"Racial Disparities in Housing and Health,"by Dolores Acevedo-Garcia & Theresa L. Osypuk “The connection between the health of the nation and the dwellings of the population is one of the most important that exists.” The words of Florence Nightingale, 19th century nursing pioneer and housing advocate, seem relevant as America tries to address the vast disparities in health status that prevail between African Americans and whites. By any measure of access to good housing, African Americans are at a clear disadvantage. Given the well-recognized effect of housing conditions on health, it is relevant to outline the racial disparities in housing and ponder whether they may underlie the racial disparities in health.July/August 2004 issue of Poverty & Race
“The connection between the health of the nation and the dwellings of the population is one of the most important that exists.” The words of Florence Nightingale, 19th century nursing pioneer and housing advocate, seem relevant as America tries to address the vast disparities in health status that prevail between African Americans and whites. By any measure of access to good housing, African Americans are at a clear disadvantage. Given the well-recognized effect of housing conditions on health, it is relevant to outline the racial disparities in housing and ponder whether they may underlie the racial disparities in health.
African American (i.e., non-Hispanic black) babies are more than twice as likely as non-Hispanic white babies to be low birthweight. In turn, low birthweight may lead to infant mortality, problems in child development, and health conditions throughout the life course. Thus, as Dalton Conley and colleagues have eloquently argued, racial disparities in low birthweight are implicated in racial inequalities in life chances and across generations, as low birthweight affects people’s potential for educational success, upward mobility and wealth accumulation.
African American babies are about 2.5 times more likely than white babies to die before they reach their first birthday. Even when maternal socioeconomic status is taken into account, there are substantial racial disparities. Black infants whose mothers have college education or higher are 2.7 times more likely to die before they turn 1 than comparable white babies. These and many other disparities have led renowned social epidemiologist David Williams to conclude that “race still matters” in relation to one’s chances for achieving a healthy life.
Racial stratification is expressed in multiple housing outcomes. The housing market and housing policies may be some of the most important vehicles for maintaining racial stratification. There are pronounced racial disparities in net worth. Roughly, the average white family has assets worth seven times the assets of the average black family. Racial/ethnic disparities in homeownership contribute substantially to racial disparities in wealth. Nationally, the homeownership rate is 75.1% for whites, but only 48.4% for African Americans. There are also sharp differences in the average quality of neighborhoods experienced by whites and African Americans. As reported by the Lewis Mumford Center, in many metro areas, blacks with incomes over $60,000 live in less advantaged neighborhoods than whites earning under $30,000.
Clearly, racial disparities in housing are a matter of concern in their own right. Their effect on health makes them even more unjustifiable, and the need to address them even more urgent. The magnitude and persistence of racial/ethnic disparities in health outcomes, even after taking into account differences in socioeconomic well-being among individuals, has led public health practitioners and researchers to seek explanations for these inequalities in the contexts where individuals live their daily lives, including their homes, their neighborhoods and their cities.
Housing and Health Disparities
Housing conditions impact health because they define our immediate living environment. Our homes are a refuge but may also be a source of dangerous exposures. Individuals who live in homes with structural problems, such as poorly designed stairs or windows, may face a higher risk of injury. Housing units may also be the source of hazardous chemical exposures, such as lead and radon. Lead poisoning in children may result in serious developmental problems, including cognitive deficits, and in adult behavioral problems. The risks at home also include biological exposures, such as cockroach and dust mite allergens, which may trigger asthma.
The quality of housing varies considerably by race. African American kids are more likely than white kids to live in houses with dangerous lead levels. Not surprisingly, African American children are more likely to have dangerous lead levels in their blood than is true for white children. According to the Centers for Disease Control and Prevention, 22% of black children living in housing built before 1946 have elevated blood lead levels, as opposed to 6% of white children living in comparable housing.
In addition to the impact of housing conditions on health, there is evidence that, on average, homeowners have better health than renters. Research found that children living in houses owned by their parents experienced lower rates of behavioral, emotional and cognitive problems. This may be because owned homes tend to be of higher quality and tend to be located in better neighborhoods, and also because homeownership may confer a sense of psychological well-being. Regardless of the reasons why homeownership promotes good health, given that whites are over 1.5 times more likely than African Americans to own their homes, it is clear that they and their children may have a better chance of being healthy.
