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Demographic Changes, A View from California: Implications for Framing Health Disparities - Workshop Summary 2 The Changing Face of American Communities: Implications for Framing Discussions About Health Disparities “NO DATA, NO PROBLEM” E. Richard Brown, Ph.D. Director, Center for Health Policy Research, University of California, Los Angeles According to E. Richard Brown, academic researchers tend to focus on statistical outcomes and their implications, without calling attention to potential inadequacy of data needed to understand and assess policy issues. However, when looking at the changing face of America and the underlying trends and patterns, it is essential to ensure that good data exist in order to examine disparities and their causes. Change in American Communities Widespread demographic changes have been sweeping the United States, particularly in the last generation. This is leading to new populations and new immigrant communities across the country, instead of only those states typically known to receive immigrants (i.e., California, Florida, Illinois, New Jersey, New York, and Texas). Rather, immigrant populations are dispersing across the country and forming new communities in many different states. Without good data, however, information about adverse health outcomes for these populations could not be tracked, leading to health disparities not being recognized, acknowledged, or addressed. Table 2-1 contains
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Demographic Changes, A View from California: Implications for Framing Health Disparities - Workshop Summary TABLE 2-1 New Populations and Communities Established Throughout the Country by Deep Demographic Changes Asian and Pacific Islander Hispanic/Latino 1970 2007 1970 2007 California 2.8% 13.7% 13.7% 36.7% Georgia 0.1% 3.2% 0.6% 7.9% Idaho 0.5% 1.7% 2.6% 10.0% Kansas 0.2% 2.6% 2.1% 9.0% Minnesota 0.2% 3.9% 0.6% 4.1% North Carolina 0.1% 2.2% 0.4% 7.2% Utah 0.6% 2.6% 4.1% 11.8% SOURCE: Bureau of the Census (1970) and data provided by E. Richard Brown, based on his analyses of Census and other data. Table created by E. Richard Brown. data from six states not typically known to receive immigrants as well as California and shows the demographic changes that have occurred. In 2007, for example, Utah’s Latino population was nearly 12 percent of the state’s population, whereas its Latino population was only 4 percent of the state’s population in 1970. The changes have also been dramatic in California, where, due to a long history of immigration, no population, ethnic, or racial group makes up a majority in the state today. Therefore, the ability to track these patterns is critical. The California Health Interview Survey (CHIS) is a comprehensive statewide survey of the health status of California residents. Sufficiently large samples of key demographic subgroups are surveyed, providing good information about immigration status, citizenship status, and so on. There is also a strong emphasis on the dissemination of the data from CHIS, with the goal being to be a source of evidence for policy discussions and policy development. The survey is conducted every 2 years, and $1 out of every $5 allocated for the survey goes toward dissemination. The CHIS also contains a data query system that allows free online access to the data. This helps get the data into the hands of the people who can use it to reduce and eliminate health disparities. In both established communities and new communities, social stratification leads to health disparities between groups. There are disparities in health and health care by race and ethnicity, income, rural versus urban residential location, gender, and other social characteristics. For example, a disparity is said to occur if the data show that there are differences in the utilization of preventive services that all members of a population group should be receiving and differences in social factors unrelated to the incidence or the prevalence of disease. In other words, if there are differences
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Demographic Changes, A View from California: Implications for Framing Health Disparities - Workshop Summary in health care utilization because of the social characteristics of the community, a disparity rather than a health care need exists. Disparities are related to a number of different factors, including person-environment interactions (diet, physical activity) and social and environmental exposures (environmental justice issues). One example of research that used CHIS data assessed the effects of air pollution on asthma. As determined by the use of geographically coded data, air pollution rates were found to be associated with higher rates of emergency room visits because of asthma and with a higher frequency of asthma symptoms. These environmental effects on health status would not have been detected without access to the CHIS data. A historical example can also be presented. In this case, the issue was not having the necessary data to make an informed policy decision. In the early 1980s in California, then-Governor George Deukmejian reached an agreement with legislative leaders to drop some recipients of the state Medi-Cal program. Those dropped were a population that was served by Medi-Cal but that did not qualify for federal matching funds. This group of medically indigent adults totaled approximately 250,000 people and the counties where they resided became responsible for providing care to that population. Not surprisingly, Lurie found that the affected population of patients encountered serious adverse health affects because of the lack of funding for their health care (Lurie et al., 1984, 1986). Brown approached the key legislative staff members in Sacramento to request funding to study the effects of this policy change. The request was denied. Without good data, then, access to strong evidence about trends or the effects of those trends was not available. Five examples of good evidence about trends and their effects, all from the CHIS data, follow. Example 1: Children’s Access to Dental Care Data indicate that oral health problems are the primary reason that children are absent from school. Additionally, dental care is critical for healthy eating as well as for social integration for adults because an obvious lack of access to dental care is an indicator of social class and social status. For example, low-income adults face a major barrier to success in their job searches because of the poor condition of their teeth. Not surprisingly, the major reason that people do not seek dental care is a lack of dental insurance. This is the case even when other sociodemographic variables are controlled for statistically. The end result is racial and ethnic disparities in children’s dental visits and in children’s overall dental health.
