By Elissa Lee
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If you follow the forces that drive health inequity all the way upstream, you begin with individual social needs, then paddle on to community-level social determinants of health, and finally arrive at society-level structural determinants of health. These are the laws, policies, and historical practices that place entire groups of people at higher risk of ill health. And we know that moving health care upstream requires working to make improvements at all three levels.

That’s why, on March 4, 2020, HealthBegins hosted the webinar: “Redlining and Health Equity: How Health Systems Can Help Dismantle Structural Racism.” Redlining and its associated inequities might seem far afield from the practice of health care, but in fact they are key determinants of health for many communities and should therefore be a key concern of upstream health care.

This webinar takes a deeper dive into redlining, which continues to affect the health and well-being of individuals and communities today, and what can be done at an individual, institutional, and policy level to address these issues.

Two distinguished guest panelists, Angela Glover Blackwell of PolicyLink and Josie Williams from the Greensboro Housing Coalition, contributed valuable perspectives to the discussion. Webinar participants came from a multitude of sectors, including hospital/healthcare delivery, health insurance and managed care, community-based organizations and social services, research/education, and public health.

 

Here is a top-level summary of key lessons from our webinar.

 

Learning Objectives:

• Describe the history of redlining in America.
• Identify the impact of redlining on current efforts to improve social determinants of health and equity.
• Detail at least three ways health systems and community partners can help dismantle and prevent redlining.

 

Rishi Manchanda, MD, MPH, HealthBegins Founder & President
Dr. Manchanda led the presentation by outlining key questions to anchor the discussion:

• What is redlining?
• How should redlining inform the way we think about and address social determinants of health and equity?
• How might proposed changes to the Community Reinvestment Act and other federal and state efforts impact redlining and the potential impact of current upstream efforts?

 

He underscored that improving health requires coordinated action at three levels:

• Population Health: Improve outcomes for defined member populations or defined patient populations (usually high and/or rising risk).
• Community Health: Improve outcomes and health, social, and economic conditions for defined geographic areas.
• Societal Health: Improve both public health and structural determinants of health equity, through policies, laws, and formal and informal approaches to decision-making, community mobilization, and accountability.

 

And he set today’s effects of redlining in their historical and societal context:

• Redlining, defined: a systematic denial of various services by federal government agencies, local governments, and the private sector to residents of specific, most notably black, neighborhoods either directly or through the selective raising of prices.
• The history of redlining starts with the Great Migration: the movement of 6 million African-Americans between 1910-1970 to escape persecution in the Jim Crow South and search out economic opportunity in the industrial North. This was the largest internal movement of any group in American history.
• In 1933, faced with a housing shortage, the federal government began a program explicitly designed to increase — and segregate — America’s housing stock. Maps of metropolitan areas created by the federal government were color-coded: Anywhere African-Americans lived was colored red to indicate to appraisers that these neighborhoods were too risky to insure mortgages.
• Redlining persists today and is clear through the denial of many services, such as financial, health care, supermarkets, and digital.

 

Josie Williams, Executive Director, Greensboro Housing Coalition
Ms. Williams then set this history in a real, present context — her community of Greensboro, North Carolina — and described lessons from a collaborative local effort to undo redlining and its health effects.

First, Ms. Williams led webinar attendees on a video tour of the “Ole Asheboro” neighborhood where she grew up, where it’s apparent that redlined communities suffer substandard housing, boarded-up buildings, and no sidewalks, whereas less than a mile away (outside the redlined district) there are wide sidewalks, thriving businesses, and multi-million dollar homes. County health data shows that redlined areas are correlated with substandard housing, high asthma rates (and subsequent hospital admissions), and lower life expectancy.

 

Then Ms. Williams described the work of the Cottage Grove Collaborative to remedy these conditions and outcomes:

• The collaborative, intended to work across sectors to address issues such as redlining, includes the Greensboro Housing Coalition and partners from a local health system, county public health, and other local agencies and nonprofits.
• Based on the collaborative’s experience, Ms. Williams recommended the following to address redlining:
  • Prioritize community voice in decision making, planning, and implementation.
    1. Develop strategies in conjunction with the neighborhood residents.
    2. Residents lead community action teams.
  • Leverage partner expertise across sectors.
    1. Involve people in health systems or invested in health to understand redlining and better understand its implications for health.
    2. Partner with developers and investors, and invite them to sit at the table with community members to come up with strategies.
  • Create alignment of agendas, goals, and a common vision.
• An example from the collaborative that incorporates the above:
  1. One apartment complex in Greensboro with 177 units had, on average, higher rates of ER admissions due to pediatric asthma and asthma complications than the whole county.
  2. The collaborative paired pediatric residents from the local health system with community members to experience a glimpse of life in the Cottage Grove neighborhood.
  3. This motivated the healthy communities director at health system Cone Health, along with pediatric residents, to speak on the issue to the Minimum Standard Housing Commission, facilitate discussions to foster culture change within Cone Health, and bring together all the health system leaders to educate them about these issues.
  4. For the first time in history, the housing commission sent down an order of repair (either the landlord fixes it, or the city would take over), and the apartment complex is undergoing rehabilitation.
• Final takeaway: ​

​Angela Glover Blackwell, Founder in Residence, PolicyLink
Ms. Glover Blackwell then expanded upon Ms. Williams’s work to describe the national stakes of redlining and potential courses of action. She framed her presentation into three principles to understand:

• We can’t change the structures without understanding our story as a nation. This nation is built on a legacy of stolen land, genocide, and human bondage. This understanding is crucial to change the narrative of who we want to be and then change policies and structures.
• Where you live is a proxy for opportunity in this nation, as redlining created disinvestment in communities. This disinvestment affects everything, including access to good schools, employment and natural job networks, reliable transportation, etc.
• The legacy of redlining continues to this day and will determine the fate of the nation.
  • People of color are experiencing unemployment/underemployment and some of the worst health outcomes.
  • By 2045, the United States will become a majority-minority country.
  • We need to invest in the people who have been left behind, as they determine the fate of our nation.

