The Rise of Vacancy - Part I (by Jeffery Fraser)

East Liberty Development, Inc. was still figuring out how to jump-start the housing market in the Pittsburgh neighborhood when it built 10 houses on Mellon Street across from a handful of vacant and blighted buildings. At $105,000 for three bedrooms, a bath and a half, a two-car garage and a zero-percent second mortgage for income-qualified buyers, the new homes were priced to sell.

None of them did. 

“Nobody was willing to buy on that block until we were able to tell them a good story, something concrete, about what was going to come about across the street,” said Kendall Pelling, project manager for the community development corporation. “We learned from experience that vacant and abandoned properties have a terrible impact on the housing market.”

Others are getting a similar education. Vacant and blighted properties are increasing across southwestern Pennsylvania, the state and the nation, robbing local governments of desperately needed tax revenue, consuming millions of tax dollars, eroding housing values, posing health and safety risks and complicating the already challenging job of reviving distressed neighborhoods.

In Allegheny County, a program for turning tax-delinquent vacant properties into community assets doesn’t come close to keeping pace with the rate at which properties become vacant. And the story is the same throughout southwestern Pennsylvania.

In Homewood, mapping routes to get children to and from school without exposing them to mean streets littered with vacant lots and abandoned buildings is one of the first steps the Homewood Children’s Village is taking as it attempts to improve the educational outcomes and overall well-being of children in one of Pittsburgh’s most distressed neighborhoods.

In Philadelphia, one of the few studies of the price that communities pay for vacancy and blight reports that housing values fall by 6.5 percent citywide and that at least $22 million a year is drained from the city in lost tax revenue and to cover maintenance, police and fire costs.

In Flint, Mich. and Cleveland, Ohio, land banks seize thousands of vacant tax-delinquent properties using laws Pennsylvania doesn’t have, and sells, rehabilitates or tears them down following comprehensive blight redevelopment strategies that haven’t been developed in southwestern Pennsylvania.

If there is a bright side to the growing problem, it lies in the opportunity vacant properties offer to redesign neighborhoods in ways that are better suited to their down-sized populations, such as widening narrow lots found in many former industrial towns to accommodate fewer, but more marketable parcels, and turning empty lots and buildings into greenways, community gardens, recreational space and other amenities that give local housing markets more appeal.

“Any community that has blighted and abandoned properties and sees them only as a strain and a drain is undervaluing the real estate,” said Court Gould, executive director of Sustainable Pittsburgh, which last year published a comprehensive report on vacant property in southwestern Pennsylvania. “We need to be thinking about those properties as stranded economic assets.”

East Liberty Development, Inc. got the message. The new houses on Mellon Street sold after the nonprofit bought the vacant properties across the street and came up with a plan to renovate some of the vacant houses and build new ones on the other lots.

Recent Pennsylvania legislation offers municipalities, community organizations, and even residents a more expansive menu of legal options for dealing with neglectful landlords, absentee owners and the vacant and blighted properties next door.

But when dealing with tens of thousands of vacant properties, effective intervention comes down to a question of scale. And in southwestern Pennsylvania, local government attempts to combat vacancy and blight fall far short of recovering anything but a fraction of the vacant lots and houses found along city, borough and township streets.

Over the past seven years, the Allegheny County Vacant Property Recovery Program has helped put some 500 vacant, tax-delinquent properties into the hands of buyers interested in turning them into side yards, small parks and other neighborhood-friendly uses. At that rate of recovery, the program barely makes a dent.

The percentage of vacant housing in the county jumped from 6.8 percent to 9.4 percent over the past two decades – a trend experienced in every county in the region, according to U.S. Census data. More than 55,000 housing units, including apartments, stand vacant. And the Census Bureau doesn’t count vacant lots, which greatly outnumber vacant houses.

“Even if we did 1,000 properties this year – and we won’t – I would have a job for life,” said Richard Ranii, who oversees the program as manager of the Housing and Human Services Division of the Allegheny County Economic Development Department.

A creeping crisis

Shifting, aging or declining population, weak housing markets, poor housing stock, crime, underperforming schools and other factors that make some communities less than desirable places to live -- all of these factors contribute to vacancy and blight. High mortgage foreclosure rates, decimated job markets other consequences of recession have exacerbated the problem.

Antiquated tax foreclosure systems can take years to move against delinquent properties, and many accrue several years’ worth of delinquent taxes and penalties. In depressed markets, such Homewood, where the average price paid for residential property was $9,060 in 2009, back taxes and penalties can easily exceed the market value of a house, encouraging owners to ignore its upkeep or to walk away from it entirely.

“There isn’t a place I go where someone doesn’t talk about a problem property they are frustrated with,” said Irene McLaughlin, an attorney and consultant on vacant property issues for the Housing Alliance of Pennsylvania and others.

