Truth On A Map

How mapping health disparities by neighborhood helped communities in King County, Washington, mobilize for change

Published 5/20/2015

King County in Washington state, home to the city of Seattle and some two million urban and suburban residents, consistently ranks among the healthiest counties in the United States. Local leaders could be forgiven for imagining that all is well when it comes to well-being in Seattle's metropolitan area.

But not so fast. Once you start taking King County apart, neighborhood by neighborhood, you quickly realize that people in gentrified parts of Seattle, for example, are far healthier than those living in lower-income pockets of the city and its suburbs.

For a group of foundation officials, public health experts, grass-roots advocates, and elected officials, those disparities were brought into stark relief in December 2013 at a forum to explore how the fields of public health and community development can work together. The forum launched an initiative called Communities of Opportunity. COO is a joint initiative between the Seattle Foundation, the Department of Public Health &endash; Seattle & King County, and the King County Department of Community and Human Services with the aim of narrowing health disparities in the region.

More than a dozen multicolored maps of King County hung around the room, highlighting nearly 400 census tracts, each consisting of about 5,000 residents. Each map featured a different health measurement — some showed income, others life expectancy, tobacco use or diabetes rates. And tract by tract, each map showed the same color pattern: a dark blue in north Seattle and east of Lake Washington, signaling high rates of health and well-being that shifted to a pale yellow and then to red and crimson, indicating that areas radiating farther south had progressively worse public health problems.

“It was very dramatic for people to see maps that show these awful disparities that are kind of hidden in the day-to-day world,” said David Fleming, vice president for public health impact at PATH, an international health non-profit, who was the director of Public Health – Seattle & King County, at the time.

"The maps really drove people to the place of saying, ‘It's neighborhood that really counts.’"

It was just remarkable how similar these maps were across conditions ,” Fleming said. “While people have produced maps before, putting 20 up in a room and having people see how identical they were really drove people to the place of saying, ‘It's neighborhood that really counts.’ ”

The maps are not just compelling evidence of inequality. They are also a starting point for COO as it visualizes King County's problems and searches for answers. Communities of Opportunity is not a simple initiative, but then neither is alleviating widespread health disparities. But good policy begins with good data, and the maps will play a central role as COO hones in on its goal to make the region's health assets more equitable.

Joining Forces

The planning process for COO began long before the maps were put on display. In early 2013, both The Seattle Foundation and King County were in the early planning stages of separate initiatives that would focus on geography as a determiner of people's health. Research has consistently shown that people's ZIP codes are as important to their health as are their genetic codes. The Robert Wood Johnson Foundation has mapped life expectancy in different counties throughout the United States and has found a 15-to-20-year difference in life expectancy depending on where one lives.

“COO's concept is basic and holistic: Treat the whole neighborhood — the places where people eat, live, work, learn, and play — as critical to its residents' health and well-being.”

With this in mind, COO wanted to look at public health more broadly than by simply calculating, for example, a person's access to medical care. Its concept is basic and holistic: Treat the whole neighborhood — the places where people eat, live, work, learn, and play — as critical to its residents’ health and well-being.

This was not the first time that the department had coordinated efforts to target the social determinants of health. As David Fleming discussed in “What Counts: Harnessing Data for America's Communities,” the public health department of Seattle & King County recently led another initiative to improve school nutrition and physical activity and reduce childhood obesity in some of the poorest districts in the county. That project also relied on collaboration across the southern parts of the county. At the end of two years, obesity dropped for children living in the project's area by 17 percent while remaining unchanged in other parts of the county.

Census tracts ranked by an index of health, housing and economic opportunity measures

Population Measures Lowest 10% (Dark green) Highest 10% (Light green)
Life expectancy 74 87
Adverse childhood experiences 20% 9.0%
Freqent mental illness 14% 4.0%
Smoking 20% 5.0%
Obesity 33% 14%
Diabetes 13% 5.0%
Preventable hospitalizations 1.0% 0.4%
Poor housing condition 8.0% 0.0%
Low-income, < 200% poverty 54% 6.0%
Unemployment 13% 3.0%

In the case of COO, it again became clear that the effort would need to be cross-sector. And since both The Seattle Foundation and King County were focusing in on place-driven projects, both groups quickly saw that working with each other would be vital if they wanted to avoid duplicative or uncoordinated efforts.

We were actually going to do harm if we didn't link up ,” said Janna Wilson, senior external relations officer at Department of Public Health – Seattle & King County.

The Process of Mapping

Along with the community ownership of the projects, COO's process is also unique because the maps required coordination between county agencies that do not usually work together — the Department of Community and Human Services and Public Health – Seattle & King County.

