Baltimore BLOG: Population Decline Part I

April 2017

This Part 1 of a 2-part series.

Part 1 | Part 2 

WELCOME to the new Baltimore BLOG! The purpose of this Blog is to promote opportunity, equity, and good health for all of Baltimore’s citizens. To that end, we ask local social justice activists for their insight into urgent and neglected problems in the city as well as recommended solutions.

For today’s discussion, Lindsay Beane has been asked about the root causes of Baltimore’s decades-long population decline. Dr. Beane is a public health expert who has been studying health disparities in Baltimore City since 1995. Her work has largely focused on the southern Park Heights community in northwest Baltimore.

Baltimore BLOG:  Baltimore’s population peaked close to 1 million in 1950, but the city has been steadily shrinking ever since. Today, there are approximately 620,000 people living in Baltimore. According to Census Bureau figures, somewhere close to 30,000 city residents were lost just in the ten years between 2000 and 2010. City officials have repeatedly attributed our long-running decline to middle class residents moving to the suburbs in search of better schools and safer streets. Do you agree with their explanation?

Dr. Beane:  All parents want good schools for their kids, and all residents want safe streets. But not everyone can afford to relocate. An exodus of the middle class was very likely a major contributor during the early decades of Baltimore’s population decline, but relocation is not what accounts for the city’s continuing decline. If you look at population data at the community level, you will see downward trends in the lower income neighborhoods throughout the city that are both dramatic and disproportionate. The decreases in these neighborhoods are not due to upward mobility or relocation to the suburbs, however. They stem from years of uncontrolled homicide, drug overdoses, and HIV infection—causes of death that, together, account for over 10% of deaths citywide and an even higher percentage of deaths in those hardest hit neighborhoods. However, the single largest cause of the city’s overall population decline, also disproportionate to those same neighborhoods, is likely incarceration.

Baltimore BLOG:  White flight was certainly a major cause of population decline after Dr. King was assassinated in 1968. A recent Baltimore SUN article (“Baltimore population falls, nearing a 100-year low, U.S. Census says,” March 23, 2017) suggests that it’s now black flight (of the same middle class demographic) that is continuing the population decline. Every time there’s a local election, mayoral candidates lament about this middle class exodus, and how he or she will attract those families back into the city. What evidence do you have for an alternative explanation?

Dr. Beane:  The exodus of Baltimore’s middle class is an old hackneyed explanation that politicians tend to pull out during election campaigns to explain why the city continues to shrink. It opens the way for conservative candidates to say that charter schools are the answer to the City’s failing schools, or that strengthening the police force and building more prisons will make our streets safer. The truth is that the flight of the middle class hasn’t been the primary contributor to population decline in Baltimore for several decades. In fact, there is even significant growth in the city’s middle class and upscale neighborhoods.

If you examine population data at the community level, several poignant trends surface. For example, the population of southern Park Heights, one of Baltimore’s larger African American ghettos, has decreased dramatically over the past 20 years. It’s a fairly typical Baltimore ghetto in terms of widespread generational poverty, high rate of unemployment, and low real estate values; and most residents’ upward mobility is severely constrained. The 1990 Census reported the population of southern Park Heights as 36,890. Ten years later, in 2000, the Census reported the population as 29,637—a very large decline of nearly 20%. A decade later, in 2010, the Census reported another 15% decline, from 29,637 to 25,100. Together, these declines constitute an overall decline of 32% over 20 years. That’s nearly one-third of the entire community! Urban renewal and any relocations—voluntary or involuntary—can also be a contributing factor to declines such as these. However, the urban renewal that is currently taking place in southern Park Heights was not yet in full swing when the 2010 Census enumeration was conducted in 2009.

On a global level, such a massive population decline is more commonly associated with war, especially wars involving “ethnic cleansing,” and natural or manmade environmental disasters.

Baltimore BLOG:  Some people might take exception to your use of the term “ghetto.” Can we step aside for a moment and have you explain why you choose to use this term?

Dr. Beane:  I agree that some readers may find my use of the term “ghetto” old-fashioned or, worse, distasteful. I use the term guardedly. Historically, the word was first used in 16th century Italy to describe the government’s deliberate segregation of its Jewish citizens. In that context, a ghetto was a designated area of the city in which a socially-defined minority group was expected or even required to live. Forced segregation of a particular group was (and, obviously, still is today) a way of declaring the inferior status of that group.

I use the term “ghetto” when I talk about Baltimore because of the word’s implications and pejorative connotation for the leadership of Baltimore (as well as the city’s complicit citizenry) who have knowingly relegated a sub-population to an enclave that is plainly unfit for healthy family life. To me, using a term like “slum” would be unacceptable because it could have negative implications for an area’s residents themselves. In contrast, the term “ghetto” ascribes the responsibility for the ghetto’s conditions to city government and society-at-large, where it belongs.

