2003, 2006, 2009
Present-day perspective on African
Americans in St. Louis
We turn now to a present-day overview of the demographic
and economic characteristics of the African American
population in the region. By understanding a population’s
demographics, we are better able to identify and address
areas of need with targeted intervention and investment.
As we have seen, examining social and economic factors
also helps us to understand their relationship with
health outcomes.
NH
Demographic trends in St. Louis
The demographics of St. Louis have changed over the
previous decade. One notable trend is the change in
population from 2000 to 2010. Census data show that
during this period there was an overall increase of 5%
in the African American population in St. Louis County
and St. Louis City combined.5 Looking at the two areas
separately, however, reveals a 12% decrease in African
American population in the City compared to a 21%
increase in the County.6
As part of the growing diversity in
the region, the youngest generation
of African Americans will make up a
significant proportion of workers and
taxpayers in the next 20 to 30 years.
The St. Louis region also became more diverse between
2000 and 2010. This was due to a decreasing population
of whites (10% decrease) coupled with a 10% increase in
the population of all other racial groups, including African
Americans.7 These data reflect a national trend in which the
majority of U.S. residents are expected to be people of color
by 2043.8 These demographic changes are already becoming
evident among the youngest children, with non-Hispanic
white children under the age of 1 now in the minority.9
Nationally, it is expected that the majority of youth will
be people of color by 2020.10 It is important to keep these
changing demographics in mind when discussing the health
and well-being of African Americans in St. Louis. As part of
the growing diversity in the region, the youngest generation
of African Americans will make up a significant proportion
of workers and taxpayers in the next 20 to 30 years.
Population of African Americans in St. Louis
Figure 10 shows the percentage of all St. Louis residents
who are African American. In total, about 30% of the St.
Louis regional population of 1.32 million people is African
American (385,116). Almost half (48%; 152,068) of City
residents are African American. In St. Louis County, more
than 1 in 5 residents is African American (23%; 233,048).
Table 1. Population estimates of African Americans
African Americans
Total Population
St. Louis County
St. Louis City
City &
County
Combined
233,048
152,068
385,116
1,000,438
318,172
1,318,610
Source: ACS 2012 1-year estimates
Figure 10. St. Louis population by race
7.0%
7.1%
7.0%
23.3%
29.2%
45.1%
47.8%
69.7%
St. Louis County
St. Louis City
63.8%
African Americans
Whites
Other
City & County combined
Source: ACS 2012 1-year estimates
Washington University in St. Louis and Saint Louis University 19
It is important to note that these estimates of population
include individuals who are within institutions like
correctional facilities and nursing homes, among others.
There are an estimated 16,857 residents of St. Louis County
and St. Louis City who are institutionalized.11 This makes
up 1.3% of the 1.32 million people in the County and City
according to the 2010 Census.12 About 1 in 3 (31%) of the
institutionalized are in correctional facilities like prisons
and jails. While making up a little less than 30% of the
regional population, 42% of St. Louis residents in
correctional facilities are African Americans (see table 2).
Several authors and commentators have noted the negative
impact of mass incarceration on African American
communities, including poor mental and physical health
outcomes for the incarcerated and their families.13–16
Figure 11. African American age and gender
distribution in St. Louis County and St. Louis City
85 and Over
75 to 84
65 to 74
55 to 64
45 to 54
35 to 44
30 to 34
Female
Male
25 to 29
20 to 24
18 to 19
15 to 17
10 to 14
5 to 9
Under 5
Table 2. Incarceration estimates by race
15.0%
St. Louis County
St. Louis City
City &
County
combined
2,902
2,395
5,297
African Americans
1,264 (44%)
956 (40%)
2,220 (42%)
Whites
1,029 (35%)
336 (14%)
1,365 (26%)
Adult residents in
correctional facilities
Source: Census 2010
Notes: Correctional facilities include: federal detention centers, federal and state prisons, local jails and
other municipal confinement facilities, correctional residential facilities
Gender and age
Among African Americans in St. Louis, there is a higher
percentage of females (55%) compared to males (45%)
(see table 3). The patterns are roughly the same in the
County and the City.
Table 3. Percent of males and females among
African Americans
St. Louis County
St. Louis City
TOTAL
Males
104,079 (45%)
69,965 (46%)
174,035 (45%)
Females
128,969 (55%)
82,112 (54%)
211,081 (55%)
Source: ACS 2012 1-year estimates
20 For The Sake Of All
10.0%
5.0%
0%
5.0%
10.0%
15.0%
Source: ACS 2012 1-year estimates
Figure 11 shows the gender breakdown by age category.
The different shapes and patterns between males and
females illustrate differences in age structures among
African Americans. Some differences can be due to life
expectancy at birth. On average, women tend to live longer
than men. There are also troubling differences in the
ability of African American men in particular to complete
education and obtain employment that may further
contribute to premature death.17
Employment, income, and poverty
Unemployment is strongly linked to poor health and higher
rates of death.18 Jobs are essential for bringing resources into
households, but they also offer many other benefits beyond
income. Both the income and benefits associated with
employment can affect health. For example, being employed
may provide access to workplace wellness programs. These
programs may support lifestyle choices like getting enough
physical activity or quitting smoking, which can affect health
and well-being.19
Employment status also influences the well-being of families.
For example, unemployment can reduce a parent’s resources
to provide proper child care.20 The quality and type of care
young children receive can have a lasting effect on their
development and ability to succeed in school. Employment
also provides many families health insurance in a largely
employer-based system.
NH
NH
NH
NH
NH
Table 4. Unemployment status for the population 16 years and over in the civilian labor force
St. Louis County
St. Louis City
City & County combined
National Rates*
Total unemployment rate (%)
9%
14%
10%
7%
African Americans
18%
26%
21%
13%
Whites
6%
6%
6%
7%
Source: ACS 2012 1-year estimates; *Current Population Survey, 2013
Employment may also offer other benefits like paid leave,
schedule flexibility, resources for elder care, and retirement
benefits. Jobs that pay well also contribute to household
financial security and give families the resources to live in
health-promoting neighborhoods.21 It is also important to
note that being in poor health can lead to unemployment
and loss of income. This is especially true as people age and
start to develop chronic diseases. However, studies suggest
that income loss due to poor health does not fully explain
the differences in health between those with lower and
higher incomes.22, 23
Dealing with the realities of having limited resources is often
stressful.24,25 Long-term stress can contribute to a variety of
health problems.26,27 Studies have suggested that this longterm stress releases a substance in the body called cortisol
that can damage the immune system and vital organs.28,29
Over time this wear-and-tear on the body can lead to more
rapid development of chronic illnesses like heart disease30
and to rapid aging.31-33
Dealing with the realities of having
limited resources is often stressful.
Long-term stress can contribute to
a variety of health problems.
With this set of facts as background, the following data offer
a snapshot of the employment, income, and poverty status
of African Americans in St. Louis.
Unemployment
As was shown in the section on historical patterns, there
has been a persistent gap in the unemployment rate for
African Americans compared to whites in St. Louis. African
Americans currently have an unemployment rate that is
more than 3.5 times higher than the rate for whites (see
table 4). The pattern is similar in the County and the City.
However, the problem is more pronounced in the City,
where roughly 1 in 4 African Americans (26%) is unemployed.
By comparison, the national, annual estimate in 2013 for
unemployment stood at 7%, and the national African
American unemployment rate was 13%.34
Unemployment rates are higher among African American
males compared to females, with 1 in 4 males 16 years and
over unemployed (see table 5). Considering the City alone,
almost a third of African American males are unemployed.
These local unemployment rates are considerably higher
than the national rates for African American men and
women. The national unemployment rate in 2013 for
African American men was 14% and 12% for women.35
Table 5. Unemployment status among African Americans
by gender for the population 16 years and over in the
civilian labor force
St. Louis County
St. Louis City
City & County
combined
Males
23%
29%
25%
Females
14%
24%
17%
Source: ACS 2012 1-year estimates
Washington University in St. Louis and Saint Louis University 21
Earned Income Tax Credits
American Recovery and Reinvestment
Act, which lifted 500,000 people out of
poverty. 39 EITCs have a consistent record
of improving employment and income for
working families, but the 2009 expansion
is set to expire in 2017.
Earned income tax credits (EITCs)
are refundable tax credits for low- and
middle-income working families. A recent
study found that EITCs provide significant
income and employment increases
for participating families. 37 EITCs are
also associated with improvements in
maternal and child health and elementary
school performance. 38 The EITC was
temporarily expanded under the 2009
Earned income tax credits are only
available to families who file an income
tax return with the IRS. The Gateway
Earned Income Tax Credit Coalition
(GECC) is one example of a private-public
partnership in St. Louis that provides
free tax preparation and other financial
services to families with low-to-moderate
incomes. GECC has several partner
organizations throughout the region.
Jobs by sector
Income
Figure 12 shows the job sectors in which African American
males and females are employed in St. Louis County and
St. Louis City. Compared to females, a higher percentage
of African American males in St. Louis have jobs in natural
resources, construction, maintenance, production,
transportation, and material moving. Whereas, compared
to males, a higher percentage of females have jobs in
management, business, science and arts.
Though employment is an important indicator of household
well-being, having a job does not fully capture the actual
resources gained from paid work and other sources of
income. Therefore, it is necessary to also describe household
income, where there are significant gaps. In St. Louis County
and St. Louis City, African Americans have a median income
that is less than half that of whites (see table 6). This figure
includes all household income from all sources in the past
12 months (e.g., investments, rental income, and government
transfers). The differences in income are about the same for
the County and the City, though income is higher for both
populations in St. Louis County.
Figure 12. African American employment by job sector
among males and females
0.5%
10.3%
7.4%
Table 6. Median household income by race
St. Louis County
St. Louis City
City and
County
combined
African Americans
$35,757
$21,931
$28,951
Whites
$65,500
$49,192
$62,010
23.3%
30.0%
19.7%
32.4%
19.6%
27.2%
29.6%
Source: ACS 2012 1-year estimates
Notes: In 2012 inflation adjusted dollars; income within the past 12 months
Males
Females
Management, Business,
Science, Arts
Natural Resources,
Construction, Maintenance
Service
Production, Transportation,
& Material Moving
Sales & Office
Source: ACS 2012 1-year estimates
22 For The Sake Of All
Table 7. Household income in the past 12 months among African Americans
Total African American Households
St. Louis County
91,304
St. Louis City
63,108
City and County combined
154,412
Less Than $10,000
8,933 (9.8%)
15,891 (25.2%)
24,824 (16.1%)
$10,000 To $14,999
10,371 (11.4%)
7,842 (12.4%)
18,213 (11.8%)
$15,000 To $24,999
13,345 (14.6%)
11,037 (17.5%)
24,382 (15.8%)
$25,000 To $34,999
12,299 (13.5%)
9,905 (15.7%)
22,204 (14.4%)
$35,000 To $49,999
14,486 (15.9%)
6,771 (10.7%)
21,257 (13.8%)
$50,000 To $74,999
15,122 (16.6%)
5,921 (9.4%)
21,043 (13.6%)
$75,000 To $99,999
8,865 (9.7%)
2,861 (4.5%)
11,726 (7.6%)
$100,000 To $149,999
6,011 (6.6%)
1,897 (3.0%)
7,908 (5.1%)
$150,000 To $199,999
1,405 (1.5%)
507 (0.8%)
1,912 (1.2%)
467 (0.5%)
476 (0.8%)
943 (0.6%)
$200,000 Or More
Source: ACS 2012 1-year estimates
Notes: Dollars adjusted for inflation to match value in 2012
Median incomes describe a type of average income. It is
important to note that while African Americans as a whole
have lower average income, a substantial proportion of
African American households have high earnings. When the
full range is examined (figure 13), many African Americans
in St. Louis have incomes that are above the median income
for the total population ($50,263).36 In fact, 28% of African
American households in the St. Louis County and St. Louis
City have incomes above $50,000. In the County, more than
a third (35%) of African American households have income
of $50,000 or more, and about 1 in 10 African American
households (9%) in the County has income of $100,000 or
more. In the City, 19% of African American households have
an income $50,000 or higher, and 5% have an income of
$100,000 or higher.
Figure 13. Household income for African Americans in St. Louis County and St. Louis City
16%
16%
14%
14%
14%
12%
8%
5%
1%
Less than
$10,000
$10,000 to
$14,999
$15,000 to
$24,999
$25,000 to
$34,999
$35,000 to
$49,999
$50,000 to
$74,999
$75,000 to
$99,999
$100,000 to
$149,999
$150,000 to
$199,999
<1%
$200,000 or
more
Source: ACS 2012 1-year estimates
Notes: Dollars adjusted for inflation to match value in 2012; percentages are rounded
Washington University in St. Louis and Saint Louis University 23
Poverty
Wealth
Poverty affects close to 1 in 3 African Americans vs. less
than 1 in 10 whites in St. Louis County and St. Louis City.40
We discussed above the link between poverty and health
in St. Louis. Research suggests that the impact of poverty
on children is especially troubling. Starting life in poverty
has negative consequences for health well into adulthood.41
Almost half (46%) of African American children under 18
live in poverty in St. Louis County and St. Louis City.42 This
places African American children in St. Louis at greater risk
for adverse health outcomes.
There are important differences between income and
wealth. Where income is the amount of financial resources
coming into (and often back out of) a household, wealth is
accumulated, or saved, resources. Building up wealth is one
way to ensure economic well-being, and wealth has also
been linked to health.43 In some studies using national data,
accounting for wealth in addition to factors like education,
income, and occupation helped to explain the gap in mortality
between African Americans and whites.44 Several national
studies also have noted a wide and persistent gap in wealth
between African Americans and whites even with
comparable levels of income.45
Figure 14: Percent of St. Louis County and St. Louis City
residents with income below poverty level
Poverty Level
9%
Whites
Unfortunately, there are very few sources of information
on household wealth at the local level. We use homeownership
and home values as indicators of wealth because a significant
proportion of overall wealth is held in the value of homes.
Homeownership also has some direct relationships with health,
especially in older individuals.46 Figure 15 shows differences
in homeownership between African Americans and whites in
St. Louis County and St. Louis City. Approximately 3 out of 4
white householders (74%) own their homes. Among African
American householders, less than half (42%) are homeowners.
Thus, a smaller proportion of African Americans have access
to the crucial wealth-building asset of homeownership.
31%
African
Americans
Source: ACS 2012 1-year estimates
Individual Development Accounts and Child Development Accounts
We can encourage families to save
money by providing incentives
and supports. Programs like Child
Development Accounts (CDAs) and
Individual Development Accounts (IDAs)
can help reduce poverty and give families
hope for the future. IDAs use matched
savings, financial education, and other
supports such as employment training,
crisis management, and mentoring to
increase financial literacy and asset
management for low-income and
low-wealth individuals and families.
Research shows that IDA programs
24 For The Sake Of All
significantly improve credit scores and
financial literacy for participants, but more
outreach is needed to reach low-resource
populations. 47-49
in Maine the opportunity to succeed.
Harold Alfond made available $500 for
each newborn to start a NextGen account
for education beyond high school.52
There is also growing evidence that CDAs
may have positive effects on health and
well-being, including social and emotional
development in children50 and depression
symptoms in mothers.51
A powerful St. Louis example is the
Promise Account program that is part
of Beyond Housing, Inc.’s 24:1 initiative
in the Normandy School District. Through
the generosity of a private donor, every
kindergartner in the Normandy School
District receives $500 in a college
savings account.
