Life expectancy rates continue to improve for the overall US population, yet disparities persist and race remains a powerful predictor of them. Blacks continue to have lower life expectancy rates than their white counterparts, and higher morbidity and mortality from the leading causes of death. Neighborhood context is a critical determinant, as it shapes the conditions in which people live and explains, in part, why some people are healthier than others.
This special supplement examines the organizations and programs that are addressing social inequalities in housing, transportation, work, and other parts of society that create disparate health outcomes.
In fact, residential segregation—the degree to which two or more groups live separately from one another in a geographic region—is a characteristic of neighborhoods linked to persistent racial health disparities. Although the policies that created segregation are now illegal, the political and social legacy of those policies remains. Particularly among blacks, it has profoundly shaped individual and community well-being. The result is neighborhoods lacking opportunities and fraught with social and physical conditions harmful to health.
Living in segregated neighborhoods creates major barriers to health, education, and employment for black populations. Higher levels of segregation are commonly linked to neighborhood economic deprivation and disinvestment, lower home values, concentrations of toxic hazards and nuisances, increased targeting for the sale of alcohol and tobacco products, higher density of fast food restaurants, and a lack of grocery stores and spaces for physical activity.
These conditions result in environments that constrain healthy decision making essential to promoting health, preventing disease, and managing illness. In addition, studies have shown that segregation plays a major role in shaping access, quality, utilization, and availability of health care and services.1 Thus the cumulative effects of exposure to segregation across one’s life span—prenatal, infancy, childhood, adolescence, on through older adulthood—have devastating consequences for life expectancy and overall well-being.
Effective efforts to eliminate racial inequalities must seriously confront the vestiges of the social policies that led to residential segregation. Today, increasing interest in federal and local fair-housing initiatives that foster neighborhood opportunity holds great promise to improve health and promote health equity.
Impact of Fair Housing Programs
Fifty years ago, the passage of Title VIII of the Civil Rights Act of 1968 (known as the Fair Housing Act) prohibited discrimination in the sale, rental, and financing of housing based on race, color, religion, sex, or national origin. Since then, the US Department of Housing and Urban Development (HUD) has played a central role in developing and executing policies that support the Fair Housing Act and that aspire to “create strong, sustainable, inclusive communities and quality affordable homes for all.” Several Fair Housing programs emphasize the redevelopment of distressed public housing and the dispersal of high-poverty areas by altering the spatial distribution of residents.
Some Fair Housing programs have had notable accomplishments. Consider the Moving to Opportunity for Fair Housing (MTO) initiative, a 10-year demonstration project that provided rental assistance and housing counseling to randomly selected families to help them move out of poverty neighborhoods. Recent studies show that families who moved out of public housing have experienced less weight gain, better diabetes control, and less psychological distress than those who stayed in public housing and in low-income neighborhoods.2-7
Other initiatives, however, have encountered significant challenges, with the dispersal of concentrated poverty in some cases having the unintended consequence of neighborhood destabilization through displacement, gentrification, and minority political disempowerment, all of which undermine community development.8
The Housing Opportunities for People Everywhere (HOPE VI) initiative, for example, sought to improve the housing conditions of residents in “severely distressed” public housing by demolition, rehabilitation, or replacement with mixed-income housing. HOPE VI grants were awarded to more than 150 cities and municipalities. In some areas, HOPE VI resulted in an increase in quality and affordable mixed-income housing and revitalized surrounding neighborhoods. In other sites, however, residents of the demolished public housing units were not able to return. Furthermore, some evidence suggests that when residents moved out of public housing, they ended up moving to other areas that were of equal or lower quality.
Expanding the Agenda
Strategies that are focused on helping individuals move out of poverty may reproduce and reinforce neighborhood differences because they do not address the root causes of segregation. A case in point is the tort model of individual injury commonly used in housing discrimination cases. Damages are typically awarded to people who have successfully filed a lawsuit in a federal or state court. Although the damage awards in Fair Housing cases attempt to quantify the monetary cost of experiencing discrimination for those who file suit and win, they do not account for other difficult-to-measure factors such as the health, economic, educational, and psychological consequences of discrimination for those who chose not to file a complaint or try to negotiate a settlement.
Getting individuals out of disadvantaged neighborhoods rather than addressing collective damages does not alter the fundamental factors that shape residential segregation. But by expanding the fair housing agenda to include and promote neighborhood equity, opportunity, place-based investment, and development, we can address the collateral consequences of segregation.
Not surprisingly, the biomedical, individual- based approach to population health parallels the person-based approach to housing segregation. For example, in the past, medical and public health efforts largely focused on individual-level approaches (such as changing health behavior and promoting health education) to combat persistent racial health disparities. In recent years, however, the health sector has increasingly recognized the need to improve social, economic, and physical conditions in order to reduce health disparities.
Investing in People and Place
Recent place-based community development programs that seek to transform neighborhoods through capacity building and economic development are promising Relatedly, incorporating a Health in All Policies (HiAP) approach can also be used to complement person-based fair housing remedies to achieve neighborhood and health equity. HiAP refers to a systematic approach in which health is integrated and prioritized within planning and decision making. Further, HiAP approaches involve inter-sectoral collaborations instead of reliance on individual organizations and agencies. Reforming housing policy legislation, regulation, implementation, and practice to incorporate these approaches would be an important step to promoting health equity.
An anti-discrimination agenda that addresses structural racism is another critical strategy. A recent US Supreme Court ruling (Texas v. Inclusive Communities) upheld the use of disparate impact and makes new rules to target segregation vital to tackling structural racism in housing. Seemingly race-neutral policies and practices, such as zoning laws that disproportionately affect the housing choices of blacks and other racial minorities and have the unintended consequence of perpetuating segregation, are prohibited.
The new HUD rule requires local municipalities to track, monitor, and report the results of housing patterns and racial bias that may produce indicators that could lead to evidence-based policies and monitoring. Evaluating and monitoring neighborhood social and economic conditions should be coupled with indicators of health to further assess the cumulative impact of segregation on housing and health equity.
A Platform for Health Equity
Addressing the underlying social and economic conditions of neighborhoods is a critical challenge and opportunity for fair housing. A healthy living environment should ensure the equitable distribution of resources, services, facilities, and institutions that give people access to information, education, employment, housing, and health care. The integration envisioned by the Fair Housing Act entails not just the desegregation of physical places, but also the desegregation of opportunities and life chances. As Dr. Martin Luther King Jr. insisted, integration does not merely involve a romantic blending of colors, but rather a real sharing of rights, responsibilities, and opportunities. 9 Policymakers, practitioners, advocates, researchers, and foundations have a stake in realizing the full potential of fair housing and broadening its scope to include neighborhood opportunity, bringing us closer to achieving health equity.