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“The large question this study addresses is the following: How do people make sense of (and cope with) toxic danger? The Martinezes’ story anticipates the complexity of the answer(s): physical and psychological suffering is compounded by doubts, disagreements, suspicions, fears, and endless waiting.” (4)

‘Flammable is a story of people’s confusion, mistakes and/or blindness regarding the toxicity that surrounds them. Flammable is also a story of silent habituation to contamination and of almost complete absence of mass protest against toxic onslaught’ (4)

“Schoolteachers, journalists, and lawyers are also part and parcel of daily life in Flammable. Together, all these actors contribute to what Flammable residents know about their place. They also influence what they ignore, what they want to know, and what they misrecognize. Government officials, company personnel, physicians, teachers, journalists, and lawyers jointly (but hardly cooperatively, given that their opinions don’t count equally) shape locals’ experiences of contamination and risk. This book examines how and why this production of shared knowledge (or lack thereof ) occurs.” (5)

“All in all, confusions, bewilderments, divisions, rumors, frustrations, and hopes are making Flammable residents wait—they wait for more testing, for further and better knowledge, for relocation, and for the “huge” settlement with one of the “powerful companies” that will, in the words of a neighbor, “allow us to move out.” This waiting is, as we will show, one of the ways in which Flammable residents experience submission.” (6) 

“We did our best to learn how to listen, look, and touch with respect and care, knowing with Nancy Scheper-Hughes (1992:28) that “seeing, listening, touching, recording, can be, if done with care and sensitivity, acts of fraternity and sisterhood, acts of solidarity. Above all, they are the work of recognition. Not to look, not to touch, not to record, can be the hostile act, the act of indifference and of turning away.” (14)

‘… the culture of toxic uncertainty is a complex web of meanings and shared understandings’ (108)

Labor of confusion: “During the long period of slowly germinating contamination, the actions of government authorities toward pollution in the neighborhood were less consistent and more contradictory than either the denial or underestimation that has been documented in the existing literature. Those multiple incongruous actions gave shape to what we term, extending the insights of students of ideology and symbolic power (Thompson 1984; Eagleton 1991; Bourdieu 1991), a labor of confusion that has a decisive effect on shared (mis)understandings.” (10)

 Ulrich Beck, social invisibility, lack of “social thinking” about environmental issues (Beck 1992)

Bourdieu, symbolic violence - misrecognition of power structures on part of the oppressed enables domination

Toxic uncertainty: “a way of experiencing toxic suffering that is shaped by what we call, borrowing from Charles Tilly (1996), the interacting “invisible elbows” of external power forces and of everyday routine survival struggles” (6)

Flammable is an account of how people in a particular place make sense of slow, invisible environmental pollution. The people of Flammable live in an Argentinean shantytown located next to petrochemical companies and storage facilities. They have been deeply affected by the rise in unemployment in the 1990s, with most residents subsisting on part-time manual jobs at one of the companies, retirement pensions, state welfare programmes and what else they can find. The area in which these residents live is known and recognized by government experts to be contaminated and unsafe for human habitation–and yet widespread confusion and uncertainty amongst residents and a lack of government actions means that the shantytown continues to exist. Auyero and Swistun explore the multitude of influences that ‘‘shape what people see, what they don’t see, what they know, what they don’t know, and what they would like to know, what they do and what they don’t do’’ (145). They show how residents gradually naturalize their situations, which, combined with the mystification of dominant discourses, contributes to their quiescence in the face of contamination. 

Public Health Alliance of Southern California. California Healthy Places Index. 2019. https://healthyplacesindex.org.

© 2018 Public Health Alliance of Southern California

Permission is hereby granted to use, reproduce, and distribute these materials for noncommercial purposes, including educational, government and community uses, with proper attribution to the Public Health Alliance of Southern California including this copyright notice. Use of this publication does not imply endorsement by the Public Health Alliance of Southern California.

© 2018 California Department of Public Health (CDPH)

Permission is hereby granted to use, reproduce, and distribute these materials for noncommercial purposes, including educational, government, and community uses, with proper attribution to the CDPH, including this copyright notice. Use of this publication does not imply endorsement by the CDPH.

The index does not include certain neighborhood characteristics critical to health because they did not meet the criteria for inclusion (described in question 3). For instance, this included physician ratios (the number of physicians per 100,000 population) because data was missing for a majority of census tracts. In fact, the steering committee was unable to locate much data on health care access or quality at the census-tract level (only data on health care insurance coverage was available).  

