Reports

About the Social and Health Landscape of Urban and Suburban America Reports
This issue brief is the first in a series of five reports using national sources of information—the Bureau of the Census, the Federal Bureau of Investigation, the Centers for Disease Control and Prevention and others—to document the social and health changes and challenges occurring in the nation’s 100 largest cities and their suburbs. Other reports will address race/ethnicity and health, public assistance and child health, and concentration of poverty in these areas, and the association of each factor with health and illness. A final publication will integrate this information, profiling each of the cities and their suburbs and presenting stories about the relationship of poverty, crime, ethnic/cultural diversity, and other characteristics to health and health care in these communities.

If you have any questions or would like to learn more about our work, please contact us.

SUNY Downstate Medical Center
450 Clarkson Avenue, Box 1240
Brooklyn, NY 11203-2098
Phone: 718-270-7727
Fax: 718-270-7565
Email: ccconf@downstate.edu

Acknowledgments
We acknowledge and thank the Robert Wood Johnson Foundation for its support of this report and the Social and Health Landscape of Urban and Suburban America project, and Nanette Goodman for her research contributions. We also thank the staff of the National Center for Health Statistics and Tom Vischi, public health consultant, for reviewing and providing insightful comments on drafts of this report.

Executive Summary
This review of seven Healthy People goals for the nation’s 100 largest cities and their surrounding areas documents considerable but inconsistent progress toward improving health in urban and suburban America. It describes, for the first time, their achievements in reaching Healthy People 2000/2010 objectives for a set of infant health and infectious disease indicators, and homicide. On average, the cities and their suburbs met or made progress toward meeting Healthy People 2000 goals for infant mortality, AIDS, tuberculosis, syphilis, and homicide between 1990 and 1999 or 2000. Low birth weight rates moved away from the 2000 target for both cities and their suburbs, on average, between 1990 and 1999 and the downward trend in gonorrhea rates reversed in many cities in the last half of the 1990s. The findings underscore the uncertainty around sustaining the progress made by many of these areas and the challenges that persist.

This report uses national sources of information from various agencies of the Centers for Disease Control and Prevention, the Federal Bureau of Investigation, and the Bureau of the Census on the 100 largest cities, and their counties and greater metropolitan areas to compare cities to their surrounding suburbs. For indicators with data available for fewer than the 100 cities, the subset is comprised primarily of the largest cities and/or their greater metropolitan areas.

Key Findings

Low Birth Weight
In 1999, none of the 100 largest cities and only two of their suburbs had met the Healthy People 2000 goal of 5 percent of live births that are low birth weight (LBW). In 1990, 14 suburbs and no cities had met the goal. Suburban areas experienced an average rate increase that was nearly 3 times that for cities (14% v. 5%). City and suburban LBW rates were lowest in the West: under 7 percent, on average. In 1999, Portland, OR, had the lowest city LBW rate (5.4%) and Stockton, CA, had the lowest suburban rate (4.5%). Atlanta experienced the largest city drop (15%) in LBW rates between 1990 and 1999, and Las Vegas, the largest suburban drop (14%).

Infant Mortality
Only in the West, city infant mortality rates were lower, on average, than suburban rates in 1999 (5.9 v. 6.3). The infant mortality rate for the 100 largest U.S. cities (8.8 deaths per 1,000 live births), on average, was above the Healthy People 2000 goal of 7 deaths per 1,000 live births, while the rate for the suburbs (6.4) was below the goal. San Francisco had the lowest city infant mortality rate in 1999 (3.8) and Rochester, NY, had the lowest suburban rate (3). Anchorage, AK, experienced the largest 1990 to 1999 decline in city infant mortality rates (52%) and Miami experienced the largest suburban decline (67%).

Tuberculosis
On average, neither cities nor their suburbs had met the Healthy People 2000 goal of 3.5 cases per 100,000 population by 2000 despite significant declines over the last decade. Northeastern cities led all regions with a 55 percent drop in average tuberculosis rates between 1990 and 2000. By 2000, however, only suburbs in the Midwest, on average, had met the 2000 goal with a rate of 1.9. Albuquerque had the lowest 2000 city TB rate: 1.6 cases. Pittsburgh showed the greatest city improvement with a 75 percent drop in its rate between 1990 and 2000.

AIDS
The largest metropolitan areas of the U.S. decreased their incidence of AIDS by 24 percent between 1990 and 2000, to 15.4 cases per 100,000 population—a rate well below the Healthy People 2000 goal of 43. Current rates are far from the 2010 target of 1 case per 100,000, however. Metropolitan areas of the Northeast have the highest average AIDS rates and those of the Midwest have the lowest rates. Only Miami, New York, and San Francisco had 2000 rates above the 2000 goal, but San Francisco achieved the greatest decline in AIDS rates (67%) between 1990 and 2000.

Syphilis
Cities reduced their syphilis rates by an average of 86 percent during the 1990s, to 5.6 cases per 100,000 population in 2000. As a group, they fell short of the Healthy People 2000 goal of 4 cases. Southern cities continued to have the highest average rate—9 per 100,000—despite an 86 percent average decline between 1990 and 2000. Two of the 100 largest cities—Akron and Cincinnati, OH—reported no new syphilis cases in 2000.

Gonorrhea
The major U.S. cities averaged a rate of 321 cases per 100,000 population in 2000, well above the Healthy People 2000 goal of 100, despite a 54 percent average decline in rates between 1990 and 2000. Rates increased, on average, by 5 percent between 1996 and 2000, however. Cities in the Midwest had the highest gonorrhea rates; cities in the West had the lowest rates. San Jose, CA, had the lowest 2000 gonorrhea rate, with 27 cases, while Atlanta made the greatest improvement between 1990 and 2000, with a rate decrease of 85 percent.

Homicide
Most of the 100 largest cities missed the Healthy People 2000 goal of 7.2 homicides per 100,000 population, with an average of 13.1 in 1999, while most suburban areas did meet that goal. The average homicide rate for the 100 largest cities declined by 34 percent from 1990 to 1999, compared to 32 percent for their suburbs. Madison, WI, had the lowest murder rate in 1999 (1.9) and Lincoln, NE, had the lowest suburban murder rate, with no murders reported in 1999. Boston witnessed the largest drop in city homicide rates for the decade (79%) and Buffalo, NY, the largest suburban area drop (80%).

