Episode 200: Antiracism in Medicine Series – Episode 11 – Racism, Redlining, and the Path Towards Reconciliation

The Clinical Problem Solvers

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CPSolvers: Anti-Racism in Medicine Series

Episode 11: Racism, Redlining, and the Path Towards Reconciliation

Show Notes by Sud Krishnamurthy, Michelle Ogunwole, Chioma Onuoha

October 12th, 2021

Summary: This episode is part of a 3-part series on Race, Place, and Health. In this episode, we invite Mr. Richard Rothstein, distinguished Fellow of the Economic Policy Institute and acclaimed author of the book, The Color of Law: A Forgotten History of How Our Government Segregated America, and Professor Fernando De Maio, PhD director of research and data use at the AMA’s Center for Health Equity, professor of sociology at DePaul University, and co-editor of the recently published book, Unequal Cities: Structural Racism and the Death Gap in America’s Largest Cities, to share their expertise on structural racism, neighborhood segregation, and health inequities.

Episode Learning Objectives:

After listening to this episode learners will be able to…

1. Explain the differences between de jure and de facto segregation
2. Explore the historical and present-day implications of neighborhood redlining and housing segregation on health disparities
3. Explain the importance of precise definitions when discussing structural racism
4. Explore short and long term remedies to segregation

Credits

• Written and produced by: Utibe R. Essien, MD, MPH, Jennifer Tsai MD, MEd, Rohan Khazanchi, MPH, Michelle Ogunwole, MD, Sudarshan Krishnamurthy, Naomi F. Fields, LaShyra Nolen, Chioma Onuoha, Dereck Paul, MD, MS, Ayana Watkins, Jazzmin Williams
• Hosts: Utibe R. Essien, MD, MPH, Jennifer Tsai MD, MEd, Rohan Khazanchi, MPH
• Infographic: Creative Edge Design
• Audio edits: David Hu
• Show notes: Sudarshan Krishnamurthy, Michelle Ogunwole, Chioma Onuoha
• Guests: Richard Rothstein, Fernando De Maio, PhD

Time Stamps

00:00 Introduction

02:29 De Jure and De Facto Segregation: The Color of Law

06:45 Health Inequities and Segregation: Unequal Cities

12:07 Defining Structural Racism

18:05 Federal Policy and Suburbanization

24:50 The Racial Wealth Gap and its Consequences

30:27 The Role of Health Equity Promoting Policy

32:00 Potential Remedies for Past Harms

39:45 Segregation of Medical Care

41:20 What Can Listeners Do Going Forward?

Episode Takeaways:

1. Terminology and Definitions of de jure and de facto segregation: The myth that segregation in modern societies has to do with private activities (e.g individual bias or bigotry that leads to a failure to sell a home to a person of color) and personal choices ( e.g. Black people prefer to live among other Black people) is referred to as de facto segregation. Adopting this worldview removes any obligation to remedy the consequences of segregation. In contrast, de jure segregation refers to the involvement of federal, state, and local governments in creating, structuring, designing, reinforcing, and perpetuating segregation. This reality of de jure segregation helps us understand that we have an obligation to remedy this constitutional violation.

2. Segregation relates to crucial public health outcomes that ultimately have an effect on life expectancy: The average life expectancy across the United States is 78.6 years; however, there exists a 10 year gap in life expectancy among the 30 largest cities in the US, from 72.9 years in Baltimore to 82.9 years in San Francisco and San Jose. Across the country, we see a 4 year gap in life expectancy between Black and White Americans; and this gap between and Black and White individuals ranges from 12 years in Washington DC, more than 8 years in Chicago, to no gap in El Paso. These gaps are not a product of lifestyle choices, biology or individual behaviors. They are a product of deep-rooted man-made policies that extend to many sectors (healthcare, education, criminal justice etc). These policies have systematically disadvantaged some groups, and have advantaged others. These policies are woven deeply into the fabric of the United States, and are intimately related to residential segregation, life expectancy, and mortality.

3. Unconstitutional housing policy in the mid-20th century led to the present day wealth gap and has implications for disparities: Discriminatory policies prohibited African Americans from being homeowners, while allowing White Americans to purchase homes and accumulate generational wealth. These policies established the wealth gap between Black and White Americans that persists today. Nationally, African Americans’ income is 60% of that of White Americans. Although one would think this leads to a 60% wealth gap as well, household wealth of African Americans is 5% (95% wealth gap) of that of White Americans. This extreme disparity between the 60% income ratio and the 5% wealth ratio is attributable to consequences of federal housing policy practiced in the mid-20th century. You can draw a line from these discriminatory housing policies, to the wealth gap, to disparities in education, health, and police brutality.

Pearls

On the importance of considering place based inequities

Variability of health inequities between communities in a single city or across different cities is critical to consider when discussing health inequity.