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Demographic Changes, A View from California: Implications for Framing Health Disparities - Workshop Summary FIGURE 2-1 Percent of children who have not seen a dentist by age 11. SOURCES: CHIS (2005); Pourat (2008). Created by E. Richard Brown. In looking more closely at these data (Figure 2-1), Latino children are the most likely to have never visited a dentist. In fact, more than a quarter of Latino children have never visited the dentist by the age of 11 years. There are also subgroup differences, with Puerto Rican and South American children being the least likely to have visited the dentist. Similar subgroup differences exist for Asian ethnic subgroups. South Asian and South Korean children are the least likely to have visited the dentist, whereas Vietnamese children are the most likely to have been to the dentist. What is critical here to note is that without good data, these subgroup differences for Latinos and Asians are invisible. Example 2: Mammogram and Pap Test Access Asian American women have the lowest cervical cancer and breast cancer screening rates among all racial and ethnic groups. Within Asian ethnic subgroups, however, there are significant differences in access to mammograms and Pap tests (Figure 2-2). South Korean women are the least likely to have had these tests, whereas Filipino women are the most likely to have been screened. The reasons for low rates of screening among these subgroups vary; but they include issues such as limited English proficiency, a lack of health insurance coverage, and the number of years that the individual has lived in the United States. However, by disaggregating the data, it is possible to target interventions to different vulnerable groups, guided
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Demographic Changes, A View from California: Implications for Framing Health Disparities - Workshop Summary FIGURE 2-2 Mammogram screening and Pap test rates differ among women by Asian ethnic subgroup. SOURCES: CHIS (2001); Kagawa-Singer et al. (2007). Created by E. Richard Brown. by an understanding of the subgroup differences. Without good data, this is not possible. Example 3: Diabetes Rates It is well known that the rates of diabetes differ among racial and ethnic groups. Diabetes is a major cause of death in the United States, and diabetes is a major cause of disability and functional limitations. Diabetes can result in blindness, permanent kidney damage, cardiovascular disease, and lower limb amputations. It is a consequence of obesity, family history, a lack of exercise, and other factors. By comparing subgroups and adjusting for age, the rates of diabetes are seen to be far lower for some Asian subgroups than for others (Figure 2-3). Rates are far lower for Chinese Americans, for example, and far higher for Filipinos and South Koreans. The diabetes rates for all Asian subgroups, however, are far lower than the diabetes rates for Native Americans, which is the group with the highest rate of diabetes in the entire population. There are also differences in the rates of diabetes among Latino subgroups. Mexicans and foreign-born Latinos have the highest rates, and these rates are considerably higher than those for all Asian American subgroups. These differences can be used to more finely target public health and clinical interventions to groups with concentrated needs for services.
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Demographic Changes, A View from California: Implications for Framing Health Disparities - Workshop Summary FIGURE 2-3 Age-adjusted diabetes prevalence by race and ethnicity, adults ages 18 years and over, 2005. SOURCE: CHIS (2005). Created by E. Richard Brown. Example 4: Variation in Diabetes Rates by Geography What accounts for the subgroup differences in the rates of diabetes among subgroups of the population described in the previous section? Both demographics and community factors play a role. In considering county-level data from the Bay Area in Northern California, the rate of diabetes in Santa Clara County is nearly 8 percent, and the rate in Solano County is 8 percent. In contrast, the rate in the nearby county of Marin was only 3 percent. These differences in the rates of diabetes are due to the demographic factors described earlier, as well as to local conditions in the community. All of these differences would be missed if the data were not disaggregated across geographic locations. For example, the food environment is very different in Marin County than it is in the other counties in that the population of Marin County has greater access to produce, locally grown food, and supermarkets as well as lower numbers of fast-food restaurants.
