key: cord-0702360-wj9nv6p7 authors: Hargrove, Taylor W; García, Catherine; Cagney, Kathleen A title: The Role of Neighborhoods in Shaping the Aging Experience During Times of Crisis date: 2020-12-21 journal: Public Policy Aging Rep DOI: 10.1093/ppar/praa041 sha: 6eb442f3a60511c2cc980d1ec51db5afdc68e542 doc_id: 702360 cord_uid: wj9nv6p7 nan As of October 8, 2020, the coronavirus disease 2019 pandemic has claimed the lives of more than 211,000 people across the nation and has infected more than 7.5 million Americans (Centers for Disease Control and Prevention, 2020) . The consequences of the pandemic are far-reaching, exceeding loss of life and deterioration of health. For example, the government policies enacted to slow the rate of transmission (e.g., "shelter-in-place" mandates; social distancing guidelines) led to limited economic activity. As a result, the United States entered an economic recession, facing reduced production and retail sales in addition to employment loss. At the same time, revitalized social movements against systemic racism, particularly police brutality, were spurred following the recent killings of several Black women and men at the hands of police, including Breonna Taylor and George Floyd. These killings may be interpreted as a reflection of institutional prejudices that disproportionately affect Black and Latinx communities (Jones & Sawyer 2020; Tate et al., 2020) . Current efforts to mitigate the spread of COVID-19, respond to the financial impacts of the pandemic, and address systemic racism often rest with federal and state government entities. However, local and more informal spaces such as neighborhoods are also consequential, especially for older adults who are experiencing multiple and compounding sources of vulnerability during this particular sociohistorical moment. Neighborhoods are important organizing features of our lives that profoundly affect how spaces operate in times of crisis and how individuals respond to, and are affected by, those crises (Browning et al., 2006) . Past scholarship also documents the powerful influence of neighborhoods on the disablement process, onset of chronic disease, and mental health across the life course (Diez Roux & Mair, 2010; Rogowski et al., 2006) , making neighborhoods essential contexts for the aging experience of community-dwelling older adults. It is therefore critical to revisit what neighborhoods mean for health and aging and their unique role in supporting vulnerable populations during the current crises. Such knowledge will not only inform social policy and programs that benefit older adults who wish to age in place, but will also collectively prepare us for crises in the future. It is therefore critical to revisit what neighborhoods mean for health and aging and their unique role in supporting vulnerable populations during the current crises. The impacts of the COVID-19 pandemic, economic recession, and revived social movements surrounding systemic racism are not felt equally. Vulnerable populations are disproportionately affected given their limited ability to garner Report, 2020 , Vol. XX, No. XX, 1-6 doi:10.1093 resources to avoid or allay risks. One such population is community-dwelling older adults, who are experiencing the brunt of negative outcomes related to COVID-19. For example, approximately 7 million community-dwelling adults above age 65 suffer from respiratory illness, making them an extremely vulnerable group during the pandemic (Cohen & Tavares, 2020) . Further, among 52,166 decedents reported to the Centers for Disease Control and Prevention via casebased surveillance between February and May 2020, 79.6% were aged 65 and older (Wortham et al., 2020) . Additionally, the shelter-in-place mandates and social distancing guidelines that were put in place to slow the transmission of COVID-19 have kept many in their homes, especially those most at risk of contracting and dying from the virus. These changes greatly increase the likelihood of social isolation and loneliness among older adults-many of whom were already considered to be socially isolated prior to the pandemic (National Academies of Science, Engineering, and Medicine, 2020)-and can lead to the development of adverse psychological outcomes, such as depression or anxiety (Coyle & Dugan, 2012; Santini et al., 2020) . Relatedly, older racial/ethnic minorities are disproportionately affected by the current crises given the systemic inequalities (e.g., residential segregation) they faced both prior to and during this period (e.g., Purtle, 2012) . Indeed, COVID-19 mortality rates for Black and Latinx individuals aged 65-74 are 5 and 4 times higher, respectively, than the mortality rate for Whites (Ford et al., 2020) . Differences in the types of contexts in which Black and Latinx older adults tend to live relative to their White counterparts are partly responsible for these disparities (Garcia et al., 2020) . A recent study, for example, found that counties with higher proportions of Black residents had higher rates of COVID-19 infections and deaths compared to other counties (Millett et al., 2020) . In fact, counties in which 13% or more of residents were Black (approximately 20% of U.S. counties) accounted for 52% of COVID-19 diagnoses and 58% of COVID-19 deaths nationwide, owing in part to the socioeconomic, environmental, and health conditions of such areas. These findings not only underscore the importance of surrounding contexts for shaping health and exposure to