Maine recently became the first state in
the U.S. to make college savings universally
available to newborns. The Harold Alfond
Foundation believes in giving every child
Figure 15. Homeownership among African American and
white households in St. Louis County and St. Louis City
Own
Table 8. Median home values in dollars ($)
Rent
58%
74%
African Americans
St. Louis City
African Americans
$108,600
$82,900
Whites
$195,600
$145,700
Source: ACS 2006-2010 5-year estimates
26%
42%
St. Louis County
Whites
Source: ACS 2012 1-year estimates
The dollar ($) value of homes provides one way to describe
the amount of wealth held in housing. Even when African
Americans do own their homes, home values differ considerably
from those of whites. In both St. Louis County and St. Louis
City, the median home value for African Americans is a little
over half the median home value for whites (see table 8).
A higher percentage of African American homeowners
in St. Louis City have a home value less than $100,000
compared to those in St. Louis County. On the other hand,
a higher percentage of African Americans in St. Louis
County have a home value of $100,000 or more. This pattern
changes again at the very highest home values, with African
Americans in the City more likely to own homes valued
at $300,000 or more. Of course, home values only give a
limited picture of overall wealth, which also includes the
value of bank accounts, retirement savings, businesses, and
other investments. The total debt that a household owes also
contributes to the determination of household wealth.
Figure 16. Home values among African American homeowners
46%
St. Louis County
Percent of African American homeowners
39%
St. Louis City
28%
18%
16%
15%
9%
6%
8%
6%
3%
4%
1%
Less than $50,000
$50,000 to $99,999
$100,000 to $149,999
$150,000 to 199,999
$200,000 to $299,999 $300,000 to $499,999
2%
$500,000 or more
Home value ($)
Source: ACS 2006-2010 5-year estimates
Washington University in St. Louis and Saint Louis University 25
03
Place matters:
NEIGHBORHOOD
RESOURCES AND HEALTH
There is growing awareness that the conditions
in which people live, learn, work, and play have
a strong impact on their health.
Braveman P., Egerter S., & Williams D.R. 2011. The social determinants of health: coming of age. Annu. Rev. Public Health. 32:381-98
26 For The Sake Of All
Where we live can either support a healthy life, or it can
make health more difficult to maintain. There is growing
awareness that the conditions in which people live, learn,
work, and play have a significant impact on their health.53
Perhaps nowhere is this more evident than the communities
in which we live. Figure 17 shows that babies born in certain
neighborhoods can have stark differences in life expectancy.
A child born in 63106 near the Jeff-Vander-Lou neighborhood
can expect to live 18 fewer years than a child born in 63105
(Clayton), 15 fewer years than a child born in 63017
(Chesterfield), 14 fewer years than children born in 63122
(Kirkwood) and 63109 (St. Louis Hills), and 3 years fewer
than a child born in 63133 (Pagedale/Wellston).
Of course, ZIP codes are relatively meaningless without
the context provided by the composition of the population
in them. Map A in figure 20 shows the percentage of the
population composed of African Americans at the ZIP codelevel. The areas that are orange on the map represent ZIP
codes with a high population of African Americans (45%
of higher), the light blue shows moderate African American
population (6 – 44%), and the dark blue shows the lowest
African American population (1 – 5%). There is a fairly
clear pattern that emerges. In general, there is a higher
concentration of African Americans in areas of north St. Louis
County, north St. Louis City, and parts of central and south
St. Louis City, with lower concentrations particularly in
the southern and western portions of St. Louis County. The
lowest life expectancies from figure 17 are also in areas with
the highest concentration of African American population.
Figure 17. Life expectancy at birth by ZIP code
ZIP codes & Life Expectancy
N
63133
70
Pagedale
Wellston
270
170
Chesterfield
63017
82
63105
85
Clayton
40
63122
81
Kirkwood
70
Jeff-Vander-Lou
63106
64
67
63109
81
St. Louis Hills
St. Louis City
44
St. Louis County
0
2.5
5
10 Miles
Source: City of St. Louis Department of Health-Center for Health Information, Planning, and Research; Census 2010; MODHSS, Death MICA 2010
Notes: Life expectancies were constructed using a calculator developed by the City of St. Louis Department of Health-Center for Health Information, Planning, and Research; ZIP code life expectancies were derived
using population counts from Census 2010 and deaths from Death MICA 2010
Washington University in St. Louis and Saint Louis University 27
Segregation in St. Louis
The patterns within neighborhoods noted above must be
understood in the context of residential segregation, by both
race and social class, and its history in St. Louis. Despite
progress in terms of anti-discrimination laws over the past
half-century, St. Louis is still confronting the legacy of past
policies and practices. It remains one of the most segregated
metropolitan areas in the U.S.54 These divisions not only
affect the social fabric of the region, but also contribute
to negative health outcomes for families living in socially
disadvantaged neighborhoods.
Communities like St. Louis became segregated, in part,
because of policies that supported the movement of
white families from city centers into suburban areas
(a phenomenon known as “white flight”) coupled with
housing discrimination against African Americans. For
example, preferential lending occurred under the Federal
Housing Administration, and restrictive deed covenants
made it illegal for African Americans to buy homes in
some neighborhoods in St. Louis.55 Over time, these factors
resulted in racially segregated areas in St. Louis. The effects
of segregated neighborhoods are widespread and often
result in neighborhoods with high concentrations of poverty
(see figure 18). For this reason segregation must be added
to the many factors we have highlighted that contribute
to differences in health.56
Maybe African American
individuals in a neighborhood
context or in front of a home.
NH
Figure 18: Process by which segregation leads to poverty
Policies that led to:
– White families
moving away from
city centers and
into suburban areas
(White Flight)
– Housing
discrimination
against African
Americans
– Fewer banks
invest in
predominantly
African
American areas
Segregation
– Lower house
values
– Separation from
people who can
influence policy
Source: Adapted from University of Michigan’s The Geography of Race in the US, Economic Consequences of Segregation
28 For The Sake Of All
– Lower tax base
– Less funding for
education and
services like job
training
– Poor job
opportunities
– Businesses move
out and fewer new
businesses start
High poverty
The Delmar Divide
An example of modern-day segregation in St. Louis is the
Delmar Divide recently highlighted by a British Broadcasting
Corporation report. The figure below shows two areas in
St. Louis separated by Delmar Blvd. The area directly to
the north of Delmar Blvd. is 99% African American. The
median home value north of Delmar is $78,000, which is a
quarter of the value for homes in the area south of Delmar
($310,000). There are also differences in income and
educational attainment. Only 5% of residents 25 years or
older in the area north of Delmar have a bachelor’s degree
or higher, compared to 67% south of Delmar. This means the
percentage of residents with a bachelor’s degree or higher is
13 times higher for residents in the area south of Delmar. Of
course, the broader region is much more complex in its racial
and economic composition than the area highlighted in the
BBC report, but this remains a compelling illustration of the
very different experiences of communities in relatively close
proximity to one another.
Figure 19: The Delmar Divide in St. Louis
Source: ACS 2007-2011 5-year estimates
Notes: The figure above represents median home values and median household income;
shaded areas represent census tracts; north of Delmar: census tract ID 1123; south of
Delmar: census tract ID 1124.
Mixed Income Incentives
Research has found that several types
of mixed income incentives promote
neighborhood diversity and help improve
quality of life for low income families.
Housing Choice Vouchers (Section 8)
are among the most effective. A 2011
cost-benefit analysis found evidence of
NH
positive net social benefits from Section
8 subsidies in terms of increased services to recipients (welfare, EITC,
food stamps, public health care, child care), improvements in child health
and education, and reduced crime and substance abuse.57
Washington University in St. Louis and Saint Louis University 29
Figure 20: Areas with higher concentrations of African American residents often have higher rates of poverty and
higher rates of death from chronic diseases. Notice that roughly the same areas are orange or light blue in each of
the maps, which present the concentration of African American population (A), the concentration of poverty (B),
heart disease death rates (C), and cancer death rates (D) in the St. Louis region.
A) T he concentration of African American population
Percent African American population by ZIP code
B) T he concentration of poverty
Percent of all residents living in poverty by ZIP code
1% – 5% (Lowest)
1% – 8% (Lowest)
6% – 44% (Middle)
9% – 18% (Middle)
45% – 97% (Highest)
19% – 54% (Highest)
No data
No data
St. Louis
City
St. Louis County
Source: US Census 2010
C) H
eart disease death rates
Heart disease death rates per 100,000 for all residents by ZIP code
N
Source: American Community Survey 2007–2011 5 year estimates
D) C
ancer death rates
Cancer death rates per 100,000 for all residents by ZIP code
103 – 196 (Lowest)
129 – 170 (Lowest)
197 – 270 (Middle)
171 – 212 (Middle)
271 – 354 (Highest)
213 – 359 (Highest)
No data
No data
Source: Chronic Disease MICA 2009–2010
Source: Chronic Disease MICA 2009–2010
Death rates were age-adjusted using the US 2000 Standard population. Rates were not included for ZIP codes with less than 20 deaths due to heart disease or cancer.
30 For The Sake Of All
Poverty in neighborhoods
Neighborhoods with high poverty can be very challenging
places to live a healthy life. One of these challenges is the
limited availability of high-quality services and amenities.
For example, studies suggest high-poverty neighborhoods
are more likely to have fast food chains, liquor stores and
convenience stores as well as greater exposure to pollution
and violent crime.58-60 Moreover, these neighborhoods
are also less likely to have supermarkets, safe places for
recreation, banks, or other anchor institutions to support
economic stability. Figure 20 helps to illustrate the health
consequences of poverty and racial segregation in St. Louis
County and St. Louis City.
Neighborhoods with high poverty
can be very challenging places to
live a healthy life.
Financial services in neighborhoods
Among the resources often missing in neighborhoods with
high levels of poverty are financial services like traditional
banks. A 2012 report called the St. Louis Neighborhood Market
DrillDown (hereafter referred to as the “DrillDown”) provides
important information about access to financial services.
Though race was not reported directly, the area that was
studied in the DrillDown report included northern St. Louis
County and St. Louis City, where a substantial proportion of
the region’s African American population resides.
The report found that almost half (47%) of residents in the
DrillDown study area live closer to a nontraditional lender
(e.g., check cashing, payday lenders, title loans) than a bank.
Another key finding was that more than 1 in 3 households in
this area lacked a credit record (figure 21). This is a sign that
the area is underbanked and lacks financial services for many
residents. Without a credit history and access to financial
services it can be more difficult to rent or own a home,
purchase insurance, and in some cases, find employment.
Local progress to address residential
segregation and neighborhood
revitalization in St. Louis
• T he Metropolitan St. Louis Equal Housing Opportunity
Council (EHOC) is the only private, not-for-profit fair
housing enforcement agency working to end housing
discrimination in the St. Louis region.
• OneSTL is a movement that advances a prosperous,
healthy and vibrant St. Louis region. One STL is being
funded by a grant received by the East-West Gateway
Council of Governments.
• Hank Webber of Washington University in St. Louis
and Todd Swanstrom of the University of MissouriSt. Louis are working together to examine disparities
and why some neighborhoods in St. Louis have been
successful in revitalization. Being close to the economic
“corridor” that runs west from downtown and having
an economically and racially diverse population were
among the noted factors.
Figure 21. Percent of all households in North St. Louis
County and St. Louis City with no credit record
(underbanked) in 2009
35%
% of households that
are underbanked
Source: St. Louis Neighborhood Market DrillDown 2012
Notes: Underbanked households: the percentage of households lacking an associated record with any of
the three major credit bureaus (Acxiom, Equifax, and Experian) in 2009
Washington University in St. Louis and Saint Louis University 31
NH
B
NH
Beacon story summary: Segregation
June Green lives in a
neighborhood near Union
Boulevard in North St. Louis.
She spoke to the St. Louis
Beacon about the impact that
segregation has had on her
health. Green has a long walk
to the bus she takes every day
for basic services that she
can no longer access in her
neighborhood, like healthy food
and visits to her doctor. “The
closest Schnucks is 2.2 miles from my front door. That’s
not a long way — if you have a car.” Green has to travel
for treatment and medication to manage her diabetes and
hypertension. Beyond a lack of nearby resources, Green
says that information is lacking on how to find support
elsewhere. Green points out that there are good things
about her neighborhood, such as social support and
access to transportation. But feeling isolated from basic
services and information adds stress to her daily life.
NH
NH
NH
Figure 22 shows the percentage of households that are
underbanked in neighborhoods covered by the DrillDown
study. The map shows limited availability of financial services
in neighborhoods located in northern, central, and southern
parts of St. Louis City. Many of these are neighborhoods with
a high concentration of African Americans.
Figure 22. Percent of households with no credit record
(underbanked) by ZIP code in 2009
North St. Louis County
0% – 26% (Lowest)
27% – 42% (Middle)
43% – 77% (Highest)
No data
Story by the St. Louis Beacon
St. Louis
City
St. Louis County
Source: St. Louis Neighborhood Market DrillDown 2012
N
Notes: Underbanked households: the percentage of households lacking an associated record with any
of the three major credit bureaus (Acxiom, Equifax, and Experian) in 2009; data extracted from Social
Compact’s CityDNA web-based mapping tool
32 For The Sake Of All
Availability of healthy food in neighborhoods
A much lower percentage of African Americans (66%) in
St. Louis City report that it is easy to buy healthy food in
their neighborhood compared to whites (86%).61 Though
fewer people report limited access in St. Louis County, there
are still differences in perceptions of healthy food access
between African Americans (73%) and whites (91%).62
Having healthy foods available in a neighborhood is one way
to help residents eat a nutritious diet. A healthy diet includes
foods like fruits, vegetables, whole grains, low-fat/non-fat
milk or dairy alternatives, lean meats, and other foods rich in
essential nutrients. Eating habits can affect the development
of diabetes, heart disease, and certain cancers.
The Centers for Disease Control and Prevention (CDC)
developed a way to measure the number of healthy and less
healthy food stores or retailers in neighborhoods using a
score. The score applies to areas called census tracts that
are smaller than ZIP codes and it is a ratio, which makes it
possible to compare across neighborhoods. Out of the total
number of food retailers in each census tract, the score
represents the percentages of healthy retailers. In other
words, low scores mean that neighborhoods contain many
convenience stores and/or fast food restaurants compared
to the number of healthy food retailers (e.g., supermarkets,
large grocery stores, produce stores or supercenters). Scores
in figure 23 were grouped together into 3 categories: poor or
no access to healthy food (orange); fair access to healthy food
(light blue); good or high access to healthy food (dark blue).
Figure 23. Availability of quality nutritious retail foods
by census tract in 2011
Good or high access
Fair access
Poor or no access
St. Louis
City
St. Louis County
Source: CDC, Division of Nutrition, Physical Activity and Obesity
N
Notes: The Modified Retail Food Environment Index (mRFEI) evaluates the availability of quality, nutritious
retail foods. Indicator statistics are available by state and by US census tract; data was extracted from
University of Missouri’s CARES 2013
The map shows a concentration of neighborhoods in
northwestern St. Louis City that have poor or no access
to nutritious retail foods. There are also poor or no access
neighborhoods in the central corridor of St. Louis City and
northern and southwestern portions of St. Louis County.
Healthy Food Financing
The Healthy Food Financing Initiative
(HFFI) provides loans and grants for
fresh food retailers in low-income
communities. It helps overcome
financial barriers for new retailers, and
provides essential funds to renovate and
expand existing stores to accommodate
fresh food. HFFI was officially adopted
as a federal program in the 2014 Farm
Bill, helping to provide low-access
communities with healthy food and
economic development. 63,64
Locally, the St. Louis Healthy Corner
Store Project takes a community-based
approach to healthy food promotion.