Conclusions
Fewer suburban areas met the Healthy People 2000 low birth weight goal in 1999 than in 1990. Overall, few urban and suburban communities made progress. The increase in LBW rates extended to cities and suburbs in all regions, with suburban communities leading these increases.

Many western cities and their suburbs have achieved similar rates on each of the Healthy People goals. Cities and suburbs in the West together had the highest rates of tuberculosis in their respective regional groups in 2000, the lowest rates of low birth weight in 1999, and the smallest differences in 1999 infant mortality and homicide rates. Examples include Portland, OR, and San Jose.

A number of cities in the Northeast and Midwest remain far apart from their suburbs on meeting Healthy People objectives. Differences between urban and suburban rates in these regions were the largest on low birth weight, infant mortality and homicide. Examples from these regions include Buffalo, Detroit, and Milwaukee.

Many southern cities and suburbs remain behind other regions on a number of key indicators. Large cities in the South have the highest average rates of syphilis and homicide, and are among the highest in tuberculosis rates. The South had the highest regional suburban average for low birth weight and infant mortality rates in 1999. Metropolitan areas in the South also experienced the smallest average decline in AIDS rates between 1990 and 2000.

Despite significant improvements, concerns remain about the uncertainty and fragility of the progress achieved. While some communities have met many goals, virtually all have fallen short of key targets, and rates even rose for specific indicators, such as low birth weight, during the last decade. In all, the report reinforces the importance of targeted efforts for areas and populations left behind, the importance of broad-based initiatives, and the need for urban and suburban communities to assure that they do not lose the gains they have made.

Introduction
In 1979, the Office of the Surgeon General, U.S. Department of Health and Human Services, released the first Healthy People report on health promotion and disease prevention.¹ This initiative created a set of goals for achieving measurable health objectives in each major stage of life, from infancy to old age. A collaborative effort of federal agencies, state health departments, nonprofit organizations, and business and scientific groups continued this work. The result was creation of Healthy People 2000 and Healthy People 2010 goals, which centered on increasing the span of healthy life, reducing racial/ethnic and socioeconomic health disparities, and achieving access to preventive health care services.2

While useful as a barometer for the nation, one of the primary applications of Healthy People 2000/2010 goals is assisting state and local level decision-makers in assessing and improving the health of residents in communities across the country. The high concentration of people living in the nation’s major metropolitan areas and the historical health challenges they face make local progress on Healthy People objectives critical to monitoring and improving the health of the nation as a whole.

This issue brief describes, for the first time, the progress of the nation’s largest cities and their surrounding suburban areas toward achieving Healthy People 2000/2010 goals for infectious diseases, infant health, and homicide. Our report also updates and expands the 1999 publication, The Social and Health Landscape of Urban and Suburban America, which documented an association between the health of cities and their surrounding areas.³

The report comes at a time when population shifts and increases have generated significant growth in suburbs and cities. Between 1990 and 2000, the populations of the 100 largest cities increased by almost 10 percent, while their suburban areas grew about 18 percent.4 Together these areas represent 153 million Americans, or 53 percent of the U.S. population. The cities include 57 million people, while the remaining metropolitan areas include 96 million people. Some suburban areas of the country, particularly in the South and West, experienced average population increases as high as 25 percent. This significant expansion in cities and, especially, suburban areas has meant that the U.S. population is 12 percent more urban at the beginning of the 21st century than it was in 1990.5 Documenting the association of this growth with communities’ effectiveness in meeting Healthy People objectives may provide important guidance for individual cities and metropolitan areas undertaking regional initiatives to improve health, and for policymakers concerned with the promise and challenges of an expanding urban horizon.

Methodology

Definitions
We present three sets of Healthy People indicators— infant health outcomes, infectious diseases, and homicide rates—on the nation’s 100 largest cities and their greater metropolitan statistical areas (MSAs) excluding the city (also referred to as “suburbs” or “suburban areas”), as defined by the 2000 Census.6 (See Table 1 for list of cities, by region.) Where some of the 100 largest cities are part of the same MSA, the city data were combined to create a single urban area that could be compared to its surrounding suburban area. For example, data for Denver and Aurora, CO, were collapsed into a single Denver/Aurora city entity. In total, the 100 largest cities make up a group of 82 city entities with distinct metropolitan areas.

The counties that make up a particular MSA may change after each decennial census. To keep comparisons across years unaffected by boundary changes, the same set of counties defining an MSA in 2000 was used in constructing all MSA-related variables for all years. Suburban rates represent the sum of the cases from all of the counties comprising an MSA less the data from the city(ies) divided by the sum of the appropriate population data for those counties less the data from the city(ies). In one instance (Anchorage), the city, county, and MSA boundaries are identical, such that only city data are reported, leading to a total reporting on 81 MSAs excluding cities, or suburbs.

The average rates presented for cities and suburbs are the unweighted means of individual city or suburban rates. The percent changes reported refer to the percent change in the average rate for a set of cities or suburbs, rather than an average of each cities’ or suburbs’ percent change.

Healthy People Goals
We based the selection of 7 Healthy People indicators on data available at the city, county, and/or MSA level from federal agencies. The indicators provide a broad sense of the health and quality of life of adults and children in urban and suburban communities.

Complete low birth weight, infant mortality, and birth data were available for cities and metropolitan areas for 1990 and 1999 from the National Center for Health Statistics (NCHS) of the Centers for Disease Control and Prevention (CDC).7 From these data, we calculated infant mortality rates per 1,000 live births and the percent of births that are low birth weight for cities and MSAs excluding cities.

For infectious diseases, data from the CDC’s National Center for Infectious Diseases (NCID) and the National Center for HIV, STD and TB Prevention (NCHSTP) were not available for all 100 cities. CDC data were available at the city- and MSA-level for tuberculosis (TB) for a subset of cities and MSAs, which we used with U.S. census population data to create city and MSA excluding city rates for a subset of the 100 largest cities and suburbs. The CDC reports AIDS data only at the MSA level. We used AIDS rates calculated by the CDC, although data were not available for all 82 MSAs of the 100 largest cities.