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Demographic Changes, A View from California: Implications for Framing Health Disparities - Workshop Summary Example 5: The Retail Food Environment Index Expanding on the role of fast-food restaurants in obesity and diabetes, researchers studying this link have developed an indicator of the role that the food environment plays in a local geographic area. This indicator, called the retail food environment index (RFEI), is the number of fast-food restaurants added to the number of convenience stores divided by the total numbers of grocery stores, produce markets, and farmer’s markets: In this way, the RFEI scores for different counties, which are computed at the census track level, can be compared to explain the differences in county-level diabetes rates. The statewide average RFEI for California is 4.2. This means that for every grocery store, produce market, or farmer’s market in a geographic area, there are 4.2 fast-food outlets or convenience stores. Higher scores, then, mean fewer healthy food alternatives, and those geographic areas with higher RFEI scores also have higher diabetes rates. Higher scores are also significantly related to obesity rates, as seen in Figure 2-4. This is an environmental justice issue, and these data can be used to provide evidence of the need for policy changes at the local level. For example, in Los Angeles city council enacted an ordinance to limit the development of new fast food outlets in South Los Angeles. This is an important example of how experts working in advocacy and policy at the local level can use data to champion an issue, even in the face of political opposition. Reaction and Discussion Roundtable member Jim Krieger asked about the diabetes rates in California for Native Americans and Pacific Islanders. In Seattle, Washington, which also has large Asian and Pacific Islander communities, the highest diabetes rates are found among Pacific Islanders, Native Americans, and Alaska natives. Brown responded that the CHIS does not currently have a good sample of data for Pacific Islanders, so any information about the diabetes rates in that community comes from hospitalization rates and mortality data. However, Brown indicated that he is working with Pacific Islander advocate groups to oversample that population to collect better data for that population. Workshop participant Christina Jose asked whether the CHIS includes
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Demographic Changes, A View from California: Implications for Framing Health Disparities - Workshop Summary FIGURE 2-4 Percent obese as a function of RFEI using urbanicity—specific buffers, adults age 18 and over, California, 2005. Source: Babey et al. (2008). Created by E. Richard Brown. information about the rates of mental health problems. Brown said that it does have a mental health module, which includes mental health status, mental health service utilization, and access to mental health services. Workshop participant Charles Vega asked about the new regulations in the city of Los Angeles that limit the number of fast-food establishments and convenience stores. In addition to these limits, he asked whether there are better ways to get healthier foods into the community. Brown responded that community groups and advocacy groups work to expand access to good food such as good-quality produce and inexpensive foods. Efforts to bring supermarkets into low-income communities are also being organized. UNITY OR APARTHEID? Mindy Thompson Fullilove, M.D. Professor of Clinical Psychiatry and Public Health, Columbia University Mindy Fullilove framed her comments as a series of philosophical issues about the changing face of American society rather than a focus on
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Demographic Changes, A View from California: Implications for Framing Health Disparities - Workshop Summary data. Her presentation began with a discussion about racism in American society and how this is “the elephant in the room” in any discussion of health disparities. Fullilove explained that the existence of racism in society “grabs everybody in the gut” and is anchored on one end by blacks saying, “Yes, there is racism in our society” and on the other end by whites saying, “But I am not racist.” All people fall somewhere along this continuum, she said, and all of us have different kinds of feelings about whether America is a racist society. The Myth System of Apartheid In considering health disparities, Fullilove argued that it is essential to acknowledge “the myth system of apartheid.” For example, while she was recently working in Paris, Fullilove read an article about what’s new in New York. One of the quotes in the article was a statement from a West African organization that described the old-line black organizations as “whiny” and that they just need to die off so that new energy can take over in Harlem. Unspoken but implicit in this statement is this: “Black people are in trouble because they don’t work hard enough, because they just didn’t get along, they didn’t want to fit in, they didn’t want to go to school.” This negation of the reality of apartheid can set back the efforts and destroy the unity that is needed to end health disparities and other inequalities, Fullilove stated. Apartheid is very real and it is all around us, Fullilove argued. One can think about the history of the United States in terms of the system of apartheid. For example, the European settlers who first came to the Americas asked the Native Americans to “just move over a little bit.” Then, there was the Constitutional Convention, where inequality was written into the United States Constitution. Both serve as historical examples of apartheid. Another example of the existence of apartheid in the United States can be seen in Los Angeles. There are actually two cities, the first being what Fullilove called “monumental Los Angeles.” This is the city with the giant bank towers and glass corporate buildings. Then there is the Los Angeles that Fullilove described as being “off the grid.” This is, according to Fullilove, the embodiment of what apartheid looks like. Monumental Los Angeles did not exist from the time of the city’s founding; it replaced the older city where residents actually lived. As an outcome of the development of monumental Los Angeles, there is no space left for low-income people, individuals with mental illness, and the other residents who will be pushed aside for the new, the glossy, and the buffed up. Marginalized people will be pushed aside in the dynamic of apartheid, because “apartheid needs to eat the space,” said Fullilove.