Neighborhood Quality and Health Disparities
Health is influenced not only by the quality of individual housing units, but also by the quality of the neighborhoods where they are located, including neighborhood physical and socioeconomic environment, infrastructure, amenities and services. Even after taking into account individuals’ socioeconomic status, better neighborhood environments may have a positive influence on health. For example, poor individuals experience better health in low-poverty neighborhoods than in high-poverty neighborhoods.
As a consequence of racial residential segregation operating at the metropolitan level, there are sharp racial disparities in neighborhood environment. According to Census data analyzed by the Mumford Center, in the Washington, DC metropolitan area, the average poor white household lives in a neighborhood where the median household income is $59,753, while the average poor black household lives in a neighborhood where the median household income is $41,412, a disparity of more than $18,000. Even middle- and high-income African Americans live in more disadvantaged neighborhoods than whites with comparable incomes. These differences are pervasive across all metropolitan areas.
Since neighborhoods influence health, and neighborhood quality varies sharply by race, differences in neighborhood environment are also likely to underlie racial disparities in health.
What is it about neighborhoods that affects health? Ingrid Ellen proposed that neighborhoods may influence health through access to services and resources, exposure to physical (e.g., pollution) and social (e.g., crime) stresses, and social networks, which may help people obtain health information and reinforce norms about healthy behaviors. For instance, although healthy eating habits are ultimately an individual choice, the ability to have a healthy diet may be constrained by limited access to healthy foods at the neighborhood level. Predominantly poor and African American neighborhoods have a higher prevalence of alcohol and fast food outlets compared to wealthy and predominantly white neighborhoods, while the opposite is true for access to supermarkets that stock a variety of fresh produce. Residents of minority neighborhoods may also have fewer opportunities to be physically active, due to higher crime rates and limited availability of green space, sidewalks and bike paths.
In addition to the effects of material problems in highly segregated neighborhoods, less tangible neighborhood characteristics may also influence health. Recent evidence from the Project on Human Development in Chicago Neighborhoods found that higher social capital (membership in civic groups, trust, reciprocity) at the neighborhood level correlated with lower cardiovascular mortality. Segregation expert Douglas Massey recently proposed that African Americans suffer from high chronic stress, which leads to health and cognitive problems, due to their chronic exposure to social disorder and violence in neighborhoods characterized by concentrated poverty. High prevalence of crime in a neighborhood may also negatively affect residents’ mental health status.
Racial Residential Segregation, Opportunity and Health Disparities
Although, on average, racial residential segregation between African Americans and whites has decreased in the last two decades, segregation levels are still very high. On average, African Americans live in neighborhoods that are over 50% black, and whites live in neighborhoods that are over 80% white. The separation between blacks and whites has serious ramifications. In metropolitan areas with higher levels of residential segregation, African Americans have fewer education and employment opportunities, and are more likely to live in neighborhoods characterized by concentrated disadvantage.
The extent to which opportunities available to African Americans in metropolitan areas are more limited than the opportunities available to whites cannot be overemphasized. For instance, in 50 of the largest 100 metro areas, the homeownership rate for blacks is between 40% and 49%, while only in three of these metro areas is the homeownership rate for whites that low. These disparities persist after taking income into account. Home loan rejection rates (the proportion of mortgage loan applications for financing purchase of a home which are rejected by banks) are another indicator of housing opportunities. In the largest 100 metro areas, the average home loan rejection rate for blacks with incomes above 120% of their metro area median income was 21%, well above the 8% average for whites. In 89 of these metro areas, banks rejected blacks for home loan applications more than twice as often as they did for whites.
Many health indicators across metropolitan areas are distinctly worse for African Americans than for whites. The mean rate of low birthweight across the 100 largest metro areas is only 4.8% for whites, but 11.3% for blacks. In the majority of metropolitan areas, the low birthweight rate is between 3% and 6% for white babies, but between 9% and 13% for black babies. In no metropolitan area do blacks have a lower rate of low birthweight babies than whites. On average, blacks experience over twice the rate of low birthweight as whites, and in five metro areas blacks experience over three times the rate of whites.
Residential segregation negatively affects the health of African Americans, possibly through its detrimental effects on individual (e.g., employment, education) and neighborhood level (e.g., concentrated poverty) factors. In metropolitan areas where racial residential segregation is higher, black adult and infant mortality rates are higher. As shown by Ingrid Ellen, African American women are more likely to have low birthweight babies in metropolitan areas where segregation is higher, especially in those where blacks are more disproportionately concentrated in the central city, which tends to be more dilapidated and socioeconomically disadvantaged than the suburbs. The Mumford Center reported that in 2000, suburbs in the majority of metropolitan areas outpaced cities on eight indicators of prosperity.
