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On July 16th 1979, the largest by volume radioactive spill in US history took place in Church Rock (Kinłitsosinil), which is located in the southeastern “checkerboard area” of the Navajo Nation (Diné Bikéyah) and northwestern New Mexico. Due to a breach in the former United Nuclear Corporation’s uranium mill tailings dam, an estimated ninety-four (~94) million gallons of radioactive, toxic, and highly acidic effluent spilled into the Puerco River (Brugge et al. 2002; SRIC 2009).

The Church Rock Uranium Mill Tailings Spill marked the disastrous beginning of the end for the uranium mining industry in the Navajo Nation and New Mexico. Ironically, the spill occurred on the very same day as an event 34 years prior that marked the beginning of the uranium boom and the dawn of the atomic age: the Trinity Test of July 16th 1945, “the day the sun rose twice.” (Szasz 1984) Unlike the world’s first nuclear explosion in southern New Mexico, the Church Rock mill spill remains relatively underreported and has not yet registered at a national scale of collective memory.

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.

This data has been used for assessments, decision making, and planning on a state, regional and local level in California by a wide range of actors, which include:

·  California Department of Public Health

·  Governor’s Office of Planning and Research

·  California Environmental Justice Alliance

·  the Hospital Association of Southern California

·  County Public Health Departments

·  Local/regional healthcare providers

For instance, Kaiser Permanente used the HPI in conducting a community health needs assessments for several areas in southern California (to comply with federal tax law requiring them to conduct a health needs assessment at least once every three years). They used the tool to identify the most under-resourced geographic communities and identify the factors that are most predictive of negative health outcomes. 

For this community health assessment, researchers also consulted residents, community leaders, government and public health department representatives through surveys, stakeholder interviews, and focus groups. The assessment identified several health needs that needed to be prioritized: access to healthcare, economic security, mental health, stroke, and suicide. This was used to guide implementation strategies in partnership with community-based organizations, hospitals and groups (e.g. identifying reducing food insecurity as a strategic priority and designing/implementing food benefits programs).

Other reports using the HPI include the Solano County Public Health Departments’ report entitled “Maternal and Child Verification of Cumulative Health Impacts from Social Factors,” the Los Angeles County Department of Public Health city and community health profiles, and the California Environmental Justice Alliance’s SB 1000 Toolkit.