By Robert A. Hahn (Click here to view the entire P&R issue)
Introduction. Segregation as a Fundamental Public Health Issue
There is a great and urgent need for public health practitioners to better understand the association of racial and ethnic segregation with ill-health and to collaborate with other agencies to address the underlying causes. This essay provides a synthesis of research on health and segregation and proposes collaborative work between public health and other agencies to jointly address this persistent problem.
While some forms of residential and ethnic residential segregation (RERS) can promote community and health (Cutler and Glaeser 1997; Fullilove 2001), far too much RERS in the United States is the consequence of poverty and restricted choice and the root of substantial poor health (Cutler, Glaeser et al. 1997). Yet, there is extensive evidence that federal, state, and local governments have been active participants in the promotion of RERS at least since the end of Reconstruction (Rothstein 2017). We know that where a person lives is a major determinant of his or her health and well-being because it affects exposure to both threats to and resources for health (Diez Roux 2001). Harmful local exposures may include pollutants, toxins, and pathogens as well as interpersonal and institutional racism, violence, and physical hazards (Williams and Collins 2001; Reskin 2012). Local resources for health may include access to healthy food, water, sanitation, recreation, transportation and employment, housing, the justice system, education, health care, and otherservices (Braveman and Gottlieb 2014). This article summarizes the multiple, interrelated ways in which RERS in the United States continues to harm minority populations; the magnitude, trends and sources of RERS; public health burden of RERS; and opportunities for redressing public health harms in order to promote public health and health equity (Williams and Collins 2001; Kramer and Hogue 2009).
Racial and ethnic residential segregation (RERS) is “the isolation of poor and/or racial minorities that live in communities and neighborhoods separated from those of other socioeconomic groups” (Li, Campbell et al. 2013). There are multiple dimensions of segregation—evenness, exposure, concentration, centralization, and clustering—each with a specific statistical definition (Massey, White et al. 1996); when a population in an area has high levels on several dimensions, it is said to be “hypersegregated” and may suffer multiple forms of deprivation (Massey and Tannen 2015). The most common measure of RERS is the “dissimilarity index”—the proportion of comparison racial and ethnic populations that would have to switch regions in order to make proportions equal in both regions. The dissimilarity index varies from 0 (identical proportions of each population in both regions, i.e., no residential segregation) to 100 (all of one population in one geographic region, all of the other population in the second region, i.e., total residential segregation) (Massey and Denton 1988). Dissimilarity rates of 30–60 are considered moderate, rates >60 are considered high. Another common measure, “exposure,” is the likelihood that a member of one group encounters a member of the other group. Exposure is a matter of the relative proportions of each group in the regions rather than the evenness of their distribution across regions (Massey, White et al. 1996).
Segregation as a Social Determinant of Health
Segregation is associated with public health harm and inequity through several pathways (Figure 1, p. 6). While the multiple associations of RERS with factors related to poor health are described separately, these factors likely interact and compound each other in a system (Reskin 2012) that reinforces and perpetuates segregation itself in a feedback loop.
a. Environment and sanitation: Minority and segregated communities are commonly located closer to sources of environmental toxic exposures than other communities (Lopez 2002; Mohai and Saha 2007; Jacobs 2011).
b. Safety: Violent crime not only harms the local population physically, but also instills fear and may deter social interaction and physical activity (Gordon-Larsen, McMurray et al. 2000).
c. Housing: Housing is a basic human need that provides shelter and, with home ownership, investment and security. Overall, Black home ownership in the United States is 25% lower than that of whites and the gap increased slightly from 1970 to 2001; trends are similar for all income levels except those with the highest income in which the gap decreased from 13.9% to 11.9% during this period (Herbert 2005). In addition, more Blacks and Hispanics live in crowded and lower quality housing (with problems of heating, plumbing, etc.) which contributes to poor mental and physical health (Changing America; Evans and Saegert 2000; Jacobs 2011).