More than 11 percent of the houses and apartments across the United States are vacant, according to the 2010 U.S. Census. In states hit hardest by the mortgage foreclosure crisis, the rate is much higher – 17.5 percent in Florida, for example, and 16.3 percent in Arizona.

Nine percent of the housing in the seven-county Pittsburgh Metropolitan Statistical Area is vacant, up from 6.8 percent in 1990.

Cities tend to have higher concentrations of vacant property, and Pittsburgh is no exception with nearly 13 percent of its houses and apartments standing vacant. Higher rates are found in several nearby cities. The vacancy rate is 19 percent in Cleveland and Youngstown, Ohio. And 15 percent of Steubenville’s housing is vacant.

Even higher concentrations are found in poor urban neighborhoods and municipalities that have endured decades of economic decline. In other words, the places shouldering the heaviest burden are the most fragile and the least likely to have the resources to do something about it.

Many pay the price

While those living on blight-ridden streets are the most directly affected, studies suggest the economic and social costs of long-standing vacancy are widely shared.

What those costs amount to in southwestern Pennsylvania is unclear. Pittsburgh’s year-old Land Recycling Task Force, planning department and others are working on an analysis of the economic impact on the city, which is expected later this year. And there is no countywide or regional accounting of the total cost of vacant property.

Philadelphia is one of the few places that examined those costs. Its study found that vacant properties reduce market values by 6.5 percent citywide and by as much as 20 percent in high-vacancy neighborhoods, resulting in an average loss in value of $8,000 for each city household. Tax-delinquent vacant properties in Philadelphia owe an estimated $70 million in back taxes, a sum that grows by $2 million every year. And vacant properties consume $20 million in city services a year, including $8 million spent on code enforcement and maintenance.

When housing values plummet, those who are hurt the most include long-time homeowners, many of them senior citizens – the very people who tend to hold together what is left of declining neighborhoods.

“We got a call last year from an elderly woman in one of those neighborhoods,” said Rob Stephany, director of the Pittsburgh Urban Redevelopment Authority. “She had a $9,000 bid from a contractor to replace her roof, which had started to leak. Her next-door neighbor’s house had sold for less than that, about $7,000. Here was a responsible, salt-of-the-earth-Greatest-Generation senior citizen asking whether she should repair her roof or just ride it out. That is loss of equity.” 

Vacant and blighted properties also play a role in unraveling of the quality of life in a neighborhood and dimming the outlooks of those who live there.

For Malik Bankston, one of the more challenging aspects taking control of vacant properties in Pittsburgh’s Larimer neighborhood and then creating gardens, parks and a safer and more vibrant place to live was convincing residents that it could be done. “It was tough getting a conversation going,” said the Kingsley Center director. “For so long, the neighborhood watched a deliberate kind of disinvestment play out, which resulted in us having one of the highest incidence of vacant and blighted property.”

More than 42 percent of the lots, houses and buildings in Larimer are unoccupied. And, like most neighborhoods with high rates of vacant and blighted property, crime rates are higher than citywide averages – in Larimer’s case, 30-50 percent higher.

In Homewood, where nearly 44 percent of the lots and 28 percent of the houses are vacant, finding ways for school children to avoid them is a priority of the Homewood Children’s Village, which is based on a program in New York’s Harlem neighborhood that concentrates community support and services on mending the social fabric and improving children’s outcomes.

“The impact of vacant and abandoned properties on kids is a real concern,” said John Wallace, a University of Pittsburgh associate professor of social work who spent several years planning the Homewood initiative. “These properties are risk factors for crime, they’re a safety risk and they’re a health risk.”

The “broken window” theory argues that is not by coincidence. The theory, introduced by social scientists James Q. Wilson and George Kelling in 1982, has become widely accepted by law enforcement. It suggests that vacant and blighted houses, abandoned cars and other visible evidence of neglect send the signal that nobody cares, erode community controls and leave neighborhoods more vulnerable to crime.

Southwestern Pennsylvania police departments don’t track the relationship between crime and vacant property. And the few local studies that looked at the relationship offer contradictory, inconclusive findings.

Evidence elsewhere suggests the relationship is not benign. Philadelphia spends close to $6 million a year on police and fire calls to vacant properties. A study published by the Federal Reserve Bank of Chicago reported violent crime rates in the city rose 2.3 percent with every 0.01 percent increase in mortgage foreclosures. After a sharp rise in foreclosures and vacancy, the Charlotte-Mecklenburg Police Department in North Carolina analyzed its records and found that high neighborhood foreclosure rates predicted higher crime rates, including violent crime, which rose steadily in those neighborhoods, but stayed much lower in places with few foreclosures.