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Demographic Changes, A View from California: Implications for Framing Health Disparities - Workshop Summary Redlining In the 1930s, the system of redlining was systematized and superimposed (Hillier, 2003) over the existing patterns of segregation. Redlining is a system of preferential investment, and it codified inequities in investments in different neighborhoods of a city. This codification took place along very specific lines that involved nonwhite status and living in a neighborhood with old buildings. This was how American cities were divided up. Only being a white Protestant was considered desirable. Nonwhite status did not simply mean Negro, however. It also included Jews, Italians, immigrants, Poles, and other ethnic groups. In other words, according to Fullilove, the conception of “race” is a made-up system and a system that is always evolving in the definition of the excluded “other.” Figure 2-5 shows a map of the city of Philadelphia in the 1930s, in which the red areas are designated for those people who were common and skilled laborers. They were a mix of the foreign-born, Negroes, and families on relief. The red zone meant “don’t invest money here.” This was not an absolute imperative but rather a guide to investment. This was saying, “Don’t invest your money where the poor people and the working people live.” Segregation had previously already existed in American cities; redlining just came in and built upon that legacy of segregation. In the United States today, different Western European ethnic groups, for example, Irish, Jewish, and Polish groups are all considered to be Caucasian. In contrast, in 1937, it was a diverse society with many different groups rather than one condensed category of Caucasian. This is what Fullilove referred to as “patterns of lumping and splitting.” The outcome of this diversity in society is social stratification, and social stratification is the basis of health disparities, according to Fullilove. Consider another, similar example of social stratification from the United States. A recent documentary called Passing Poston followed Japanese Americans who were imprisoned during World War II and who went back to visit the Poston internment camp many decades later. During World War II, Japanese American citizens were herded onto trains and interned in camps, causing them to lose their land, homes, businesses, and most importantly, their status as free people. In contrast, no effort was made to intern German or Italian citizens during World War II in the United States, even though the United States was also at war with Germany and Italy. Another example of the effects of residential segregation can be seen in the evolution of Boston Harbor, as described by Herbert Gans in his famous book Urban Villagers (1962). The Boston Harbor geographic area was a largely Italian community that was destroyed over time through the process of urban renewal. Not only did this lead to “grieving for a lost home,” but
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Demographic Changes, A View from California: Implications for Framing Health Disparities - Workshop Summary FIGURE 2-5 Redlining of Philadelphia. SOURCE: Federal Home Loan Bank Board.
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Demographic Changes, A View from California: Implications for Framing Health Disparities - Workshop Summary it also led to the scattering of people across the greater Boston area. Social networks were destroyed and the resources of the former residents were undermined. However, in looking more specifically at how urban renewal affected African Americans, the story is different. African Americans could move only to other segregated neighborhoods. Urban renewal for African Americans, then, constituted a deepening of apartheid, according to Fullilove. Neighborhoods that had previously been made up of mixed populations of African Americans and immigrants from Europe became black-only neighborhoods. Downtown Pittsburgh, Pennsylvania, is another example of how urban renewal efforts affected African Americans (Figure 2-6). Before urban renewal, the Hill District of Pittsburgh was composed of both African Americans and ethnic immigrant groups. African Americans, however, could only move to other parts of the Hill District or other African Ameri- FIGURE 2-6 Movements of different ethnic groups in Pittsburgh, Pennsylvania, from 1930 to 1995. SOURCE: Wallace and Fullilove (2008).