Syphilis and gonorrhea data are only reported for cities. Thus, we used the city rates calculated by the CDC for primary and secondary syphilis and gonorrhea, and did not combine data for cities that were part of the same MSA. For cities that do not have a separate health department that collects and reports sexually transmitted diseases (STDs), the CDC reports the case numbers and rates of the county or counties containing the city.8 For all infectious diseases, we report crude incidence rates (new cases in a given year per 100,000 population).

We used city and county data for murder and nonnegligent manslaughter from the Federal Bureau of Investigation (FBI) to create city and MSA excluding city crude homicide rates (unadjusted by age) for 1990 and 1999. For cities or counties in three states—Kansas, Kentucky, and Illinois—the FBI did not report crime data. Data for cities and counties in these states were obtained from state police websites. If data for an outlying county of an MSA were not available from either the FBI or a state, we excluded that county’s homicide and population data from the suburban rate.9 If crime data from more than one county were missing, we did not include the homicide rate for that suburb.

Infant Health Indicators

Infant and maternal health indicators such as infant mortality and low birth weight are important measures of a nation’s overall health and well-being, and serve as predictors of health status of the next generation.10 We compared infant mortality and low birth weight rates of the 100 largest cities and their suburbs to related Healthy People 2000 and 2010 objectives, and by region.11 (See Tables 2-4.) We examined progress toward the 2000 objectives at 1990 and by 1999, and note progress toward 2010 goals.

Low Birth Weight
• Neither the cities nor the suburbs, on average, had met the Healthy People 2000 goal of 5 percent of births that are low birth weight in 1999, but cities and suburbs in the West came the closest.

• Suburban areas experienced a higher average increase in low birth weight rates (14%) than their cities (5%), with only 2 suburbs and none of the 100 largest cities meeting the 2000 low birth weight goal in 1999.

Low birth weight (LBW), defined as less than 2,500 grams or 5.5 pounds, can result either from babies being born prematurely or full-term but small.12 Low birth weight is associated with several long-term disabilities, including cerebral palsy, autism, mental retardation, vision and hearing impairments, and other disorders.13 Cigarette smoking is a primary risk factor for both types of LBW. Despite a drop in the percent of women who smoke during their pregnancy, from 18 percent to 13 percent between 1990 and 1999, nationally, the LBW rate increased almost 9 percent to 7.6 percent of all births.14 The Healthy People 2000 LBW goal is 5 percent and remains the same for 2010.15

A primary explanation for the increase in low birth weight of full-term babies is that as more women who delayed childbearing have turned to assisted reproductive technology, the rate of multiple births has increased dramatically, resulting in a greater proportion of babies born underweight.16 Nationally, the LBW rate increased only 1 percent among singleton births between 1989 and 1998.

Overall and regional trends in U.S. cities and their suburbs. Low birth weight rates generally increased between 1990 and 1999 across the 100 largest cities and their suburbs. City LBW rates were much higher than suburban rates in both 1990 and 1999. The increase in rates for the suburbs, however, was three times that of the cities over those years. At rates of 8.9 percent and 7.0 percent, respectively, neither cities nor their suburbs, on average, achieved the Healthy People 5 percent LBW target in 1999. (See Chart 1.)

Although the gap between city and suburban LBW rates narrowed over the last decade, the divide is still considerable in all regions except the West. The Northeast had the highest 1999 city average (10.5%), despite having the smallest average city increase of 2 percent (along with cities in the West). The Midwest experienced the largest average increase in both city (7%) and suburban rates (22%). Suburban LBW rates were highest in the South. (See Chart 2.)

City and suburban highlights. None of the regions’ cities or suburbs had collectively met the 2000 LBW goal by 1999. The West came closest, with an average city LBW rate of 6.9 percent and a suburban average rate of 6.2 percent. The West also saw the lowest regional increase (7%) in average suburban LBW rates between 1990 and 1999.

None of the 100 largest cities met the Healthy People 2000 LBW goal in either 1990 or 1999. Fourteen suburbs had met the 2000 LBW goal in 1990, but by 1999, only two suburban areas, Portland, OR (5%), and Stockton, CA (4.5%), were still meeting the goal. Portland also had the lowest city LBW rate (5.4%) in 1999.

While most cities saw their LBW rate increase between 1990 and 1999, 26 cities, in fact, experienced a decrease in their LBW rate. The cities with the largest decreases were a mix of cities with some of the highest and lowest rates. Atlanta experienced the largest rate decrease—15 percent—of any city examined, although its 1999 LBW rate remained relatively high (10.6%). Las Vegas had the largest suburban area drop (14%) in LBW rates between 1990 and 1999.

Infant Mortality
• Infant mortality rates for the largest U.S. cities averaged 8.8 in 1999, above the Healthy People 2000 goal of 7.0 deaths per 1,000 live births, while the suburban areas averaged a rate of 6.4.

• In the West, 1999 infant mortality rates were lower in the cities, on average, than in the suburbs.

The infant mortality rate refers to the number of infant deaths within the first year of life per 1,000 live births per year.17 As a nation, the U.S. has made steady progress in reducing infant deaths, but the U.S. is still ranked 27 on infant mortality—at the bottom of rankings among industrialized countries—below Greece and Portugal, for example, and tied with Cuba.18 Despite a steady decline in black infant deaths over the last decade, racial and ethnic disparities in U.S. infant mortality rates persist, with black infant mortality rates twice the rate for whites.19

Two factors likely account for most of the decline in infant mortality over the past 10 years.20 The first is the introduction of new technologies in the 1990s that allow the smallest babies to survive in the 28 days of life (the neonatal period), producing reductions in neonatal mortality rates. The second is a change in infant sleeping positions from the stomach to the back or side, as a result of a broad public education campaign that has reduced rates of Sudden Infant Death Syndrome (SIDS) and has largely affected the postneonatal infant mortality rate.
Caution must be used in the interpretation of infant mortality rates, particularly at the city level. According to the NCHS, the mother’s city of residence may not be accurately recorded on the birth certificate, which may compromise the validity of city-specific rates.

