On a late afternoon in east Sacramento, people jogging on quiet, clean boulevards under leafy sycamore trees pass neatly painted houses with sweeping lawns. Children ride bikes. Owners walk dogs.
Residents flock to the Trader Joe's on Folsom Boulevard, stocked with fresh salads and whole-grain cereals, and OneSpeed Pizza, which features local ingredients and home delivery by bicycle.
Just three-quarters of a mile away in Oak Park, it's too late for Nance Sheffield to take her 7-week-old daughter to McClatchy Park.
By this hour, Sheffield says, the park is overrun by undesirables and is a more likely spot for drug deals than play dates.
On a six-block stroll from her apartment, along high-traffic streets, she passes two liquor stores, a takeout Chinese restaurant, a convenience store selling chips and sodas, and little in the way of fresh food choices. The curbs are littered with paper cups and empty cigarette packs. It's relatively clean on this day, Sheffield said, because the trash doesn't include used condoms or spent needles.
Those are some of the visible differences between the two neighborhoods. Beneath the surface are disparities just as stark in matters that are anything but superficial: residents' rates of death and disease.
The 95819 and 95817 ZIP codes, which encompass much of east Sacramento and Oak Park, respectively, share a border. Each has about 15,000 residents. But an analysis performed by the nonprofit Valley Vision on behalf of local hospitals in 2010 showed that Oak Park residents are more than three times as likely to go to the emergency room for asthma, diabetes or high blood pressure.
They were more than 80 percent more likely to go there for mental health problems and almost 50 percent more likely to go for heart disease. Their babies have a 30 percent higher chance of starting life with low birth weight an indicator of the mother's health and prenatal care and a predictor of the newborn's health and survival.
On the ultimate indicator of overall health life expectancy east Sacramento residents can expect to live just over 82 years, 3 1/2 years longer than their Oak Park neighbors.
Such health disparities don't appear just between these two ZIP codes.
Glaring differences in health and life expectancy exist between affluent and poor neighborhoods across the Sacramento region, California, the United States and the world.
In the San Joaquin Valley, a study released last month by the Joint Center for Political and Economic Studies found more dramatic disparities than in Sacramento. Rates of early death in the lowest-income ZIP codes were nearly double those in the highest-income ZIP codes, and life expectancy varied by up to 21 years, the Washington, D.C., think tank found.
Increasingly, public health experts believe the neighborhoods themselves not simply the people in them are partly to blame.
Health risks accumulate
How could a neighborhood affect your health?
Evidence has mounted over the past decade that certain conditions are linked to a higher risk of death and disease. It's not just the obvious such as the toxins in air pollution but also factors such as unsafe streets, poor transportation, low education levels, and communities with more fast-food restaurants than supermarkets.
Those factors tend to concentrate in poor neighborhoods. Because many ethnic minorities live in low-income areas, the effects also divide unequally along racial lines.
Now, a growing group of researchers and public health officials are pressing for a collective attack on these problems.
"To understand your individual health, you need to look at more than just your behavior," said Jonathan London, director of the Center for Regional Change at UC Davis. "You need to look at the factors that affect that behavior, and many of those have to do with where you live.
"Where you live influences deeply your exposure to bad stuff, like air pollution, water pollution and violence, and it reduces your access to good stuff, like good jobs, good food, healthy air, healthy water, a peaceful environment, street trees."
Tackling the inequality among neighborhoods could potentially save more lives and dollars than better medicine, the advocates say.
Researchers have estimated that medical advances in the 1990s saved the lives of 177,000 Americans over the course of that decade. If the gap in mortality rates between whites and African Americans had been erased, 886,000 lives would have been saved a fivefold increase.
"Health doesn't just happen in the doctor's office," said Linda Rudolph, deputy director for chronic disease prevention and health promotion at the California Department of Public Health. "Our physical, social and economic environments are just as important, if not more important, in determining our health and longevity than the health care we receive."
Scientifically, researchers can't prove that neighborhood environments cause ill health; the influences of the social setting, public safety, poverty, education, genetics, pollution, individual behavior, and access to proper food and health care are too complex and interwoven.
And it's not that it's impossible for a resident in a poor neighborhood to look after his or her health. Sheffield, for instance, said she has cut her weight from 500 pounds down to nearly 250 by walking and cooking at home. She gets healthy food from the public Women, Infants and Children program and the farm stand at nearby American Legion High School.
The problem, public health specialists say, is that poor neighborhoods can make healthy choices a lot harder.
"There's compelling evidence there that the neighborhood really does matter," said Paula Braveman, director of the Center on Social Disparities in Health at UC San Francisco.
Braveman and others also point to the demoralizing effect of being surrounded by crime and hopelessness in struggling communities, and the ravaging effects of chronic stress on the body. Over the course of years, such constant stress can trigger hormone, nerve and immune responses that wear down our organs.
Old habits die hard
But is this a problem for the government or other outsiders to solve? Some Oak Park residents aren't convinced.
"If right now McClatchy Park was pristine," the people exercising there would be those "who already know better," said Latisha Daniels, vice president of the Oak Park Neighborhood Association.
She maintains that people's mentality and habits matter more than their environment and that bad health habits are born out of poverty and racial alienation and passed down through generations.
In communities like hers, where whole families might suffer high blood pressure or diabetes, "Bad health is normal," said Daniels. "You have to re-educate people what 'normal' should be, and that's what's difficult. You have to convince people that what their family has done for the last 50 years or so is not OK. How do you break a five-generation habit?"
At the same time, she agrees that safer parks and more stores offering fresh produce could encourage some neighbors to exercise and eat well.
"Your environment supports your belief system," she said.
That's what many public health specialists say, as well.
"We know that just focusing on individual behavior without changing the environment rarely accomplishes anything," Braveman said by email. "We need both."
The Oak Park community is working on that. By teaming with police and other local agencies over the past few years, residents have helped reduce crime and recruit new businesses like the Old Soul coffee shop, Daniels said. The neighborhood association is fighting to block a McDonald's from opening at Stockton Boulevard and Broadway, adjacent to a Jack in the Box.
Residents of east Sacramento also work hard to maintain and improve their community's health. The McKinley, East Sacramento Neighborhood Association has a land-use committee that spends "many, many volunteer hours encouraging developers to be cognizant of the desire for a walkable, livable and healthy neighborhood," said past president Nancy Cornelius by email.
The government's work is just beginning. California's 2-year-old Health in All Policies task force brings together 18 state agencies to tackle health problems. Many like the state departments of transportation, planning, finance and forestry have jobs that hadn't been conspicuously about health before.
"In my mind, this work has the greatest potential to reduce and eliminate health disparities in California," Ron Chapman, the state's director of public health, recently told a group of UC Davis medical residents.
Chapman is also working to create a state office of health equities. He showed the doctors a statistic that one in four California children now lives in poverty.
As long as the disparities remain, he said, "That's a really bad predictor for the future health of these children."