d. Transportation: Transportation provides passage to employment and other resources and may also be a source of pollution and injury. Public transportation resources for low-income and minority communities are often inadequate (Sanchez, Stolz et al. 2003). Nevertheless, greater proportions of minority populations rely on public transportation than do whites, and minority populations spend greater proportions of their incomes on transportation (Bureau of Transportation Statistics 2003).
e. Employment: The residential segregation of Blacks and Hispanics is associated with diminished employment opportunities, lower wages, and their multiple health consequences, a phenomenon referred to as “spatial mismatch,” i.e., the spatial separation of residence and employment opportunities (Turner 2008).
f. Cost of living: For the same quality goods, residents in low-income and segregated neighborhoods pay more than those living outside of such neighborhoods, an excess referred to as the “poverty” or “ghetto tax” (Karger 2007; Pager and Shepherd 2008).
g. Education: The segregation of minority communities is associated with lower quality schooling (Ong and Rickles 2004; Bohrnstedt 2015), with substantial long term health consequences (Johnson 2011; Hahn and Truman 2015). It is estimated that the cognitive skills of children whose families have lived in poor neighborhoods for two generations are diminished by the equivalent of between two and four years of schooling (Sharkey 2013).
h. Nutrition, alcohol, and substance abuse: Segregated neighborhoods often have reduced access to full-service, relatively less expensive supermarkets (Powell, Slater et al. 2007), high concentrations of fast-food and lesl nutritious food (Powell, Chaloupka et al. 2007), and higher densities of alcohol outlets (Powell, Slater et al. 2007). These conditions are associated with obesity (Corral, Landrine et al. 2011) and higher rates of alcohol- and drug related harms (Campbell, Hahn et al. 2009).
i. Health Care: Residential segregation is also associated with reduced access to health care services (Smedley, Stith et al. 2003; White, Haas et al. 2012) and lower utilization (Gaskin, Dinwiddie et al. 2011). While access and utilization have greatly increased with the Affordable Care Act (Long, Kenney et al. 2014), segregated populations have long had less access and lower quality health care than higher income populations (Smedley, Stith et al. 2003).
j. Recreation: Regions with high concentrations of minority populations are associated with fewer opportunities for indoor and outdoor physical activity, e.g. gyms and parks, less physical activity, and high rates of being overweight (Gordon-Larsen, Nelson et al. 2006).
k. Justice: High rates of police strength in U.S. cities are associated with the proportions of Blacks in the population, the degree of Black/white racial segregation, and income disparities, independent of level of crime (Kent and Carmichael 2014). “Disproportionate minority contact” is a well recognized problem referring to the participation of minority subjects principally Blacks and Hispanics—in all phases of the justice system, from arrest to incarceration—in excess of their proportion in the population
While the consequences of RERS are predominantly negative, RERS has also been found to promote community empowerment which itself may have health benefits (LaVeist 1993).
Consequences of Segregation on Health
In all 38 Metropolitan Statistical Areas (SMAs) with populations greater than 1 million in 1980, infant mortality rates for Blacks exceeded those of whites (Polednak 1991). In a statistical regression analysis including female householder, poverty, median family income, and the segregation dissimilarity index, only segregation was a statistically significant predictor of excess Black infant mortality. Black infant mortality exceeded white infant mortality by 2/1000 live births in the least segregated SMAs and by 9/1000 live births at highest levels of segregation.
An analysis of U.S. metropolitan areas in 2000 indicates that, adjusted for background demographics, including income and education, the likelihood of poor self-rated health was 50% higher among Blacks than among whites, and that controlling for white/ Black segregation essentially eliminates this gap (Subramanian, AcevedoGarcia et al. 2005). In the period 1989–1994, residential location is estimated to have accounted for between 15% and 75% (depending on age and gender) of the difference in Black and white self-rated health not accounted for by individual-level characteristics (Do, Finch et al. 2008). Econometric analysis of U.S. residents 20–30 years of age in the 1990 census suggests that the elimination of the causes of RERS for Blacks would result in the elimination of white-Black gaps in employment, earnings, and high school graduation (Cutler and Glaeser 1997). Segregation decreases the opportunity for children to escape from the cycle of poverty (Chetty, Hendren et al. 2014).