A partnership of the University of
Missouri Extension and the City of
St. Louis Health Department, the project
works with local corner stores and
markets to provide affordable, healthy
foods, classes on nutrition, and cooking
demonstrations to raise awareness
about healthy choices.
Washington University in St. Louis and Saint Louis University 33
04
Education and health:
A FOUNDATION
FOR WELL-BEING
Policies that address factors like education
could have a bigger influence on health than
all medical advances combined.
Woolf SH, Johnson RE, Phillips RL, Philipsen M. Giving everyone the health of the educated: An examination of whether social change would save more lives than medical advances. Am J Public Health.
2007: 97(4):679-683.
34 For The Sake Of All
EDUCATION
GOOD HEALTH
Health and education are closely related and this relationship
moves in two directions: higher levels of education are
associated with good health, and children and families in
good health tend to have better education-related outcomes.
How does education affect health?
There are multiple ways in which educational attainment
may affect health. Educational attainment is thought to
improve health by increasing knowledge, literacy, and healthy
behaviors.69 An increase in knowledge, for example, may help
people make better decisions regarding their lifestyle and
medical care. Another way in which educational attainment
may affect health is through employment opportunities.
People with higher levels of education generally have access
to better working conditions, more work-related resources,
and higher incomes. As we have already seen, a good job
can translate into health-related benefits such as health
insurance, sick leave, retirement savings, and childcare.
Individuals with higher levels of education also have higher
incomes, which can provide greater access to safe housing,
schools with more resources, and health-promoting lifestyles
such as eating healthy foods and exercising. Higher levels of
education may also influence social and psychological aspects
of people’s lives. For example, education has been linked to
greater social support, higher social standing, and having a
greater sense of control. These factors influence people’s ability
to access social and economic resources, to engage in healthy
behaviors, and to manage stress levels, all of which are linked
to health outcomes like disease, disability, and death.70
High school completion
EDUCATION
GOOD HEALTH
Educational attainment is defined as the years or level
of schooling completed. People with less education face
disadvantages in health, such as more risk factors for poor
health, higher rates of disease, and shorter lifespans. For
example, compared to those with higher levels of education,
Americans with less education are more likely to have health
problems, to smoke, and to be obese.65,66 Research shows
that compared with college graduates, U.S. adults without
a high school diploma are likely to die 9 years sooner.67
This means that education is actually a very powerful health
intervention. One analysis suggests that giving everyone the
education of those who complete college would save more
lives than all of the medical advances of the last 20 years
combined.68 As was noted in the Introduction, however,
the gap in death rates among those with lower and higher
education has been widening for several decades.
Because the relationship between education and health is
so strong, educational attainment is of particular concern
for African Americans in St. Louis. As we noted above, in
2012, over 2,000 African American 9 – 12 graders were
classified as high school dropouts.71 This means that about
1 in 10 African American high school students dropped out
of school. Unless they resume their education, this places
them at high risk for both lower incomes and poorer health.
These students are likely to earn about $7,000 less per year
than high school graduates. Their lifetime earnings loss
(ranging from $347,000 to $739,410) reduces purchasing
power at regional businesses, lowers tax receipts, and adds
to the costs of social services and unemployment assistance.
Using earnings alone, St. Louis leaves $694 million to
$1.5 billion “on the table” when we let dropouts occur.
1 IN 10 AFRICAN AMERICAN 9-12 GRADERS
DROPPED OUT OF SCHOOL
Washington University in St. Louis and Saint Louis University 35
Education data from the past 50 years show that college
attendance has increased among African Americans in
St. Louis (see page 17). This improvement is important to
supporting better health. However, there is still much room
for improvement. High school completion is a prerequisite
for college attendance. The map of high school dropout
(figure 24) indicates there are still areas in both St. Louis City
and St. Louis County where high school dropout is a concern.
This suggests that we need further investment in educational
programs that are designed to improve school completion.
Intervening to improve high school completion is also one
important way to support health and well-being.
School performance and college readiness
Figure 24. Percent high school dropout by ZIP code
Figure 25. Percent African American enrollment by school
district in St. Louis City and St. Louis County
Monitoring school performance and college readiness in
children and adolescents is one way to identify risk of school
dropout. The Missouri Assessment Program (MAP) is a
statewide school testing program. On the next few pages,
we present data on MAP performance for school districts
in St. Louis City and St. Louis County. Figure 25 shows the
percentage of African American students enrolled in school
districts in St. Louis City and St. Louis County. Note that
the school districts with the highest percentage of African
American students (40 – 99%) are Hazelwood, FergusonFlorissant, Riverview Gardens, Jennings, Normandy,
University City, and St. Louis Public Schools.
0% – 2% (Lowest)
5% – 16% (Lowest)
3% – 7% (Middle)
17% – 39% (Middle)
8% – 20% (Highest)
40% – 99% (Highest)
No Data
Hazelwood
Ferguson- Riverview
Florissant Gardens
Pattonville
Ritenour
Jennings
University City
Normandy
Clayton
St. Louis
Public Schools
Ladue
Parkway
Rockwood
Kirkwood
St. Louis
City
Webster
Groves
Lindbergh
Schools
Mehlville
Valley Park
St. Louis County
MaplewoodRichmond Heights
Brentwood
Hancock Place
Bayless
Affton 101
N
Source: ACS 2007-2011 5-year estimates.
Source: Missouri Department of Elementary & Secondary Education (DESE)
Note: % civilian population 16 to 19 years: not high school graduate, not enrolled [dropped out]
Note: Rockwood extends beyond the boundaries of St. Louis County; data does not include students
enrolled in Special School District
The American Graduate initiative
is addressing high school dropout in
St. Louis. The Nine Network of Public
Media has partnered with education
leaders, youth-serving non-profits,
and others to develop strategies for
highlighting the importance of the dropout
crisis. There has also been a conscious
effort to include the voices of youth in
this effort.
36 For The Sake Of All
Performance in 3rd grade English Language Arts
Performance in 8th grade math
English Language Arts performance in 3rd grade is a measure
of college readiness and health literacy. Students who do
not read well by third grade have four times higher risk of
not earning a high school diploma compared to proficient
readers.72 Additionally, students who perform below basic
on the state’s English Language Arts examination are likely
to need extra classes before taking college-level courses.73
Because performance in 3rd grade English Language Arts is
linked to high school completion and college readiness, it
is important that we monitor how students are performing
on this test in the St. Louis region. Figure 26 shows that
the percentage of African American students below basic
in 3rd grade English Language Arts ranges from 0 to 30%.
Supporting school districts with a high percentage of
students who perform below basic is one way to help prevent
high school dropout and increase the number of high school
graduates who are ready for college.
Performance in eighth grade math indicates learning that
has taken place in earlier grades and during the final year
of middle school. Similar to 3rd grade English Language Arts,
students who struggle in eighth grade math are at greater
risk of dropping out of school compared to students who
are proficient.74 In St. Louis, a high percentage of African
American students are performing at the below basic level
on the MAP eighth grade math test, ranging from almost
1 in 10 in the best performing district to nearly 6 in 10 in
the lowest performing district (see figure 27). This level of
performance indicates a significant need to intervene in
early grades and suggests troubling educational and health
outcomes if left unaddressed.
Figure 26. Percent of 3rd grade African American
students below basic in English Language Arts
achievement by school district in 2013
Figure 27. Percent of 8th grade African American
students below basic in math achievement by
school district in 2013
School District
School District
St. Louis City
30%
Riverview Gardens
Riverview Gardens
30%
Normandy
Webster Groves
20%
Normandy
18%
Ferguson-Florissant R-II
15%
University City
13%
St. Louis City
Kirkwood R-VII
12%
Bayless
12%
Jennings
Ladue
Hazelwood
Pattonville R-III
11%
Rockwood R-VI
10%
Rockwood R-VI
Bayless
Ladue
28%
22%
University City
22%
21%
Mehlville R-IX
5%
Clayton
Affton 101 0%
28%
24%
Hazelwood
8%
7%
Maplewood-Richmond Heights
Clayton 0%
33%
29%
Lindbergh Schools 0%
Brentwood 0%
36%
34%
Parkway C-2
Maplewood-Richmond Heights 0%
Hancock Place 0%
36%
Hancock Place
8%
Parkway C-2
43%
37%
Ferguson-Florissant R-II
9%
Mehlville R-IX
Kirkwood R-VII
11%
10%
46%
Webster Groves
Ritenour
Pattonville R-III
48%
Ritenour
Valley Park
Jennings
59%
52%
% of 3rd grade African
American students
below basic in English
Language Arts
achievement
20%
15%
13%
Lindbergh Schools
12%
Valley Park
Brentwood
Afton 101
9%
% of 8th grade African
American students
below basic in math
achievement
8%
Source: Missouri Department of Elementary & Secondary Education (DESE); Missouri Assessment
Program (MAP) 2013
Source: Missouri Department of Elementary & Secondary Education (DESE); Missouri Assessment Program
(MAP) 2013
Note: Data does not include students enrolled in Special School District
Note: Data does not include students enrolled in Special School District
Washington University in St. Louis and Saint Louis University 37
Figure 28. Percentage of African American students
below basic in Algebra 1 achievement by school district
School District
Riverview Gardens
43%
Normandy
36%
Afton 101
33%
Valley Park
29%
St. Louis City
26%
Jennings
26%
Ladue
23%
University City
22%
Hazelwood
19%
Kirkwood R-VII
19%
Ferguson-Florissant R-II
17%
16%
Clayton
15%
Ritenour
Parkway C-2
12%
Mehlville R-IX
12%
11%
Webster Groves
10%
Brentwood
10%
Rockwood R-VI
Bayless
8%
7%
Pattonville R-III
6%
Maplewood-Richmond Heights
Lindbergh Schools
3%
Hancock Place 0%
% of African American
students below
basic in Algebra 1
achievement
Source: Missouri Department of Elementary & Secondary Education (DESE); Missouri Assessment Program
(MAP) 2013
Note: Data does not include students enrolled in Special School District
Performance in Algebra I
Another indicator of college readiness is Algebra I
performance.75 Achievement in math predicts college
success in two-year and four-year colleges. In many districts,
performance among African American students on the state’s
algebra test suggests students are doing well enough to attend
college (see table 9). Other districts have very high rates of
students classified by the state as below basic (see figure 28).
These students are at risk of not being prepared for collegelevel work or technical and vocational training, and this may
limit their future employment opportunities.
38 For The Sake Of All
While it is important to make note of students who are
unprepared for college, it is also important to highlight
students who have the necessary skills for higher education.
Compared to those with below basic proficiency, students
who are proficient or advanced are more likely to complete
high school and attend college. Table 9 shows the percentage
of African American students with proficient or advanced
achievement on the three portions of the MAP exam that we
have discussed (English Language Arts, Mathematics, and
Algebra 1). Proficiency or advanced status above 50% for
African American students in each subject is shown in bold.
Table 9. Percent of African American students with Proficient or Advanced academic achievement
School district
English Language Arts
Mathematics
Algebra 1
Affton 101
44%
15%
42%
Bayless
23%
14%
33%
Brentwood
47%
73%
90%
Clayton
46%
44%
56%
Ferguson-Florissant R-II
30%
28%
26%
Hancock Place
76%
10%
45%
Hazelwood
36%
36%
25%
Jennings
35%
24%
39%
Kirkwood R-VII
29%
13%
48%
Ladue
40%
5%
31%
Lindbergh Schools
62%
33%
63%
Maplewood-Richmond Heights
62%
12%
42%
Mehlville R-IX
27%
21%
28%
Normandy
25%
9%
14%
Parkway C-2
38%
25%
43%
Pattonville R-III
31%
21%
54%
Ritenour
34%
12%
25%
Riverview Gardens
14%
4%
11%
Rockwood R-VI
38%
11%
38%
St. Louis City
19%
14%
27%
University City
26%
32%
32%
Valley Park
35%
35%
43%
Webster Groves
36%
23%
41%
Source: Missouri Department of Elementary & Secondary Education (DESE); Missouri Assessment Program (MAP) 2013
Notes: English Language Arts achievement among grade 3 non-Hispanic African Americans; Mathematics achievement among grade 8 non-Hispanic African American students; Algebra 1 achievement among non-Hispanic
African American students
Washington University in St. Louis and Saint Louis University 39
Highest level of education
It is not only the academic performance of students currently
in school that is important for health. So too is the level of
educational attainment in the adult population. Figure 29
shows the highest level of education for African Americans
25 years or older in St. Louis. A majority of African
Americans in this age range have attended college, and about
one in four have earned at least an associate’s degree. Notice
that a higher percentage of African American women have
associate’s, bachelor’s or graduate degrees as their highest
level of education compared with men.
Figure 29. Highest level of education among
African Americans 25 and older in St. Louis City
and St. Louis County
Graduate Degree
8.4%
5.0%
11.5%
8.7%
Bachelor’s Degree
Associate’s Degree
Female
8.4%
7.9%
28.3%
28.7%
Some College, No Degree
GEO or Alternative Credential
4.1%
4.9%
22.4%
25.1%
High School Diploma
13.0%
15.3%
9th to 12th Grade, No Diploma
Less than 9th Grade
Source: ACS 2012 1-year estimates
Male
What are the differences in education
by race?
Among white residents 25 years and older in St. Louis, 73%
have some college or more as their highest level of education.
That percentage drops to 54% among African Americans.
4.0%
4.3%
Figure 30. Highest level of education among those 25 and
older in St. Louis City and St. Louis County
Whites
African Americans
27%
73%
46%
High School or Less
Source: ACS 2012 1-year estimates
40 For The Sake Of All
54%
Some College or More
Figure 31. Percent of infants born in 2011 who received
inadequate prenatal care by mothers’ level of education,
St. Louis County and St. Louis City
46%
White
African American
Percent of infants who received
inadequate prenatal care
37%
25%
24%
14%
8%
8%
2%
Less than
high school
High school
degree
Some
college
College
degree or
more
Mothers’ level of education
Source: MODHSS, Birth MICA
Notes: Prenatal care adequacy (Missouri index)
Mother’s education and health
One example of the considerable impact that education
can have on health is the relationship between a mother’s
education and her child’s health. Higher levels of education
for parents, especially for mothers, are associated with
better health and well-being for their children.76 We noted
that one way education affects health is through an increase
in knowledge, which may help people to make healthier
decisions. Mothers with higher levels of education also have
the resources that come with better jobs and higher incomes.
Higher levels of education for
parents, especially for mothers, are
associated with better health and
well-being for their children.
Although education is important to health, it is not the only
explanation for health disparities. Figures 31 and 32 show
that at every level of education, there is still a considerable
difference between African Americans and whites in receipt
of adequate prenatal care and low birth weight. Of particular
note is that African American women with a college degree
or more education are more likely to have a low birth
weight baby than white women with less than high school
education. Low-birth-weight and preterm infants are at an
increased risk for many health and academic problems that
last through adolescence.77,78 Some have argued that the stress
associated with racism and discrimination helps to explain
the difference between birth outcomes in the most educated
African American women compared with the least educated
white women.79,80
Figure 32. Percent of low birth weight births in 2011
by mothers’ level of education, St. Louis County and
St. Louis City
White
17%
Percent of low birth weight births
NH
African American
16%
15%
11%
9%
8%
5%
Less than
high school
High school
degree
Some
college
6%
College
degree or
more
Mothers’ level of education
Source: MODHSS, Birth MICA 2011
Note: Low birth weight: (# of live births weighing less than 2500g / # of live births)*100
Washington University in St. Louis and Saint Louis University 41
How does health affect education?