Whether residents of neighborhoods with a high percentage of vacant, boarded-up stores and homes, litter and graffiti have a higher incidence of disease and premature death was a question RAND researchers looked at in 2003. Even after controlling for poverty, they found that those who live in deteriorating neighborhoods have higher rates of premature death and death by cardiovascular disease and homicide than people in neighborhoods that are not in decline.

That was not the only troubling effect they noted. In neighborhoods where residents were seen as willing to work toward a common good, the rate of premature deaths was lower. The one exception was in neighborhoods with a high number of vacant homes and other signs of decline, where the willingness of residents to help out made no difference.

Liabilities to assets

The flip side of vacant and blighted properties is that under the right circumstances they can be used to improve conditions in the neighborhoods they helped lead down a path of decline. In southwestern Pennsylvania, both public and private sector interest in reclaiming vacant property to add elbowroom and a little green to crowded urban neighborhoods is growing.

“With a lot of liabilities, your only option is to eliminate or reduce them. To be able to turn a liability into a asset is a unique opportunity,” said Frederick Thieman, executive director of the Buhl Foundation, which funded the Sustainable Pittsburgh report on vacant property in southwestern Pennsylvania. “Vacant property provides us with such an opportunity.”

Demolition is a common municipal response to abandoned houses. Clarksburg. W.Va. took a low-interest state loan to finance a campaign against the blight that had accumulated during decades of economic decline, tearing down nearly 300 homes. More than half of the 900 vacant houses acquired by a public land bank in Cuyahoga County, Ohio last year have been razed.

“It’s like cleaning the cancer cells out of the body so the rest can be healthy,” said Frank Ford, vice president for research and development at Neighborhood Progress, Inc., a Cleveland neighborhood development agency. “It’s hard for me to say that. Like most of my colleagues, I was a preservationist 20 years ago. We rehabbed houses. That’s not feasible now. The market isn’t going to come back until we clear out the bad stuff and allow it to come back.”

“Greening” vacant lots is an increasingly popular strategy for helping turn around distressed neighborhoods.

In Pittsburgh, the city’s Green Up Pittsburgh program has put hundreds of vacant lots in the hands of community groups and residents who use them as neighborhood green spaces and side yards. Before Larimer residents decided to reinvent themselves as a green community, nonprofits used vacant lots to introduce them to ideas such as community gardens and urban farming. And in Homewood, a community group that began gardening vacant lots a decade ago established its own urban landscaping company and youth training program.

But before any house is rehabilitated or lot seeded with sunflowers, those interested in doing the work must take title of the property, which can be a time-consuming and costly process. In some cases, their local government lends them a hand.

Allegheny County, for example, helps municipalities and others acquire vacant properties through eminent domain-like powers granted in the state’s Urban Redevelopment Authority law and pays for clearing the title, which costs about $3,000.

And Pittsburgh takes tax-delinquent properties through treasurer’s sales, “quiets” the titles and holds them in its land reserve until community groups arrange financing to buy them. But financial and staffing constraints cap acquisitions at 300 properties a year, which represents about 1.5 percent of the vacant houses and lots in the city.

Pennsylvania added a number of legal tools to help combat vacancy and blight in recent years. The state’s new conservatorship act, for example, allows community groups and others to petition courts to appoint a third party to take temporary possession of a blighted property, rehabilitate or demolish it, and then offer the property back to the owner for the cost of the work done or sell it under court supervision to someone else.

But the consensus best practice for tackling vacant property on a large scale is not available in Pennsylvania. Genesee County, Mich. and Cuyahoga County in Ohio are showing how land banking and property tax reform can be used across entire counties to take control of thousands of vacant tax-delinquent properties, keep them out the hands of slumlords and speculators and manage them as community assets.

In June, legislation to empower land banks was introduced in the Pennsylvania House of Representatives by state Rep. John Taylor (R-Philadelphia). The bill, which received the endorsement of Pittsburgh Mayor Luke Ravenstahl, is under consideration in the House Urban Affairs Committee.

But costs are an issue. Genesee County and other land banks are able to recover much, if not all, of their operating costs through sales and the collection tax liens and penalties.

Start-up costs are another matter. While a land bank in Pittsburgh is estimated to cost $3.7 million a year to operate, it could take another $15 million to clear the titles of the more than 7,500 vacant properties in the city’s inventory, according to an unpublished report prepared for the city Land Recycling Task Force.

Spending that kind of money makes many municipal officials nervous, particularly when most face serious budget shortfalls. “We run into that all of the time,” said Dan Kildee, a former Genesee County treasurer who now directs the Center for Community Progress, a nonprofit that specializes in vacant property issues. “But it ignores the costs taxpayers already pay for vacant property and abandonment. You have to measure the cost of change against the cost of the current path that we’re on. Anybody who argues that the current path we’re on is the right one isn’t examining the full cost of vacant and abandoned property.”