An analysis of the U.S. adult population in the 1980s indicates that, adjusted for family income, the annual likelihood of death was 2.8 times higher for Black men ages 25 – 44 years living in census tracts with >70% Blacks than in tracts with <10% Blacks, and similarly 2.1 times greater for Black women living in high compared with low concentration Black tracts (Jackson, Anderson et al. 2000). In 1990, elevated mortality in U.S. cities from heart disease, cancers, and homicide among Black men was associated with segregation (measured by isolation), and heart disease and cancers among Black women were associated with segregation; among whites, only cancer mortality among men was associated with segregation (Collins and Williams 1999). It is estimated that approximately 176,000 deaths per year are associated with racial segregation in the United States (Galea, Tracy et al. 2011). This number exceeds the number of deaths attributable to cigarette smoking among 35- 64 year olds in the Unitd States and is approximately one third of all mortality among Blacks and Hispanics in the United States in 2014 (Rogers, Hummer et al. 2005; National Center for Health Statistics 2016).
Causes of Segregation
Racism, the systematic discrimination in attitudes, actions, and policies against populations assumed to be “races,” is a root cause of segregation, and segregation, in turn, reinforces racism when the consequences of segregation are blamed on the segregated population due to a lack of understanding of structural discrimination and exposure to other groups (Mahoney 1995; Williams and Collins 2001). There is evidence, for example, that segregation leads to increased poverty (Teitz and Chapple 1998). In the past, federal and state policies have supported segregationist principles (United States Commission on Civil Rights 1973; Rothstein 2017), and programs such as “urban renewal” have led to the destruction of minority communities (Fullilove 2001).
The Fair Housing Act (1968) charges the U.S. Department of Housing and Urban Development (HUD) with promoting housing and urban development “in a manner affirmatively to further the purposes of fair housing” (United States Commission on Civil Rights 1973). The Fair Housing Act also prohibited discrimination on the basis of race, color, religion, or national origin in the sale or rental of housing, the financing of housing, or the provision of brokerage services”(United States Commission on Civil Rights 1973). However, in the 2012 HUD survey of housing discrimination, Black interviewers were informed of 17.0% fewer homes and shown 17.7% fewer homes than otherwise similar whites (Turner, Santos et al. 2013). Asians were informed of 15.5% fewer homes and shown 18.8% fewer homes than otherwise identical whites. Similar rates of discrimination wer reported in 1977 (Wienk 1979). In the 2012 survey, Hispanics were found not to be discriminated against.
Redressing Segregation for Health Equity
While HHS’s Healthy People 2020 (US Department of Health Human Services 2010) recognizes that housing and residential segregation are fundamental social determinants of health, the reduction of RERS is not included as a primary objective of Healthy People 2020. This is a critical gap. There are multiple approaches to redressing RERS, some included in HUD’s Strategic Plan 2014–2018 (Department of Housing and Urban Development 2010). Health agencies can support these strategies as well. Public health personnel and policy makers can collaborate in surveillance, research, policy, and programming, with personnel from housing, justice, transportation, and environmental agencies to advance public health.
Efforts can be made A) to address and reduce RERS and, B) insofar as RERS continues, to reduce its harms; some strategies address both outcomes. Efforts to address RERS are a potential key to the elimination of the system of racial discrimination that underlies health inequity (Reskin 2012).