disease, but also highlight persistent structural-level determinants of racial/ethnic health inequalities among older adults. The economic consequences of the pandemic place older adults in an even more precarious situation. Adults aged 55 and older constitute approximately one-fifth of the share of Americans who are unemployed due to the economic ramifications of the pandemic (Cubanski et al., 2020) . Millions of older adults have lost access to employer-sponsored health insurance, a particularly important resource given that they are more likely to suffer from chronic conditions in need of consistent and ongoing medical treatment. Unemployment also threatens the economic security of many older adults, who will have a more difficult time withstanding the short-and long-term demands imposed by the pandemic (e.g., securing food and transit, meeting rent obligations, contributing to retirement and savings, investing in community infrastructures; Li & Mutchler, 2020) . Moreover, prior work indicates that those living in vulnerable neighborhoods are more likely to experience delays in receiving resources (e.g., food, medicine, transportation) post-disaster (Lichtveld, 2018) , further compounding older adults' ability to recover from crises. Older adults also have a unique relationship with the current social movements against systemic racism. For many, particularly Black Americans, these social movements represent a continuation or resurfacing of decades-long efforts to combat systemic injustices, including police brutality. They also highlight the long-term consequences for Black adults, in particular, of experiencing de jure and de facto segregation for a large portion of their lives. Indeed, these forms of segregation shaped access to opportunities and resources across generations, influencing the ability to combat subsequent health and economic crises by leveraging community resources and neighborhood amenities, accessing health services, and obtaining additional economic support. In all these circumstances-COVID-19, economic downturns, and social movements related to racism-context plays a critical role. The risk of contagion, economic vibrancy, and interactions with police are, to a large degree, experienced locally. The focus on federal and state responses in each of these instances, however, has largely overlooked the importance of the proximal social and physical environment. Existing literature on disasters highlights how critical neighborhoods and community members can be in times of crisis. For example, a recent study suggests that after Superstorm Sandy, residents turned to nearby, informal sources of support (e.g., their neighbors) before engaging formal entities (Cagney et al., 2016) . After Hurricane María, residents in Puerto Rico did not expect any governmental assistance to appear and knew they would have to rely on their own communities to meet their immediate needs (Hayward et al., 2019) . In Toa Baja, Mentes Puertorriqueñas en Acción (MEP), a communitybased organization consisting of a network of students, organized the #EnAcción initiative, the first effort to specifically mobilize communities in a post-disaster scenario (Hayward et al., 2019) . The MEP volunteers checked on family members and neighbors in the community, then followed with a more organized response of providing basic necessities. When Hurricane Katrina devastated Black communities in New Orleans and displaced many from their homes, survivors turned to faith-based organizations to receive material, emotional, and social support: resources critical for recovery post-disaster given the absence and degree of response from the Federal Emergency Management Agency (Alawiyah et al., 2011) . Collectively, these studies demonstrate how communities, particularly those that have experienced decades of disinvestment and economic hardship, turn to initiatives spearheaded by fellow community members in times of crisis, as they cannot always rely on formal support. Local contexts, therefore, become extremely important for social network interaction and for establishing and sustaining the types of connections that are critical in times of need, especially when governments fall short of providing resources and protections to all groups. The current health, economic, and policing crises in the United States, however, may be challenging the ability of communities to partake in such intervention efforts. The social norms of reciprocity and social capital that have traditionally existed in communities may be shifting, affecting the types of social networks to which individuals may turn for assistance. Shelter-in-place mandates and social distancing measures have led older adults to increasingly rely on distal others for everyday needs, such as delivery services that can provide food, medication, and household supplies. For example, Meals on Wheels-the leadership organization for thousands of community-based programs nationwide that provide meal deliveries and safety checks-reported that between March and April 2020, programs were serving, on average, 77% more meals and 47% more seniors, and that waiting lists for meals grew by 26% (Meals on Wheels, 2020). Local contexts, therefore, become extremely important for social network interaction and for establishing and sustaining the types of connections that are critical in times of need, especially when governments fall short of providing resources and protections to all groups. Federal responses to the