Upward Immobility

Rachel Traughber: It has been nearly a century since the Homeowners’ Loan Corporation was established, and the creation of its infamous “Residential Security” maps of nearly every major American city.

Jason Newton: Those maps may not be familiar to you, but you’ve probably heard of the term the maps invented — Redlining, an official government policy that institutionalized housing discrimination against Black families and other minorities across America.

RT: We spoke to Dr. Nancy Krieger and Dr. Mary Bassett — both from the Harvard T.H. Chan School of Public Health — about the devastating effects of this racist policy that are still being felt to this day, and how they reinforced the structural racism leading to a litany of poor health outcomes for minorities. Many that were exacerbated, tragically, during the Covid-19 pandemic.

JN: I’m Jason Newton

RT: and I’m Rachel Traughber. And this is Unequal: a Harvard University series exploring race and inequality in the United States.

RT: Professor Bassett, let’s start with the basics. What is redlining, and why is it important to understand in a health context?

Professor Mary Bassett: Well, redlining is shorthand for a policy that emerged and was promulgated principally by government after the Great Depression in the 1930s, when something called the Homeowners Loan Corporation was established to help government insure mortgages and make mortgages more available to the public. It used to be that you had to have a huge share of the purchase price before you could buy a house, but that went down to just 10% when government stepped in to help guarantee mortgages.

And in order to help accelerate this program, they gave guidance in the cities where redlining became prominent. They gave guidance on what areas were mortgage-worthy areas. And they literally coded them with red ink around the communities that would not be considered eligible for these government insured loans.

And that is where the word redlining comes from. Because literally, the borders of these communities were outlined in red ink. And the strategy included an assessment of the racial composition of that neighborhood. So that high credit risk neighborhoods were ones that were predominantly Negro, as people of African descent were called then. So, neighborhoods that were black neighborhoods were redlined. And the people who live there would not be eligible for, for these loans would become victim to predatory private lending that charge exorbitant rates for mortgages and not eligible for homeownership at all, which, of course, is one of the principal assets that underlies the intergenerational transfer of wealth.

JN: And did that track well with the neighborhood that you grew up in, in Washington Heights, you said on the border of Harlem, which, obviously is a historically African American community and Washington Heights being largely Latino community?

MB: Yeah. Well, when my parents bought their house, they discovered that the community had been redlined. And they had a great deal of difficulty obtaining a mortgage. And it turned out, in the end, that it was a small bank that was headquartered in Puerto Rico, where the bank manager was able to take the chance on my father, who was a university professor, to make… lend my parents money to buy their house. So redlining was historical, and persisted, even after the Fair Housing Act should have overturned it. So, we see the impact of redlining that affected my family personally, yes.

RT: So, when you’re thinking about the implications of this for, for people’s health, what exactly is the connection between a policy like redlining that was set up in the 30’s, and is maintained in some ways today, and health? Where does that connection happen and what does it look like?

MB: Well, I think of redlining as one of the key examples of structural racism. And by structural racism, I mean, the type of racism that works without individuals expressing prejudiced opinions, because it’s embedded in the way institutions work. And this case, it was embedded in the way the banking industry worked. It was embedded in how realtors valued homes and markets; it’s embedded in the way private homeowner organizations set up private covenants that excluded black people from their neighborhoods. All… multiple institutions engaged in achieving residential segregation.

Now, what did that mean for health? Well, basically, these communities became multiply disinvested in… Redlining kind of set up a platform for neighborhood deprivation, from everything from the amount of tree cover, to the availability of retail food outlets, to the safety of the streets. All of these, it turns out, are factors that affect our health, and they’re often referred to as the social determinants of health.

And structural racism is really antecedent to the social determinants of health. It’s what explains why people of African descent are disproportionately poor, have low levels of educational attainment, have access to health care that may not be of high quality, live in neighborhoods where there has been public disinvestment and private disinvestment. All of those social determinants of health have a lot to do with how healthy we are. And of course, it includes access to health care.

RT: Professor Krieger, you and your colleagues have studied the health effects of redlining to two states – specifically, cancer rates in Massachusetts and, along with Professor Bassett, preterm birth rates in New York. There have been a few other studies of different health conditions in other redlined areas: Why did you pick these two particular states for the two studies you conducted?