There are at least three ways in which health challenges may
lead to high school dropout:81
Having explored how education affects health, we turn now
to the effect of health on education and learning. Specifically,
we will discuss patterns related to health that lead to a
greater risk for school dropout.
1) Childhood illness
2) Mental health problems
3) Poor school performance and risky behaviors
All three patterns increase the risk for leaving school before
high school completion.
EDUCATION
GOOD HEALTH
The Center on Society
and Health at Virginia
Commonwealth University
is raising awareness about
the association between
education and health through
their “Education and Health
Initiative.” Visit their website
to learn more (see Resources).
Figure 33. Three patterns related to health that can increase high school dropout
Childhood illness
Access to health care
Serious illness
Problems at school
Asthma, Diabetes
Low access, Low use,
Not following treatment
Hospital stay,
Poorly managed illness
Absent, Tardy,
Low grades
2 Mental health problems can affect learning and behavior
Childhood behavior
challenges
ADHD, Conduct disorders
Behavior and
learning in
elementary school
Behavior and learning
in middle school and
high school
Lower grades,
Suspension
Lower grades,
Substance use,
Poor choices
3 Poor school performance can increase risky behaviors for teenagers
Poor school
performance
Low grades, Failing classes
Source: Adapted from California Dropout Research Project
42 For The Sake Of All
Risky behaviors
Related health
problems
Substance use,
Unprotected sex
Substance dependence,
Unplanned pregnancy
High School Dropout
1 Low access to health care or low health care utilization allows treatable illnesses to affect schooling
Pattern 1: Childhood illness
Illnesses that begin early and continue throughout life limit
students’ ability to complete school. The effects of childhood
illness on education are often influenced by access to medical
care and utilization of medical services. Asthma is the most
common chronic childhood illness nationally. Asthma
disproportionately affects low-income and racial and ethnic
minority children in urban areas.82–84 Poorly controlled
asthma is a serious problem for high school-age African
Americans in St. Louis. In 2011, the rate of emergency room
visits for asthma was 7 times higher for African Americans
ages 15 to 19 compared with white youth in the same age
group.85 Research shows that asthma negatively affects
academic achievement through86
Figure 34. Emergency room visits per 1,000 for mental
health conditions among youth under 15 years in
St. Louis County and St. Louis City in 2011
6
100%
higher
3
Whites
African Americans
Source: MODHSS, Emergency Room MICA 2011
> missed days of school
> negative impacts on learning, behavior, and motivation
> limitations to “school connectedness” (school
connectedness is the belief by students that adults
in the school care about their learning as well as
about them as individuals87)
A study conducted in St. Louis Public Schools found that
children who miss more days of school do less well on the
Missouri Assessment Program (MAP) test.88 Ultimately,
repeated school absences interrupt learning and are a strong
predictor of school dropout.89
Missouri State Asthma Plan
A joint effort of the Missouri
Asthma Coalition and the
Missouri Department of
Health and Senior Services,
the Missouri State Asthma
Plan for 2010 – 2014 lays out
a strategy to reduce asthma
NH
hospitalizations and missed
days of school and work due to asthma, reduce disparities in asthma,
and increase access to formal asthma prevention and management.
The plan takes a comprehensive, systems-based approach to asthma
in Missouri, involving needs assessment and surveillance, workforce
development, partnership engagement, and developing and implementing
effective community-based interventions.
Pattern 2: Mental health problems
Nationally, one in five students experiences mental health
problems.90 Locally, 12.3% (St. Louis County) and 12.7%
(St. Louis City) of 6 – 12 graders say they have considered
suicide in the last year.91 Based on a small sample of 6 – 12
graders in St. Louis County, 28% of African Americans said
they had a diagnosed mental health problem. This is more
than two times the rate for whites (12%).92 Emergency room
visits and hospitalizations for mental health problems may
be signs that children are not being screened and treated
properly in community or outpatient settings. In 2011, the
rate of emergency room visits for mental health conditions
in St. Louis among African American youth was double
the rate among white youth (see figure 34). The rate of
hospitalizations for mental health conditions was also
much higher among African American youth compared
with white youth (see figure 35). Over time, mental health
problems increase the risk of school dropout. For example,
Attention Deficit Hyperactivity Disorder (ADHD) and
behavioral disorders can lead to poor performance at school.
The stigma associated with mental health conditions also
can influence some parents’ willingness to seek mental
health care for their children, with potentially negative
effects on their education.93
Washington University in St. Louis and Saint Louis University 43
Figure 35. Inpatient hospitalizations per 10,000 for
mental health conditions among youth under 15 years
in St. Louis County and St. Louis City in 2011
55
31
Whites
77%
higher
African Americans
Source: MODHSS, Emergency Room MICA
B
Beacon story summary:
Mental health and school dropout
Bullied at school, Malik
Avery struggled with
physical and emotional
stress and suicidal
thoughts, which led him
to drop out. Avery has
since sought help, and
earned his high school
diploma through the
St. Louis Public School System’s high school graduation
initiative. In an interview with the St. Louis Beacon,
Avery’s counselor, Charlie E. Bean, discusses the impact
of mental health on education. Avery was bullied and
school became mentally and emotionally exhausting for
him. Counseling and mental health services are essential
to keeping young people like Avery enrolled in high school,
says Bean, who counsels 350 St. Louis youth at high risk
for dropout.
Story by the St. Louis Beacon
Pattern 3: Poor school performance and risky behaviors
The first two patterns describe how chronic illness and
mental health problems affect education. The relationship
between education and risky behaviors for teenagers,
however, moves in both directions. This means that African
American students who earn low grades are more likely
to take part in behaviors that expose them to more health
risks.94 These new health risks can lead to a higher dropout
risk. For example, a student who earns low grades may be
more likely to use drugs, become sexually active early in life,
or become involved in violence. This student may be on the
path to failing in school and dropping out.
Violence not only disrupts the
learning process, but also leads to
absences that increase a student’s
risk of poor school performance
and dropout.
Injuries that result from violence and fighting have become
more common in children and youth, and disproportionately
affect children from racial and ethnic minority groups
in urban areas.95 A national study by the CDC revealed
that nearly 6% of students miss at least one day of school
following physical fighting due to feeling unsafe.96 Violence
not only disrupts the learning process, but also leads to
absences that increase a student’s risk of poor school
performance and dropout. According to the CDC, youth
violence (including youth homicides and assault related
injuries) result in approximately $16 billion in medical and
lost work costs annually.97 In St. Louis, injuries resulting
from fighting increase more than four-fold among African
Americans in the high-school years. Though a comparable
increase is seen for white youth in high school, there is
a very large disparity in overall rates of injuries due to
fighting (see table 10). African American youth are injured
at a rate that is over 6 times higher than whites.
Table 10. Injury rate per 100,000 due to fighting by race
and age in St. Louis City and St. Louis County in 2011
Under 15 years
15 – 19 years
African Americans
211
990
Whites
24
156
Source: MODHSS, Injury MICA
44 For The Sake Of All
Although teenagers’ sexual activity alone is not considered
an unhealthy behavior, consequences of sexual activity
may lead to poor academic and health outcomes.98 For
example, having unprotected sex at younger ages may lead
to teen pregnancies and sexually transmitted diseases.
Teen pregnancies and births may distract students from
focusing on school work and eventually lead to high school
dropout.99 Figure 36 shows that teen pregnancy rates are
more than four times higher in African American teens
compared with white teens in St. Louis County. In St. Louis
City, African American teen girls are more than three times
more likely to become pregnant compared with white teen
girls. Although teen pregnancy rates are higher in St. Louis
City compared to St. Louis County, the difference in teen
pregnancy rates between African Americans and whites is
larger in St. Louis County.
Figure 36. Pregnancy rates per 1,000 among females
age 15 – 19 by race in 2010
St. Louis County
7,914
5,121
Whites
African Americans
595
268
St. Louis County
St. Louis City
Source: MODHSS, Child Health Profile
Figure 38. Gonorrhea rates per 100,000 among females
age 15 – 19 by race from 2005 – 2009
3,519
89
77
17
Figure 37. Chlamydia rates per 100,000 among females
age 15 – 19 by race from 2005 – 2009
28
Whites
1,970
African Americans
Whites
African Americans
St. Louis City
136
52
Source: MODHSS, Fertility Rate MICA
Figures 37 and 38 show that the pattern in rates of sexually
transmitted diseases, like chlamydia and gonorrhea, is similar
to that in teen pregnancy rates. Rates of chlamydia and
gonorrhea among teens are higher in St. Louis City compared
with St. Louis County among both African Americans
and whites. And there is a large disparity between African
American teens and white teens. In St. Louis County, African
American teens are 19 times more likely to become infected
with chlamydia compared with white teens. In St. Louis City,
African American teens are 13 times more likely to become
infected with chlamydia compared with white teens. The
disparity by race is even larger for gonorrhea infections. In
St. Louis County, African American teens are 38 times more
likely to become infected with gonorrhea compared with
white teens. And in St. Louis City, African American teens
are 26 times more likely to become infected with gonorrhea
compared with white teens. It should be noted that these
disparities are not the result of more risky sexual behaviors
among African American teens. Rather, they are the result
of closed networks of sexual partners in which infected
individuals are active.
St. Louis County
St. Louis City
Source: MODHSS, Child Health Profile
Coordinated school health programs can
help address some of the educational
barriers that children and adolescents
face. In August 2012, Mercy Children’s
Hospital and the St. Louis Public Schools
opened a school-based clinic at Roosevelt
NH
High School. The Boeing Company
supported this program with grant funding. The goal of the clinic is
to decrease time lost from school due to health problems.
Washington University in St. Louis and Saint Louis University 45
05
Health Profile:
AFRICAN AMERICANS
IN ST. LOUIS
Health is fundamental to human well-being.
Health makes it possible for us to engage fully
in the activities of our daily lives and make
contributions to our communities.
46 For The Sake Of All
5.1 Chronic diseases
Chronic diseases are long-lasting conditions that impact
health and well-being. Although these diseases cannot be
cured, they can be prevented and managed.100 Social and
economic factors like education, income, and neighborhood
conditions can contribute to chronic diseases like heart
disease, cancer, and diabetes in many ways. Some of the
pathways that have already been identified include:
> Education can increase income, which can provide
access to safe housing
> Income and wealth can provide the opportunity
to live in health-promoting neighborhoods
> Education can increase knowledge, literacy, and
healthy behaviors
> Education can provide social support, higher social
standing, and sense of control
Social and economic factors
like education, income, and
neighborhood conditions can
contribute to chronic diseases
like heart disease, cancer, and
diabetes in many ways.
Chronic diseases also weaken businesses and our local and
state economies in the form of missed school and work days,
lost productivity, and high health care costs. A healthier
workforce in the St. Louis region would mean a decrease in
health care spending and a more productive local economy.
If we reduced the disparity in chronic diseases like heart
disease, cancer, and diabetes, St. Louis could save $65 million
a year in inpatient hospital charges.
> Living in poverty and having few resources can be
a source of long-term stress
> High poverty neighborhoods can often have limited
services and amenities
> Employment can offer access to health insurance
and workplace wellness programs
Chronic diseases affect many of us. Nearly half of all adults
in the U.S. had at least one chronic disease in 2008.101 African
Americans have higher rates of many chronic diseases and
the complications that follow than other groups. These
differences in health have been highlighted in recent
Missouri and St. Louis reports.102,103
Chronic disease also has a significant impact on 0ur
economy, accounting for nearly one-third of all health
spending in the U.S., or about $350 billion each year.104
Local hospital charges for chronic disease are also
incredibly high. In 2011 alone, charges for hospital care
for diabetes, heart disease, and cancer among all St. Louis
residents was $1.1 billion.105 Among African Americans,
charges for hospital care for diabetes, heart disease, and
cancer was $395 million.106 These amounts would be even
higher if they included other types of chronic diseases.
$1.1 BILLION
HOSPITAL CHARGES FOR HEART DISEASE,
CANCER, AND DIABETES IN ST. LOUIS
WHICH IS EQUIVALENT TO BUYING 3
EDWARD JONES DOMES EVERY YEAR!
+
+
Washington University in St. Louis and Saint Louis University 47
Figure 39 shows the percentage (i.e., prevalence) of adults
in the St. Louis region who had certain chronic diseases or
conditions in 2011. These data are based on survey responses
from the 2011 County-Level Study (see Resources). There
are differences between African Americans and whites for
several chronic diseases and conditions. In general, the
largest differences are in obesity, asthma, and diabetes,
with African Americans more likely to have these diseases
compared with whites in St. Louis County and St. Louis City.
Obesity is of particular concern because it plays a significant
role in the development of chronic diseases such as heart
disease, diabetes, and certain cancers.107 Almost half of
African American adults (46%) in St. Louis County are obese.
In St. Louis City, 38% of African American adults are obese.
In St. Louis County, the percentage of African Americans
who have asthma is double that of whites (16% vs. 8%). This
difference is roughly the same in St. Louis City (15% vs. 8%).
In St. Louis County, 14% of African Americans have diabetes
compared to 8% of whites. The disparity is smaller in St.
Louis City, where 14% of African Americans have diabetes
compared with 11% of whites.
Figure 39 also shows that for some diseases whites have
a higher prevalence compared with African Americans.
One example is cancer. In St. Louis County, a higher
percentage of whites have cancer (10%) compared with
African Americans (4%). In St. Louis City, a higher percentage
of whites also have cancer (12%) compared with African
Americans (6%). The prevalence of disease is only one way
to look at how chronic illness affects health and well-being,
though. Despite having lower cancer prevalence, African
Americans have higher rates of hospitalization and death due
to cancer compared with whites. Previous maps also suggest
that many neighborhoods with a high percentage of African
Americans also have high rates of cancer deaths (see page 30).
Figure 40 shows that for each chronic disease type, African
Americans have a higher rate of death compared with whites.
Similar differences also exist for four major types of cancer
(figure 41).
Figure 39. Chronic disease outcomes among adults by race in 2011
St. Louis City
St. Louis County
Obese
27%
28%
28%
Ever been told had arthritis
Ever been told had
vision impairment
Current asthma
18%
15%
8%
Ever been told had diabetes
Ever been told had cancer
Ever been told had COPD,
emphysema or chronic bronchitis
6%
15%
38%
Obese
Ever been told had
vision impairment
17%
18%
Current asthma
Ever been told had diabetes
12%
Ever been told had cancer
46%
21%
26%
Ever been told had arthritis
14%
11%
5%
8%
23%
16%
8%
8%
4%
Ever been told had COPD,
emphysema or chronic bronchitis
5%
6%
14%
10%
Whites
African Americans
Source: MODHSS, Health & Preventive Practices Profile; County-level Study 2011
Notes: Age-adjusted weighted percent; among non-Hispanic African American and white adults (18+); obese (≥30 BMI) ; COPD (chronic obstructive pulmonary disease)
48 For The Sake Of All
NH
Figure 40. Chronic disease death rates by race
in St. Louis County and St. Louis City in 2011
256
Heart
Disease
175
216
Cancer
161
53
Stroke
Diabetes
15
59
Lung
Cancer
47
23
Colorectal
Cancer
12
19
Breast
Cancer
40
45
Figure 41. Cancer death rates by race in St. Louis County
and St. Louis City in 2011
Whites
African Americans
Prostate
Cancer
13
14
6
Whites
African Americans
Source: MODHSS, Chronic Disease MICA
Source: MODHSS, Chronic Disease MICA
Notes: Rates are per 100,000 and age adjusted using 2000 standard population; stroke: cerebrovascular
disease
Notes: Rates are per 100,000 and age adjusted using 2000 standard population; lung cancer: malignant
neoplasms of trachea/bronchus/lung; colorectal cancer: malignant neoplasms of colon/rectum/anus;
breast cancer: malignant neoplasms of breast; prostate cancer: malignant neoplasms of prostate
Washington University in St. Louis and Saint Louis University 49
In St. Louis County and St. Louis City, African Americans
have higher hospitalization rates for almost all diseases and
conditions considered (figure 42). A similar pattern exists
for rates of emergency room (ER) visits (figure 44). Figure
43 highlights the difference in diabetes hospitalization rates
between African Americans and whites. Figure 45 is similar
but it highlights the difference in asthma ER rates between
African Americans and whites.