In our research, we have seen that African Americans are more likely to report that their health is poor or fair (as opposed to good or excellent) in metropolitan areas where they are more likely to be isolated in predominantly black neighborhoods.
The Role of Housing Policies in Reducing Health Disparities
Government policies address many aspects of housing, from safety standards for individual housing units, to housing discrimination, to housing assistance for low-income households. Therefore, it seems reasonable to ask whether housing policies may contribute to correcting racial disparities in housing and thus racial disparities in health. There is evidence on the positive effects on health of interventions that address hazardous physical, chemical and biological exposures at the level of the housing unit. In the case of childhood lead exposure, research has documented the positive impact that various methods of lead hazard control have on dust and blood lead levels. We know considerably less about the possible effects on health of interventions and policies that address the socioeconomic (e.g., homeownership promotion) and locational (e.g., desegregation) aspects of housing.
A wide range of policies is available to reduce residential segregation across neighborhoods and along the central city-suburban divide, including restricting the power of local governments to enact exclusionary zoning regulations; limiting suburban growth (i.e., sprawl) through direct or indirect controls; and deconcentrating public housing. Of these policies, only the last mentioned, specifically variants of the Section 8 housing voucher program, has been evaluated for its effects on health.
Housing mobility policies involve the geographic deconcentration of recipients of government housing assistance. Generally, their aim is to achieve racial desegregation and to offer individuals the opportunity to move from highly disadvantaged to middle-income neighborhoods. Improving health has not been an explicit objective of housing mobility policies, but given what is known about the link between neighborhoods, segregation and health, these policies may contribute to better health outcomes.
A compelling indication of the potentially beneficial impact of housing mobility policy on health has emerged from the Moving to Opportunity (MTO) policy demonstration. The participants in MTO were very-low-income families with children who lived in public housing or Section 8 project-based housing located in central city, high-poverty neighborhoods in five large cities (Baltimore, Boston, Chicago, Los Angeles, New York). Eligible participants were randomly assigned to one of three groups. The experimental group was offered Section 8 housing vouchers good only in low-poverty neighborhoods, as well as housing search counseling. The Section 8 group was offered an unrestricted Section 8 voucher. The control group stayed in traditional public housing. Researchers have followed the three groups since 1994, documenting their educational and employment outcomes, receipt of public assistance, and several health indicators. The latest evaluation report by HUD showed that girls in the experimental group—i.e., those who moved to low-poverty neighborhoods—had improved mental health and a lower risk of using marijuana and smoking than girls who stayed in public housing. Adults in the experimental group experienced significantly lower obesity than those in public housing, and lower prevalence of mental health problems (psychological distress and depression). These findings suggest that housing mobility policies may contribute to improving health for children and parents. However, little is known about the mechanisms through which housing mobility may improve health. Is it because homes in low-poverty neighborhoods are of better quality? Is it because in those neighborhoods people are less likely to suffer from the stress associated with fearing and witnessing crime? Or is it because those neighborhoods offer more institutional resources, such as better schools and childcare?
Housing mobility may also have unintended negative health consequences that housing and public health advocates should not overlook. During the 1990s, under the HOPE VI program, the federal government changed its housing policy towards low-income households, moving away from project-based assistance towards an increased use of housing vouchers and mixed-income housing developments. The nature and scale of such policy changes warrants an examination of its possible health effects, especially on families that have been displaced and are unable to find affordable housing. In a tracking study of HOPE VI, the Urban Institute has identified health problems as a major issue for former residents of distressed public housing.
The public health field is trying to address wide racial disparities in health. Sharp racial disparities also exist in housing at multiple levels, including access to safe homes and neighborhoods, and to opportunity in metropolitan areas. Given the effects of housing, neighborhood quality and segregation on health, the field is embarking upon a more systematic understanding of how addressing housing disparities at multiple levels may contribute to correcting health disparities. The links seem clear. Can we make them actionable?
Dolores Acevedo-Garcia is Associate Professor at the Bouvé College of Health Sciences, Northeastern Univ. and Associate Director of the Institute on Urban Health Research. She is Project Director of diversitydata.org and a member of PRRAC’s Social Science Advisory Board. firstname.lastname@example.org
Theresa L. Osypuk is Assistant Professor at the Bouvé College of Health Sciences, Northeastern Univ. and Research Director of diversitydata.org. She is a social epidemiologist researching racial and socioeconomic disparities in health, their geographic patterns, and causes. T.Osypuk@neu.edu
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