Professor Nancy Krieger: So, just to be very clear, there’s currently only 13 published studies in the literature on historical redlining and health, which have used various study designs. It’s still a very new area of research… for having… and looking at that in relation to contemporary health conditions, and the studies vary widely in their methodology and also what the outcomes are. So, I think it’s really important to frame what our work was that we’ve already published as part of a very new, truly nascent literature, that’s beginning and there are lots of discussions that are methodologic that are really important about how you actually figure out what the right ways are to divvy up the population data in relation to these past historical boundaries which don’t neatly map onto current census boundaries, for example, for census tracks, block groups, or even blocks.

NK: I say that because there’s a lot of scientific rigor that goes into these studies and work that is being figured out. What you need to have to do this kind of work and to do it properly is individual health records that you can geocode to their block level so that you can make sure you’re attributing people correctly to the right redlined area, because you have to superimpose the redlined areas on to contemporary geographies, that gives you the population counts that you need to compute rates. We’re not just looking at cases, we’re looking at rates which is the number of cases per population per area per unit time.

So, from that standpoint what we needed is what to have access to these data and we went to two places that we knew we could do this. We’ve worked extensively for many years, my team and I, with the Massachusetts Cancer Registry, and what we looked at was actually the… what was going on with regard to the stage of diagnosis for cancer, and we chose that because we… our rationale for choosing cancer stage of diagnosis is that really does depend on your current circumstances. It’s not about the etiologic period – that is, how long it takes to get from whatever the exposure is to the actual diagnosis of cancer – it’s about given that you’ve got this process going on in your body at what point is it captured, and that refers to conditions in the here and now that can be plausibly linked to contemporary conditions of both not only what your own household economic circumstances are, but also the access to transportation and to healthcare facilities, and the many other things that go into the actual access to health care for being diagnosed with cancer.

So we specifically chose cancer stage diagnosis and we looked at it for Massachusetts because we had access to the Massachusetts Cancer Registry data at the individual level for many years which our team geocoded, and as part of our practice we return all vehicles to the cancer registry so they’re able to allow other people to also use the geo codes that we assigned to the cases, because all the registry has – like any entity that works on medical records – is the actual address, and you have to convert the address into geo codes that can be assigned in a geo referenced way to a map, and then also again allocated in relation to contemporary population counts for the denominators but also the boundaries of the red line and other areas that were designated by the Homeowners Loan Corporation or HOLC.

Similarly for New York City, that’s one of… that’s the largest city in the U.S., it’s incredibly an important location, and we also were because of our good relations with the New York City Health Department or… or Department of Health and Mental Hygiene. We were able to get access to their birth records and also do the geocoding and do the linkage to the HOLC maps at that time. And so… in one sense these are quote unquote “convenience samples” because we had the necessary collegial relations with the health departments and the cancer registry to do this research, but also, one start somewhere, and simply to dive into a national analysis, well, that would be a little difficult in terms of getting all the individual level health records that you need to geocode each individually to be able to do this kind of work properly.

RT: What did your studies find in those two cities?

NK: In brief, both studies showed the importance of historical redlining in combination and also independent from contemporary census tract conditions that people live in where historical redlining does set up the people who live in those areas for worse health outcomes in our studies defined strictly in relation to risk of premature birth, and also in relation to late-stage cancer diagnosis, especially for lung cancer for men and for breast cancer for women.

JN: Professor Bassett, you talked about structural racism, and the health effects of structural racism are obviously complex and often come with a variety of factors, be it economic, or social, etc., that complicate responding to them directly. But given this complexity, what would a public policy solution to the health effects of living in a redlined neighborhood look like in your opinion?

MB: Well, there are a whole host of correctives and we’re seeing some of them under the banner of what’s being called “reparations.” But basically, it should involve the reinvestment in communities that have been disadvantaged by bad policies for decades. And not only helping individual families but reinvesting in the public infrastructure of these communities, and, of course, there are also people who make the case for individual reparations for people of African descent, who were the victim, not only of redlining but of centuries of uncompensated labor.

So, I think that structural problems need structural solutions, and I’m glad that we’re beginning to see, you know, some of those raised and some jurisdictions seeking tend to take them.

JN: And the thinking a lot of times when it comes to, to big public policy is that the states are kind of like the “test labs” for policy. Do you know of any examples from America, in particular, where any of this has been tried before? Can you give us any examples of what successful public health policy might look like to help combat this history of entrenched racism and inequality?