A. Addressing and Reducing RERS
1.Fully enforce anti-discrimination laws: Promote justice and equity by more actively enforcing the body of law that prohibits discrimination in housing on the basis of race, ethnicity, and other factors. HUD’s Plan for 2014-8 notes that “housing discrimination still takes on blatant forms in some instances,” and includes as an objective to “reduce housing discrimination, affirmatively further fair housing through HUD programs, and promote diverse, inclusive communities” (Department of Housing and Urban Development 2014). Housing rights enforcement actions may be brought by the Departments of Justice and HUD, or by plaintiffs claiming discrimination. HUD also funds NGOs under the auspices of the National Fair Housing Alliance (National Fair Housing Alliance 2015), to prosecute cases of discrimination. There is evidence that strong enforcement is associated with reduced rates of discrimination (Ross and Turner 2005; Department of Housing and Urban Development 2010). But only a very small proportion of instances of housing discrimination are reported to these agencies investigated or remedied. It is estimated that approximately 1,760,000 incidents of discrimination against Black home-seekers occur annually (Simonson 2004). HUD receives reports of and investigates several thousand claims of racial discrimination and brings several suits each year; in 2014, the total number of claims brought for racial discrimination was approximately 6,000—about 0.3% of the estimated number of discriminatory events (National Fair Housing Alliance 2015).
2. Provide opportunities for low-income populations to move: Promote housing programs such as Moving to Opportunity that have been found to benefit their recipients—including improvements in housing, employment, and reductions in obesity, diabetes risk, and alcohol abuse (Fauth, Leventhal et al. 2004; Ludwig, Sanbonmatsu et al. 2011; Sanbonmatsu, Ludwig et al. 2011). Under President Obama, efforts were made to assure that relocation programs do not send recipients into segregated neighborhoods (Davis and Applebaum). The HUD Department of Transportation—Environmental Protection Agency Partnership for Sustainable Communities coordinated the development of affordable housing and transportation to improve access to employment and other resources (E.P.A. and Office of Sustainable Communities 2014).
3. Promote the use of federal, state, and local governments tax incentives to motivate investments that encourage residential integration or allow residents to remain in their neighborhoods despite movements such as gentrification (Reskin 2012), or facilitates the renovation or construction of housing for low income populations in areas of opportunity, as with the HUD Low-Income Tax Credit program (Hollar 2014).
4. Implement the recent HUD Affirmatively Furthering Fair Housing (AFFH) rule: a “legal requirement [in the Fair Housing Act] that federal agencies and federal grantees further the purposes of the Fair Housing Act.” The rule requires HUD fund recipients to use local data (including on “environmental health”) and advance fair housing and overcome prior segregation (HUD 2015). It also encourages local interagency collaboration.
5. Implement education programs to reduce racism and its consequences: A recent meta-analysis indicates that many anti-prejudice programs for school-age children and youth are effective in reducing prejudicial attitudes and behavior that are an underlying cause of ongoing RERS (Beelmann and Heinemann 2014).
B. Eliminating and Reducing the Harms of Ongoing RERS
1.Support resource development (e.g., healthy foods, banks, health care services, transportation) in segregated neighborhoods that can improve access to resources for health.(Austin 2004) For example, from 2004–2010, the Pennsylvania Fresh Food Financing Initiative supported a program to increase the number of supermarkets in under-served communities across Pennsylvania.
2. Promote anti-poverty programs: Many federal programs provide support for various aspects of life among the poor, including those living in segregated communities (Pfeiffer).
3. Zone for public health, for example, for alcohol outlet density that can reduce public health harm in low income communities (Campbell, Hahn et al. 2009).
4. Strengthen public services (e.g., community policing, sanitation, transportation, health care) in segregated regions, for example, The King County Equity and Social Justice Strategic Plan 2016-2022 (Constantine 2016).
Racial and ethnic residential segregation is a fundamental social determinant that adversely affects the health of large proportions of many minority communities and is a critical source of health inequity. While racial and ethnic residential segregation persists, it is unlikely that racial and ethnic health inequities will be eliminated. Public health leaders, researchers, and practitioners should collaborate in surveillance, research, program and policy design, evaluation, and support agencies promoting housing and the implementation and enforcement of fair housing law.
Robert A. Hahn, firstname.lastname@example.org, is an Adjunct Associate Professor in the Department of Anthropology at Emory University.