Stress and Health Disparities in Sensitive Urban Zones

Samantha Post

France boasts a centralized healthcare system that spends twenty percent more than

EU average on healthcare, and covers nearly all of the population. Despite this, health

disparities remain a serious issue in France. Mortality and life expectancy averages differ

drastically between socioeconomic groups, and the prevalence of chronic diseases, and

unhealthy lifestyle habits such as smoking vary based on education level (OCED, 2017).

These disparities are concentrated in sensitive urban zones (ZUS) due to their high

unemployment rates, and lack of access to good education and healthcare, where nearly one-

quarter of residents blame their living conditions for their physical and mental health (Parizot,

Chauvin, Firdion, & Paugam, 2003-2004). Though little research has been done to explore

the causes of France’s health disparities, I argue that poverty and unemployment in ZUS

increase stress, a psychological and physiological response that has extremely negative

effects on health.

This interpretative research paper explains health disparities in ZUS following a

sociocultural model of stress. This paper will determine primary stressors for residents in

ZUS, explain the effects of these stressors on health as supported by research, and propose an

intervention and prevention program that would reduce health disparities in France.

What are ZUS?

Zones urbaines sensibles, or sensitive urban zones (ZUS) are urban areas in France

characterized by run-down building complexes or neighborhoods, a concentration of first-

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and second-generation immigrants, and a shortage of employment opportunities (ONZUS,

2014). Approximately ten million people reside in ZUS, yet one out of eight ZUS do not

house a health establishment, and the health establishments in ZUS lack proper and updated

medical equipment (ONZUS, 2014).

ZUS are neighborhoods inside of or surrounding big cities like Paris, Lyon, and

Marseille, and are more commonly referred to as the quartiers and cités. Though they are not

always less safe than other neighborhoods, ZUS are perceived as dangerous, particularly due

to their large black-market economy involving drug, gun and stolen good trade. Not only are

these areas emphasized as “no-go zones” to tourists, but they are described by French news

platforms as “breeding zones” for Islamic terrorists. Additionally, they are stereotyped to be

filled with “violent youth”, particularly after week-long riots that occurred in urban areas all

over France in 2005 which were provoked by discriminatory police killings. ZUS are also

physically and institutionally separated from the cities that they are a part of. Though France

has an elaborate public transportation system serving everywhere from mountain villages to

beach towns, less than half of ZUS have a train station (ONZUS, 2014). Finally, these areas

are overcrowded and lack updated infrastructure, as the housing projects that constitute them

were built in the 1950s to accommodate a large influx of immigrants (Parizot, Chauvin,

Firdion, & Paugam, 2003-2004). Stereotyped, separated, and ignored, ZUS and those living

in them face countless disadvantages.

France’s 2017 country Health Profile found individuals with low education levels to

be twice as likely to live with hypertension, depression and asthma as individuals with high

levels of education (ONZUS, 2014). In addition, only sixty percent of low-income French

reported being in good health, a group that also reported a proportion of unmet health needs

(e.g., dental care) three times higher than those with higher income. Obesity rates for low

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 income French are double, and life expectancy for individuals working in lower income jobs

(e.g., manual labor) was found to be six years shorter than those in higher income jobs

(OCED, 2017).

By definition, ZUS are urban areas with very high levels of unemployment. Hiring

discrimination and lower education levels in ZUS both work together to increase

unemployment rates, which in turn affects poverty levels. Research done in France suggests

that employers discriminate based on race and ethnicity in their hiring processes, and due to

high immigrant populations in ZUS, this could be one explanation for higher unemployment

rates. Individuals living in ZUS have, on average, lower education levels than those living in

non-ZUS, which may suggest why it is harder for those in ZUS to compete in the job market.

The effects of unemployment and poverty on stress may explain why health disparities are

prevalent in ZUS.

Lower
education
levels

High
unemployment Health
rates Poverty problems

Hiring
discrimination

Primary Stressors in ZUS

Hiring Discrimination

The last published National Observation of ZUS in 2014 emphasizes the gravity of

ZUS unemployment, finding the average unemployment rate in ZUS to be double (22.2%)

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the national unemployment rate (10%), and the unemployment rate for young adults in ZUS

to be even higher, at forty-two percent (OCED, 2017). One reason for higher unemployment

rates in ZUS is their large immigrant population of particularly African and North-African

descent and the hiring discrimination that is commonplace in France.