Overall and regional trends in U.S. cities and their suburbs. In 1990, neither cities, nor their suburbs, as a group, had met the Healthy People 2000 goal of 7 infant deaths per 1,000 live births. By 1999, the suburbs of the 100 largest cities, on average, had met the goal, while the cities, as a group, had not. Yet, the infant mortality rates for cities declined 21 percent, from 11.1 to 8.8 per 1,000 live births between 1990 and 1999, with similar declines occurring in the suburbs (22%). (See Chart 3.)

City and suburban infant mortality rates differed considerably by region. The Northeast showed the largest gap in rates between cities and their suburbs. In the Midwest as well, cities tended to have much higher rates on average than their suburbs. Rates were lowest for both cities and suburbs, on average, in the West. The South had the highest suburban infant mortality rates, on average, but had relatively low city infant mortality rates compared to the Northeast and Midwest. (See Chart 4.)

Between 1990 and 1999, cities in the West made the strongest improvement in reducing infant mortality—by 31 percent in the last decade from 8.5 to 5.9—leading to an average rate that is lower than that of their suburbs (6.3) in 1999. In the South, cities and their suburbs made similar strides in reducing the average infant mortality rate (18% and 21%, respectively).

City and suburban highlights. Ten cities had achieved the Healthy People 2000 infant mortality goal by 1990, along with 29 suburbs. By 1999, 30 cities (3 times as many as in 1990) and 56 suburbs (nearly double the number in 1990) had achieved the 2000 infant mortality goal. All but 9 of the 82 city cases examined had a decrease in their infant mortality rate between 1990 and 1999, with all the increases occurring in the South or Midwest, except for Honolulu. Anchorage experienced the largest 1990 to 1999 decline in city infant mortality rates (52%) and Miami experienced the largest suburban area decline (67%).

Three cities—San Francisco, Anchorage, and Spokane, WA—had met the Healthy People 2010 infant mortality goal of 4.5 deaths per 1,000 live births by 1999, as had 11 suburban areas across the country, with Rochester, NY, having the lowest suburban rate (3.0).

Infectious Diseases: Tuberculosis, AIDS, Syphilis, Gonorrhea

Overall, national rates of tuberculosis (TB), Acquired Immunodeficiency Syndrome (AIDS), and the sexually transmitted diseases (STDs) of syphilis and gonorrhea declined over the 1990s. Because of the relationship of these diseases to one another—gonorrhea and syphilis facilitate transmission of HIV and other STDs; HIV greatly increases the risk of developing tuberculosis—it is important to understand the dynamics of each to advance toward the goals.

This section describes the progress that cities, suburbs or greater metropolitan areas made toward meeting Healthy People 2000 and 2010 objectives on these four diseases, depending on the level of data available from the CDC. For tuberculosis only, the CDC reports city and metropolitan area data, allowing us to make comparisons between cities and their suburbs. For STDs, the CDC reports data at the city level only, and for AIDS, at the MSA level only. (See Tables 2-4.)

Tuberculosis
• City tuberculosis rates in 2000 averaged 13.1 cases per 100,000 population—three times the Healthy People 2000 goal of 3.5 cases.

• Tuberculosis rates were much lower in suburban areas than cities, but, on average, only suburbs in the Midwest met the 2000 goal.

Tuberculosis (TB) is a preventable, treatable disease caused by bacteria that generally affect the lungs, but can affect other organs as well. Over time, treatment has become increasingly difficult, however, because of a proliferation of drug-resistant strains.21 Persons with HIV and AIDS are especially at high risk of contracting TB. Ten percent of new TB cases occur in HIV-positive individuals each year.

After a steady decline in tuberculosis cases since the early 1950s, the trend reversed in the late-1980s—after significant cuts in public health funding.22 The public health response to the last epidemic included strengthening reporting and expanding directly observed therapy, efforts that are key to TB control.23 The 2000 TB rate of 5.8 cases per 100,000 population (16,377 cases) was the lowest U.S. rate ever, but well above the Healthy People 2000 goal of 3.5 cases per 100,000 population.24

Efforts are underway to eliminate TB from the United States, as reflected in the Healthy People 2010 goal of 1 case per 100,000. At the same time, individuals at risk from HIV infection and other vulnerable populations, such as foreign-born individuals, present special challenges to U.S. cities and suburbs in meeting this goal. In 1992, immigrants represented 27 percent of all reported cases; by 2000, the figure was 46 percent, even as the number of cases dropped 39 percent during the same period.25

Overall and regional trends in U.S. cities and their suburbs. Tracking with the nation as a whole, cities and suburbs made considerable progress in stemming the rate of new TB cases over the last decade, after rates peaked in 1992. In 1990, cities averaged a rate of 17.5 cases per 100,000 population—five times the Healthy People 2000 TB goal of 3.5 cases.26 By 1996 the rate had dropped to 15.2 cases. This trend continued between 1996 and 2000, when rates declined an additional 14 percent to 13.1 cases, while the average suburban rate dropped 32 percent to 4.0 cases—less than one-third the average city rate, but still above the Healthy People 2000 goal. (See Chart 5.)

Between 1990 and 2000, cities in the Northeast, South, and West saw significant reductions in their average TB rates. Northeastern cities, with the highest average rate in 1990 (27 cases), led the regions with a 55 percent decline to a rate of 12.3 cases by 2000. Cities in the Midwest had the lowest average TB rate in both 1990 and 2000. Only the midwestern suburbs, on average, had met the Healthy People 2000 goal in 1996 with a rate of 2.7 cases, and maintained the goal into 2000. (See Chart 6.)

Cities in the South and West averaged the highest TB rates in 2000, at just over 14 cases per 100,000, or 4 times the Healthy People 2000 goal. City rates in both regions dropped about 25 percent from their 1990 averages. The average TB rate for suburban areas dropped by almost half between 1996 and 2000 in the West, and by 24 percent in the South.