(Matt Stroud of PittsburghTODAY.org contributed to the reporting for this article).

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Diabetes Rates in Region Still High (by Tanya Kenkre and Bernard Goldstein)

The Pittsburgh MSA continues to have relatively high rates of diabetes as compared to benchmark areas, and our black community is particularly affected.  The newly available 2008 data from the Centers for Disease Control report an overall adult diabetes rate of 8.9% in 2008 as compared to 8.4% in 2007.  While we are just about at the US average of 8.8% adult diabetics, we once again rank poorly among comparison cities who average 8.1%.  Since 2003 Pittsburgh has had the 9th through 15th worst level of diabetes among the benchmark cities, ranking 11th in 2008.  Black residents of our area are particularly affected by diabetes with a reported rate of 16.4%.  Since 2003 African-Americans in the Pittsburgh region have consistently ranked worst or next to worst among the 15 benchmark areas.   In relation to gender, Pittsburgh men do more poorly than Pittsburgh area women.  For men there is an 11.0% overall rate of diabetes – only Detroit being higher.   Our women are at 7.1%, which for the first time since 2003 puts us better off than the benchmark average.  It will be important to see if this trend for women continues. 

 

The Pittsburgh Indicator health data are highly consistent with our medical understanding of the causes and adverse outcomes of diabetes, the cause mostly being obesity and the outcomes including death due to cardiovascular disease.   If you look at our “Overweight and Obesity” data the evidence is clear that we are “Fat City” – and checking the data under “Heart Attack Death Rates  shows that we are among the leaders in dying from heart attacks.   This is a long time problem in our area that will not get better until we get our food intake under control. 

Fat City Again (by Dr. Bernard Goldstein and Dr. Tanya Kenkre)

The latest data from the U.S. Centers for Disease Control show the Pittsburgh area to have a high rate of obesity, particularly among men and among the black population.  Our rate of adult obesity in 2008 ranked second highest among the 15 benchmark regions. 

The obesity rate for Pittsburgh men is 32.3 percent. This compared to a benchmark average of 27.0 percent and 27.6 percent for men across the nation.  The obesity rate for Pittsburgh women is 25.3 percent, just under the obesity rates for women in benchmark regions and the nation – 25.6 and 25.8 respectively.

The problem is present in both our white and black populations, although far worse among blacks – who in 2008 were reported to have the incredibly high rate of 46.8 percent obesity as compared to 36.1 percent in benchmark regions and 36.9 percent nationally.  This level of obesity among black residents of the Pittsburgh area is higher than any of the comparison metropolitan areas – but there are reasons to be cautious in our accepting of the numbers.

The data are derived from a national telephone survey done by the CDC each year and are based on self-reported height and weight which are used to calculate whether the individual is normal in weight, overweight or obese.  As with any such survey, the error margin can be large, particularly for smaller population sizes.   Accordingly, to help interpret the importance of these findings, we have presented the data for the Pittsburgh area black and white populations, and males and females, for each year from 2003 to 2008.

Certain patterns are repeated each year and are hard to argue with.  First and foremost, there are more obese adults in the Pittsburgh area as is evident from having more adult obesity than national or benchmark averages in all but one year.   It is also clear that Pittsburgh area men rather than women are responsible for this negative distinction.  Our men rank at or above the benchmark and national averages every year, while the percent of obesity among women is around the national and benchmark averages.

The level of obesity among the white population of Pittsburgh is consistently higher than the benchmark and national averages in each of the six years 2003-2008, ranking 10th to 14th among the 15 comparison areas.  For the black population, the numbers are not as consistent which is not surprising in view of the smaller number of survey responses.  In 2007, the black obesity rate in the Pittsburgh area was relatively low, while in 2008 it is very high.   Presumably, this represents the instability that occurs with smaller numbers – but it is certainly an issue to watch closely and on which to take action.

Three other points are obvious from these data.  First, obesity is a rapidly increasing problem in the United States; the overall national average has increased every year since 2003.  It affects us in many ways, from a higher level of diabetes in the nation, a problem which we have previously reported for the Pittsburgh area, to runaway health costs which will make a mockery of our current attempts at health care reform.  Second, obesity rates are much higher each year among black than white Americans, adding to the many health and health care burdens of this community.  Third, and perhaps most important, is information that is not reported:  The CDC obesity figures are for adults; children are not part of their telephone survey.  Obesity in children is increasing rapidly and, in addition to health issues, is a potentially enormous burden to our country in terms of national productivity and quality of life.