Figure 44. ER rates due to chronic diseases and conditions
by race in St. Louis County and St. Louis City in 2011
Heart
Disease
Asthma
Hypertension
Heart
Disease
208
102
Cancer
33
Stroke
28
Diabetes
44
0.7
5.3
4.3
Stroke
0.5
0.3
Whites
Cancer
0.3
0.1
African
Americans
Notes: Rates are per 1,000 and age adjusted using 2000 standard population; arthritis includes other
types of joint disorders; COPD (chronic obstructive pulmonary disease); stroke (cerebrovascular disease)
50
24
Arthritis
Figure 45. Asthma ER rates by race in St. Louis County
and St. Louis City in 2011
33
46
5
COPD
1.8
Source: MODHSS, Chronic Disease MICA
54
8
Hypertension
6.8
1.0
50
13
Asthma
14.9
4.4
COPD
Diabetes
20.2
2.5
Arthritis
Figure 42. Inpatient hospitalization rates due to chronic
diseases and conditions by race in St. Louis County and
St. Louis City in 2011
25
8.6
Whites
14
African
Americans
25
WHITES
AFRICAN AMERICANS
3
20*
Per 1,000
Source: MODHSS, Chronic Disease MICA
Per 1,000
*17 more people per 1,000
Notes: Rates are per 10,000 and age adjusted using 2000 standard population; arthritis includes other
types of joint disorders; COPD (chronic obstructive pulmonary disease); stroke (cerebrovascular disease)
Adapted from Visualizing Health (see resources)
Source: MODHSS, Chronic Disease MICA
Figure 43. Diabetes inpatient hospitalization rates
by race in St. Louis County and St. Louis City in 2011
WHITES
AFRICAN AMERICANS
13
54*
Per 10,000
Per 10,000
*41 more people per 10,000
Adapted from Visualizing Health (see resources)
Source: MODHSS, Chronic Disease MICA
Notes: Rates are per 10,000 and age adjusted using 2000 standard population
50 For The Sake Of All
Notes: Rates are per 1,000 and age adjusted using 2000 standard population; rates are rounded
B
Beacon story summary: Chronic Disease
There is hope for those affected by
chronic disease. A story in the St. Louis
Beacon highlights several individuals
and organizations in St. Louis helping
people to cope with and manage chronic
illnesses. Sherrill Jackson is a 21-year
breast cancer survivor and founder of
an organization called the Breakfast
Club. This organization educates the
public about breast cancer and support
services. The Breakfast Club has
educated more than 12,000 people about
breast health. Jackson thinks there is
still a great need to support people and
raise awareness. “But even in 2013,
there is still a lack of education. There
are still women who are afraid to talk
about breast cancer.” Another active
voice in the community is Shermane
Winters-Wofford, a two-time stroke
survivor. She has spoken in front of
audiences and empowers people to
make healthier choices. “All we have
to start doing now is taking little bitty
steps to make lifestyle changes.” The
Empowerment Network is another
organization but focuses on combating
prostate cancer among African
American men in St. Louis. Walter
Prichard, who works for the network,
talks about some of the challenges.
“We take our health for granted, and
don’t take our medications. But the
Empowerment Network is spreading
5.2 Lifestyle risk and protective factors
As noted in the Introduction to this report, 40% of the
premature deaths in the United States can be attributed to
behavioral patterns. In fact, many of the chronic diseases we
have discussed are closely linked to behaviors that can be
changed, like diet, physical activity, and smoking and risk
factors for disease like obesity, high blood pressure, and high
cholesterol. So, it is important to examine these and other
behaviors and risk factors for African Americans in St. Louis.
HEALTHY LIFESTYLES HELP
PREVENT CHRONIC DISEASE
+
LOSING
WEIGHT
+
HEALTHY
EATING
+
PHYSICAL
ACTIVITY
NO
SMOKING
Sherrill Jackson
Shermaine WintersWofford
the message that knowledge can save
your life. We are raising awareness
through programs and resources.”
Story by the St. Louis Beacon
While personal responsibility for making healthy lifestyle
choices is important, the context in which choices are made
matters a great deal. Table 11 shows that even though African
Americans and whites in St. Louis report relatively equal
access to sidewalks and bike lanes for physical activity, there
are differences in the perceptions of safety in neighborhoods
where African Americans live. This may help to explain
the higher percentages of African Americans reporting
no leisure time physical activity in both the City and the
County. African Americans in St. Louis are also less likely
to report that it is “easy to purchase healthy food” in their
neighborhoods. Though eating fruits and vegetables at
recommended levels seems to be a problem for both whites
and African Americans, the lack of convenient access to
healthy foods may pose an additional barrier for African
Americans. (See page 33 for map of access to healthy foods
in the region.)
While personal responsibility for
making healthy lifestyle choices
is important, the context in which
choices are made matters a great deal.
Washington University in St. Louis and Saint Louis University 51
Table 11. Lifestyle risk and protective factors among adults by race in 2011
St. Louis County
St. Louis City
Whites
African Americans
Whites
African Americans
No leisure time physical activity
16%
31%
22%
28%
Use walking trails, parks, playgrounds
or sports fields for physical activity
53%
56%
45%
47%
Have sidewalks in their neighborhood
78%
77%
90%
96%
Have roads and streets with
shoulders or marked lanes for bicycling
in their community
45%
47%
63%
65%
Consider their neighborhood to be
extremely or quite safe
87%
62%
65%
39%
Strongly agree or agree that it
is easy to purchase healthy food in
their neighborhood
91%
73%
86%
66%
Ate fruits and vegetables less than
5 times per day
87%
88%
89%
88%
Source: MODHSS, Health & Preventive Practices Profile; County -­level Study 2011
Notes: Age-­adjusted weighted percents; among non-­Hispanic African American and white adults (18+)
We are somewhat limited in our ability to examine certain
risk factors for chronic disease because existing data only
tell us about the percentage of people who have ever been
told they have conditions like high blood pressure or high
cholesterol. We don’t know whether these conditions are
being treated with medications to manage them. However,
in both the City and County, African Americans are more
likely to report high blood pressure compared with whites,
while levels of high cholesterol are comparable or lower.
For an important, additional risk factor, obesity, African
Americans have rates that are 23 percentage points higher in
St. Louis County and 11 percentage points higher in the City
of St. Louis. Obesity is so important because it is associated
with the other risk factors (i.e., high blood pressure and
cholesterol) and with chronic diseases, as noted above.108–110
Table 12. Chronic disease risk factors among adults in 2011
St. Louis County
St. Louis City
Whites
African Americans
Whites
African Americans
Ever been told had high blood pressure
30%
37%
31%
42%
Ever been told had high cholesterol
40%
39%
41%
40%
Obese (≥30 BMI)
23%
46%
27%
38%
Source: MODHSS, Health & Preventive Practices Profile; County -­level Study 2011
Notes: Age-­adjusted weighted percents; among non-­Hispanic African American and white adults (18+) ; high cholesterol (among those age 35 and older who have had cholesterol checked)
52 For The Sake Of All
Cigarette smoking is the leading preventable cause of early
death and disease.111 Smoking causes damage to nearly every
organ system in the body, and even secondhand exposure
to smoking can have serious health consequences. In the
U.S., more than 400,000 lives are lost each year because
of smoking. More than 20 million people have died due to
smoking-related illnesses since the U.S. Surgeon General
released the landmark report citing the dangers of cigarettes
in 1964. Both nationally and in the St. Louis region, African
American adults smoke at comparable or lower levels
compared with whites (see table 13). African Americans in
both the City and County are also more likely to have made
a quit attempt in the past year or to want to quit in the next
6 months, but are less likely to be aware of the available
resources to support quitting, like telephone-based quitlines
and other counseling services for smoking cessation.112
Table 13. Tobacco use among adults by race in 2011
St. Louis County
St. Louis City
Whites
African Americans
Whites
African Americans
Current cigarette smoking
20%
18%
28%
28%
Former cigarette smoking
25%
17%
27%
16%
Source: MODHSS, Tobacco Use Profile; County-level Study 2011
Notes: Age-adjusted weighted percent; among non-Hispanic African American and white adults (18+)
Table 14. Tobacco cessation among adults by race in 2011
St. Louis County
St. Louis City
Whites
African Americans
Whites
African Americans
Current smokers who made a quit
attempt in past year
57%
66%
29%
67%
Current smokers who intend to quit
in next 6 months
71%
78%
53%
79%
Current smokers who are aware of
telephone quitline services
46%
31%
43%
38%
Current smokers who are aware of
cessation counseling services other
than quitlines
49%
31%
39%
33%
Source: MODHSS, Tobacco Cessation Profile; County-level Study 2011
Notes: Age-adjusted weighted percent; among non-Hispanic African American and white adults (18+)
Washington University in St. Louis and Saint Louis University 53
Cigarette smoking is another health factor that has a
socioeconomic gradient. Individuals with lower levels
of education and income are more likely to smoke than
those with higher education and income. In the St. Louis
metropolitan area, individuals with less than high school
education smoke at 5 times the rate of those with college
education, and figure 46 shows that smoking decreases
as education level increases, consistent with the gradient.
A similar relationship can be seen for smoking and
income. Because, as we have seen, African Americans are
disproportionately represented among those with lower
educational attainment and lower income, there is a greater
risk of smoking for individuals in those subgroups.
For African Americans in St. Louis,
there remain challenges to leading
a healthy lifestyle that go beyond
personal choice.
Figure 47. Cigarette smoking by income level in the
St. Louis metro area* in 2011
45%
Current cigarette smoking
38%
Figure 46. Cigarette smoking by highest level
of education in the St. Louis metro area* in 2011
27%
24%
43%
Current cigarette smoking
20%
16%
30%
29%
< $15,000
$15-$24,999 $25-34,999 $35-$49,999 $50-$74,999
$75,000 +
Income ($) level
8%
Source: MODHSS, Health and Preventive Practices Profiles; County-level Study 2011
Notes: Age-adjusted weighted percent; among all adults (18+); HS (high school); GED (general educational
development); *St. Louis metro area includes the following Missouri counties: Franklin, Jefferson, Lincoln,
St. Charles, St. Louis City, St. Louis County, Warren, and Washington
< HS
HS or GED
Some post HS
College graduate
Highest level of education
Source: MODHSS, Health and Preventive Practices Profiles; County-level Study 2011
Notes: Age-adjusted weighted percent; among all adults (18+); HS (high school); GED (general educational
development); *St. Louis metro area includes the following Missouri counties: Franklin, Jefferson, Lincoln,
St. Charles, St. Louis City, St. Louis County, Warren, and Washington
54 For The Sake Of All
As important as all of these behaviors are to health, the social
context in which they take place is equally important. For
African Americans in St. Louis, there remain challenges to
leading a healthy lifestyle that go beyond personal choice.
5.3 Health insurance and access to
primary care
category are more than 2.5 times as likely to be uninsured
compared with whites (28.8% vs. 11.4%). Almost all older
adults, regardless of race, have health insurance.
Having health insurance is essential for appropriate medical
care. One report found that 25% of uninsured adults said
that cost concerns prevented them from going to the doctor
when they needed.113 In comparison, only 4% of those with
employer-provided health insurance and 9% with Medicaid
reported that cost concerns prevented them from seeing the
doctor. People without health insurance are less likely to have
a primary care physician or provider (PCP).114 The uninsured
also receive fewer health services like dental care and often
get treatment for health problems when it is too late.115 These
and other barriers help to explain why the uninsured tend to
have worse health outcomes.
Primary care is important for preventing disease and
promoting well-being throughout the life span. PCPs are also
necessary in order to direct people to necessary specialty care
(e.g., providers who care for very specific conditions).116,117
Figure 48 shows the percentage of the population with health
insurance coverage in St. Louis City and St. Louis County
combined. It shows insurance status for children and youth
(under 18), adults (18-64), and older adults (65+) among
African Americans and whites. Though the proportion
of uninsured children and youth (under 18) is relatively
small, it is twice as large for African Americans compared
with whites. The insured status for adults ages 18 to 64 is
considerably lower, and African American adults in this age
Primary care is important for
preventing disease and promoting
well-being throughout the life span.
There are a total of 1,273 practicing health care providers
in all specialties in St. Louis County and 441 in St. Louis
City according to a 2014 report.118 These numbers include
physicians (doctors of medicine — MDs and doctors of
osteopathic medicine — DOs), nurse practitioners, and
physician assistants. In St. Louis County, 765 (60.1%) of
all providers are practicing in primary care. There are 226
(51.2%) practicing PCPs in St. Louis City. Primary care
includes family medicine, internal medicine, pediatrics,
and general practice.
Figure 48. Health insurance coverage by race in St. Louis County and St. Louis City
6.6%
3.0%
11.4%
0.7%
0.2%
99.3%
99.8%
28.8%
93.4%
97.0%
88.6%
71.2%
African Americans
under 18
Whites under 18
African Americans
18 to 64
Whites 18 to 64
African Americans
65 & Over
Whites 65 & Older
Insured
Uninsured
Source: ACS 2012 1-year estimates
Washington University in St. Louis and Saint Louis University 55
Previous reports have highlighted many concerns about
PCP access for African Americans. The North St. Louis
Health Care Access Study and the Understanding Our Needs
report by the City of St. Louis Department of Health help
show the barriers to health care access faced by many
African Americans in St. Louis City. For example,
Understanding Our Needs found that most of the City’s
PCPs are concentrated around the major teaching hospitals
(e.g., Barnes-Jewish Hospital, St. Louis University Hospital)
but there are relatively few PCPs practicing in neighborhoods
where there is a high African American population.119
St. Louis County’s Community Health Needs Assessment
reported that 28% of African Americans lacked a usual
source of health care.120 By comparison, only 12% of whites
in St. Louis County lacked a usual source of care.121 In North
County, where 45% of the population is African American,
20% of all adults report no regular source of care.122 Rates
for emergency room (ER) visits and hospital admissions
are also higher in North County compared to the County
overall.123 Those who lack a usual source of care often use
ERs at higher rates, which is much more costly compared
with primary care.
The St. Louis health care safety net provides care for our
most vulnerable residents, who often lack health insurance.
The safety net served 26% of all residents in St. Louis
County and St. Louis City in 2011.124 This system has played
an integral role in improving primary care access for lowincome and uninsured people in St. Louis, but lack of health
insurance and limited access to PCPs remain challenges for
many African Americans in St. Louis.
56 For The Sake Of All
5.4 Maternal and child health
A woman’s behavior, environment, and social circumstances
(e.g., education, employment, and social support) affect her
health and the health of her children. Maternal and child
health is recognized as a key indicator of population health in
the United States and around the world.125,126 Pregnancy and
childbirth can provide the opportunity to identify health risks
and prevent future health complications in women and their
children.127 Improving the health and well-being of mothers,
infants, and children is important because their health
shapes the health of our next generation.
Maternal and child health covers a broad range of topics
like infant and maternal mortality, prenatal care, breastfeeding,
child abuse, and access to care. This subsection provides
a snapshot of maternal and child health with a focus on
prenatal care, maternal and infant health, and social
determinants of health as they relate to maternal and
child health among African Americans in St. Louis.