 The index was previously critiqued in ways that led to a shift from framing data in terms of “disadvantage” towards a framework of “opportunity”. This led to not only a renaming of the index (from “the Health Disadvantage Index to the Healthy Places Index) but also a shift in reporting of data (e.g. highlight the percentage of the population with a BA degree or higher rather than the percentage of population without a college degree). 

The HPI is also limited in terms of the effects of confounding, with some indicators with strong evidence of health effects showing contrary associations with life expectancy at birth by census tract. The steering committee has also acknowledged that the HPI might not be accurate for census tracts undergoing rapid population change (e.g. due to immigration, rapid gentrification, or other changes).

The HPI notably does not correlate strongly with CalEnviroScreen, which the steering committee for the HPI noted failed to identify one-third of census tracts with the worst conditions for population health. The HPI is ultimately more centered on considering environmental factors as a part of overall health, rather than as a central determinant. However, this disconnect between CalEnviroScreen and the HPI may also be a reflection of the challenges environmental injustice advocates have faced in linking environmental factors to health outcomes (which might not be as visible and geographically direct as the links between health and other indicators).

The HPI draws data about 25 community characteristics into a single indexed HPI score. The includes sub-scores for 8 “Policy Action Areas”: Economic, Education, Housing, Health Care Access, Neighborhood, Clean Environment, Transportation, and Social Factors. These scores are meant to be used to evaluate health geographically. Each policy action area includes the following individual indicators and weights:

ECONOMIC (0.32)

• Poverty
• Employment
• Income

EDUCATION (0.19)

• Pre-school enrollment
• High school enrollment
• Bachelors attainment

HEALTHCARE (0.05)

• Insured adults

HOUSING (0.05)

• Severe cost burden low income
• Homeownership
• Kitchen and plumbing
• Crowding

NEIGHBORHOOD (0.08)

• Retail jobs
• Supermarket access
• Parks
• Tree canopy
• Alcohol establishments

CLEAN ENVIRONMENT (0.05)

• Diesel PM
• Ozone
• PM2.5
• Drinking water

SOCIAL (0.10)

• Two parent household
• Voting

TRANSPORTATION (0.16)

• Healthy community
• Automobile access

*The steering committee for the HPI sought to include race/ethnicity as a 9th policy action area, but they were prohibited from doing so by state law which does not allow California state agencies to use race as a basis for public contracting.

The primary HPI Index is designed to align with life expectancy at birth as a predictive measure of community health status. However, the Healthy Places mapping tool can also be used to create custom scores using different indicators. The mapping tool includes detailed definitions of each indicator.

Each indicator is linked to a policy guide, which outlines concrete actions (e.g. best practices, emerging policy options) that local jurisdictions can take to improve HPI indicators. These actions are sometimes aimed at addressing direct links between policy and an action area, and other times aimed at addressed the root causes of an action area. The mapping tool also enables filtering results by “Decision support layers” like health outcomes, health risk behaviors, race/ethnicity, climate change effects, and other layers that the alliance identifies as important for advancing “resilient, equitable communities in California”. Geographies (e.g. census tracts) can also be compared by indicator using a ranking tool. The pool function can be used to create customized aggregations of data to map (e.g. adding several census-tracts together).

Data is available at several different scales: census-tracts, congressional districts, state assembly districts, state senate districts, cities, core based statistical areas, elementary school districts, metropolitan planning organization and medical service study areas.  

Creating maps by different combinations of indicators or geographic aggregations could be tinkered with to produce provocative data visualizations. Ranking scores can be used to draw distinction between different census tracts. However, clear inequities are evident even without these adjustments, with the HPI index score clearly demonstrating noticeable differences across geographies. 

The California Healthy Places Index is made available by the Public Health Alliance of Southern California. Their mission is to “make health equity and racial justice a reality” through collaboration and data (https://www.thepublichealthalliance.org/). They engage in advocacy and mobilization to generate this change. They are composed of a coalition of executives representing 10 local health jurisdictions in Southern California (including Long Beach, Los Angeles, Orange, and Riverside, among others), an area they highlight as representing 60% of California’s population (with which they blur the boundaries between “California” and “Southern California”).

The alliance emphasizes pursuing equity using publicly available data and collaboration (with government agencies, legislators, hospitals, health plans, philanthropy, and community advocates). They present the Healthy Places Index (HPI) as a tool for exploring how life expectancy is impacted by community conditions.

More specifically, the HPI was created by a steering committee made up of epidemiologists and 3 public health coalitions led by the alliance.