City and suburban highlights. Only 5 of 79 cities had met the Healthy People 2000 goal for tuberculosis in 1990: Omaha and Lincoln, NE; Colorado Springs, CO; Madison, WI; and Toledo, OH. By 2000 (with fewer cities reporting) 6 of 58 cities had met the 2000 goal, with all but 15 cities showing a decline over the last decade. Albuquerque had the lowest 2000 TB rate (1.6 cases). Pittsburgh showed the greatest improvement with a 75 percent drop between 1990 and 2000.

AIDS
• Metropolitan areas reduced their average AIDS rate from 20.2 in 1990 to 15.4 in 2000 —a rate well below the Healthy People 2000 goal of 43 new AIDS cases per 100,000 population.

• Only three metropolitan areas—Miami, New York, and San Francisco—failed to meet the 2000 goal for AIDS.

The CDC estimates that as many as 950,000 people in the U.S. may currently be living with HIV or AIDS, with more than 340,000 living with AIDS.27 After rising throughout the 1980s and peaking in the early 1990s at 150,000 new cases per year, AIDS incidence in the U.S. has declined significantly, stabilizing at approximately 40,000 cases annually to a rate of 14.7 cases per 100,000 in 2000.28 This dramatic decrease is primarily a result of the introduction of highly active anti-retroviral therapy (HAART) in the mid-1990s. Compared with 1990, individuals diagnosed with AIDS in 1999 were much more likely to be heterosexual, female, African American, or Hispanic, intravenous drug users, and living in the South.29

Overall and regional trends in US metropolitan areas. Metropolitan area AIDS rates followed the U.S. trend over the 1990s. Because the incidence rate of AIDS did not peak until 1993, when the CDC expanded the definition of AIDS, and HAART had not come into use yet, AIDS rates were higher mid-decade than at 1990 or 2000.30 Thus, metropolitan areas made moderate progress, reducing the average AIDS rate by 24 percent between 1990 and 2000. The metropolitan areas, on average, had achieved the Healthy People 2000 AIDS rate goal of 43 in 1990 and 2000, but they are far from achieving the 2010 goal of 1 case per 100,000 population. (See Chart 7.)

Metropolitan areas of the Northeast have had the highest average AIDS rates between 1990 and 2000 and the Midwest has had the lowest metropolitan rates. For both the Northeast and West, the average metropolitan area AIDS rate dropped by more than half between 1995 and 2000. Metropolitan areas in the South experienced the smallest overall decline in AIDS rates between 1990 and 2000 (2%) and had the second highest average after MSAs in the Northeast. (See Chart 8.)

Metropolitan area highlights. In 1990, all but 5 of 64 greater metropolitan areas had reached the Healthy People 2000. By 2000, only Miami, with the highest AIDS rate in 2000 (58 cases per 100,000), New York, and San Francisco remained above the target, while Jersey City and Newark, which had missed the target in 1990, met it by 2000. San Francisco experienced the greatest metropolitan area decline in AIDS rates—67 percent—between 1990 and 2000.

A number of metropolitan areas experienced an increase in their incidence of AIDS between 1990 and 2000. Of 7 MSAs with an increase of 50 percent or greater, 6 were located in the South. No MSAs have yet achieved the Healthy People 2010 AIDS goal.

Primary and Secondary Syphilis
• City syphilis rates declined by 86 percent between 1990 and 2000, but, on average, they still fell short of the Healthy People target of 4 cases per 100,000 population.

• Cities in the West had the lowest syphilis rates on average (2 cases) in 2000 and cities in the South had the highest rates (9 cases).

Syphilis is a venereal disease treatable with antibiotics. Left untreated, it can lead to adverse pregnancy outcomes such as stillbirth and congenital infections, and increases the risk of HIV transmission.31 In 1990, the U.S. primary and secondary syphilis rate peaked at 20.3 per 100,000 population, a rate not seen since 1949.32 By 2000, the U.S. rate of 2.2 was the lowest since reporting began in 1941, and below the Healthy People 2000 goal of 4 cases. With the dramatic decline in syphilis rates over the last decade, the CDC is leading a national effort with state and local health departments to eliminate syphilis from the United States, reflected in the Healthy People 2010 goal of 0.4 per cases 100,000.33 More than 80 percent of U.S. counties had no reports of syphilis in 2000.34 Nonetheless, the disease remains a pernicious public health threat in the South, especially in communities with concentrations of low-income African Americans. Although the black to white ratio in syphilis rates has declined with the overall drop in cases, the 2000 syphilis rate among blacks was 21 times that for whites, making syphilis an extreme example of racial disparities in health.35

Overall and regional trends in U.S. cities. The drop in city syphilis rates between 1990 and 2000 (86%) kept pace with a national decline of almost 90 percent. The largest decrease in rates occurred between 1990 and 1996. Despite the progress, the 2000 city average was still above the Healthy People 2000 goal of 4 cases per 100,000 population. (See Chart 9.)

Cities in the Northeast witnessed the greatest 1990-2000 decline in average syphilis rates (95%) to 2.5 cases per 100,000. Cities in the Midwest and West had the lowest average in 1990, with the western cities continuing to have the lowest average in 2000 (2 cases). Cities in the South continued to have the highest average rate in 2000—more than twice the Healthy People 2000 goal—even after an 86 percent decline since 1990. (See Chart 10.)

City Highlights. In 1990, only 5 of 57 cities (Honolulu, Indianapolis, San Jose, Wichita, KS, and Omaha) with data reported had met the Healthy People 2000 goal for syphilis. Between 1990 and 2000, all of the cities experienced a rate decline except for Baltimore and Indianapolis. Indianapolis had the fourth lowest rate in 1990 but the second highest rate in 2000. About two-thirds of the cities had met the Healthy People 2000 goal in 2000. Seven cities also met the 2010 syphilis goal of 0.2 cases per 100,000: Akron and Cincinnati (each with no new cases in 2000), Honolulu, Sacramento, San Jose, Kansas City, MO, and Pittsburgh.

Gonorrhea
• Averaging a rate of 321 gonorrhea cases per 100,000 population in 2000, cities missed the Healthy People 2000 goal of 100 new cases per 100,000.