Prenatal care and maternal health
Prenatal care is the health care received during pregnancy,
and is an essential component of a healthy pregnancy and
childbirth. Babies of mothers who do not receive prenatal
care are at an increased risk of low birth weight and death.128
Prenatal care allows doctors to diagnose and treat health
problems early, and to discuss behaviors that can improve
the health of mothers and their families.
Figure 49 shows that in 27% of African American births,
the mother received inadequate prenatal care in St. Louis
County. In St. Louis City, 38% of African American births
were to mothers who received inadequate prenatal care
(see figure 50). The percentage of white births to mothers
who received inadequate prenatal care is much lower (5% in
St. Louis County and 8% in St. Louis City). Interventions are
needed to close these gaps and to ensure that every mother
and every baby has access to adequate prenatal care.
The health status of a mother during pregnancy also affects
the well-being of both mother and child. For example, obese
women are at an increased risk of health complications
during pregnancy, such as high blood pressure and
gestational diabetes.129 Maternal obesity is also associated
with an increased risk of fetal developmental complications
and childhood obesity.130 Rates of births to mothers who are
obese are about two times greater among African Americans
compared with whites in both St. Louis County and St. Louis
City (see figures 49 and 50). Smoking during pregnancy
is an example of a behavior that is known to cause health
complications for mothers and babies, including increased
risk of miscarriage, problems that lead to dangerous bleeding,
increased risk for preterm birth, and increased risk of birth
defects.131–133 Figures 49 and 50 show that rates of births to
mothers who smoked during pregnancy in St. Louis County
are similar among whites and African Americans (10% and
11%, respectively). In St. Louis City, 18% of African American
births were to women who smoked during pregnancy,
compared with 13% for whites.
As mentioned throughout this report, social and economic
factors and the surrounding environment influence behaviors
and health outcomes, and this holds true for behaviors and
diseases that affect maternal and child health. Smoking and
obesity are not only a result of personal choices. Research
shows that compared with African American women who
do not smoke, African American women smokers were more
likely to have lower levels of education, to enroll in prenatal
care late (in the second or third trimester), and to believe
that smoking did not harm them or their babies “a lot.”
Another study found that household food insecurity (i.e.,
lack of access to enough food for an active, healthy life for
all household members134) was associated with being severely
obese before pregnancy and with having greater weight gain
during pregnancy compared with women from food secure
households. Findings like these are important to consider
when developing and implementing programs to improve
the health of mothers and children.
Figure 49. Prenatal care and maternal health by race
in St. Louis County in 2011
31%
27%
18%
11%
10%
5%
Inadequate
prenatal care
Mother smoked
during pregnancy
Mother is obese
African Americans
Whites
Source: MODHSS, Birth MICA
Notes: Rates are per 100 (%) live births; prenatal care adequacy (Missouri Index); obese (≥30 BMI)
Figure 50. Prenatal care and maternal health by race
in St. Louis City in 2011
38%
30%
18%
15%
13%
8%
Inadequate
prenatal care
Mother smoked
during pregnancy
Whites
Mother is obese
African Americans
Source: MODHSS, Birth MICA
Notes: Rates are per 100 (%) live births; prenatal care adequacy (Missouri Index); obese (≥30 BMI)
Washington University in St. Louis and Saint Louis University 57
Infant health and social determinants of health
There are many indicators that help us assess the health
of infants. Two common indicators of infant health are
preterm birth and low birth weight. Preterm birth is defined
as the birth of an infant prior to 37 weeks of pregnancy,
which increases the risk of infant death and long-term
disabilities connected to children’s nervous systems. This is
because important growth of organ systems happens in the
final weeks of pregnancy. In the U.S., preterm birth affects
approximately 1 of every 8 babies (about 13%).135 In St. Louis
County, preterm birth affects African American infants (18%)
at a higher rate than the national average and at a higher rate
compared with whites (10%).136 Rates of preterm birth in the
County and the City are similar.137 Low birth weight refers
to infants who weigh 5.5 pounds or less at birth. In St. Louis
County, 14% of African American infants born in 2011 were
classified as low birth weight.138 This rate among African
American infants is a little over twice the rate of whites.
In St. Louis City, 17% of African American infants born in
2011 were classified as low birth weight.139 Likewise, this
rate is over twice the rate of whites.
Racial disparities also exist in infant mortality (i.e., the
death of children under 1 year of age). In the U.S., African
American infants are more than two times more likely to
die before the age of 1 compared with white infants. The
difference is higher in the St. Louis region, where African
American infants are 3 times more likely to die compared
with white infants. Figure 51 shows that in St. Louis County,
11 more African American infants per 1,000 die before their
first birthday compared with white infants. Figure 52 shows
that the difference in infant mortality by race in St. Louis
City is 10 more infants per 1,000.
Figure 51. Infant death rate in St. Louis County
AFRICAN AMERICANS
16*
WHITES
5
Per 1,000
Per 1,000
*11 more people per 1,000
Adapted from Visualizing Health (see resources)
Source: MODHSS, Infant Health Profile
Notes: Data years include 2000-2010
Figure 52. Infant death rate in St. Louis City
AFRICAN AMERICANS
15*
WHITES
5
Per 1,000
Per 1,000
*10 more people per 1,000
Adapted from Visualizing Health (see resources)
Source: MODHSS, Infant Health Profile
Notes: Data years include 2000-2010
There is growing awareness of the importance of
women’s health before and between pregnancies
(i.e. preconception health). This shift from exclusive
care during pregnancy to also considering
preconception health demonstrates an
understanding that a woman’s health over her
lifespan impacts her health and that of her baby
before, during, and after pregnancy.
Local progress to improve maternal and child health in Missouri and the St. Louis region
> T he Maternal, Child and Family Health
Coalition (MCFHC) fosters local and
national partnerships to improve
birth outcomes and promote healthy
families and communities. Examples
of MCFHC initiatives and partnerships
include St. Louis Healthy Start and
the Gateway Immunization Coalition.
> Nurses for Newborns provides
home-based education, healthcare,
and positive parenting skills. Nurse
58 For The Sake Of All
home visitors provide many services
to women and children at risk,
including physical and mental health
assessments, referrals to specialized
services, and help connect women
with local resources.
> Parents as Teachers provides
information and support that parents
need to help their children develop
optimally during the early years of life.
Parents as teachers develop curricula,
train professionals, and provide
many services and resources,
including an evidence-based
home visiting model.140
> T he Nurse-Family Partnership
is a nationally-recognized, evidencebased program141 implemented
through the St. Louis County Health
Department. This program provides
nurse home visitation services to
low-income, first-time mothers.
Higher levels of education benefit women and their children
in many ways, including increased knowledge of health and
healthy behaviors, increased resources, and greater access
to quality health care. The relationship between maternal
education and infant health was described on page 41.
Among African American infants in St. Louis County, 16%
have mothers with less than 12 years of education, and that
percentage is even higher in St. Louis City (29%). African
American infants are three times more likely to have a
mother with less than 12 years of education compared with
white infants. Although education is essential to improving
maternal and child health, disparities in birth outcomes by
race exist within each level of education (see page 41).
to their first birthday. It is possible for the percentages reported
to exceed 100% due to in-migration to St. Louis County and
St. Louis City. WIC is a special supplemental nutrition program
that serves pregnant women, new mothers, and children
under the age of five, and provides food and services like health
screening, nutrition education, and breastfeeding promotion.143
Median family incomes and enrollment in programs for
low-income families indicate that African American infants
in the County and the City are also more likely to live in
low-income families compared with white infants. Among
African American infants born in 2010 in St. Louis County
and St. Louis City, 72% (County) and 94% (City) were eligible
for Medicaid (figures 53 and 54). Participation in the Women,
Infants and Children (WIC) program among African American
infants was even higher. Among African American infants born
in 2008 in St. Louis County and St. Louis City, 80% (County)
and approximately 100% (City) were eligible for WIC.142
Residents are eligible for the WIC Infant program from birth
Researchers have tried to explain the differences in rates of
adverse birth and infant health outcomes by race. Differences
in behavior and socioeconomic status are part of the
explanation. However, other factors like neighborhood quality,
stress, health care access and quality, and exposure to racial
discrimination also help explain these disparities.144–146 For
example, a recent study found that everyday discrimination
was associated with lower birth weight and that this
relationship is mediated by maternal depression (i.e., women
who experienced greater discrimination experienced more
depressive symptoms and these symptoms were associated
with lower infant birth weight).147 Another study showed
that neighborhood conditions such as poverty levels,
unemployment, and education contributed to preterm birth
differences between African Americans and whites.148 It is also
important to understand that pregnancy and birth-related
outcomes are influenced by many factors, and that these
outcomes are interrelated. For example, preterm birth is a risk
factor for infant mortality.149
Figure 53. Mother’s education status and Medicaid
eligibility by race in St. Louis County
Figure 54. Mother’s education status and Medicaid
eligibility by race in St. Louis City
94%
72%
22%
32%
29%
16%
9%
5%
Mother has less than
12 years of education
Whites
Infants eligible for
Medicaid
African Americans
Mother has less than
12 years of education
Whites
Infants eligible for
Medicaid
African Americans
Source: MODHSS, Birth MICA; MODHSS Infant Health Profile
Source: MODHSS, Birth MICA; MODHSS Infant Health Profile
Notes: Mother’s education (2011); Infants on Medicaid (2010); infants on Medicaid refers to number of
resident infants (less than one year of age) eligible for Medicaid (having a Medicaid card -unduplicative
count) on December 31 of given year and the percent this number is of total resident live births for
calendar year. Medicaid status is acquired from Department of Social Services files. Percent may be over
100 due to in migration to geographic area.
Notes: Mother’s education (2011); Infants on Medicaid (2010); infants on Medicaid refers to number of
resident infants (less than one year of age) eligible for Medicaid (having a Medicaid card -unduplicative
count) on December 31 of given year and the percent this number is of total resident live births for
calendar year. Medicaid status is acquired from Department of Social Services files. Percent may be over
100 due to in migration to geographic area.
Washington University in St. Louis and Saint Louis University 59
5.5 Mental health
While the specific causes and symptoms of mental health
problems differ for everyone, mental health can have a
tremendous impact on social functioning and economic
status. This is true not only for an individual, but for entire
families. Persons with mental health conditions are at
increased risk for school dropout, imprisonment, and lower
income throughout their lives.150–152 There are also links
between poor mental health and physical health problems
such as heart disease and diabetes.153,154
Persons with mental health
conditions are at increased risk for
school dropout, imprisonment, and
lower income throughout their lives.
Mental health conditions include mood disorders such as
depression and bipolar disorder and anxiety disorders such
as generalized anxiety disorder and post-traumatic stress
disorder. Mental health conditions can develop from early
childhood through late life. The impacts can range from
having no symptoms to severe impairment in daily activities
to suicidal thoughts and actions.
Prevalence of mental health conditions
Nationally, about 19% of the general public has some type
of mental illness.155 About 4% have a serious mental illness,
such as schizophrenia, that substantially interferes with daily
functioning.156 There are not significant national differences
in mental health prevalence between whites and African
Americans.157 For serious mental illness, the rate for whites
is 4%, compared to 3% for African Americans.158 Figure 55
shows the number of days all adults reported poor mental
health in St. Louis City and St. Louis County.
Figure 55. Poor mental health days among all adults
in St. Louis City and St. Louis County
In St. Louis City, adults spend 4.5 DAYS A MONTH in poor mental health.
In St. Louis County the figure is 3 DAYS A MONTH. That’s nearly half a
week or more feeling hopeless, anxious or overwhelmed.
SUN.
MON.
TUES.
WED.
THURS.
FRI.
SAT.
Source: University of Wisconsin Population Health Institute, County Health Rankings & Roadmaps 2014
Notes: Indicators are age-adjusted; derived from Behavioral Risk Factor Surveillance System (BRFSS); data
years include 2006-2012
60 For The Sake Of All
Diagnosis (28% vs. 12%) and treatment with medication
(21% vs. 10%) for mental illness is twice as high for African
American youth as white youth.159 Additionally, 36% of
African American parents in St. Louis County reported
drug and alcohol abuse as a challenge for youth in their
neighborhoods.160 Comparable data was not available for
St. Louis City youth.
Mental health impacts
Mental health can impact several areas of a person’s
life. Poor mental health in early childhood is associated
with higher rates of school dropout,161 lower household
income,162,163 higher rates of divorce,164 and higher rates
of incarceration later in life.165,166 Drug and alcohol use
disorders are also more common for individuals with
mental illness.167 Mental health conditions that begin early
in life are also associated with imprisonment.168,169 A 2012
study of mental health in the criminal justice system found
that imprisoned men and women had a rate of serious
mental illness three times that of the general population.170
Approximately 64% of individuals in jail and prison have
mental health conditions.171 Racial and ethnic minorities
are overrepresented in the prison system, with 1 in 3
African American males incarcerated at some point in
their lives.172 As noted in the demographic overview,
African Americans account for 42% of St. Louis residents
in correctional facilities, though they are less than 30%
of the regional population.
Mental health and race
We have already established that African Americans have
higher poverty, lower income, and higher unemployment
compared to whites in St. Louis County and St. Louis City.
We have also seen that African Americans often have worse
health outcomes compared to others. Considering these data,
it may be surprising to see that African Americans have lower
rates of mental illness at a national level. In St. Louis County
and St. Louis City, African American adults have lower rates
of depression compared to whites. Depression affects 17%
of African Americans compared with 20% of whites in
St. Louis County.173 In St. Louis City, depression affects 16%
of African Americans compared with 25% of whites.174 While
these findings are consistent with results from national
studies, it seems puzzling considering the economic and
physical health disparities described above. However, estimates
of alcohol and substance abuse disorders are higher in St. Louis
for African Americans compared to whites. Also, social stigma
connected to mental illness or mistrust of mental health care
can keep people from seeking the treatment they need.175,176
Despite lower rates of depression, there are large differences
in mental health treatment between African Americans and
whites in St. Louis County and St. Louis City. Figure 56
shows emergency room (ER) visit rates for all mental health
conditions in St. Louis City and St. Louis County combined.
The African American ER visit rate is 121% higher than
that of whites. African Americans visited the ER for serious
mental illness (schizophrenia and related disorders) at
a rate nearly 10 times that of whites (2.9 compared to
0.3 per 1,000).177 Rates for alcohol and substance-related
visits are also higher for African Americans compared with
that of whites (6.2 compared to 3.1 per 1,000).178
Figure 56. Emergency room rates due to mental health
conditions by race in St. Louis County and St. Louis City
in 2011
121%
Higher
9.6
21.2
Whites
African
Americans
B
Beacon story summary: The need for
community-based mental health
Struggling with depression, graphic
artist La’Shay Williams shared her
story with the St. Louis Beacon.
When experiences with two bad
relationships left her feeling she
had no way out, Williams chose not
to seek help from a mental health
professional for her depression and
turned to her faith to help her heal.
The article reports on the stigma associated with mental
illness that keeps many African Americans from seeking
professional treatment for mental health issues like
depression, anxiety, substance abuse, and schizophrenia.
Research shows that better awareness and screening
for mental illness can make treatment more accessible.
The World Health Organization recommends communitybased mental health services such as mental health
centers and awareness campaigns to help reduce the
stigma associated with mental health treatment and
prevent costly and ineffective trips to the emergency
room. Additionally, increased data collection and sharing
has been shown to improve mental health awareness and
knowledge in racial and ethnic minority communities.