This is not the place to consider all of the societal and individual issues that contribute to the American obesity epidemic.  A few points seem obvious.  First, our measures to date in dealing with obesity epidemic have been relatively futile, as is evidenced by the yearly increase in the extent of obesity nationally and locally as shown in these figures.  Second, studies have documented what we all have seen - fat parents have fat children.  If we really care about the next generation we must confront obesity as a major national problem for both adults and children.

Exploring women's health issues (by Tanya Kenkre and Bernard Goldstein)

The Pittsburgh region does not compare well with benchmark regions in indicators of women’s health, both for our white and black populations.  We evaluated a variety of measures that are used to measure adult women’s health, other than those related to pregnancy.  Data from the two most recent nationwide CDC telephone surveys show that in 2006 we were last and 2008 next to last among 15 comparable regions in mammography rates for black women.  For white women we were 14th in 2006, and for 2008 we are still below average, but not as dramatically.  When we looked at another test of proven value for preventing cancer, the pap test for early cervical cancer, white women in our region also do very poorly. In 2006 we ranked 14th and in 2008 we ranked last among the 15 benchmark regions.  Pap test rates for black women are not included in this indicator because we are not satisfied that the sample size of the most recent survey leads to reliable results.  Earlier survey results, however, on Pap smears for black Pittsburghers was as negative as it is for white Pittsburghers.  

Nationwide there is no difference between white and black women over the age of 40 in mammography rates in the past two years for which data are available, both being at 75.7%, while white women in benchmark regions report somewhat higher mammography rates than black women, 77.1% vs. 74.5%.  Both white and black women in Pittsburgh are well below these averages.  Again, it is black women who have the far lower rate (57.9% vs. 72.5% in white women).  

Why do we do so poorlyin these two important measures of disease prevention?  One possible partial explanation is that women in our area have relatively low rates of health care coverage.   For white women we are third from the bottom and for black women we rank last.  This is unlikely to be the full explanation – less than 10% of white women are not covered by a health plan while close to 20% have not had a pap test within the past three years and 27.5% over the age of 40 have not had a mammogram in the past two years.  20% of black women report not having health care coverage – twice the rate of white women, but again not likely to beenough to account for the difference observed in mammography and pap smear rates.

We also compared the percent of women who reported that they did not see a doctor because of cost in the previous year.  Although indirect, this might tell us something about whether cost issues played a role in the failure to obtain mammography or a pap test.    Again, black women in the Pittsburgh MSA have a higher rate of reporting that cost was a deterrent to see a doctor than did white women (15.2% vs 12.0%); but for this indicator black women in Pittsburgh did better than the national or benchmark averages for black women, while Pittsburgh white women did somewhat worse than the benchmark average and were equal to the national average for white women. 

How good are these data?   There is always the potential for faulty sampling or misreporting on telephone survey data.  Data problems in terms of consistency across some of the possible explanatory metrics are present, so we caution against overinterpreting the findings.  The limitations of these data sources are magnified when the population size becomes too small.  For example, the pap smear rates reported for African-American women were among the lowest in comparison with benchmark areas in 2006, but in 2008 were among the highest.  This most likely represents statistical variation among surveys due to the small sample of randomly chosen women.   Mortality, which is based on all death certificates, is a much more stable measure.  Accordingly, we place more reliance on CDC’s telephone survey data for white women in the Pittsburgh area as the sample size is larger; and more reliance on mortality data than on telephone survey responses. 

One approach to check on the validity of the benchmark approach is to evaluate whether the data conforms to expectations.  In addition to data on black and white women, the CDC also reports on Hispanic women.  Because we have created few low end jobs in recent years, the Pittsburgh MSA is thought to have had a low rate of Hispanic immigrants.  The Hispanic community, although small, is on average believed to be relatively more affluent and educated than Hispanic communities in the rest of the country.  As expected, and providing some support to the overall validity of the indicator data, for both 2006 and 2008 CDC reported a much higher rate of mammography, pap smears and health plan enrollment than for Hispanic communities in other benchmark cities, and a lower rate of having not seen a doctor because of cost considerations.   Hispanic women do better than white or black women in our MSA when examining Pap tests and mammography rates; they also do better than black women when examining rates of health care coverage and not seeing a doctor due to cost.  With respect to these last two measures, they do about as well as white women in our MSA.  Nationally they do worse than white or black women in all but mammography rates which are about the same. 