• City gonorrhea rates were lowest in the West (124 cases) and highest in the Midwest (380 cases) in 2000.

Like syphilis, gonorrhea is a sexually transmitted disease treatable with antibiotics. Left untreated, it can cause pelvic inflammatory disease in women, a major cause of infertility, and can result in male infertility as well; it also increases the risk of HIV transmission. Three-quarters of all individuals with a gonorrhea case reported to the CDC were between 15 and 24 years of age and were African American. Nationally, rates of gonorrhea had been declining since 1975, from a peak of 468 cases per 100,000 population to an all time low of 122 achieved in 1997.37 Since then, rates have stabilized at about 132 cases per 100,000.

Overall and regional trends in U.S. cities. Gonorrhea rates in major cities fell sharply over the 1990s, declining by 54 percent, similar to the decrease for the U.S. as a whole. City rates, however, increased by 5 percent in the last half of the decade. By 2000, neither the U.S. nor cities as a group achieved the Healthy People 2000 goal of 100 cases per 100,000 population. (See Chart 11.)

Regionally, city rates for gonorrhea declined between 48 percent and 60 percent over the last decade, with the greatest decline occurring among cities located in the South and Midwest. Cities in the Midwest had the highest regional average, after rates increased 22 percent between 1996 and 2000. Cities in the West have averaged the lowest gonorrhea rates over the 1990s, declining to 105 cases in 1996, close to the 2000 target of 100 cases. By 2000, however, the average rate had risen to 124 cases. (See Chart 12.)

City Highlights. In 1990, only three cities (El Paso, Honolulu, and San Jose) met the Healthy People 2000 goal for gonorrhea rates. By 2000, the number of cities reaching the 2000 goal had risen to 9, despite the rate trend upward in the last half of the 1990s. These cities were located in the West, with the exception of Yonkers, NY, and Miami. San Jose had the lowest rate (27 cases) in 2000 and came closest to meeting the Healthy People 2010 goal for gonorrhea of 19 cases per 100,000 population.

Atlanta and Washington, D.C., had the two highest rates in 1990 (3,134 and 2,420 cases, respectively), but by 2000, their rates had dropped more than 75 percent. Cities with the highest rates in 2000 included Richmond, VA, (924 cases), Rochester, NY, (895), Baltimore (886) and St. Louis (862).

Homicide
• Most of the 100 largest cities missed the Healthy People 2000 goal of 7.2 homicides per 100,000 population, with an average rate of 13.1 homicides in 1999, while most suburban areas met that goal.

• The average homicide rate declined by 34 percent for the cities from 1990 to 1999, and declined by 32 percent for suburban areas.

Homicide rates represent an important measure of a community’s health and quality of life. The FBI defines “murder and nonnegligent manslaughter” (homicide) as the “willful (nonnegligent) killing of one human being by another” and excludes deaths by negligence, suicide, or accident.38 The determination of murder is based only on the basis of police investigation. The Healthy People goals for reducing violent deaths are based on the National Vital Statistics System, which determines homicide rates from death certificates submitted by states.39

Nationally, murder rates declined significantly over the 1990s from 9.4 homicides per 100,000 population in 1990 to a rate of 5.7 homicides in 1999, and 5.5 in 2000. Thus, the U.S. met the Healthy People 2000 goal of 7.2 homicides per 100,000 population.40 Recently released preliminary data show that the number of murders increased 3 percent between 2000 and 2001.41 It is too soon to tell whether this is an aberration or the beginning of a new, upward trend.

The reasons behind the dramatic decline in murder rates over the last decade are complex, but have been attributed to improved economic conditions, an aging population and fewer 17-25 year olds, the decline of the crack cocaine epidemic, and better police prevention strategies.42 Despite the progress, murder remains a major public health concern. Homicide is the second leading cause of death for 15-24 year olds.43

Overall and regional trends in U.S. cities and their suburbs. Murder rates in the largest cities remain well above their surrounding suburbs. The 1999 average city murder rate (13.1 per 100,000) was almost twice the Healthy People 2000 goal, whereas the suburbs, on average, met the 2000 objective before 1990, and by 1999 were close to meeting the 2010 goal of 3 per 100,000 population, with an average rate of 3.4.44 (See Chart 13.)

Cities in the Northeast experienced the steepest decline in the average murder rate: 43 percent between 1990 and 1999, from 22.2 homicides per 100,000 to 12.8. Cities in the Midwest had the smallest decline—18 percent—to an average rate of 14.1 homicides. City rates were lowest in the West in 1999 (8.8 homicides), following a 32 percent decrease from the 1990 average. Cities in the South had the highest murder rates, on average, in 1999, at nearly 16 homicides per 100,000, yet still experienced a relatively large decline in the average rate from 1990 (40%). (See Chart 14 and Table 2.)

Suburban murder rates in 1999 were lowest in the Northeast and Midwest, where the ratio of city to suburban rates was the highest. The South averaged relatively high city and suburban murder rates compared to the other regions. The difference between city and suburban murder rates was smallest in the West.

City and suburban highlights. In 1990, only 9 cities had met the Healthy People 2000 homicide goal. By 1999, 21 cities had met the goal. The cities with the greatest decline in murder rates—exceeding 70 percent between 1990 and 1999—were Boston, Tacoma, Augusta, GA, and New York. Buffalo had the largest suburban rate decline (80%). Madison, WI, had the lowest 1999 murder rate of the 100 largest cities, at 1.9 homicides, after increasing 23 percent over 1990. In addition, El Paso, and San Jose met the 2010 goal of 3 homicides per 100,000 population in 1999. Only 5 suburbs had homicide rates above the 2000 target in 1999, and about half of the suburbs had met the 2010 goal by then. Lincoln, NE had the lowest suburban murder rate, with none reported in 1999.

Status and Progress of Cities and Suburbs in Meeting Healthy People Goals

With a few exceptions, we restrict our discussion here to those cities and surrounding areas with complete data on the 7 health indicators we examined. We also note urban areas where data from national sources were not available, to show the current limitations in the completeness of data for the 100 largest U.S. cities.45 (Table 3 summarizes the number of Healthy People 2000 goals cities and suburbs met using all available information from the CDC and the FBI related to these goals.)