Studies found eight-six percent of men whose parents were both born in France to be

employed, whereas only sixty-five percent of men who had at least one parent born outside of

France were found to be employed (Jacquement, 2013). For women, these numbers were

even lower. Additionally, studies have shown that individuals with North-African sounding

names (e.g., Youssef, Mohammed, Medhi, etc.) were forty percent less likely to be called

back for a job interview (Jacquement, 2013). Studies have also found religious discrimination

against Muslims: while twenty-one percent of candidates perceived as Catholic were called

back for a job interview, only eight percent of candidates perceived as Muslim received a call

(Jacquement, 2013). Due to the fact that more than half of the people living in ZUS are

immigrants or descendants of immigrants, and the majority of them are of Maghreb-origin,

discrimination against Maghreb and Muslim sounding job candidates may play a role in high

ZUS unemployment rates.

Poor Education

France’s centralized school system is organized so that all schools are required to

follow the national curriculum according to the national teaching schedule. French students

have to take multiple national exams, which place them in different educational and career

trajectories depending on how they score. The problem with this system is that schools are

funded by local taxes, putting schools in areas of extreme poverty such as ZUS at a serious

disadvantage. Schools in ZUS tend to lack necessary resources such as textbooks, pencils,

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and technology, which affects both learning and teaching abilities. In addition, the national

curriculum does not allow time to compensate for children who are struggling. For example,

there are no specialized school programs for young immigrants who are not fluent in French.

A young child’s inability to succeed in primary or secondary school due to a language barrier

can have serious impacts on their future.

According to France’s 2014 National Observation of ZUS, only eighteen percent of

those who obtain their high school Baccalaureate (equivalent to U.S. High School Diploma)

in ZUS go on to pursue higher education compared to thirty-five percent of all French

(ONZUS, 2014). Moreover, the number of ZUS residents who do not obtain their high school

diploma (39%) is nearly double the total amount of French who do not obtain theirs (20%)

(ONZUS, 2014). In other words, the number of ZUS students who do not finish high school

is nearly twice the national average, which emphasizes the large educational disparities

between neighborhoods. It is reasonable to assume that the educational disparities in ZUS

play a role in the number of students finishing high school, which in turn plays a role in

employment rates.

Unemployment & Poverty

In France, unemployment is a national issue which particularly affects young adults.

The job market for those finishing university is extremely competitive, requiring many

French young adults to return to university to complete multiple internships, bachelors or

master’s degrees so they can meet the requirements to secure a job. Because of the high

competition, many jobs require specialized degrees, previous experience in the field, and

higher levels education. Young adults in ZUS, with forty percent lacking a high-school

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diploma and only eighteen percent pursuing higher education, are collectively at a

disadvantage in the job market.

High levels of unemployment and people with less education working lower-income

jobs have significant impacts on poverty. Thirty-eight percent of those in ZUS were living in

poverty in 2014, which is three times the national average (ONZUS, 2014). Children are even

more adversely affected by poverty, with one in two children in ZUS living in poverty

(ONZUS, 2014). Poverty has been shown to impact individuals in many different ways,

including psychological and physiological wellbeing. In a study done by INSEE, a French

data collection organization only sixty percent of individuals in France’s lowest income

group reported being in good health, compared to seventy-three percent of France’s highest

income group (OCED, 2017).

Of those who are able to find a job in ZUS, many end up occupying lower income

jobs: in 2014, twenty percent of employed people in ZUS worked in business and automotive

repair; eighteen percent in hospitality; thirteen percent in construction; and ten percent in

manufacturing (ONZUS, 2014). Again, France’s 2017 Country Health Profile found life

expectancy for men working in manual labor occupations (e.g., construction, manufacturing,

and automotive repair) to be six years shorter than those working as executives and managers

(OCED, 2017).