Finally, and most importantly, what difference does it make that white and black women in the Pittsburgh region have lower rates for preventive activities?  One way to check is to look at breast cancer rates in our areas as compared to the benchmark areas and the rest of the country.  (We could not look at cervical cancer rates because the incidence for black women is lower than acceptable for benchmark comparisons).  Unfortunately, the breast cancer mortality rates in the Pittsburgh region are higher for both white and black women than for the rest of the US or for the benchmark areas.  In our region, the breast cancer mortality for white women in 2004, the last year for which data are available, was 27.3 per 100,000, as compared to the benchmark average of 24.9 and the national average of 23.8.  For black women, the Pittsburgh MSA mortality rate for breast cancer was 34.2 as compared to the benchmark average of 31.7 and the national average of 32.3.   In comparison to other cities we are ranked 9th for black women; but for white women only Philadelphia had a higher breast cancer mortality in 2004.  We emphasize that the data can be expected to move back and forth through the years, but the findings are consistent.   Mammography is a proven preventive measure for the early detection of breast cancer when it is far more likely to be treatable.   Low mammography rates predict that more women in our area will die of breast cancer – and that is what is happening.

As We See Ourselves (by Tanya Kenkre and Bernard Goldstein)

A reasonably effective way to evaluate overall health status is to simply ask.  A question on the annual Behavioral Risk Factor Surveillance study by the US Centers for Disease Control is “Would you say in general your health is excellent; very good; good; fair; or poor?”   The data are shown by CDC as the percent reporting only fair or poor health. 

To find out how people in our MSA respond to this question, we constructed three year moving averages in which we added the data from the most recent year while subtracting the data from the fourth previous year to determine the average response.  We did this because of the relative instability of data from any one given year.  Posted are three moving averages covering 2003-2005; 2004-2006 and 2005-2007.  

Relatively speaking, in 2005-2007 blacks self-reported poorer health status than whites nationally (20.6% vs. 13.8% ); in benchmark cities (20.0% vs. 11.9%)  as well as in our region (19.9% vs. 13.8%).   Women self-report poorer health than men nationally (17.4% vs. 15.7%) and in benchmark cities (14.5% vs. 13.1%) and, by a slight margin in our area (14.5% vs. 14.1%).    

In general, people in our MSA report fair or poor health at a rate similar to the benchmark averages.  Among benchmark cities, the people in Minneapolis and Denver consistently report better health and those in Detroit worse health status. 

When the 2009 data are reported, it will be interesting to see whether winning both the Super Bowl and the Stanley Cup is associated with people in our area feeling better about their health. 

Pittsburgh men eating their way to bad health (By Tanya Kenkre and Bernard Goldstein)

The Pittsburgh Indicators Project has previously reported that Pittsburghers tend to be heavier than most Americans, on the whole as well as the average of benchmark regions.  A closer look at the data reveals that Pittsburgh men are particularly overweight.   We have a lower percent of men who are in the normal BMI range, and more in the combined overweight and obese categories, than any of the other 14 regions that are part of the Pittsburgh Indicators comparison group.  Pittsburgh women are near the average in the rankings for the proportion with healthy BMIs.  Unfortunately, Pittsburgh area women are on the higher end of the rankings in terms of the percent who are obese.  The BMI is based on the height and weight provided during a telephone interview to a national sample that is of sufficient size to be reasonably robust statistically.

 Adult onset diabetes is one of the major health problems caused by not keeping to normal weight.  Having relatively fewer men and women with normal weight would predict that we have more diabetics – which in fact we do.   Diabetes leads to a significantly increased risk of stroke, heart attack, blindness, kidney disease, neurological disease and a host of other life shortening and life limiting disorders.  The total costs for diabetes in 2007 in the United States are estimated by the American Diabetes Association as 174 billion dollars, up 32% since 2004 (http://www.diabetes.org/diabetes-statistics/cost-of-diabetes-in-us.jsp).  The amount spent on diabetes and on the many complications of this disease account for about 20% of total health care costs.   The cost per individual with diabetes averages over $11,000 per year.  While we found no specific dollar costs for the Pittsburgh region, it appears obvious that a region with more obesity will have more diabetes and more health care costs.

 Why are we overweight?  For any individual, weight gain or loss is determined by whether we take in more or less calories than we expend in our daily activities.  For each one of us, the less we eat or the more we exercise will make a difference.  In attempting to understand whether our region’s problem is that we eat too much or exercise too little, we consulted the CDC data base on physical activity.  Like the data on weight, the data on physical activity come from an annual national phone questionnaire and have all of the potential problems of such an approach.  CDC codes the responses as indicating sufficient exercise, insufficient exercise, or no exerciseFrom this data, it appears that women in our region are just about at the national and benchmark averages in terms of physical activity, while the good news is that men in our area are considerably above average.   While care is necessary in interpreting data from telephone surveys, it seems an inescapable conclusion that in comparison with the rest of the country, men in the Pittsburgh region are fat because we eat too much, not because we exercise too little.  

 Men in our region (and women too) take great pride in the number one ranking of many of our sports teams.  Being number one in overweight and obesity is a ranking that we could do without.