She described key elements of the transformative public policy that will be required to overcome this legacy and create lasting impact. That public policy must:

• Create more affordable housing in existing communities of opportunity.
• Maintain and stabilize affordable housing in communities that are becoming communities of opportunity.
• Ensure that every community is a community of opportunity.

Ms. Glover Blackwell detailed active initiatives and policies that target redlining:

• All-In Cities Anti-Displacement Policy Network: 10 communities across the nation sharing and developing new strategies to create affordable housing, build business stability, create community ownership, propose equitable development, and protect tenants.
• When Renters Rise, Cities Thrive: Over 50 percent of renters have rent burden (spend more than 30 percent of household income on rent). Without this burden, there would be $124 billion more in the community (average of $6,200 per household).
• The Partnership for the Bay Area’s Future: Foundations, individual donors, and community organizations committed to protect 175,000 households over the next five years and produce 8,000 homes.
• Community Reinvestment Act: The current administration has proposed changes to this federal law that threaten to divert funds from affordable housing, small businesses, and economic development in low-income communities to sports stadiums, bridges, infrastructure, and bigger small businesses. The act should focus more on the most vulnerable people to achieve the curb cut effect; designing for those who have been the most historically excluded creates improved opportunities for all.

Finally, Ms. Glover Blackwell suggested several strategies to combat gentrification:

• Look into the PolicyLink Anti-Displacement Policy Network for strategies.
• Remember that it is easier to bake in affordability during development of a neighborhood than after.
• Instate aggressive inclusionary zoning.

Sadena Thevarajah, JD, Managing Director, HealthBegins
Ms. Thevarajah concluded the presentations by highlighting how to integrate this understanding of redlining into our approach to clinical-community partnerships. She presented steps for each level of action:

• Individual level
  • Learn the history of redlining.
  • Look at maps of your area (Mapping Inequality is a good resource).
  • Be an internal champion and catalyst.
  • Make a commitment to prioritize the resident voice.
• Institutional level
  • Examine institutional projects and actions by using a Racial Equity Impact Assessment (e.g. RaceForward toolkit).
  • Contract for equity. This includes provisions within contracts and how the contracting process itself is carried out. Institutions can also level the economic playing field by sourcing staff or organizations from historically redlined communities. Government Alliance for Race and Equity provides tools to help contract for equity.
  • Invest for racial equity. As health systems are major institutional investors, there is an opportunity and responsibility to make sure their investment portfolios help undo redlining.
• State/federal level
  • Monitor new and updated regulations, such as the Community Reinvestment Act, one of the most important laws to hold banks accountable to banking and lending inequalities. While it could use reform to manage modern realities, the current administration’s proposal reinstates harmful practices like redlining. Useful resources to learn more about this topic include:
    • National Community Development Association
    • National Fair Housing Alliance 
  • Review policy proposals through this election cycle.
  • Find related state and local campaigns that look at the relationship of redlining and other issues, such as environmental justice (see the Environmental Justice Health Alliance) and economic redistribution.

 

RECOMMENDED RESOURCES FOR FURTHER LEARNING

 

The Warmth of Other Suns, by Isabel Wilkerson, to learn more about the Great Migration.

 

“The Curb Cut Effect,” by Angela Glover Blackwell in the Stanford Social Innovation Review, discussing how laws and programs designed for vulnerable groups often end up benefiting everyone.

 

The Color of Law: A Forgotten History of How Our Government Segregated America, by Richard Rothenstein, a primer for understanding how government policy has shaped segregation in America.

 

Mapping Inequality from the University of Richmond, a mobile collection of redlining maps of 200 cities produced by the Home Owners’ Loan Corporation in the 1930s.

 

RaceForward toolkit, a Racial Equity Impact Assessment (REIA) that helps to systematically examine how different racial and ethnic groups will likely be affected by proposed action or decision.

 

Government Alliance for Race and Equity, a national network of government agencies working to achieve racial equity and advance opportunities for all, with several helpful tools for contracting for equity.

 

National Community Development Association and National Fair Housing Alliance, nonprofit organizations with resources on community and economic development, affordable housing programs, housing discrimination, and equal housing opportunity for all.

 

The All-In Cities Anti-Displacement Policy Network, an initiative of PolicyLink, for strategies regarding gentrification.

 

NEXT STEPS

• Take action using the resources and strategies above.
• Share your successes and setbacks using the hashtag #UndoRedlining in social media and online communication to continue this conversation.
• ​Tell us about what you’re doing! We’re at info@healthbegins.org.