What a Victorian Disease Detective Proved About Urban Health


In her 2018 book Segregation By Design, Trounstine details how local public works in the early 1900s significantly reduced outbreaks of diseases such as cholera and typhoid fever. The infectious disease mortality rate dropped by 75 percent between 1900 and 1940, and part of that decline was due to the development of public water and sewer systems by local municipalities. These benefits were far from universal, however, and from the beginning low-income residents and communities of color received fewer of these types of services. Even when they did receive them, the services were of lower quality. “They were less likely to be connected to sewers, to have graded and paved streets, or to benefit from disease mitigation programs,” Trounstine writes.

These inequalities persist today, with some neighborhoods having access to clean water, ample green space with playgrounds, and functioning sewers, while others don’t. Segregation, both official and de facto, allowed for that unequal provision of public goods and services. Trounstine argues that local governments have deepened this divide by shaping residential geography through local land use policies, such as zoning laws. It’s what she calls “segregation by design.”

During the second half of the 20th century, as white flight left urban centers with a reduced tax base, those inequalities widened—and, with them, the politics of the advantaged and disadvantaged diverged, too. In advantaged places, Trounstine found that residents are politically conservative and vote at higher rates for Republican presidential candidates, favor lower taxes and limited spending, and see inequality as a result of individual failings. Ultimately, by regulating land use, planning, zoning, and redevelopment without taking into account the challenges faced by marginalized communities, local governments have deepened segregation along lines of race and class—a process that has benefited white property owners at the expense of people of color and the poor, Trounstine concludes.

The consequences of this divide have been far-reaching and long-lasting. Researchers have found that racial segregation influences a broad spectrum of factors that determine a person’s life outcome, leading to higher poverty rates, lower educational attainment, and higher rates of incarceration. Segregated neighborhoods become communities where this disadvantage compounds, leading to an entrenched inequality that is difficult to escape and is passed from each generation to the next, according to Harvard Professor Robert Sampson, who explores this in his book, Great American City: Chicago and the Enduring Neighborhood Effect. Sampson concludes that this inequality can be broken through the type of structural intervention that governments are equipped to handle. History, however, has shown us that those with political power have failed to take action to eliminate these inequalities, leaving communities of color asking whether the American dream of equality for all will ever be within reach during their lifetimes.

Throughout his life, the writer James Baldwin questioned whether the United States would finally confront the hypocrisy of a democracy that was founded on principles of equality, but had in fact created a system that valued white lives above all other lives. At the height of the civil rights movement in the early 1960s, Baldwin cautioned his nephew of the perils ahead for him in a country that placed him in a ghetto, intending for him to “perish.” In his essay “A Letter to My Nephew,” which became part of his 1963 book The Fire Next Time, Baldwin decried the conditions into which his nephew was born: “conditions not far removed from those described for us by Charles Dickens in the London of more than a hundred years ago.” The 1960s was an era of violence and resistance to the calls for change—a dark moment in our history, as freedom fighters lost their lives in this battle for civil rights and equality. “I know how black it looks today for you,” Baldwin wrote his nephew. Yet despite all of his trepidations, Baldwin held out hope that we collectively could “make America what America must become.”

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