The Health-Related Consequences of Redlining

The legacy of redlining continues to harm minority health, with Black individuals facing higher rates of health issues, linked to environmental factors and limited access to resources in regions previously redlined. | Image Credit: Djavan Rodriguez - stock.adobe.com

Historic redlining has shown evidence linking it to health-related outcomes through how it suppresses economic opportunity, human capital, knowledge, skill, and value contributed to society.¹ Redlining can be defined as the act of systemically denying a multitude of services to residents of targeted neighborhoods, typically based on race or ethnicity, and exists primarily in urban communities.

The Federal Housing Administration (FHA) promoted redlining between 1934 through the 1960s.² The FHA worked with the Home Owner’s Loan Corporation (HOLC) to ensure mortgages were approved based on racially discriminatory criteria.³ Through the FHA, HOLC, and combined acts of other forms of continuous systemic racism, minority populations have experienced far reaching impacts.

The long-term impacts of systemic racist policies such as redlining are negatively affecting the health of minority populations through lack of access to care, greater risk of fatal diseases or conditions, greater risk of morbidity from treatable illness, and the perpetuation of racist ideologies.¹ Policies that target health care access should be prioritized, as well as education and economic empowerment advocacy for underserved populations that are now burdened by the long-standing results of redlining.

Obstetric and Peripartum Disparities

The US has the highest infant and maternal mortality rates compared with almost any other Organization for Economic Cooperation and Development nation.³ However, the nation has the largest health expenditures compared with its counterparts.

A cohort study analyzed 64,804 live births among 15 zip codes in historic HOLC regions between 2005 and 2018.³ Researchers found the lowest preterm birth rate for zip codes historically referred to as “best” or “still desirable” regions (7.55%) and the highest overall preterm birth rate in zip codes historically defined as “hazardous” (12.38%).

Additionally, various published studies have found significantly higher rates of mortality and morbidity linked to pregnancy in Black women compared with all other racial and ethnic groups.⁴ Black women are 2 to 4 times more likely than White women to die in the peripartum stage of pregnancy due to cardiovascular, cerebrovascular, and pulmonary complications.

Maternal outcomes were analyzed among delivery records spanning from California, Florida, Kentucky, Maryland, and New York between 2007 through 2014.⁴ The study found Black women have an increased risk of inpatient maternal mortality, cesarean delivery, and extended length of stay, regardless of the insurance type and income bracket of the patient.

Black women’s pregnancies are often impacted by redlining because these communities experience higher levels of industrial pollution and toxic hazard site waste.⁵ Previously redlined areas are also prone to higher crime rates, creating stressful environments for residents that could potentially cause long-term health issues for the fetus. Continuous psychosocial stressors during the mother’s gestational period can threaten the overall well-being of the fetus.

HIV and Viral Suppression

Black patients with HIV continue to be disproportionately affected by historically racist practices as well.⁶ The HIV incidence rate for every 100,000 Black people was almost 9 times higher compared with White patients 13 years and older. Data has found significantly higher prevalence of persons living with HIV between Black patients vs White, but less Black patients diagnosed with HIV have achieved viral suppression.

Policies to decrease the financial burdens of HIV care and increase access to HIV medical services include the adoption of Medicaid expansion and the use of the Ryan White HIV/AIDS Program (RWHAP). Despite these services, viral suppression between Black and White enrollees was 13% in favor of White patients in 2010 but nearly halved to 8.1% in 2016.

A study examined the relationship between HIV care and viral suppression among Black patients with HIV living in Census tracts historically marked by redlining. Black patients were more likely than White patients to reside in areas with high rates of poverty (50.8% vs 26.9%), low educational attainment (40% vs 23.1%), and low median household income (51% vs 22.8%). Additionally, Black patients were more likely to live in areas with high rates of uninsured residents (52% vs 32.9%).

In an observational study, researchers sought to characterize how historical and contemporary housing practices are connected to the experiences of patients with HIV.⁷ Participants had a residential address within historically mapped HOLC-rated neighborhoods. More Black individuals (69.9%) living within redlined neighborhoods were a part of the study compared with Black individuals not living in these regions (56.8%). The study found newly diagnosed patients with HIV in redlined neighborhoods have a longer time to viral suppression compared with patients from nonredlined communities.

Asthma Exacerbations

Asthma cases in association with redlining have led to neighborhood-level asthma-related exposures such as air pollution.⁵ Urban minority communities have been historically displaced and subjected to ongoing industrialization methods that ultimately increase factors that further impact people with asthma. Non-Hispanic Black patients are nearly 4 times as likely to die from asthma compared with non-Hispanic White populations.

