(Editor's note: The Fresh Perspectives blog launched in 2014 as a platform for new physicians who have been out of training for no more than seven years. Marie Ramas, M.D., leaves the blog with this final post as she enters her eighth year of practice. We thank her for all of her contributions to the AAFP Fresh Perspectives and Leader Voices blogs.)
If you let too many cooks in the kitchen, it could cloud your vision of what you want to do.
-- Mary Elizabeth Winstead
Few places evoke such intense and vivid memories as does a kitchen. Perhaps the mélange of sensory input or the tapestry of images spark such a hard-wiring in us that it revives a familiarity or nostalgia. It's a place where people congregate, transitions occur and life's mundane rituals ebb and flow.
That sense of familiarity allows for freedom of thought, being and emotions. Similarly, urban communities have their own pulse and center whereby familiar traditions and cadences ebb and flow. Each barrio has its own distinct flavor and vibe. More importantly, their inhabitants -- who often have low incomes -- slip into a cycle of survival, sometimes spending more than half their income on rent. Their neighborhoods, however, reveal a colorful display of art, cuisine and culture.
Although this social ecosystem seems to have always existed, changes to urban areas with low-income, mostly minority populations became prevalent in the late 1940s during a phase known as urban renewal.
It aimed to create better living conditions in low-income urban areas, but this revitalization attracted the attention of wealthier (and typically white) investors who were seeking to create a market for capital gain. As a result, building projects led to the destruction of the homes and neighborhoods of the poor and marginalized. With time, the buildings and homes translated into a change of businesses and eventually the faces that they served.
As the façade of a neighborhood changes architecturally, so does its mix of inhabitants as the price of once-affordable housing rises, forcing low-income minorities out of their homes and cultural milieus. Soon urban renewal became synonymous with dilution of cultural vitality and community.
The word "gentrification" was coined by sociologist Ruth Glass in 1964 in response to change in post-war London. She noted that as the city became more advanced and metropolitan, middle-class jobs became more specialized and lower-level work became rarer. The middle class began invading once-modest neighborhoods. Eventually, the character of communities adjusted to meet the demands of the new populace.
An influx of new business, lower crime and higher demand for real estate are beneficial to communities, but these changes typically result in loss of affordable rental properties for existing residents and damage to local businesses as their clientele is forced elsewhere. That is gentrification in a nutshell: the transformation of neighborhoods from low-value to high-value, leading to the displacement of long-time residents and businesses.
Living in southern New Hampshire, I have witnessed the result of such changes in the form of new patients who have been forced to relocate from bordering Massachusetts. A new family came to my practice after moving across the state line. Their landlord had nearly tripled the rent for their townhome of more than 10 years after an influx of professional city-dwellers moved to their area on the outskirts of Boston. As a result of moving across the state border, they lost their housing voucher, as well as familial help with the household and children. They also had to find new jobs due to the lack of adequate public transportation. In a short time, both the adults and children felt like foreigners in a strange land. When they came to me, they felt the pressure of seeking financial stability while coping with stark contrasts between their new lives and what they left behind.
This change comes as a shock for those who are displaced. Accessibility to ethnic cuisine and culture, affordable rental properties and work opportunities are limited just a few miles north of the metro area. Lack of public transportation becomes a real issue for many patients who formerly lived in a more urban environment, and this poses a challenge when they need health care. Suddenly, the subspecialists who provided charity care could be as much as an hour away from my patients. My patients not only had to find alternative ways to navigate their new city, they also needed help managing the mounds of paperwork required to apply for social services.
Gentrification is about much more than housing. As The New York Times pointed out earlier this year, the issue is cultural ownership.
The appropriation of cultural traditions can hurt communities by sensationalizing common denominators of life in poverty (think tiny homes, food trucks, "raw" water), as well as devaluing the uniqueness of minority communities. These pop-cultural trends thus lead to further marginalization of minority groups, both economically and psychologically.
One of my refugee patients expressed confusion about why some rich urban residents care so much about raising chickens -- something considered mundane in his own country. That patient now works for less than the minimum wage and lives in a small apartment with his family of four, with no yard to call his own.
As physicians, we have to understand a patient's clinical context as a whole before we can treat symptoms. This is simply good medicine. Unintended consequences from gentrification affect the condition of a community and can thus serve as indicators of social determinants of health. For instance, sparsity of affordable resources will affect one's access to healthy food and education. Increased stress resulting from displacement or conversion of communities can lead to metabolic disorders that are already prominent in lower socioeconomic cohorts.
These perpetual cycles self-propagate without structural checks and balances in our current systems. The CDC provides examples of initiatives, funding programs, subsidies and local political alliances that can help deter or slow down the process of gentrification. However, these efforts are limited by stakeholders' level of interest and transparency and commitment to invest.
The ultimate goal of any community should be for its members to become the best version of themselves regardless of socioeconomic, ethnic or cultural standing. Unfortunately, history has demonstrated that instead of creating a fusion of tastes, too many cooks in the kitchen can cloud your vision of what you want to do. I would venture to say that we need all cooks to be equally vested in the outcome and to understand that the pots may cook unevenly without a well-functioning kitchen.
As family doctors, we have opportunities to validate the importance of diverse communities by sharing our stories with legislators and advocating on behalf of our patients. Whether we live in a rural or an urban setting, it is vital to see how socioeconomic pressures affect the overall health and well-being of our patients. Encouraging our patients to vote and pay close attention to what candidates say about these issues will help others enjoy the rich history of our communities with pride and create thriving healthscapes.
Marie-Elizabeth Ramas, M.D., practices family medicine, including maternity care, in Nashua, N.H. She enjoys spending time with her husband, Ray, and their three children.