Pittsburgh is Obese (by Tanya Kenkre and Bernard Goldstein)

The Pittsburgh region continues to have a problem with obesity, and it is getting worse.  The data shows that we are now fourth highest among the 15 benchmark cities in our extent of obesity.  According to the CDC, in 2007 26.8% of the Pittsburgh MSA population was obese, defined as having a BMI equal to or greater than 30.  This is up from 23.2% in 2006. 

 Since 2003 there has been a steady increase in obesity but a relatively steady percent of overweight in both the benchmark and national averages. For our MSA we have a general increase in obesity and a reasonably steady level of overweight.  One explanation is that roughly as many have gone from normal to overweight as have moved from the overweight to the obese category.  

There is a seemingly paradoxical finding in that Boston and Denver were again the two cities with the lowest proportion of obese individuals, with less than 20% of the population – but they are the two highest benchmark areas in terms of overweight (BMI 25 or over but less than 30).  The CDC calculates the BMI based upon interviews in which the respondent reports their height and weight.  It is possible that the Boston and Denver areas have developed strategies that keep the overweight from becoming obese, but normal individuals are still gaining sufficient weight to advance into the overweight category.  Another conceivable interpretation is that people in Boston and Denver are more vain than the rest of us, and are therefore more likely to overstate their height and understate their weight in a telephone interview.  But whatever the interpretation, obesity in our MSA exceeds that in the rest of the  benchmark areas.  Obesity is a reasonably certain predictor of health problems, including our relatively high diabetes levels, and of health care costs. 

Health Updates Accent Positive (by Tanya Kenkre and Bernard Goldstein)

Newly available data reported by the Centers for Disease Control has allowed us to add information for 2007 to the previously reported Health indicators for health care coverage, diabetes, and smoking. The Pittsburgh region maintains its position as having better than average health care coverage, when calculated either for the entire population or for adults under the age of 65.

Perhaps most notable among all of the benchmark regions is the marked decline in uninsured among 18-64 year olds in the Boston area, from 12.7% to 6.9%, reflecting the impact of Massachusetts’ mandated health care insurance law. Experience with the Massachusetts program is being considered by the new administration and by Congress as part of the national health care reform initiative.

Other indicators that have been updated show continued problems in the Pittsburgh region. We report a relatively high level of diabetes as compared to other benchmark regions and to the United States as a whole. Statistics on smoking also demonstrate our persistent problem, although some improvement has occurred. Our current smoker rate among adults is 20.2%, which is slightly below the benchmark average of 20.3%, but still higher than the US average of 18.3%.

Smoking rates continue to decline nationally, but again we do not do as well as other areas. Nationally, there has been a 16.9% decline in smoking from 2003-2007. For the benchmark areas the average decline is 13.6% and for our area it is only 12.0%. The CDC’s survey data again demonstrate that the Pittsburgh region is among the worst in terms of the percent of our population who report never having smoked. Clearly, there is a need for us to work harder on tobacco cessation and prevention programs, and to target youth.

In the Middle of the Pack but Improving (by Nicholas G. Castle and Aiju Men)

New Health indicator data on nursing homes present a mixed picture. The data come from the annual nursing home certification process in which almost all nursing homes participate. Surveyors visit each nursing home, and collect data as part of the certification process. When safety violations are found they are recorded as part of this data. The data is commonly used by researchers and the federal government as a source of nursing home information.

We caution that there is skepticism about using an indicator such as nursing home safety violations to compare different localities. This skepticism is based in the unevenness by which local authorities pursue and report violations.

Focusing on violations can also lead to paradoxical interpretations, particularly as not all violations will be detected. For example, if Pittsburgh traffic police were more concerned about stop sign violations than those in Indianapolis, using data based on traffic tickets could make it seem as if Pittsburgh drivers were more likely to ignore stop signs than those in Indianapolis. But, as drivers became aware of how rigorously stop sign infractions were being enforced, Pittsburgh might actually have fewer drivers ignoring stop signs than Indianapolis.

Even recognizing such skepticism, we believe that two points about the nursing home safety violation data appear evident. One is that we are consistently in the middle of the pack, having about twice as many violations as the best comparison location and half that of the worst. The second is that for virtually all localities, the number of nursing home safety violations has decreased every year. This decrease is evidence of the value of indicators as a measurement of the effect and value of enforcement. It demonstrates how far we can go in achieving patient safety goals on our way to the only acceptable level of safety violation in nursing homes, which is zero.

The analyses were conducted by Nicholas G. Castle and Aiju Men, both from the Department of Health Policy & Management, Graduate School of Public Health, University of Pittsburgh.

One Place at One Time (by John G. Craig Jr.)