“If you want to talk silos, you should see data people from two county agencies try to agree on a small set of measures,” said Kirsten Wysen, project manager of COO. “It took about five months because we had so many different data sources that came from different geographic areas — whether from cities, ZIP codes, census tracts, or census blocks.”

Once the departments agreed on a set of measures, the data scientists harnessed new tools to create maps of neighborhood indicators. Usually, maps are created with data at the city level or higher (county or statewide, for example) to ensure they’re reliable. The closer in you zoom, the smaller the totals become, and thus the estimates of true change are harder to decipher. But the epidemiologists and statisticians used breakthrough GIS analytics as well as a Bayesian predictive model (the same type of model Nate Silver used to predict the 2012 election) to fill in the gaps and holes in the data.

“I would say, ‘Hello, use the map! Keep it simple! We have the data, who can argue with that?’”

The disparities that were revealed are astounding. In areas around north Seattle and the eastside in the 10 percent of census tracts that rank highest on a mix of 10 health and social measures, life expectancy is 87 years. In the lowest 10 percent, areas spanning south to the airport and beyond, it's 74. In some areas, the smoking rate hovers at 5 percent, whereas about one-fifth of the population smokes in other areas. The obesity rate is twice as high in the lowest-ranking zones as it is in the highest.

Wysen said the maps kept the early planning conversations “honest,” and that attendees couldn’t gloss over the fact that only several miles away, people's health and life expectancy were vastly different.

“Folks would go off on this tangent about what we were targeting and I would say, ‘Hello, use the map! Keep it simple!’” said Sili Savusa, executive director of the White Center Community Development Association, who was also involved in the planning process. “We have the data, who can argue with that?”

Not everyone saw the maps the same way. Some grass-roots advocates asked, “Why aren’t more people seeing these maps?” (They did eventually make it into the local paper.) But others saw the maps as something they should be very careful with, fearing possible unintended consequence of preventing business owners from opening businesses in high-poverty areas, for example.

But the maps that drilled down to small areas also illuminated something older maps had been hiding: the reality of the area's vast disparities. As Fleming described, the suburbanization of Seattle's poverty means people who live and work in the more affluent urban core (including, often, people working in public health or foundations) often don’t see poverty up-close — it's pocketed, suburbanized and more isolated.

“People were often smug, because if you look at King County on a national map, we’re above average. But it hides the truth of the amount of disparity we have,” Fleming said. “That was the other ‘aha’ piece of this.”

At the same time, none of the data was necessarily surprising on its own. But Wysen said it was the visualization that was compelling and helped clarify to people how closely neighborhood and health are tied.

The maps were also an expression of what people who live and work in low-income communities in King Country experience each day and know instinctively to be true.

“[The maps were] using the county data to validate these are where poor people live,” Savusa said. “In a lot of ways, the really wonky people always need to add more data. Sometimes it was just making the case. We don’t need to talk about it anymore.”

Using the Maps to Target

After much planning and mapping, in early October COO asked for letters of interest for their grant program and did numerous site visits. But this time they did something different, thanks to the maps. To target their efforts to the areas with the most need, COO only accepted proposals from organizations that worked in the 20 percent of the county ranked lowest on the map — the areas colored dark red and crimson.

In February, COO awarded its second round of funding totaling $1.5 million to three organizations for initiatives aimed at reducing health disparities by neighborhood. Savusa's organization, The White Center Community Development Association, will use the $150,000 each year to build capacity and staff for its housing and community development programs. It is also building its own database to share with non-profits in White Center so they can better understand the needs of the people they serve.

In the SeaTac and Tukwila area, Global to Local is a working to build a Food Innovation Network, or a concentrated area of food-oriented businesses. Residents are interested starting businesses such as catering, small scale food processing, baking, food trucks, and urban farms. The group is also working on a shared kitchen for community entrepreneurs. Their goal is to provide greater access to healthy food in the region's low-income neighborhoods and provide new economic opportunities.

And in the Rainer Valley region of southeast Seattle, HomeSight is planning to help spur the efforts of four different community-led coalitions. It's also creating a food innovation district and working to steer land use for transit-oriented development.

And although the use of data mapping were instrumental in the planning stages on the front end, Wilson said they’ve continued to use them to help illustrate the situation in the region.

“In the absence of action today, we are condemning our children to be looking at that same map.”

“We use the maps all the time. It helps bring people to the table,” she said.

Wilson emphasizes that the map is not an end it in itself but only a beginning step in helping identify the problem. Although COO is still in its early stages, its long-term vision aims to work with community organizations to improve people's lives and health and build a more equitable King County.

Or, as Fleming summed up: “In the absence of action today, we are condemning our children to be looking at that same map.”

Written by: Kathleen Costanza
Photos by: Nat Soti; Kathleen Costanza
Video shot and edited by: Nat Soti

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