Story by the St. Louis Beacon
Source: MODHSS, Emergency Room MICA
Notes: Rates are per 1,000 and age adjusted using US 2000 standard population
Figure 57 shows the differences by race for inpatient
hospitalizations for all mental health conditions. The African
American hospitalization rate is 64% higher than that of
whites. The difference in hospitalization rates for serious
mental illness (schizophrenia) is particularly striking —
African Americans have a rate (64.9 per 10,000) nearly
5 times that of whites (14.3 per 10,000).179 Hospitalization,
the most expensive and least effective treatment option
for mental illness, is often the only source of health care
for many individuals.
High hospitalization rates for mental health point
to a lack of access to care for many living in St. Louis.
The North St. Louis Health Care Access Study found that
access to mental health services was lowest for racial and
ethnic minority and low-income residents.180 Moreover,
the report found that many residents in North St. Louis
City felt the only ways to access mental health care were
through acts of violence, jail, or psychosis.181
Figure 57. Inpatient hospitalization rates due to mental
health conditions by race in St. Louis County and
St. Louis City in 2011
64%
Higher
119.5
195.6
Whites
African
Americans
Source: MODHSS, Inpatient Hospitalization MICA
Notes: Rates are per 10,000 and age adjusted using US 2000 standard population
Washington University in St. Louis and Saint Louis University 61
Hospital charges for mental health in St. Louis
Local mental health resources
Annual hospital charges in 2011 for mental health conditions
were estimated to be $230 million in St. Louis City and
St. Louis County combined. Among African Americans
alone, that figure is $96 million.182 This means that charges
for hospital-based mental health treatment for African
Americans, who make up about 30% of the population in the
St. Louis region, amounts to 42% of the charges for treatment
for all of St. Louis City and County.183
> T he Amanda Luckett Murphy Hopewell Center takes
a community-based approach to mental health care,
providing comprehensive inpatient and outpatient
mental health services, transportation assistance,
and community integration programming.
Annual hospital charges for mental health
conditions in 2011 in St. Louis
> Places for People serves diverse community members,
including people who experience mental disorders,
homelessness, trauma, medical disorders, and
substance abuse disorders. In addition to providing
mental health services, they provide assistance with
medication and housing.
$96 million
> Mental Health First Aid Missouri is one example of an
effort to raise awareness of mental health conditions.
This is a course to educate the general public about
how to recognize mental health conditions.
AFRICAN AMERICANS
$230 million
ALL ST. LOUIS RESIDENTS
Mental health and suicide
Nationally, suicide is the 10th leading cause of death for all
ages, but the 4th leading cause of death for those between
18 and 65 years old.184 St. Louis suicide rates mirror national
trends, with lower rates for African Americans compared
to whites (see table 15). Many individuals with mental
health conditions are at high risk for suicide, and those with
co-occurring substance use issues are at even higher risk.
Though rates of common types of mental illness are lower
for African Americans in St. Louis, access to mental health
treatment remains a challenge, as it does for the region as a
whole. Both greater awareness and investment are needed
to address lack of access to vital mental health treatment.
Eliminating racial and ethnic differences in mental health
could save as much as $27 million in inpatient hospital
charges. Other economic impacts associated with poor
mental health include crime, imprisonment, reduced
earnings and employment, and family disruption.
Table 15. Suicide rates by race in 2011
St. Louis County
African Americans
Whites
St. Louis City
City & County Combined
Number
Rate
Number
Rate
Number
Rate
9
3.6*
13
9.0*
22
5.8
120
16
28
17.9
148
16.2
Source: MODHSS, Death MICA
Notes: Rates are per 100,000 and age adjusted using US 2000 standard population; *rate is unstable (numerator less than 20)
5.6 Violence and injury
Violence has been identified as a public health issue
for several decades. Agencies like the Centers for Disease
Control and Prevention (CDC) and the World Health
Organization (WHO) suggest that the problem of violence
must be addressed like other public health problems:
through collaboration across multiple sectors of society.
We noted previously that behavior was essential to
62 For The Sake Of All
preventing chronic disease, and preventing violence also
means changing behavior.185 Not just individual behavior,
but the health, social, and environmental conditions that
are associated with violence also must be addressed.186 In this
way the public health approach to violence is also similar to
the response to infectious diseases like tuberculosis, small
pox, and polio. By understanding how violence is “transmitted”
in a community, we can take steps to prevent it.
Homicide
The overall homicide death rate in 2011 among African
Americans is more than twice as high in St. Louis City
(53 per 100,000) compared to St. Louis County (24 per
100,000).187 A large proportion of the homicide deaths in
2011 among African Americans in both the County (90%)
and City (87%) were due to firearms.188 The homicide death
rate among African Americans in St. Louis County and
St. Louis City combined is more than 12 times higher than
the rate for whites (figure 58). Interventions that support
nurturing relationships between parents and children,
conflict resolution, job skills training, youth mentoring,
and strategies that address unemployment and access
to quality education have been identified as effective in
preventing homicide and other violent crimes.189 There
are also interventions like Cure Violence (see description
in box to the right) that have been successful in violence
prevention by using trusted community members to
“interrupt transmission.”190
Figure 58. Homicide death rates by race in St. Louis
County and St. Louis City in 2011
Homicide rate per 100,000
36
3
African Americans
Whites
Source: MODHSS, Death MICA
Notes: Rates are per 100,000 and age adjusted using US 2000 standard population
Cure Violence
Founded by physician and epidemiologist, Dr. Gary
Slutkin, Cure Violence is a Chicago-based organization
that has experienced success in addressing homicide
using a public health model. Cure Violence’s prevention
strategy includes three steps using the terminology of
the spread of disease: 1) Interrupt “transmission” of
acts of violence, 2) Identify and change the thinking
of highest potential “transmitters” of violence, and 3)
Change group norms about the acceptability of violence
in communities. Originally established under the name
Cease Fire, Inc, the organization was credited with
helping to reduce crime in its target area by 67% in
its first year. The model has already been replicated
50 times in 15 cities and 8 countries.
Youth violence
Although homicide no longer ranks among the top fifteen
leading causes of death in adults, it is still the second leading
cause of death in youth ages 13 to 24 nationwide.191 Homicide
is the number one cause of death for African-American
youth ages 10 to 24.192
Local data are equally troubling. Last year the St. Louis
Regional Youth Violence Prevention Task Force Community
Plan reported that St. Louis ranks second nationally in the
rate of youth killed by gun violence at 50 per 100,000 —
a rate that is three times the national average of youth killed
by gun violence, and that is high even for some of the most
violent regions in the world.193 The community plan also
reported that 85% of youth in St. Louis City and 31% of
youth in St. Louis County live in environments that have at
least one risk factor for violence. These risk factors include
teen parenthood, frequent changes in residence, and singleparent households.194
Neighborhood violence can affect youth in the region even
if they are not personally involved in violent activity. Some
parents refuse to allow their children to play outdoors
or walk to and from school because of the fear of violent
crime.195 Nearly a third of African American parents (31%)
in St. Louis County say that youth violence and gang activity
are serious concerns.196
Washington University in St. Louis and Saint Louis University 63
Firearm injuries
St. Louis Regional Youth Violence
Prevention Task Force
In 2012, St. Louis Mayor Francis Slay and his Commission
on Children, Youth and Families partnered with over 200
community stakeholders to develop a comprehensive
youth violence prevention plan for the region.
This 55-page report describes the St. Louis metropolitan
area’s youth violence statistics and the task force
recommendations in the areas of prevention, intervention,
enforcement, and re-entry. The report also includes
examples of organizations doing work in the St. Louis
Region to address youth development. A link to the report
is available under Resources.
While thousands of people are killed by firearms annually,
the vast majority of those injured survive.197 In 2012 the
United States experienced 81,396 firearm injuries, the
highest number ever recorded. Thirty-four percent of
those injured were African American, even though African
Americans make up only 12 – 13% of the U.S. population.
African Americans have been injured by firearms more
than any other group for many years.198
African Americans in St. Louis are also disproportionately
affected by firearm injuries. The rate of African American
firearm injuries in St. Louis County is 16 times higher
than the rate for whites in St. Louis County and the rate
for African Americans in St. Louis City is 12 times higher
than it is for whites (see table 16).
Table 16. Firearm injury rates by race in 2011
Injury
Even when violence does not end in death, African Americans
in St. Louis are more likely to be victimized. In the City of
St. Louis and St. Louis County, African Americans are 5 times
more likely to be injured in a fight, 1.3 times more likely
to overdose from drugs or alcohol, 6 times more likely to be
injured from abuse, neglect or rape, and 17 times more likely
to be injured by firearms (figure 59).
St. Louis County
St. Louis City
City and
County
combined
111
209
150
7
18
9
African Americans
Whites
Source: MODHSS, Death MICA
Notes: Rates are per 100,000 and age adjusted using US 2000 standard population
Figure 59. Injury rates by mechanism by race in St. Louis
County and St. Louis City in 2011
81
Fight
398
Drug or
Alcohol
Overdose
Firearm
229
299
9
150
Abuse,
Neglect, or
Rape
Whites
African Americans
35
206
Injury Rates per 100,000
Source: MODHSS, Injury MICA
Notes: Rates are per 100,000 and age adjusted using US 2000 standard population
64 For The Sake Of All
The impact of violence
When violence is experienced at a young age it can result
in substance abuse, learning disabilities, post-traumatic stress
syndrome, anxiety, depression and severe physical harm.199
There are also long-term social and health issues like poverty,
low educational attainment, and maternal and child health
problems. At the level of communities, violence severs
basic human connections, engendering fear, social isolation,
and helplessness.200–202
Not only is violence harmful to health and well-being; it is
costly. According to the CDC, the cost of the 51,173 violent
deaths in 2005 totaled $215 million dollars in medical charges
and $47 billion in work loss costs for that year.203
The Public Health Approach
Violence demands an approach that is very similar to
how we would fight a disease. The public health approach
to violence offers a clear framework for preventing violence
and addressing its negative health, economic, and other
social consequences.
The steps of the public health approach
1
Surveillance
What is the problem?
Define the violence problem through
systematic data collection.
4
2
Implementation
Identify Risk & Protective Factors
Scaling up effective policy & programs
Scale-up effective and promising
interventions and evaluate their impact
and cost-effectiveness.
What are the causes?
Conduct research to find out why
violence occurs and who it affects.
3
Develop & Evaluate Intervention
What works and for whom?
Design, implement and evaluate
interventions to see what works.
Source: World Health Organization
5.7 HIV/AIDS and other STDs
Infections can often be a direct cause of disease. Infectious
diseases are caused by an organism like a bacteria or virus.
Despite significant improvements over the last century,
infectious diseases are still a major cause of death and
disability.204 In St. Louis, sexually transmitted diseases (STDs)
and HIV/AIDS are two major types of infectious disease that
impact well-being. HIV/AIDS is also a cause of death for
those in St. Louis County and St. Louis City.205
STDs and HIV/AIDS
In St. Louis County and St. Louis City, there are large
differences in rates of STDs and HIV/AIDS between
African Americans and whites (see tables 17 – 19).
Like other aspects of health, social and economic factors
are important contributors to these differences.206
Factors like income, unemployment, education and
segregation all contribute to the prevalence of STDs.207–212
The wide differences in STD rates are unlikely to be the
result of differences in sexual behaviors. For example,
national data show that there are only small differences
in sexual behaviors between African American and white
women.213 Moreover, it has been suggested that behaviors like
condom use cannot fully account for the differences seen in
STD rates.214–216 Efforts to reduce differences in STDs must
address the underlying social and economic differences that
exist. Discrimination based on sexual orientation and stigma
associated with HIV in particular also make efforts to address
HIV/AIDS more challenging.217 STDs are of concern because,
if left untreated, they can lead to multiple health problems.
For example, untreated STDs may increase risk of certain
cancers, increase risk of infertility, support the transmission
of HIV, and harm babies born to infected mothers.218
Factors like income, unemployment,
education and segregation all
contribute to the prevalence of STDs.
As shown on page 45, African American female adolescents
(age 15-19) have high rates of gonorrhea and chlamydia in
St. Louis County and St. Louis City. Previous studies have
also shown that adolescent females experience higher rates
of STDs.219,220 This is partially explained by sexual partner
characteristics. Adolescent females who have older male
sexual partners increase their risk for STDs.221 Older male
partners are more likely to have had multiple sexual partners
throughout their lives and are more likely to be already
infected compared with younger partners.222 Also, adolescent
females are less likely to use contraceptives.223 These are
just some of the reasons why it has been suggested that
adolescent females who have sex with older male partners
are at higher risk for STDs and HIV.224–227
Washington University in St. Louis and Saint Louis University 65
Gonorrhea and chlamydia
Gonorrhea and chlamydia are two common types of
sexually transmitted disease. Table 17 shows gonorrhea
and chlamydia rates among African American and white
females in St. Louis County and St. Louis City. (To our
knowledge, comparable data for African American males
is not publicly available for St. Louis County and St. Louis
City.) In St. Louis County, African American females have
a gonorrhea rate that is 22 times higher than white females,
and the chlamydia rate is 13 times higher among African
American females compared with whites. STD rates are
higher in St. Louis City compared with St. Louis County.
Large disparities also exist in St. Louis City. The gonorrhea
rate among African American females is 15 times higher
compared with white females, and the chlamydia rate is
13 times higher among African American females compared
with white females. Figures 60 and 61 highlight the
differences in chlamydia rates between African American
and white females in St. Louis County and St. Louis City.
Table 17. STD rates among females (age 15 – 44),
2007 – 2009
St. Louis County
St. Louis City
Gonorrhea
Cases
Rate
Cases
Rate
African Americans
1,771
1,037.9
2,266
2,041.7
182
46.5
139
135.2
Chlamydia
Cases
Rate
Cases
Rate
African Americans
5,470
3,205.7
6,299
5,675.6
970
247.9
463
450.2
Whites
Figure 61. Chlamydia rates among females (age 15 – 44)
in St. Louis County, 2007 – 2009
AFRICAN AMERICAN FEMALES
WHITE FEMALES
3,206*
248
Per 100,000
Per 100,000
*2,958 more people per 100,000
Adapted from Visualizing Health (see resources)
Source: MODHSS, Women’s Reproductive Health Profile
HIV/AIDS
HIV (human immunodeficiency virus) is a virus that can
be transmitted in many ways. For example, from mother to
child during pregnancy, birth, and breast feeding, through
injection drug use, or sexual contact. HIV can eventually
lead to AIDS (acquired immunodeficiency syndrome). There
is no cure for this disease, but it can be managed through
treatment and care. Survival for individuals with HIV has
increased with better treatment. Many live as long as those
who are uninfected. However, many of the same factors
we have described as interfering with health also impact
whether individuals receive adequate treatment for HIV.