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Demographic Changes, A View from California: Implications for Framing Health Disparities - Workshop Summary can neighborhoods, unlike the immigrants, who scattered elsewhere across the city. In looking at big city neighborhoods before 1960 that were destroyed through urban renewal, Fullilove pointed out that several mechanisms were at play. First, the redlining followed the African Americans. If an area was populated by African Americans and they moved out, that area became a different zone (i.e., it was no longer a redlined zone). All of the investment thus went into improving the areas receiving new investment rather than the African American neighborhoods. In contrast, when African Americans move to other neighborhoods, the disinvestment follows them, according to Fullilove. The lack of supermarkets in African American neighborhoods is an example of this problem of the disinvestment process. Second, HOPE VI, the Housing and Urban Development program created in the early 1990s, demolished housing projects that were determined to be severely stressed and displaced the populations living in those projects. Gentrification then occurred in those areas and further displaced the population. It is, Fullilove asserted, the same pattern that urban renewal followed in the 1950s in the United States, and in the 1950s urban renewal followed the path of redlining in the 1930s that caused changes in patterns of investment, patterns of resource access, and patterns of space sharing. Fullilove stated that there are two hypotheses about this population displacement process. The first is the idea that the United States is trying to do the same thing that happened in Europe: move the poor out of the cities and move the well-to-do back into the city centers from the suburbs. This is called “the vast white ring conspiracy hypothesis,” as humorously depicted in Figure 2-7. The second hypothesis, offered by David Harvey (1973), is that developers make money by building new buildings and not by maintaining or improving already existing buildings. In looking at American cities, according to Fullilove, the urban areas have already been built, so where do developers want to go next? They go back to the city center; to land that has been cleared by the processes of disinvestment and urban renewal. Developers can then start tearing down old buildings and building new buildings all over again. If Harvey’s hypothesis is correct, then, the city center is the place to build, and white people will follow because their dollars are needed to inhabit all of the new dwellings that are being built. However, according to Harvey, once the new development moves out to the first ring of the older suburbs, which by then will have suffered from disinvestment, the same cycle will take place: buildings will be torn down and then built up all over again, but this time in the first ring of the suburbs.
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Demographic Changes, A View from California: Implications for Framing Health Disparities - Workshop Summary FIGURE 2-7 The Plan. SOURCE: TOLES © The Washington Post. Reprinted with permission of UNIVERSAL UCLICK. All rights reserved. Collective Consciousness Fullilove described work on the topic of collective consciousness that she coauthored with Rodrick Wallace (2008). That work focused on how groups work together. Under conditions of apartheid, the dysfunctional assumptions that are a part of the apartheid system impede the ability to collaborate across groups. For example, she said, white people and black people hold different assumptions about how the world works. Black people, for example, believe that the government is out to get them. White people, stated Fullilove, in contrast, believe that black people whine too much (and some Africans apparently share this belief, as noted earlier in this section). These are very different worldviews, which make it difficult to communicate across groups to find common causes and solutions. In addition, the more groups that are involved, the more complicated the conversations will be. This, in turn, leads
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Demographic Changes, A View from California: Implications for Framing Health Disparities - Workshop Summary to social disintegration, ideological barriers between groups, and the inequitable distribution of resources across groups. This is the context in which the urgent problems of health disparities exist. Fullilove described data indicating that in considering the health of white men, even rich white men living in the United States had worse health outcomes than poor white men living in Great Britain (Banks et al., 2006). In other words, a system of apartheid benefits no one, not even those people in the most privileged group (rich white men). It is important to note that Americans believe that, in general, white people are doing okay and black people are not, she observed. However, the data of Banks and colleagues show that this is not true: everyone living in the United States, even those in the most privileged groups, is suffering because of health disparities. This is what Fullilove calls a “classic double bind.” A double bind is when a person receives conflicting messages that make it unclear how to respond. How, then, does one get out of a double-bind situation? The answer is through the process of reframing the issue. How, then, is the issue of health disparities to be framed? Fullilove stated that