Most indicator programs issue reports, more often than not bi-annually. Pittsburgh Indicators depends on a web site that is updated every time new data become available with the result that it is changing weekly. An unfortunate by-product of this important emphasis on timely information is a lack of appreciation of the volume and comprehensiveness of information available on www.pittsburghtoday.org.

Thanks to the magazine Pittsburgh Quarterly and the Pittsburgh Foundation, which have supported indicator work since its inception, a new 20-page report has been made available in the magazine's winter issue that addresses the problem. It does so by pulling together an overview of all the data available in topic areas and accompanying it with explanatory material on the significance of particular indictors.

There is also information on the organizational structure of Pittsburgh Indicators as well as brief essays from experts in various areas of Pittsburgh life on why they are involved in the project and why particular information is worth paying attention to.

To view the entire article click here, to get a hard copy of the report pick up a copy of the magazine.

The indicator report is presented in a format that permits its easy separation from the rest of the publication, permitting its retention as a separate piece of reference and reading material. As always, all criticism, proposed improvements for the web site and its content and the direction of the project are particularly welcome in this Forum.

Preterm Births: A Significant Local Problem (by Mita Lovalekar and Bernard Goldstein, MD)

The Pittsburgh region does not do well among our benchmark comparison areas in the extent to which both white and black mothers are delivering prematurely, with the rates being particularly high for blacks. In 2003-2004 the Pittsburgh MSA rate of very premature births, defined as live births before 32 weeks of pregnancy, was tied with Denver for the highest rate among white mothers at 1.9% of all births. For births to black mothers, only Detroit has a higher rate at 4.6% as compared to Pittsburgh at 4.5%.

Download Excel file of very premature births.

We do not do quite as poorly in comparison to other benchmark areas in all preterm births, which is defined as live births before 37 weeks of gestation (pregnancies usually last 40 weeks). We rank fourth highest with 18.0% premature birth among blacks and seventh highest with 11.3% among white women. The higher incidence of prematurity among blacks is seen in all of the benchmark areas and is a national phenomenon with major health consequences.

Download Excel file of all premature births.

Preterm births are a significant contributor to infant mortality nationally and globally. In the United States premature births are the major cause of infant mortality. According to the World Health Organization, preterm births were responsible for 28% of infant mortality worldwide in 2003, second only to infectious diseases. Premature babies are often born with lungs unable to bring their bodies enough oxygen; fragile blood vessels that can bleed into a baby’s brain; and other problems resulting in short term risks of death and life long impairments. Hospital costs related to premature babies were estimated at just under $12 billion in 2000. Prematurity has been associated with a greater risk for attention-deficit-hyperactivity disorder (ADHD) and with a variety of intellectual, motor and mental impairments. In general, the greater the degree of prematurity, the greater the likelihood of health and behavioral deficits that persist until adulthood.

Within the United States, the black - white difference in premature births is an important health difference with significant short-term and long-term consequences. Those cities with a greater degree of racially segregated housing have been reported to have a higher level of preterm births. Poverty and behavioral factors, including, smoking, substance abuse, and poor nutrition all contribute. Comparing the difference between black and white premature birth levels among the benchmark areas demonstrates that the absolute and percent disparity tends to be higher in the Pittsburgh region.

The relatively wider range among benchmark cities in the rate of preterm births among black mothers as compared to white mothers suggests that local non-genetic factors are important. For the gestational period before 37 weeks the range among comparison areas was12.5-20.3% of all births among blacks as compared to 9.9-12.5% among whites; and for the gestational period before 32 weeks it was 2.8-4.6% among blacks as compared to 1.3-1.9% among whites. This wider range may be due to smaller numbers, but it also consistent with there being local factors at work beyond the national causes of the much higher level of preterm births among Blacks. Such local factors can and should be addressed. For example, in our region there is previous information indicating a particularly high rate of smoking among pregnant African-American women. Also notable is a recent study in Montgomery County, Maryland by the US military’s Uniformed Services University of the Health Sciences reporting that home visits by nurses during pregnancy decreased preterm births by over 70%.

The US Centers for Disease Control and Prevention sets targets every ten years for national health endpoints, including premature births. These targets are set based upon what is achievable. The Healthy 2010 targets for total preterm births is 7.6% and for very premature infants is 1.1% - levels that we are far from achieving nationally or in the Pittsburgh region. Preventing prematurity includes eliminating smoking; good nutrition including neither being overweight nor underweight; prevention and treatment of pelvic infections; and reducing unplanned pregnancies. All are doable – and all can be achieved by an active comprehensive effort engaging women of childbearing age through health providers, public health agencies and the community.

Mita Lovalekar
Bernard Goldstein, MD
University of Pittsburgh Graduate School of Public Health