Table 18. Newly diagnosed HIV cases and rates by race
in 2012
Whites
Whites
African Americans
Cases
%
Rate*
Cases
%
Rate*
St. Louis City
32
30.5%
23.2
68
64.8%
44.6
St. Louis County
21
19.4%
3.1
81
75.0%
35
Source: MODHSS, Women’s Reproductive Health Profile
Notes: Rates are per 100,000 females ages 15 – 44; data years include 2007 – 2009
Source: MODHSS, 2012 Epidemiologic Profile of HIV, STD and Hepatitis in Missouri
Notes: Rates are per 100,000; row percentages are shown; percentages do not total 100% because other
race/ethnicities are not shown
Figure 60. Chlamydia rates among females (age 15 – 44)
in St. Louis City, 2007 – 2009
AFRICAN AMERICAN FEMALES
5,676*
Per 100,000
*5,226 more people per 100,000
Adapted from Visualizing Health (see resources)
Source: MODHSS, Women’s Reproductive Health Profile
66 For The Sake Of All
WHITE FEMALES
450
Per 100,000
In St. Louis City and St. Louis County, there were 213 newly
diagnosed HIV cases in 2012.228 Despite being about 30%
of the population in these two counties combined, African
Americans represented 70% of new HIV cases. African
Americans represented 65% of the 105 new HIV cases in
St. Louis City. This imbalance is even more pronounced in
St. Louis County, where African Americans represented 75%
of the 108 new HIV cases (see table 18). Rates represent a
standard way of measuring the amount of disease between
populations. In St. Louis City, the HIV rate among African
Americans (44.6) is twice as large compared with whites
(23.2). The disparity is even wider in St. Louis County. The
HIV rate among African Americans (35) is 11 times larger
compared with whites (3.1).
Table 19. Newly diagnosed AIDS cases and rates by
race in 2012
Whites
African Americans
Cases
%
Rate*
Cases
%
Rate*
St. Louis City
9
40.9%
6.5
11
50.0%
7.2
St. Louis County
8
28.6%
1.2
19
67.9%
8.2
St. Louis Effort for AIDS is a non-profit
organization dedicated to providing education
about HIV/AIDS prevention. The organization
also offers comprehensive services to those
impacted by HIV/AIDS. Some of these services
include free and confidential testing and
support groups.
Source: MODHSS, 2012 Epidemiologic Profile of HIV, STD and Hepatitis in Missouri
Note: Rates are per 100,000; row percentages are shown; percentages may not total due to rounding
AIDS is the stage of HIV infection when the immune system
is severely damaged. When this happens, the body becomes
susceptible to infections and cancers that are linked to
infection. When indicators of immune system functioning
in the blood fall below a certain threshold, it has progressed
to AIDS. Without medical care, those with AIDS are less
likely to survive.229 In St. Louis City and St. Louis County,
there were 50 newly diagnosed cases of AIDS in 2012.230
In St. Louis City, African American represented 50% of
new AIDS cases. In St. Louis County, African Americans
represented 68% of new AIDS cases (see table 19). The
AIDS rate in St. Louis City is slightly larger among African
Americans compared to whites. However, the AIDS rate in
St. Louis County is a different picture. The AIDS rate among
African Americans is almost 7 times higher than whites in
St. Louis County. It should be noted that these rates may not
be reliable given the small number of cases involved. For this
reason, these rates should be viewed with caution.
HIV in St. Louis City
This map highlights HIV cases that occurred between 2006
and 2011 in St. Louis City. The map identifies hot spots or
clusters of HIV cases in neighborhood areas called census
tracts. The highest rates are in red and lowest in blue. HIV
hot spots are located in parts of the central corridor and
neighborhoods just below. Areas in the most southern parts
of St. Louis City have the lowest rates of HIV (cold spots).
The location or geography of where HIV cases occur is
becoming recognized as one of the most important factors
that shape patterns of HIV.
Figure 62. HIV cases in St. Louis City (2006 – 2011)
HIV/AIDS can eventually lead to death. There were a total
of 375 deaths due to HIV/AIDS from 2001 – 2011 among
African Americans in St. Louis County and St. Louis City.231
In St. Louis County, the HIV/AIDS death rate for African
Americans (6 deaths per year per 100,000) is 6 times higher
than whites (1 death per year per 100,000).232 In St. Louis
City, the HIV/AIDS death rate for African Americans
(14 deaths per year per 100,000) is over twice as high as
the death rate for whites (6 deaths per year per 100,000).233
N
Source: Hot spot analysis and map by Enbal Shacham, PhD, MEd, MPE
Notes: Hot spot analysis calculated using the Getis-Ord Gi* statistic; HIV cases are controlled for four
census tract level factors including: percent African American, percent below poverty, percent below
high school, and percent between 15 and 44 years.
Washington University in St. Louis and Saint Louis University 67
06
RECOMMENDATIONS
We cannot afford to continue like this.
Something has to change in order for everyone
in the St. Louis region to be able to thrive
and contribute to its growth and vitality.
68 For The Sake Of All
Even though we face considerable challenges to ensure
Targeted investments and strategies include:
health and well-being for the sake of all in the St. Louis
> Making college savings accounts universally available for
region, there are tangible steps we can take to address
children at birth or school entry, and providing additional
those challenges. We have highlighted some examples for
savings as incentives for educational success and parental
this community and other communities around the country
engagement throughout K-12 schooling.
throughout this report. The following is a specific set of
policy and programmatic recommendations responding
> Making financial advice and services easily accessible
to the major themes of our briefs and this report. We
and affordable to families at all income levels.
have underlined where the recommendations have been
modified to respond to themes that emerged from the
3 Invest in coordinated school health
Community Feedback Forum (see pages 07-08).
1
programs for all students.
Invest in quality early childhood
development for all children.
Poor health can be a serious barrier to educational success.
Every $1 invested in early childhood returns between
$7 and $17 of benefit for society.
Setting up children to succeed at the youngest ages has
powerful health effects as well. A recent study showed that
individuals who had high-quality early childhood programming
as children were less likely to have risk factors for heart disease
and diabetes in their mid-30s.234
Targeted investments and strategies include:
> Expanding all children’s access to well-designed
early childhood programs with a) small class sizes,
b) qualified teachers, c) significant time spent on
instruction, d) school-family partnerships, and
e) an emphasis on social and emotional development
in addition to academic preparation.
> Improving the level of child care subsidies for
low-income families
> Expanding home visitation services and other supports
to parents that cover the prenatal through early
childhood period
2
Help low-to-moderate income families
create economic opportunities.
Targeted investments and strategies include:
> Expanding coordinated school health programs to all
schools, particularly those in high-poverty communities.
> Making positive child and youth development
opportunities available through afterschool and other
programming in partnership with the community.
> Implementing evaluation, technical assistance, and
resource plans to support school districts in their efforts
to create or expand coordinated school health programs.
> Fully funding early childhood programs at the state level
> Implementing a quality improvement process with
accountability measures
According to the Centers for Disease Control and Prevention,
health activities in schools need to be better integrated
and coordinated. Bringing the main parts of school health
together through an organized approach can help schools
improve service delivery, build partnerships, and develop
healthy behaviors in students and staff.
> Building private-public partnerships to support
coordinated school health efforts.
4
I nvest in mental health awareness,
screening, treatment, and surveillance.
There is a significant need for accessible, community-based
mental health services in the St. Louis region.
Without greater investment in this area, there are large
social and economic costs. The region must also change
norms around seeking necessary mental health treatment
as a vital part of addressing care of overall health.
Children who have savings in their names — even in small
amounts — are up to 3 times more likely to attend college
and 4 times more likely to graduate compared with students
without savings. 235
Targeted investments and strategies include:
There is emerging evidence that having financial assets like
college savings accounts is associated with better social and
emotional development for children236 and lower levels of
depressive symptoms for mothers.237
> Improving mental health awareness using community-wide
education to change community norms and increasing
screenings in medical and other settings.
> Investing in counseling and psychological services for
young people through private and public sources.
Washington University in St. Louis and Saint Louis University 69
> Investing in more outpatient community mental
health centers, particularly in areas of need, and
coordinate screenings and referrals for high-risk
populations.
6
> Improving the quality and availability of mental health
data by establishing regional systems for tracking and
reporting on the prevalence of mental health conditions
and their treatment.
5
Invest in quality neighborhoods
for all in St. Louis.
Our region continues to be divided along lines of race
and social class, and where you live has a considerable
impact on your health.
Neighborhoods also offer very different opportunities
to engage in a healthy lifestyle.
Targeted investments and strategies include:
> Promoting development and housing choice without
displacement.
> Investing in the viability, stabilization, and health
promotion of neighborhoods through strategic community
partnerships and regional economic integration.
oordinate and expand chronic
C
and infectious disease prevention
and management.
Chronic and infectious diseases carry large human
and economic costs for our region.
The heath care sector needs partners to adequately
address this burden of disease. Cross-sector collaboration
and investment is needed to make St. Louis a healthy and
productive place to live.
Targeted investments and strategies include:
> Expanding health promotion partnerships across sectors
to address chronic diseases that are the leading causes
of death in the region.
> Addressing social and economic barriers to health in
medical settings.
> Considering the health impacts of all policies at the state
and local level.
> Investing in chronic and infectious disease prevention
and management by making healthy behavioral choices
easy choices.
> Addressing violence as a public health problem that
impacts the quality of neighborhoods.
> Using tax, zoning, and other housing policies to allow
residents choice and voice in development.
> Promoting the benefits of diverse neighborhoods
through community partnerships that highlight model
communities.
> Safeguarding fair housing by enforcing existing laws.
Call to action:
> Business: establish private-public
partnerships to advance education,
economic development, and health;
invest in employee health
> Philanthropies: incentivize work across
sectors; focus on social determinants to
impact health
policy across sectors (e.g., education
and economic development impact on
health)
> Early childhood providers: adopt
standards for high quality programming;
integrate health in delivery of services
> Education: implement coordinated
school health and school-based health
care; ensure educational equity
> Health care systems: expand notion
of health to include social and economic
factors; enhance community partnerships
and presence in areas of high need
> Local and state policy makers: examine
health in all policies; consider impact of
> Community and economic development:
make neighborhoods accessible across
70 For The Sake Of All
socioeconomic lines; foster development
without displacement; focus on features
of neighborhoods that support health;
include everyone in economic benefits
of development
> Individual community members and
community groups: contact elected
representatives and ask them to consider
policies in line with recommendations;
organize your own community-level
response to recommendations; seek out
more information about promising and
proven strategies and support them
GLOSSARY OF TERMS
Age-adjusted rate
Age adjusting rates is a way to make fairer comparisons
between groups with different age distributions. For example,
a county having a higher percentage of elderly people may
have a higher rate of death or hospitalization than a county
with a younger population, merely because the elderly are
more likely to die or be hospitalized. Age adjustment can
make the different groups more comparable.
Health
The state of complete physical, mental, and social well-being,
and not merely the absence of disease or infirmity. Health has
many dimensions-anatomical, physiological and mental-and
is largely culturally defined.
Health disparities
Differences in morbidity and mortality due to various causes
experienced by specific sub-populations.
Hospital charges
Charges are the total amount of billed charges for the
hospital stay (i.e., hospitalization). Charges do not necessarily
reflect costs of providing services or the final reimbursement
amount. Hospitalizations refer to hospital discharges of
St. Louis County and St. Louis City residents from nonfederal and non-state acute care (average days of care less
than 30 days) general and specialty hospitals whose facilities
are open to the general public.
Life expectancy at birth
Provides an estimate of the number of years a person is
expected to live. It is a good measure of the overall health of
an area. Life expectancy is calculated using birth, death, and
population data.
Live birth
Live birth is defined as the complete expulsion or extraction
from its mother of a child, irrespective of the duration of
pregnancy, which after such expulsion or extraction, breathes
or shows any other evidence of life such as beating of the
heart, pulsation of the umbilical cord, or definite movement
of voluntary muscles, whether or not the umbilical cord has
been cut or the placenta is attached. The definition is also
irrespective of birth weight.
Morbidity
A measure of disease incidence or prevalence in a given
population, location or other grouping of interest.
Mortality
A measure of deaths in a given population, location or other
grouping of interest.
Prevalence
The proportion (usually a percentage) of a population that
has a defined risk factor, disease, or condition at a particular
point in time.
Rates
A rate is a ratio of those having the event of interest to the
population of those at risk of having the given health event.
Rates are calculated by dividing the number of events by
the population at risk, or a related population, and then
multiplying by a constant.
Socioeconomic gradient in health
This term refers to the stepwise fashion health outcomes
improve as socioeconomic status improves. This gradient can
be measured by a person’s income, occupation, or the highest
level of education he or she has.
Social determinants of health
The social determinants of health are conditions in the
environments in which people are born, live, learn, work,
play, and age that affect a wide range of health, functioning,
and quality of life outcomes and risks.
Vital statistics
The data derived from certificates and reports of birth, death,
spontaneous fetal death, marriage, dissolution of marriage
and related reports.
Washington University in St. Louis and Saint Louis University 71
RESOURCES
Nurses for Newborns
http://www.nfnf.org/index.php
Amanda Lockett Murphy Hopewell Center
http://www.hopewellcenter.com/
Nurse-Family Partnership (Building Blocks in Missouri)
http://www.stlouisco.com/HealthandWellness
HealthCentersandMedicalServices
PublicHealthNursingProgram/NurseFamilyPartnership
American Community Survey
http://www.census.gov/acs/www/Downloads/data_
documentation/Accuracy/ACS_Accuracy_of_Data_2012.pdf
American Graduate
http://americangraduate.ninenet.org/
Beyond Housing
http://www.beyondhousing.org/
Community Data Profiles
http://health.mo.gov/data/CommunityDataProfiles/index.html
Coordinated School Health (CDC)
http://www.cdc.gov/HealthyYouth/cshp/
Cure Violence
http://cureviolence.org
Delmar Divide (BBC)
http://www.bbc.com/news/magazine-17361995
Estimated cost of life lost and deaths due to social factors
http://forthesakeofall.files.wordpress.com/2013/08/brief1_
appendix.pdf
OneSTL
http://www.onestl.org/
Parents as Teachers
http://www.parentsasteachers.org/
Patient Abstract System (PAS)
http://health.mo.gov/data/patientabstractsystem/index.php
Places for People
http://www.placesforpeople.org/
Preconception health in St. Louis (MCFHC)
http://stl-mcfhc.org/docs/mcfhc_womens_health_report.pdf
Project LAUNCH
http://projectlaunch.promoteprevent.org/
St. Louis Effort for AIDS
http://www.stlefa.org/
St. Louis Equal Housing Opportunity Council
http://www.ehocstl.org/
Gateway Earned Income Tax Credit Coalition
http://gatewayeitc.org/
St. Louis Healthy Corner Store Project
http://extension.missouri.edu/stlouis/healthycornerstore.aspx
Harold Alfond College Challenge
http://www.500forbaby.org/
St. Louis Neighborhood Market DrillDown
http://drilldownstl.org/wordpress/wp-content/
uploads/2012/09/FinalDrillDownReport.pdf
Healthy Food Financing Initiative
http://www.acf.hhs.gov/programs/ocs/resource/healthy-foodfinancing-initiative-0
Maternal, Child and Family Health Coalition
http://stl-mcfhc.org/wp/
Mental Health First Aid Missouri
http://www.mentalhealthfirstaid.org/cs/
Missouri County-level Study (CLS)
http://health.mo.gov/data/cls/designmethodology.php
Missouri Department of Elementary & Secondary
Education (DESE)
http://mcds.dese.mo.gov/Pages/default.aspx
Missouri Information for Community Assessment (MICA)
http://health.mo.gov/data/mica/MICA/
Missouri State Asthma Plan
http://health.mo.gov/living/healthcondiseases/chronic/
asthma/pdf/asthmastateplan.pdf
72 For The Sake Of All
St. Louis Regional Health Commission
http://www.stlrhc.org/
St. Louis Regional Youth Violence Prevention Task Force
https://stlouis-mo.gov/government/departments/
mayor/documents/loader.cfm?csModule=security/
getfile&pageid=369606
United Way of Greater St. Louis
http://www.stl.unitedway.org/
VCU Center on Society and Health
http://www.societyhealth.vcu.edu/
Visualizing Health
http://www.vizhealth.org/
Vital Statistics
http://health.mo.gov/data/vitalstatistics/
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