July 22, 2022
When violent crime fell over a 15-year period in Chicago, heart disease deaths declined at a similar rate, suggesting public safety improvements correspond to better cardiovascular health among residents, according to new research from the University of Pennsylvania.
The analysis, published in the Journal of the American Heart Association, found that violent crime in Chicago declined by 16% from 2000 to 2014. During that same span, cardiovascular disease mortality dropped by 13%.
And in a group of Chicago neighborhoods where violent crime had declined by an average of 59%, there was a 15% drop in heart disease mortality. That suggests larger declines in violent crime correlate to more significant improvements in cardiovascular health, strengthening the association.
The study is one of several led by Penn researchers who have examined the relationships between violence, health and the environments in which people live. The research points to the profound impact that the legacy of racial segregation continues have on the health of communities of color, which are disproportionately affected by violence.
"There is increasing evidence that where we live, our neighborhood or built environment, contributes to our health, including cardiovascular health," said Dr. Lauren Eberly, the study's lead author and a clinical fellow in Cardiovascular Medicine at Penn. "Consistent with this, we feel our results implicate violent crime as a potential social determinant of cardiovascular health, but it is situated in a broader context of structural racism and is reflective of the legacy of racism and its lasting health consequences."
Heart disease is the leading cause of death in the United States, claiming some 697,000 lives in 2020 — about 1 in 5 deaths, even in a year marked by the emergence of COVID-19. Coronary heart disease, which develops over decades, is the most frequent killer, often resulting in a blockage of blood flow that causes heart attacks. Stroke, peripheral arterial disease and aortic disease also are common forms of cardiovascular disease that can lead to health complications and death.
Death rates for heart disease declined for all racial and ethnic groups between 1999 to 2017, overlapping with the period of the Chicago analysis, but other studies have shown that the rate of that decline in mortality slowed down between 2011 and 2019.
Black men and women have the nation's highest age-adjusted death rates for cardiovascular disease, which accounted for 208 deaths per 100,000 people in 2017, compared to 168.9 deaths among white people and 114.1 deaths among Hispanic people, per statistics from the U.S. Centers of Disease Control and Prevention.
The Penn study looked at 77 community areas in Chicago, taking cardiovascular health data from the Department of Public Health Division of Vital Records and violent crime stats from the Chicago Police Data Portal. The study did not break down violent crime by type — a variable that often fluctuates with ebbs and flows in shootings, burglaries, assaults and carjackings, for example.
The aim of the study was to assess the association between declining crime and heart disease during the period of the analysis, which was the most recent data set available to examine fully.
Even in parts of Chicago with the lowest changes in violent crime — a decrease of about 10% — cardiovascular mortality still declined by more than 11%.
Eberly believes the findings may have a bearing on the slowing decline of heart disease mortality in recent years. Violent crime, particularly gun crime, has been on the rise in cities like Chicago and Philadelphia, both of which recorded their highest annual homicide totals in 2021. The implications for cardiovascular health will hit high-crime areas the hardest, the study suggests.
"Because community areas that experienced the smallest decline in crime also experienced the smallest improvements in cardiovascular mortality, pre-existing disparities in mortality between neighborhoods in the city are likely to worsen over time, especially with the recent rise in crime rates in the United States," Eberly said. "While these results represent one large, urban U.S. city that could potentially not be generalizable to other cities, we suspect that these results are likely reflective of many other large urban cities across the country."
How violent crime impacts the development of heart disease in communities that are already at high risk for it is likely caused by many factors. A 2016 study found that anxiety and formal anxiety disorders are commonly associated with poor cardiovascular health.
"There is a biologic basis for violent crime leading to poor cardiovascular health," Eberly said. "From previous studies, we know that exposure to crime influences biology and behavior in ways that can contribute to development of cardiovascular disease. For example, living in a high crime area has been associated with delays in seeking care and filling medications, as well as lower rates of physical activity and unhealthy eating, and substance use."
In a more immediate sense, exposure to violent crime also activates stress response pathways. That can lead to impaired glucose metabolism, chronic inflammation and higher blood pressure, which all play a key role in cardiovascular disease development, Eberly said.
Another study out of Drexel University, published in 2020, found that the experience of discrimination over a lifetime is associated with high blood pressure in African American adults.
That study followed 1,845 Black Mississippi residents over three periods between 2000 and 2013. Those who participated did not have high blood pressure at the start of the study, but were surveyed over a number of years about experiences with discrimination in nine areas, including school, employment and housing. The researchers found that those who reported medium and high levels of discrimination had a 49% and 34% increased risk for hypertension, respectively, compared to those who reported low levels of lifetime discrimination.
The Penn study on Chicago didn't explicitly examine the racial makeups of the neighborhoods where it assessed relative changes in violent crime and heart disease deaths. But the body of research showing that violent crime disproportionally affects areas where people of color live is a reality that underlies population health, particularly in large cities.
Eberly and her colleagues at Penn are focused on understanding the ways in which structural racism intersects with health care, compounding the hardships that inequality has on communities.
In cities like Chicago and Philadelphia, the conditions of neighborhoods and the prevalence of crime can go a long way toward explaining why communities of color suffer from poorer health.
"I think often there is a failure to give sufficient attention to the importance of the built environment or the impact of the neighborhood environment, including poverty, on health," Eberly said. "The health care industry in the United States invests a lot in therapeutics and treatment of diseases, but we aren't investing upstream to make communities healthier through strategies like prioritizing preventative medicine, ensuring equitable access to care with universal health care coverage, or targeted community investment, particularly for communities of color to rectify prior injustices to ensure equitable health outcomes."
Dr. Eugenia South, co-author of the Chicago study and director of the Penn Urban Lab, has been a leading advocated for neighborhood interventions such as structural repairs to the homes of low-income owners and greening of vacant lots. She and her colleague, Penn sociologist and criminologist John MacDonald, led an analysis in Philadelphia of how a city-funded home repair program reduced shootings on the blocks where such repairs were completed.
If even one home on a block received repairs, the study found that total crime dropped by 21.9% on that side of the block, and homicides specifically dropped by 21.9%. The improvement grew as more homes were repaired, showing that simple, non-police interventions can have a demonstrable effect on localized rates of violent crime.
Disinvestment in communities of color can have far-reaching consequences that play off of one another, not only reducing quality of life, but lowering the long-term health outlook of those who live in historically neglected areas. That cycle is perpetuated by high rates of violent crime.
Eberly would like to see further investigation of how place-based, environmental interventions that decrease crime may also impact cardiovascular health.
"We hope that, given these results, people will consider the root causes of violence," Eberly said. "We must acknowledge the legacy of racist policies and practices that have led to concentrated disadvantage and crime in Black and other racially and ethnically minoritized neighborhoods. Policies must be implemented to address the health consequences of structural racism and racial segregation."