Segregation by race, based both on legal mandates as well as on de facto social segregation, is a longstanding practice in Baltimore dating back to Reconstruction. Antero Pietila does a great job of tracing Baltimore’s historic housing segregation in his book, Not in My Neighborhood: How Bigotry Shaped a Great American City. A lot of people are currently exploring the city’s historic policies of segregation that were fueled by the Plessy v Ferguson decision in 1896.

In public dialogue, we often associate the notion of segregation with geographic boundaries and housing, but it’s certainly not limited to housing. Formal policies of segregation also involve the targeting and attempted control of a specified sub-group, in this case, a demographic group based on race—or perhaps I should say: based on skin color, since the concocted concept of “race” obscures the simple fact of prejudice. Another topic for another day…

Baltimore BLOG:  You say that segregation is not implemented only in terms of housing or residential location. Can you give us another concrete example?

Dr. Beane:  Sure. Former Mayor Martin O’Malley’s “Zero Tolerance” crime-fighting policies were based on profiling, which is another form of segregation. The Zero Tolerance policies explicitly mandated continuous police harassment of the residents of Baltimore’s African American ghettos. This harassment (including police brutality and over 300,000 wrongful arrests in four years) is detailed in the U.S. Department of Justice’s August 2016 investigatory report of the Baltimore City Police. According to the DOJ, many of the Police Department’s discriminatory practices rose to the level of “unconstitutional.” It will be interesting to see what sort of class action lawsuits this report engenders.

Segregation is an extremely effective strategy as it preys on the human tendency to distinguish between “us” and “them.” That tendency may have carried benefits when primitive humans were nomadic and running across unknown tribes while foraging in new territory. It would have been important to distinguish between tribes with positive versus negative intentions. But, in today’s global community, the labeling of “us” versus “them” due to religious or cultural or economic or skin color differences is counter-productive and even dangerous—giving justification to war, for example.

In terms of modern day segregation, if you examine any major disparity or inequity related to African Americans in Baltimore—such as generational poverty, substandard housing, low educational attainment, high rates of homicide and suicide, uncontrolled infectious disease, premature mortality, or mass incarceration—the root cause and ongoing mechanism is segregation stemming from racism.

Baltimore BLOG:  Thank you for that clarification. Back to our topic of population decline—how much of the decline in Baltimore’s ghettos is due to death and how much of it is due to incarceration?

Dr. Beane:  Let’s start with the toll that the HIV epidemic has taken in many African American neighborhoods. Thanks to medical advances, deaths due to AIDS (late stage HIV disease) have declined significantly over the past two decades. These advances only help, however, if individuals infected with HIV are successfully brought into medical care early and kept in care over time to facilitate their taking daily medications. This is not an easy task in Baltimore as the epidemic largely impacts historically hard-to-reach and hard-to-engage stigmatized populations of addicts, prostitutes, and transgender individuals who often encounter prejudice and disrespect at hospitals and health clinics. If these individuals are also homeless, that makes linking them with healthcare even harder. More than half of new patients coming into the city’s HIV clinics have already progressed to AIDS or late stage disease. Medicine slows the progress of the disease, but so far we don’t have a way to reverse that progress. So, while we can celebrate the medical advances, the benefits of those advances are not equally shared.

One also needs to temper the good news that HIV-related deaths have declined with an understanding that accurate HIV surveillance, even an accurate count of deaths caused by HIV, is undermined by many factors. At first glance, there appears to be an abundance of federal and state regulations surrounding the reporting of positive HIV test results, AIDS diagnoses, and related deaths. One might easily presume that the State of Maryland collects appropriate data on everyone that has been impacted by the epidemic and that the State can confirm the accuracy of their reports. But there is nothing easy about disease surveillance, even under the best of circumstances. Even a death statistic is challenging. The total number of deaths may be relatively easy to confirm, but confirming the cause of those deaths is another matter.

Cause of death is a complex statistic to control for accuracy—particularly when we are talking about a disease that attacks the immune system leading to multiple potentially lethal conditions. Doctors figured out a long time ago, that an HIV infected individual with a weakened immune system is likely to die of an opportunistic infection such as pneumonia or an AIDS-related cancer. This is why AIDS is a broadly defined syndrome and collection of conditions and diseases, rather than a narrowly defined disease state. It only follows that a disease that weakens and eventually destroys the immune system would make it harder for an individual to battle other health problems. But even though we know that the HIV virus attacks the body in a systemic way via the immune system, we still don’t hear much about HIV’s impact on diabetes or hypertension or congestive heart failure or asthma. Depending on the sophistication of the coroner or medical examiner, his/her reliable adherence to State (and federal) reporting mandates and definitions, and any backdrop of political pressure, deaths due to AIDS (or late stage HIV disease) may well be under-reported.

When you add disenfranchised populations to the mix, things can get extremely complicated. For years in Baltimore, many if not most of the individuals infected with HIV were injecting drugs and/or trading sex for drugs or for money. The State’s reports over the last decade, however, suggest that injecting drugs has become less and less of a problem in terms of a vehicle for HIV transmission. Those of us who work in drug recovery are puzzled by these reports since our observations at the community level suggest otherwise.