she believes that the frame that should be used is that “apartheid harms us all.” Once apartheid is understood, new strategies for action can begin to be put into place. Fullilove described her father, Ernest Thompson, who was the first full-time, paid African American organizer for his union, the United Electrical Radio and Machine Workers of America. It was his role within the union to help his colleagues understand that the oppression of minorities and women destroyed the unity of the union. Thompson’s message was that overcoming racism and sexism were essential to the unity of the workers. All workers would benefit from getting past old divisions because of social segregation and racist stereotypes and realizing that everyone shares an investment in job security, job safety, and decent pay. Reaction and Discussion Roundtable member Allan Goldberg raised the issue of the situation in New Orleans, Louisiana, after Hurricane Katrina. He stated that the country turned its back on New Orleans and that this would not have happened if it had been, for example, Orlando, Florida that had been hit. He asked Fullilove what people can do to reenergize around these issues and make sure that this does not happen again. Fullilove replied that, unfortunately, this is typical in the history of the United States: events like Hurricane Katrina happen in all of major U.S. cities, and the outcome is the replication of inequality and the marginalization of the vulnerable. She suggested that simple things, like learning another
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Demographic Changes, A View from California: Implications for Framing Health Disparities - Workshop Summary language, can help to change things. Fullilove also suggested that this is a constant battle. A second questioner, Gilda Haas, talked about legislation passed in the city of Los Angeles that protects residential hotels. She stated that this is a long-term fight but that it can result in people who live in buildings providing affordable housing being protected from the forces of development. Fullilove responded with a story about Miles Horton, who founded the Highlander School during the 1930s. The Highlander School was an institution for labor and civil rights organizing that had been founded in the South. Horton said that in life, one should have a goal. However, if that goal is attainable during one’s lifetime, then that is not a good goal. Instead, a bigger goal, something that will not be attained during one’s lifetime, is needed. Today, Fullilove said, laudable goals include working to make the United States an equitable society, working for global sustainability, and working for climate change. These are the goals to be passed along because they will not be resolved during our current lifetime. REFERENCES Babey, S. H., A. L. Diamant, T. A. Hastert, S. Harvey, H. Goldstein, R. Flournoy, R. Banthia, V. Rubin, S. Treuhaft. 2008. Designed for Disease: The Link Between Local Food Environments and Obesity and Diabetes. University of California, Los Angeles Center for Health Policy Research. Banks, J., M. Marmot, Z. Oldfield, and J. Smith. 2006. The SES health gradient on both sides of the Atlantic. Presented at National Bureau of Economic Research, Inc. Conference on the Economics of Aging. National Bureau of Economic Research, Inc. Working Paper 12674. Cambridge, MA: National Bureau of Economic Research, Inc. Bureau of the Census. 1970. Available at: www.census.gov/population/www/documentation/ twps0056.html. CHIS (California Health Interview Survey). 2001. Los Angeles, CA: UCLA Center for Health Policy Research. Available at: http://www.chis.ucla.edu/BER/stateAsian.asp?tableID=18; http://www.chis.ucla.edu/BER/state.asp?tableID=17. CHIS. 2005. Los Angeles, CA: UCLA Center for Health Policy Research. Federal Home Loan Bank Board Home Owner’s Loan Corporation. Cartographic Records, Record Group 195.3. College Park, MD: National Archives II, 1933-51. Gans, H. J. 1962. The Urban Villagers; Group and Class in the Life of Italian-Americans. New York: Free Press of Glencoe. Harvey, D. 1973. Social Justice and the City. Baltimore, MD: The Johns Hopkins University Press. Hillier, A. E. 2003. Spatial analysis of historical redlining: a methodological explanation. Journal of Housing Research 14(1):137–168. Kagawa-Singer, M., N. Pourat, N. Breen, S. Coughlin, T. Abend McLean, T. S. McNeel, and N. A Ponce. 2007. Breast and cervical cancer screening rates of subgroups of Asian American women in California. Medical Care Research and Review (64):706–730. Lurie, N., N. Ward, M. Shapiro, and R. Brook. 1984. Termination from Medi-Cal—does it affect health? New England Journal of Medicine 311(7):480–484.
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Demographic Changes, A View from California: Implications for Framing Health Disparities - Workshop Summary Lurie, N., N. Ward, M. Shapiro, C. Gallego, R. Vaghaiwalla, and R. Brook. 1986. Special report. Termination of Medi-Cal benefits: a follow-up study one year later. New England Journal of Medicine 314(19):1266–1268. Pourat, N. 2008. Haves and Have-Nots: A Look at Children’s Use of Dental Care in California, 2005. Oakland, CA: HealthCare Foundation. Toles, T. 1998. The Plan, Universal Press Syndicate. Wallace, R., and M. Fullilove. 2008. Collective Consciousness and Its Discontents: Institutional Distributed Cognition, Racial Policy and Public Health in the United States. New York: Springer Publications.
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