COVID-19 pandemic also support the importance of community-based interventions that rely on distal actors. The Coronavirus Aid, Relief, and Economic Security (CARES) Act, which was signed into law in March 2020, provided nearly $1 billion in funding to community-based organizations tasked with helping older adults through the pandemic. Services funded under this Act include home meal deliveries, personal care assistance, help with household chores and grocery shopping, transportation to essential services, and counseling. These priority areas, as identified from a federal standpoint, reflect a focus on addressing the immediate needs and challenges facing community-dwelling older adults. While important, such responses may only have an impact in the short term. Federal and local responses are also needed to address the long-term consequences stemming from all three crises the United States is experiencing, including the ability of neighborhoods and communities to positively impact the health and well-being of older adults in the future. One way the long-term role of communities is being challenged is by changes to the neighborhood context itself. The resources and amenities available in communities are critical to the health and aging of older adults (Kerr et al., 2012) . Such factors depend on investments in communities, which are often based on the socioeconomic characteristics of residents. The recent economic recession is critically impacting such investments, especially within neighborhoods that were already economically deprived. The degree of job loss that has occurred and the reallocation of funds to address pressing health needs of the pandemic have led to limited financial resources to invest in communities, both currently and in the future (Belz & Sheiner 2020; Li & Mutchler, 2020) . The constrained finances of individuals may also affect the ability to pay mortgages and property taxes, leading to reduced funds for maintaining or improving individual homes and community infrastructures or for long-term community investments, such as road repair or collective institutions. Moreover, the recent protests against systemic racism and police brutality have brought attention to large-scale vulnerabilities in society and the acute and long-term needs of community members. Specifically, the current social movements highlight continued unequal access to healthy and safe neighborhoods in the United States. Communities characterized by economic, social, and political disadvantages, which are often home to Black and Latinx residents, are the result of institutional policies and practices that exclude racial/ethnic minorities from accessing particular neighborhoods while also limiting their ability to accrue wealth and other advantages in their own neighborhoods (Massey & Denton, 1993; Williams & Collins, 2001) . Such neighborhoods constrain opportunities for healthy living by increasing residents' exposure to environmental stressors and environmental pollutants while also restricting spaces for mobility and social cohesion (Diez Roux & Mair, 2010) . Differences in the neighborhoods where older adults live are also a primary factor driving the persistence of racial/ethnic health disparities (Williams & Mohammed, 2013) . While interventions from the current social movements have not yet had the opportunity to emerge, what has resulted are calls to transfer some of the funds allocated to police departments and reinvest them in local, disadvantaged communities. Such calls reflect increased focus on the historical and contemporary ramifications of structural racism, which place adults in environments that disparately affect their health and well-being. Reinvestment in the built and social aspects of local neighborhoods, such as housing, sidewalks and street connectivity, social services, transportation, and health care, may create better spaces for supporting vulnerable populations. Indeed, as design features of neighborhoods influence the development of age-friendly communities via their impacts on mobility, access to services, physical activity, and social engagement and cohesion (Latham & Clarke 2018; Lehning et al., 2007; Yen & Anderson, 2012) . Reinvestment efforts may be especially consequential for Black and Latinx older adults, who are more likely to live in disadvantaged communities. In the absence of evaluations of specific programs developed in response to the current crises, existing community aging initiatives such as the AdvantAge Initiative, the World Health Organization's Global Age-Friendly Cities Project, and Communities for All Ages (Scharlach, 2012) provide guidance for bringing together community members, local and state government officials, and other stakeholders to evaluate and improve the age-friendliness of communities in the long term, particularly aspects of the built environment. The unprecedented time the United States is facing as a result of the COVID-19 pandemic, economic recession, and social movements to end systemic racism makes it essential to understand the current and future role of communities in shaping the health and well-being of vulnerable populations, particularly older adults. The ways community resources, social capital, and connections are activated may change to adjust to the current crises, which are sure to alter the future. It will be important that policymakers, program administrators, and city leaders reach into communities to understand what sort of direct assistance people