A number of cities and suburbs showed similar achievements in reaching Healthy People 2000 goals. Some, such as Austin and San Jose improved on the progress they had already made earlier in the decade, so that they met most of the Healthy People targets by 1999 or 2000. Others made significant strides more recently. For example, the city and suburban area of Portland, OR, together, had met only 3 goals in 1990. By 2000, they had met 8 goals. Other western areas included San Diego (from 3 goals to 7) and Fresno (from 2 goals to 5).

A few cities in other parts of the U.S. that lagged behind their suburbs in 1990 improved significantly on a number of indicators and now more closely parallel their suburbs. Examples include El Paso (from 4 to 7 goals) and Houston (from 2 to 6 goals). The Texas communities are especially noteworthy, given that cities and suburban areas in the South, on average, have not done as well as those in other regions. Other areas which had struggled to meet any goals in 1990 made progress by the end of the decade. Examples include Los Angeles (from 1 goal to 5) and Jersey City (from 1 goal to 5).

Areas where the suburbs but not the city met Healthy People 2000 goals tend to be located in the Northeast and Midwest. Typical examples of this pattern are older industrial cities such as Cleveland, Detroit, St. Louis, Milwaukee, and Philadelphia.

Some city and suburban communities share common challenges in meeting the Healthy People 2000 goals on infant health indicators, tuberculosis, and homicide. A number of cities in the South comprise this group, including Miami, New Orleans, and Norfolk, VA, where the city and suburbs together have reached three or fewer selected goals.

Conclusions and Implications

Comparing city and suburban communities to each other, within regions and nationally, reveals how close some areas have grown and the considerable distance that remains between others. Our findings also raise concerns around specific indicators and the challenges to sustaining progress.

Rising Rates of Low Birth Weight in Cities and Suburbs
Our review found that fewer urban areas overall met the Healthy People 2000 low birth weight (LBW) goal in 2000 than in 1990. What distinguishes this troubling trend further is the breadth of increase—cities and suburbs in all regions—as well as the double digit gains in most suburban communities compared with the much lower rates of increase in the cities. This trend increases the importance of intensifying interventions to reduce low birth weight, such as further improving rates of smoking cessation and the use of prenatal care among pregnant women. It also raises critical questions about the diffusion of technology to meet the needs of low birth weight neonates. Their high numbers were traditionally associated with inner cities, but the substantial increase of LBW neonates in suburban areas places greater importance on access to high quality services over the broader urban region.

Cities and Suburbs—Growing Healthier Together or Growing Apart?
Some cities and their surrounding areas are seeing increasing commonality related to the health goals we examined. Nowhere is this more apparent than in the West. Cities and suburbs there had the highest average rates of tuberculosis for their respective regional groups in 2000, the lowest rates of low birth weight infants in 1999, and the smallest differences in 1999 infant mortality rates and homicide rates. As an indication of just how close these areas have grown, the western cities, which lagged their suburbs in infant mortality rates in 1990, now have slightly better rates. Moreover, half of the 30 cities and suburbs that together achieved 5 or more of the Healthy People 2000 goals in 1999 or 2000 were located in the West.

A number of cities, especially in the Northeast and Midwest, remain far apart from their suburbs on a number of Healthy People goals. Differences between city and suburban rates were the largest in these regions for low birth weight, homicide, and infant mortality. Progress toward the Healthy People 2000 objectives was mostly limited to suburban areas.

Finally, in the South, some cities and/or their suburbs are not doing as well as other communities. For example, cities in this region, on average, have the highest rates of syphilis and homicide, and are among the highest in TB rates. The South had the highest suburban averages of LBW and infant mortality rates in 1999. Metropolitan areas in the South also experienced the smallest average decline in AIDS rates between 1990 and 2000.

A Cautionary Note on Healthy People Progress
This review has demonstrated that many suburban areas and their cities have made substantial and broad improvements toward meeting the Healthy People goals. Even many urban communities that have not reached the targets have made progress reducing disease incidence, infant mortality, and homicide. Despite these successes, concerns remain about the level and fragility of that progress. While some communities have met many goals, virtually all have fallen short of key targets. Significant racial and ethnic disparities in health persist, perpetuating great inequalities among individuals and communities.46 Access to and quality of health care, as well remain major challenges for vulnerable populations in urban and suburban areas.

The recent trends in gonorrhea show how rates can improve for a period of time and then rise significantly. Although AIDS rates have stabilized in recent years, new reports indicate that 60 percent to 90 percent of individuals infected with HIV in the U.S. do not know they have the virus.47 Further, preliminary FBI reports find that slightly more murders took place in 2001 than 2000. Regional challenges remain as well, particularly regarding infectious diseases. In all, this report, while documenting gains in many urban communities, offers evidence to support targeted city and regional efforts for areas not participating in this progress. The findings also reinforce the importance of continued vigilance, even in areas with great progress, to assure that cities and suburbs take steps to sustain and build on the gains they have made.

Notes

1 National Center for Health Statistics, Healthy People 2000 Final Review (Hyattsville, MD: Public Health Service, 2001). <http://www.cdc.gov/nchs/data/hp2000/hp2k01-acc.pdf>

2 U.S. Department of Health and Human Services. Healthy People 2010:Volume 1. 2nd ed. (Washington, DC: U.S. Government Printing Office, November 2000). <www.health.gov/healthypeople/document>

3 D.P. Andrulis, N.J. Goodman, The Social and Health Landscape of Urban and Suburban America (Chicago: AHA Press, 1999).

4 Tabulations based on data from U.S. Bureau of the Census, Census 2000 Supplementary Survey Summary Tables and Census of Population and Housing, 1990 Census Summary Tape 3. <http://factfinder.census.gov/servlet/BasicFactsServlet>

5 D. Firestone, “The new-look suburbs: denser or more far-flung,” New York Times, April 17, 2001: A1.

6 U.S. Bureau of the Census, Census 2000 Supplementary Survey Summary Tables, and “Metropolitan areas and components, 1999, with fips codes” (revised 28 January 2002). <http://www.census.gov/population/estimates/metro-city/99mfips.txt>

7 Centers for Disease Control and Prevention, Sexually Transmitted Disease Surveillance, 2000 (Atlanta: U.S. Department of Health and Human Services, CDC, September 2001). We do not know how many or which cities have county rather than city data reported.