This is a great example of how data can send you in the wrong direction. “Mode of transmission” data is self-reported, meaning that individuals who are infected with HIV declare how they became infected. No one is in a position to verify the self-report for accuracy, so men can report whatever they want. The self-reporting of how HIV was transmitted has always been a problem. The statistical odds of a man being infected with HIV as a result of intercourse with an infected woman are extremely low (due to physiological reasons). But more and more men in Baltimore report heterosexual sex as the way they contracted HIV. Those reports should be viewed with at least a hint of skepticism. The more likely explanation for the increase in self-reported heterosexual transmission is men’s fear of being stigmatized as a homosexual or drug addict. It’s a complicated issue but shame on us for simply recording an answer that is not scientifically possible—a skewed analysis of what’s contributing to the ongoing epidemic impedes our ability to do what is needed to end it.

I would add that, in addition to the HIV self-report issue, co-morbidity (or having more than one disease or health condition) is very common in Baltimore’s African American population. We hear about the contraindications of hepatitis medications in someone diagnosed with both hepatitis and HIV, and we also hear about medication non-adherence among individuals infected with HIV who are drug users or individuals suffering from mental illness such as major depression. But we almost never hear about the cumulative effect of HIV plus diabetes plus asthma, or the combined impact of HIV with a continued use of heroin or cocaine. Unfortunately, the confluence of three or four such health risk factors is extremely common in Baltimore’s ghettos. An estimated 90% of Baltimore’s injection drug users are infected with hepatitis C and somewhere upwards of 40% are also infected with HIV. Some of these individuals, if not most of them, are also likely to be burdened with one of the common chronic diseases among African Americans, such as diabetes, hypertension, heart disease, or asthma in addition to HIV.

If a person additionally suffers from depression or is continually exposed to violence in their neighborhood and suffers from stress or PTSD as a result, you start to create an untenable set of circumstances for the human body to survive. Looking at it from this angle, you can see that HIV may simply be the tipping point for a community that is already vulnerable due to longstanding segregation and lack of resources.

Baltimore BLOG:  What you’re describing suggests a catastrophe. Would you really say the situation is that bleak?

Dr. Beane: The death rate in the impoverished African American communities in Baltimore is catastrophic. However, statistical reports can be very misleading when they present aggregate data—that is, data representing the city’s overall population versus data specific to one geographic community or one demographic sub-population. Baltimore’s citywide rate of mortality (the number of deaths per 100,000 residents), for example, is 37% higher than the State of Maryland overall. This aggregated statistic includes black and white, rich and poor citizens living in all neighborhoods of the city. If we zeroed in on a predominantly African American neighborhood like southern Park Heights, which is impoverished and burdened with an illicit drug trade, the rate of mortality is likely to be much higher. It might be 50% higher than the state overall, 100% higher, or even 200% higher.

Unfortunately, sub-population or community-specific data are not easy to obtain. When the health department reports citywide data by race alone, the statistic for African Americans includes poor Blacks living in Sandtown or Cherry Hill as well as wealthy Blacks living in upscale waterfront condos. The net effect is a dilution of the data and a masking of the very high rates of disease and death among Blacks living in the city’s poorest neighborhoods. Separating out data by both race and poverty as well as by geographic boundaries would reveal that Baltimore’s African American segregated ghettos are severely over-burdened by deaths due to many causes: heart disease, diabetes and stroke, respiratory conditions, and breast and colon cancer, for example, as well as HIV, homicide, and drug overdose.

Several groups in the city have shared mappings that reveal Dr. Lawrence Brown’s “black butterfly” of violence, police harassment, poverty, and vacant property data specific to certain Baltimore neighborhoods. Geocoded data are not yet available for all public health topics, but the outline of the butterfly is unlikely to vary by much.

Baltimore BLOG:  Why is it so important to focus in on data at the community level?

Dr. Beane:  When you look at community level data, you can assess a specific community’s trends and compare them against the trends of nearby communities or of the city as a whole. This gives you a frame of reference.

Let’s put southern Park Heights’ population decline in the context of the city’s overall decline. In the decade between 1990 and 2000, the citywide population decreased by 11.5% (from 735,000 to 650,000). This is a major decrease. But the population of the southern Park Heights community decreased by 20% in that same decade. And the overall 20-year decrease of the citywide population (from 1990 to 2010) was 16% compared with a 32% decrease of Park Heights’ population (11,790 people) over that same time period—again, revealing a community rate of decrease that is twice as steep as the overall citywide decrease.

I haven’t completed a citywide analysis yet, but if you add in the resident losses from Cherry Hill in southwest Baltimore, Sandtown-Winchester where the uprising over Freddie Gray’s police-related death took place, and the Middle East which surrounds Johns Hopkins’ medical campus in East Baltimore, I suspect that the total declines in the impoverished African American communities in our city would account for 40% to 50% or possibly even more of the city’s overall decline. This suggests the city’s population decline over the past 20 years has been caused by a very different problem than a “middle class exodus,” and thus a very different solution is required.

Urban Health
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