need during these times. Doing so will also help improve socioeconomic circumstances at individual, local, and state levels, as it is more expensive to support residents in nursing homes than in the community (e.g., Kaye et al., 2010) . This moment in history has also brought attention to the social inequities that already exist in the United States and that are being amplified by the pandemic and economic recession, such as access to affordable, safe housing. It is critical that we continue to think beyond solutions to the current circumstances to identify systemic levers that will address root issues so that we may better respond to challenges in the future. One strategy for helping residents stay in the community, particularly during times of crisis, would be to require or encourage publicly funded homes to include accessibility features for the elderly, such as zerostep entryways. Indeed, home environments can present critical barriers to aging in place if they are not suitable for the changing functional needs of older adults. Several local jurisdictions (e.g., Atlanta, GA; Austin, TX) have required aging-friendly designs in publicly funded housing, while others have incentivized these features through programs such as tax credits (U.S. Department of Housing Urban Development, 2013). Another avenue for improving older adults' ability to age in place is to increase funding for home-and community-based services. One study, for example, found states that invested more in community-based services, particularly home meal delivery programs, had fewer low-care residents living in nursing homes, indicating the capacity of such states to keep older adults in community environments (Thomas & Mor, 2013) . Additionally, a Medicaid waiver program in South Carolina that offered home-and community-based programs showed success at keeping frail older adults in communities, thereby delaying institutionalization (Pande et al., 2007) . These types of efforts not only increase the health and well-being of older adults, but also help reduce financial strains to state budgets, as more than half of Medicaid expenditures for long-term care go to institutional settings (Rousseau et al., 2013) . In the short term, we reemphasize the importance of funding interventions that foster connections among residents to address the immediate needs of older adults. New initiatives could be modeled after programs such as Meals on Wheels or intergenerational communication programs (e.g., Students to Seniors) that check in on older residents on a regular basis to ensure they have the essentials needed for the week and to provide companionship. These can begin through more informal channels, such as block groups, and operate on a smaller scale, focusing on local connections and thus potentially enhancing accountability. This form of initiative can reinforce norms of reciprocity and contribute to a reservoir of support that all residents may draw on in times of need. It is also important to acknowledge that a large share of older adults do not live independently. Instead, many live in institutional settings such as nursing homes. What we propose here likely operates differently in institutional communities, and it will be important for policymakers and community leaders to give specific attention to such spaces when surveying the consequences of various crises and developing community-level interventions to address them. Yet, what remains consistent despite the exact intervention or living space is the notion that accountability rests locally: that we have immediate responsibilities to one another that must be fulfilled to create opportunities for healthy and happy living. The extended duration of the pandemic, economic recession, and social movements will require consistency and commitment over the entire course of this experience. A potential positive outcome from such efforts is that the infrastructure created will continue to provide support for all community members who are socially or physically isolated. The current situation in the United States also has implications for how we think about community and our vulnerable populations in the future. Are we, for example, experiencing a turning point in how we think about community and reciprocity? Will this experience have a fundamental impact on the social fabric of community? While only time will give us the exact answers to these questions, the intersection of the pandemic, economic recession, and social movements underscores the critical import of community for sustaining population health and well-being. This work was facilitated by the Network on Life Course Health Dynamics and Disparities in 21st Century America (NLCHDD; grant #R24AG045061) from the National Institute on Aging (NIA) of the National Institutes of Health. The NLCHDD received additional support for its annual meetings from the Michigan Center on the Demography of Aging (NIA grant #P30AG012846). Spirituality and faith-based interventions: Pathways to disaster resilience for African American Hurricane Katrina survivors How will the coronavirus affect state and local government budgets? Brookings Institution Neighborhood social processes, physical conditions, and disaster-related mortality: The case of the 1995 Chicago heat wave Social resources and community resilience in the wake of superstorm Sandy CDC COVID data tracker Who are the most at-risk older adults in the covid-19 era? 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