GONORRHEA: Physical Environment Linked to Disease Rate
While in prior studies STDs "have been considered to be caused solely by the behavior of individuals," researchers at the Louisiana State University Medical Center in New Orleans have determined that regardless of individual characteristics, "gonorrhea is clustered in neighborhoods that are physically deteriorated." In a study published in this month's issue of the American Journal of Public Health, researchers led by Deborah Cohen describe how they used social scientist James Q. Wilson's "Broken Windows" theory: "[T]he appearance of the physical environment provides direct messages that regulate individual behavior" and a "disordered physical environment is not only a consequence of neglect but also a signal to others that behaviors that are usually prohibited are tolerated." Researchers examined 55 block groups in New Orleans neighborhoods, determining a "broken windows" index based upon the percentage of homes with major, minor or cosmetic structural damage, the percentage of streets with trash, abandoned cars or graffiti and the number of physical problems or building code violations in high schools. Cohen mapped cases of gonorrhea between 1994-1996 and calculated the case rate by block group. The researchers considered other factors, including poverty index and percentages of residents who were married, African American, home owners, between the ages of 15 and 24 and female, comparing those and the broken windows index to rates of gonorrhea. After entering all variables into a formula, "only broken windows remained significantly related to gonorrhea," the researchers write. Further, gonorrhea rates "were significantly higher in neighborhoods with both high broken window indexes and high poverty indexes" than in block groups with low broken window scores and high poverty indexes. There were no significant differences in gonorrhea group rates when researchers compared block groups with low broken window indexes and high poverty indexes to those with low broken window indexes and low poverty indexes.
The Individual v. The Environment
From their results, the researchers suggested that "physical deterioration of a neighborhood is either a marker for a risk factor for gonorrhea or itself a risk factor for gonorrhea." But, they admitted, "We have insufficient information to determine whether the broken windows measurement is directly associated with high-risk sexual behavior or reduced health care seeking behavior or whether the association is mediated by another construct." However, the researchers speculated there are a few possibilities, including the theory that those with high-risk behaviors and low health care seeking behaviors cause the problems in the environment. It is possible, the researchers write, that the deteriorated neighborhoods represent individuals who "have few constraints on their behavior, intentionally create a disorderly environment and engage in high-risk sexual behavior." But on the other hand, the environment itself could cause people to have the high-risk behaviors coupled with poor health care seeking behaviors because surroundings filled with deterioration "may be a signal that there are no rules and no one cares." Further, an "uncared-for environment may indicate that self-care is not a priority" and those with symptoms "may ignore them rather than seek help." If individuals have determined that an uncared-for environment indicates that no one cares about their behavior, "the attention and physical pleasure associated with sex and/or drug use may be a strong motivation to have casual sexual partners." The researchers surmised that the neighborhood environment effect "should be further considered because the implications for influencing disease rates at the population level are enormous." Further, they suggested that prevention programs "that target the conditions in which people live may in the long run have a dramatic impact on STD rates at the population level" (Cohen et al., American Journal of Public Health, 2/00 issue).
The Decent Housing-Health Care Link
In an accompanying editorial, Dr. Mindy Fullilove of the New York State Psychiatric Institute and Columbia University, said that "although theoretical data suggests that 'broken windows' signal neglect and are associated with the onset of 'neglect behaviors' -- drug use, prostitution -- the exact relationships are more subtle than that." But she added, "we have all too little data of this sort from which to build and test theories, hence the importance of this paper." Further, Fullilove asserted that the medical community has essentially ignored the impact of structural factors on health, saying, "Were physicians and others to insist that decent housing is essential to health care, other sectors in our country would pay attention" (Stern, Reuters Health, 2/4).