8 The exception is that 1990 birth data was missing for Plano TX, which is part of the Dallas MSA.

9 For the following cities, the suburban homicide rate excluded murder and population data from one outlying county: Boston, Memphis, Kansas City, St. Louis, Cincinnati, Washington, DC. Cleveland’s MSA had two counties with missing data, and no county data were available for Honolulu, making their suburban homicide rates missing.

10 DHHS, Healthy People 2010 (2000).

11 Tabulation of rates based on 1990 and 1999 birth, low birth weight and infant death data for cities and MSAs provided by the CDC, National Center for Health Statistics.

12 NCHS, Data Definitions. < http://www.cdc.gov/nchs/datawh/nchsdefs/birthweight.htm>

13 DHHS, Healthy People 2010 (2000).

14 R. Wertheimer et al, The Right Start for America's Newborns: A Decade of City and State Trends (1990-1999) (Baltimore: The Annie Casey Foundation, 2002).

15 NCHS, Healthy People 2000 Final Review (2001).

16 Ibid.

17 K.D. Peters, K.D. Kochanek, S.L. Murphy, Vital Statistics of the United States, Volume II, Mortality, Part A (National Center for Health Statistics, Hyattsville, MD: U.S. Government Printing Office, 1998.)

18 NCHS, Health, United States, 2001 with Urban and Rural Chartbook, Table 26. Infant mortality rates and international rankings: Selected countries, selected years, 1960-97 (Hyattsville, MD: DHHS, 2001).

19 NCHS, Health United States, 2001, Table 23. Infant mortality rates, fetal mortality, and perinatal mortality rates, according to race: United States, selected years 1950-99.

20 NCHS, Healthy People 2000 Final Review (2001).

21 National Institute of Allergy and Infectious Diseases. Fact Sheet, Tuberculosis (March 2002). <http://www.niaid.nih.gov/newsroom/focuson/tb02/tb.htm>

22 National Center for HIV, STD and TB Prevention, TB Elimination: Now is the Time (2002). <http://www.cdc.gov/nchstp/tb/worldtb2002/NIT.htm>

23 NCHS, Healthy People 2000 Final Review (2001).

24 NCHSTP, Reported Tuberculosis in the United States 2000, Table 1. Tuberculosis cases and case rates per 100,000 population, deaths and death rates per 100,000 population: United States, 1953-2000. <http://www.cdc.gov/nchstp/tb/surv/surv2000/default.htm>

25 CDC, “Tuberculosis morbidity among US-born and foreign-born populations—United States, 2000,” MMWR 51, no. 5 (8 February 2002): 101-104.

26 Tabulations based on tuberculosis case data from CDC, NCHSTP for 1990, 1996, and 2000, and Bureau of the Census population data for 1990 and 2000. The CDC did not report metropolitan area tuberculosis data in 1990.

27 P.L. Fleming et al, HIV Prevalence in the United States, 2000 (9th Conference on Retroviruses and Opportunistic Infections, Seattle WA, 24-28 February 2002) Abstract 11.

28 CDC, “HIV and AIDS –United States, 1981-2000.” MMWR 50, no. 21 (1 June 2001): 430-433.

29 J.M. Karon et al, “HIV in the United States at the turn of the century: An epidemic in transition,” American Journal of Public Health 91, no. 7 (July 2001):1060-1068.

30 NCHSTP, HIV/AIDS Surveillance Report 2000 12, no. 2; HIV/AIDS Surveillance Report 1995 7, no. 2; HIV/AIDS Surveillance Report 1990 (January 1990).

31 NCHS, Healthy People 2000 Final Review (2001).

32 NCHSTP, 2000 National STD Surveillance Report, Table 1. Cases of sexually transmitted diseases reported by state health departments and rates per 100,000 civilian population: United States, 1941–2000. <http://www.cdc.gov/std/stats/Tables/2000Table1.htm>

33 NCHSTP, The National Plan to Eliminate Syphilis from the United States (October 1999). <http://www.cdc.gov/stopsyphilis/Plan.pdf>

34 NCHSTP, 2000 National STD Surveillance Report. <http://www.cdc.gov/std/stats/2000Syphilis.htm>

35 NCHS, Healthy People 2000 Final Review (2001).

36 NCHSTP, Gonorrhea Fact Sheet. <http://www.cdc.gov/nchstp/dstd/Fact_Sheets/FactsGonorrhea.htm>

37 NCHSTP, 2000 National STD Surveillance Report, Table 1.

38 Federal Bureau of Investigation, Crime in the United States 2000, Uniform Crime Reports (Washington, DC: U.S. Department of Justice, 2001): 407.

39 NCHS, Healthy People 2000 Final Review (2001).

40 The 1999 U.S. homicide rate reported by the National Vital Statistics System was 6.2 per 100,000 population (age-adjusted and non age-adjusted). The Healthy People homicide goals, based on NVSS rates, are age-adjusted rate. The FBI rates that we tabulated are not age-adjusted.

41 FBI, “Uniform crime reports January-December 2001” (Press release, 24 June 2002).

42 J.A. Butts, Youth Crime Drop (Washington, DC: The Urban Institute, December 2000).

43 D.L. Hoyert et al, National Vital Statistics Reports. Deaths: Final Data for 1999 49, no. 8 (21 September 2001).

44 Tabulations based on data from FBI Crime in the United States, Uniform Crime Reports: 1990 and 1999, and U.S. Bureau of the Census population data for 1990 and 2000.

45 See www.downstate.edu/urbansoc_healthdata/ to review the progress of cities and their suburbs toward meeting Healthy People 2000 goals in 1990.

46 Institute of Medicine, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (Washington, DC: National Academy Press, 2002).

47 L. Altman, “AIDS study finds many unaware they have virus,” The New York Times (July 8, 2002): A1.