Impacts on Health

Stress Physiology

Socioeconomic status has been long linked to poor health, and the stress that poverty

and unemployment provoke contribute in affecting these negative health outcomes. Stress, or

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the perception of threatening stimuli coupled with physiological and psychological responses

evolved as a normal and important defense mechanism which worked to give humans more

energy to respond to perceived threats. However, chronic stress, or exposure to constantly

threatening stimuli coupled with a constant bodily response can provoke a number of

negative health outcomes.

The fight or flight stress response is the physiological reaction that humans have to

events perceived as stressful. When an event is perceived as stressful, the fight or flight stress

response first activates the hypothalamic-pituitary-adrenal (HPA) neural network and the

Sympathetic Nervous System (SNS) (Freberg, 2017). The HPA is stimulated to release stress

hormones, which influences the SNS to increase blood flow to areas of the body that might

help respond to the perceived danger (such as the heart, lungs, back and leg muscles), and

decreased blood flow to areas that are not needed (e.g., digestive system) (Freberg, 2017).

The HPA network works as a negative feedback mechanism: once cortisol is released and the

body has responded to the perceived threat, the HPA system stops releasing cortisol so that

the body can return to normal (Freberg, 2017).

Chronic stress is dangerous because it dysregulates the HPA network, decreasing both

its susceptibility to activation and its ability to self-regulate once the stressful situation ends

(Evans & Pilyoung, 2007). In other words, individuals with a dysregulated HPA will be less

likely to activate their fight-or-flight stress response when faced with an acute stressor

compared to those with a normal HPA, and their feedback mechanism is unable to tell when a

stressful event has ended therefore will continue to release stress hormones into the body.

This results in an increased production of stress hormones (e.g., cortisol, epinephrine, and

norepinephrine), which increase stimulation of the heart and blood pressure levels (Evans &

Pilyoung, 2007). Coronary heart disease, strokes, and heart attacks are examples of heart

problems that can result from overstimulation of the heart and high blood pressure.

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 In addition, chronic stress has been found to reduce telomere length and telomerase

activity, which has been strongly associated with high mortality rates (Epel, Blackburn, Lin,

et al, 2004). Telomeres are structures at the end of chromosomes which are responsible for

the replication of DNA and play roles in aging, and disease such as cancer, and telomerase is

an enzyme that aids in this process (Epel, Blackburn, Lin, et al, 2004).

Stress, Unemployment, and Poverty

Much research has been conducted on the links between unemployment, poverty, and

stress, finding that feelings of helplessness, social environment and unhealthy stress

management tactics play significant roles.

Glass, and Singer emphasize that not having a job and steady source of income makes

people feel helpless, and the feeling of helplessness increases peoples’ stress (Glass & Singer,

1972). In other words, learned helplessness or the belief that one has no control over their

life circumstances increase individuals’ perceptions of threatening experiences, consequently

increasing their stress response. Studies done by Kasl, and Cobb looked at physiological

health changes in individuals before and after they were laid off. They found unemployed

workers to have higher norepinephrine and epinephrine levels, and higher blood pressure in

comparison to the workers that were employed (Kasl & Cobb, 1970). This research

demonstrates the negative physiological effects of unemployment, specifically due to stress

activation of the fight or flight stress response, releasing stress hormones into the body, and

increasing heart rate and blood pressure. Additional research suggests that as the time spent

unemployed increases, the levels of epinephrine and norepinephrine also increase (Baum, et

al., 1986). In other words, the longer someone in unemployed, the more they will be impacted

by chronic stress. Finally, unemployment has been shown to lead to unhealthy behaviors such

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as alcohol and tobacco consumption, and unhealthy diet and exercise habits. Alcohol and

tobacco consumption are often unhealthy forms of stress management, whereas exercise is a

healthier form. In both cases, if people are not educated about the healthy ways to handle

their stress and engage in unhealthy behaviors (e.g., drinking several alcohol beverages per

night, eating lots of saturated fat, and not having an exercise routine), they increase their

likelihood of developing health issues.

