As many urban academic medical centers have become the world’s leaders in research and patient care, their bordering neighborhoods have suffered through decades of disinvestment and economic blight. Medical students often receive their first years of training in hospitals that serve these disadvantaged populations. While the current focus on social determinants of health represents a rising cornerstone of medical education, what else do medical students need to know about inner city poverty?
In order to serve marginalized populations both in the hospital and in the community, we need to first understand the processes that led to their decline. The story of inner city poverty encompasses a complex and tortuous course through America’s history — one that is far too complex to detail here. Some key events, however, are important to recognize.
Over the Great Migration in the early 20th century and the New Great Migration in the late 20th century, urban cities saw a rise in minority — largely Black American — populations as the ostensible promise of economic prosperity drew hopeful families to inner city neighborhoods. The end of post-World War II prosperity was the impetus for a steady decline in industrial productivity, and inner city communities, which relied heavily on their labor capital in factories and plants, suffered greatly during the rise of America’s post-industrial economy.
But inner city poverty has always been less about production slowdown, and more about the disappearance of economic opportunity. Middle-class flight from inner city neighborhoods decentralized social and economic capital from urban areas to suburban neighborhoods. Additional structural economic and political shifts, including the infamous practice of “redlining,” produced extremely disadvantaged neighborhoods that still house some of the nation’s most vulnerable populations today.
If inner city poverty was largely instigated by these insults, then underpinning its persistence today is extreme isolation. These neighborhoods were walled off from society, and thus their plight was out of sight, out of mind to many Americans. The effects of this isolation can be seen in almost every aspect of inner city life today. The efflux of businesses and transportation networks from these areas caused economic isolation, which, today, takes the shape of spatial mismatch between workers and potential jobs. Social isolation subordinated low to no-income families, depriving them of the networks required for upward mobility. The isolation of schools from their suburban and private counterparts lead to disinvested educational systems that often fail their students.
Similarly, the implications of isolation on health are innumerable: food deserts, environmental pollutants, the inaccessibility of health care and pharmacies. Isolation is an American disaster, and it shows its face in the emergency rooms of our hospitals every single day.
Under the extreme conditions of these devastated areas, residents needed to adapt in order to survive. Crimes seen in inner city neighborhoods are largely crimes of poverty, which we distinguish from crimes elsewhere because they disproportionately occur in disadvantaged communities — where desperation begets survival behavior. Teens face barriers to completing school as many must choose between supporting their families or getting to class every day.
Knowledge of arithmetic and language arts confers little-to-no benefit in their daily lives, so dropping out of school barely resembles an actual choice. Furthermore, the lack of valuable job opportunities makes involvement in underground economies tempting. These are all ways people remain afloat in a world that, in many ways, seems entirely set against them.
Poverty and undue violence is a public health crisis that continues to plague America’s inner city and racial-minority predominant neighborhoods. As medical students, we need to build careers that not only advocate for improved health care, but leverage the history of poverty in America to guide systemic and durable change.
Indeed, community engagement has become the vanguard of medical school charity. Efforts like free clinics, medical student volunteerism in community organizations and health care delivery in safety-net hospitals demonstrate our desire to provide for communities in need. However, we cannot forget to also address the broader issues that afflict our neighbors. Acknowledging the past is the only way to change the future, which is why we — in the most impressionable stages of our careers — must wield this knowledge to recognize future opportunities for sustainable change.
Exemplary forms of sustainable efforts exist, and plenty of schools have begun implementing programs that address poverty at a higher level. Partnerships with minority-owned businesses provide an excellent opportunity for large medical campuses to mutually benefit from cash flow that actually reaches the pockets of inner city Americans. Other universities and their medical campuses have created employment programs that recruit inner city populations, which not only allow for internal economic growth within these communities, but also benefit the massive operations that medical centers require for their upkeep. Beyond job opportunities, many medical centers target their communities’ youth through educational outreach and pipeline programs leading to higher education.
Some universities engage their surrounding communities in the research sector as well. Community-based participatory research (CBPR) is a form of community-engaged research supported by the National Institute of Minority Health and Health Disparities. The idea, put simply, is that researchers identify their areas of investigation not by their own introspection — which often misses the mark for disadvantaged populations — but by hosting meetings with community members to highlight their perceived needs.
However, whatever the goal of community engagement programs, their sole presence at medical schools is not enough. While many voluntary efforts appear impactful on paper, in practice they have the propensity to fail if not evaluated carefully. A cursory google search reveals countless outreach activities, but very few outcome metrics. Numerous barriers may prevent medical schools from assessing their community-based programs, including available staff, funding and knowledge. Medical students, however, are in the perfect position to offer their time and expertise to assess and improve existing programs. By constantly evaluating and critiquing outreach programs, we challenge ourselves to build truly impactful programs that supersede a long history of CV-boosting volunteerism in medicine.
Medical students must learn the history of their communities in order to make these changes. Regarding inner city neighborhoods, a historical lens allows us to identify the broader processes by which urban poverty came about. Only once we have mastered this knowledge can we effectively target systemic issues at a higher level.
In the meantime, we should continue to volunteer in free clinics and participate in programs that provide immediate assistance to our patients. But we must also look to the past for guidance toward future change. If recent attention on police violence and criminal-justice system reform have us questioning what we can do to help combat inner city poverty, then the writing is on the wall. It reads: preserve and elevate your neighbors, or become complicit in their erasure.
Image credit: Pruitt-Igoe-collapses (CC BY 2.0) by Renato Saboya