MB: Well, of course all of the… the whole host of legislation in the mid 1960’s, under the general heading of the Great Society were… that whole bunch of legislation, the Civil Rights Act, the Fair Housing Act, the Voting Rights Act, as well as other efforts, tackling the environment, and so on. All of these were associated over time, with a decline in premature mortality. This is work that Nancy Krieger and her group published a couple of years ago, when we have a better policy environment – a more equitable and more democratic policy environment – we see the rates of premature mortality go down, and we see the racial gap in premature mortality narrow. And that’s what her analysis showed.

It’s pretty striking. I didn’t know until I read her paper, for example, that it wasn’t until the mid 1990’s, that black men in this country achieved a stable life expectancy of 65 years, meaning that that life expectancy hadn’t gone down below that, again. That was achieved in the 40’s and 50’s for the white population, and also much earlier for black women.

So, you know, better policies are reflected in lower mortality rates, and it should be a source of worry for all Americans, regardless of their race, that the United States is now experiencing a decline in overall life expectancy, one that began before COVID, but clearly will be accelerated by the COVID-19 pandemic, which in many ways really displayed lots of the effects of structural racism that we’ve been talking about.

JN: Absolutely, yeah, we all see that play out just really on a daily basis over this past year. It’s been really interesting and tragic at the same time. So, it sounds like you see this as a top-down problem that was created by government policy in particular. So, do you believe that it must be corrected through top-down government policy as well? Or is there any space at the city, state, local level? Or should this be something at the federal level where they have the most resources and can implement it across all 50 states?

MB: Well, clearly the federal government had a key role to play in, in establishing redlining as a driver of residential segregation. That wasn’t the only driver, but it was a key one and government has an obligation at the federal level to correct it. That said, of course, there are opportunities at local and state levels to adopt policies that are pro equity. And I wouldn’t say that anyone should give up, that all efforts are needed. But an important lesson from history is that government policy helped drive these inequities. This was not the result of simply 1000 private prejudices. This was the result of concerted and intentional government policy.

So, I am… and by that, I mean federal government policy. So, I think we need action at all levels. And certainly, when I was in New York City, an example of an action that the De Blasio Administration was taking was the implementation of a universal pre-k program. There’s lots of evidence that investing in early childhood is one of the most cost-effective interventions that we have. If we get the early years right for children, they are well set to withstand adversity in the years to come. So that would be an example of something that can be done, you know, within a city or within a state. But ideally, it really should be done nationwide. Our whole nation has borne the brunt of these bad policies, and we need federal action to fix them.

RT: Professor Krieger, if people are interested in learning about redlining and health in their own backyard, maybe even in their own city, where can they go to find out more?

NK: Yes. I mean there are two websites that I would definitely recommend where you can play around and see if your own city… One that comes from the University of Richmond is called “Mapping Inequality Redlining in New Deal America,” and that gets you right into what all the digitized maps are as well as what the notes were that accompany the ratings for each of the neighborhoods. And then they’ve most recently produced a new website that’s called “Not Even Past: Social Vulnerability and the Legacy of Redlining.” And what this does is gives a digitized display of the trajectories of areas in terms of what they were for their HOLC grades, to what their contemporary social and economic conditions are. And they again include some health data that I would just offer some caveats about, but nevertheless, they’re there, and you can start to look at them.

There’s also a very important report that was issued in September 2020 by the National Community Reinvestment Coalition, called “Redlining and Neighborhood Health.” That report is available on the web. There is a great video, which gives you a national sense, which is based on the book by Rothstein, Richard Rothstein, his book is called “The Color of Law: A forgotten history of how our government segregated America,” that was published in 2017. And the video, which is freely accessible and about 17 minutes, is called, “Segregated by design,” And it’s a wonderful introduction to the horrors of racialized economic segregation as wrought by historical redlining, due to the actions of the US federal government.

RT: Again that was Dr. Nancy Krieger, professor of Social Epidemiology and director of the HSPH Harvard T.H. Chan School of Public Health Interdisciplinary Concentration on Women, Gender, and Health.

JN: And Dr. Mary Bassett, director of the FXB Center for Health and Human Rights and professor of the Practice of Health and Human Rights. Both are in the Department of Social and Behavioral Sciences at the Harvard T.H. Chan School of Public Health. If you are interested in what you heard and want to learn more about Harvard’s Unequal project, visit us online at harvard.edu/unequal.

Segregated by design

The Color of Law: A Forgotten History of How Our Government Segregated America

Mapping inequality

Not Even Past: Social Vulnerability and the Legacy of Redlining

Redlining and Neighborhood Health