Additionally, a study that examined the amount of time adolescents spent living in

poverty, their social environments, and their stress levels found that the longer time spent in

poverty, the more chronic adolescents’ HPA activity was levels (Evans & Pilyoung, 2007). In

other words, poverty impacted adolescents’ fight or flight stress response and dysregulated

their HPA, primarily due to the noise and crowding common in poor neighborhoods. Other

neighborhood contexts such as toxins, substandard housing and pollutants have been found to

increase physiological stress responses levels (Evans & Pilyoung, 2007). Experts also

emphasize the unique experience of poverty for children and adolescents to include feelings

of helplessness towards their situation due to lack of control, and parental neglect due to

parents focus on monetary income and survival levels (Evans & Pilyoung, 2007).

There are many reasons why low socioeconomic status is associated with negative

health outcomes, and perceived lack of control, social environments and unhealthy stress

management tactics influence chronic stress levels and their life-long impact.

Prevention and Intervention

Hiring discrimination and lower education levels in ZUS, among other factors,

influence unemployment rates. Unemployment rates are correlated to poverty levels, and both

have been shown to increase stress, which is associated with many negative health outcomes.
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In order to prevent stress-related health issues in ZUS such as cardiovascular disease, high

blood pressure, cancer, and heart attacks, the state is responsible for reforming education and

implementing policy to prevent hiring discrimination. In order to help those currently being

affected by stress-induced unemployment and poverty, social programs should be

implemented to help alleviate stress and teach stress management.

Social programs
Educational
reform

Decline in
Increased Decline in stress-
employment related
Poverty health
problems
Affirmative
action

In reforming their education system, France should consider that schools in ZUS have

different needs and require additional funding in order to have the same resources as schools

in non-ZUS. Schools in ZUS should receive necessary teaching supplies, and learning

material, including but not limited to updated textbooks, desks, chairs, pens and pencils,

laptops, projectors, books, games, and access to research databases. In addition, school funds

should contribute towards improving school infrastructure. For example, some schools do not

have adequate heating or air conditioning, making it difficult environment to learn and teach

effectively. They also lack updated plumbing systems, and have classrooms that are too tiny

to fit entire classes. Finally, ZUS schools should be given the time and resources to

accommodate for students who need additional help. An example of this would be by

providing French language courses, for students who are not native French speakers.

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Receiving a good education effects income and resources, and can produce social and

psychological benefits that affect health behaviors. Increased income can allow for

individuals to move out of stressful environments (e.g., crowded, loud, etc.), purchasing

healthier food, paying for health services, and increasing social networks. Employment and

increased income would also alleviate chronic stress that unemployment and poverty can

provoke. Investing in ZUS schools would be the first step in reducing educational disparities

which are linked to poverty and unemployment in ZUS.

Affirmative action is a policy implemented in the United States that aims to promote

employment of groups that are discriminated against. Companies, organizations, schools, and

other institutions are required to hire a certain proportion of minorities which is

representative of the regional population. In ZUS, this would work by encouraging the

employment of immigrants and descendants of immigrants, as they constitute half of the ZUS

population. It would also work by sanctioning companies that do not adhere to these quotas

and therefore discouraging hiring discrimination on the basis of race, ethnicity, and religion.

ZUS are located in main metropolitan areas in France, where jobs are plentiful. By

implementing affirmative action in France, more minorities living in ZUS would have the

opportunity to be employed.

Finally, the implementation of community social programs to alleviate stress and

teach stress management would help individuals who are currently suffering from poverty

and job-related stress. This would include programs that encourage and make available

different forms of stress management, such as affordable gyms, religious institutions, and free

yoga classes. Programs that would alleviate stress include free childcare, and community

kitchens. Providing basic needs such as food and childcare may alleviate feelings of

helplessness that are commonly linked to negative stress outcomes.

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 The issue of health disparities in ZUS are multidimensional, and cannot be tackled

with one or two prevention and intervention plans. It requires institutional, political, and

cultural change. However, community programs and social problems that interact with

community members, empathize with their experiences, and provide support would support

individuals who are currently suffering and at risk for stress-related health diseases. In

addition, state investment in ZUS education, and government policies sanctioning

discrimination would help tackle the underlying causes of health disparities.

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