Research can point to an exorbitant amount of data pointing to environmental factors caused by redlining that exacerbate symptoms of patients with asthma. A considerable amount of carbon emissions is caused by automobiles, adding to the already existing air pollution. In the 1940s and 1950s, highways were constructed in communities where land acquisition was the weakest and overlapped areas the HOLC labeled “hazardous” on security maps. Freeway construction is partially to blame for the higher levels of air pollutants linked to underserved, minority populations.

An ecological assessment of HOLC risk grades and asthma exacerbations were conducted based on security maps made available for 8 cities across California. Results found an upward trend among populations of non-Hispanic Black and Hispanic individuals who lived in poverty and were subject to diesel exhaust particle emissions (P < .0001). The average asthma-related emergency department visits were 2.4 times higher in Census tracts that were historically redlined. The redlined Census tracts had a 1.39-fold increase in asthma emergency department visits compared with lowest-risk Census tracts. These results suggest this discriminatory practice has contributed to current racial and ethnic asthma disparities.

Solutions

Policy initiatives can be developed to address and support populations negatively impacted by redlining.¹ For example, vouchers, tax credits, and grants can all work to improve access to quality housing within previously redlined regions. Improving educational opportunities could involve expanding early childhood programs, supporting funding for special needs education in public schools, and altering underlying public school funding mechanisms in the US that tie district budgets to property taxes.

Health care access and affordability can be targeted through revisions of value-based care reimbursement models to address patients’ social needs and extend mandatory coverage of nonclinical services in Medicaid. The effects of redlining can be mitigated through economic empowerment with geographically adjusted livable minimum wages, standardizing asset limits in public benefit programs, and tax incentives for the creation of employment opportunities within historically redlined neighborhoods. Reparations have also been considered as an option to close gaps on historic injustices to establish wealth equity.

The environments of previously redlined communities need to be a focus area of improvement as well. Investments into public transportation can assist with job accessibility and overall ease of travel. Issues like food insecurity could be mitigated by widening public Supplemental Nutrition Assistance Program coverage and benefits. The removal of zoning barriers can be addressed by providing tax incentives for supermarket or healthy retail store placements within formerly redlined neighborhoods.

The enduring legacy of redlining continues to disproportionately impact the health and well-being of minority communities. Redlining has created a cycle of economic inequality and health disparities that persist to this day by systematically denying services to residents of targeted neighborhoods. Policy makers must prioritize investments in housing, education, health care, and economic empowerment for underserved populations to address these deep-rooted issues. Only through comprehensive and targeted interventions can we begin to dismantle the structural barriers created by redlining and build a more equitable and just society.

References

1. Egede LE, Walker RJ, Campbell JA, Linde S, Hawks LC, Burgess KM. Modern day consequences of historic redlining: finding a path forward. J Gen Intern Med. 2023;38(6):1534-1537. doi:10.1007/s11606-023-08051-4

2. Redlining. Federal Reserve History. June 2, 2023. Accessed October 2, 2024. https://www.federalreservehistory.org/essays/redlining#:~:text=Historically%2C%20mortgage%20lenders%20once%20widely

3. Hollenbach SJ, Thornburg LL, Glantz JC, Hill E. Associations between historically redlined districts and racial disparities in current obstetric outcomes. JAMA Netw Open. 2021;4(9):e2126707. doi:10.1001/jamanetworkopen.2021.26707

4. Tangel V, White RS, Nachamie AS, Pick JS. Racial and ethnic disparities in maternal outcomes and the disadvantage of peripartum Black women: a multistate analysis, 2007-2014. Am J Perinatol. 2019;36(8):835-848. doi:10.1055/s-0038-1675207

5. Nardone A, Casey JA, Morello-Frosch R, Mujahid M, Balmes JR, Thakur N. Associations between historical residential redlining and current age-adjusted rates of emergency department visits due to asthma across eight cities in California: an ecological study. Lancet Planet Health. 2020;964(1):e24-e31. doi:10.1016/S2542-5196(19)30241-4

6. Logan J, Crepaz N, Luo F, et al. HIV care outcomes in relation to racial redlining and structural factors affecting medical care access among Black and White persons with diagnosed HIV-United States, 2017. AIDS Behav. 2022;26(9):2941-2953. doi:10.1007/s10461-022-03641-5

7. Bassler JR, Ostrenga L, Levitan EB, et al. Redlining and time to viral suppression among persons with HIV. JAMA Intern Med. Published online September 30, 2024. doi:10.1001/jamainternmed.2024.5003