“We tend to think of health inequities as big, monolithic, deeply entrenched patterns, and they are, but their variability is really important. It gives us a sense of how different things can be.”-Professor Fernando De Maio

On language and the use of the term ‘structural racism’

Structural racism is a word that is used often, however many people do not know what it really means. Professor DeMaio notes that confusion around terminology is not a reason to shy away from discussions around it. He declares that one of our greatest challenges, and also one of our obligations, is to address structural racism head on.

“It’s our collective responsibility to explain it, to define it, to communicate it in effective ways to physicians, to healthcare systems, to the public at large and in detail, with data and with narratives, all the ways through which racism impacts our health.” -Professor Fernando De Maio

On Remedies to segregation

Mr. Rothstein shares two examples of potential remedies to segregation. The first would specifically address the constitutional violation that prohibited African Americans from becoming homeowners. The remedy would be for the government to buy up homes at market value in neighborhoods where African Americans were not allowed to buy homes, and sell them back to qualified African American buyers at deeply discounted rates.

The second remedy would correct a policy– the low-income housing tax credit– that reinforces segregation. Currently, low-income housing tax credit is a federal program distributed to housing developers who build housing for low-income families. However, this program reinforces segregation as developers are more inclined to build low-income housing in low-income neighborhoods. This can be reversed by placing a priority on use of these tax credits in higher-opportunity communities and prohibiting the use of this credit for creating more segregated communities.

Mr. Rothstein notes that the challenge is not in thinking of ideas or potential remedies…

“ We know what the policies are to create equality, a more equal society and a non-segregated society. What’s missing is not policy ideas. What’s missing is a new civil rights movement that’s going to create the political environment where those policies have to be implemented.”-Mr. Richard Rothstein

On being a citizen and the collective effort needed to change the status quo

Mr. Rothstein leaves us with these wise words to consider as we head back into our professional roles in medicine.

“In addition to being a physician, you’re a citizen. And I think the most important thing you can do is align yourself with other citizens in whatever profession they are, because this is going to take a community effort” -Mr. Richard Rothstein

References

1. Rothstein, R. (2017). The Color of Law: A Forgotten History of How Our Government Segregated America.
2. Benjamins MR, De Maio F. Unequal Cities: Structural Racism and the Death Gap in America’s 30 Largest Cities. Baltimore: Johns Hopkins University Press; 2021.
3. De Maio F, Ansell D. “As Natural as the Air Around Us”: On the Origin and Development of the Concept of Structural Violence in Health Research. Int J Health Serv. 2018;48(4):749-759. doi:10.1177/0020731418792825
4. Benjamins MR, Silva A, Saiyed NS, De Maio FG. Comparison of All-Cause Mortality Rates and Inequities Between Black and White Populations Across the 30 Most Populous US Cities. JAMA Netw Open. 2021;4(1):e2032086. doi:10.1001/jamanetworkopen.2020.32086
5. Metzl JM, Maybank A, De Maio F. Responding to the COVID-19 Pandemic: The Need for a Structurally Competent Health Care System. JAMA. 2020;324(3):231-232. doi:10.1001/jama.2020.9289
6. Liao TF, De Maio F. Association of Social and Economic Inequality With Coronavirus Disease 2019 Incidence and Mortality Across US Counties. JAMA Netw Open. 2021;4(1):e2034578. doi:10.1001/jamanetworkopen.2020.34578
7. Krieger M, Boyd R, De Maio F, Maybank A. “Medicine’s Privileged Gatekeepers: Producing Harmful Ignorance About Racism And Health, ” Health Affairs Blog, April 20, 2021. doi: 10.1377/hblog20210415.305480
8. Wilkinson RG. Unhealthy Societies: The Afflictions of Inequality. London: Routledge; 2005.
9. Metzl JM, Hansen H. Structural competency: theorizing a new medical engagement with stigma and inequality. Soc Sci Med. 2014;103:126-133. doi:10.1016/j.socscimed.2013.06.032
10. The “Redress Project,”, i.e. the New Movement to Redress Racial Segregation, will launch early next year. For anyone who wants to receive more information about the launch of the New Movement to Redress Racial Segregation, please click here NMRRS.
11. For a brief 8 minute summary of talks about how segregation happened, see this: https://www.facebook.com/NowThisPolitics/videos/270363507375249/
12. See the 17-minute animated film, “Segregated by Design” https://www.segregatedbydesign.com/
13. For a high school curriculum unit to teach this history: https://www.zinnedproject.org/materials/how-red-lines-built-white-wealth-color-of-law-lesson
14. Rothstein, R. (2020, February 3). Opinion | The Neighborhoods We Will Not Share. The New York Times. https://www.nytimes.com/2020/01/20/opinion/fair-housing-act-trump.html
15. Rothstein, R. (2020b, April 21). The Coronavirus Will Explode Achievement Gaps in Education. Shelterforce. https://shelterforce.org/2020/04/13/the-coronavirus-will-explode-achievement-gaps-in-education/
16. Rothstein, R. (2020c, August 14). Opinion | The Black Lives Next Door. The New York Times. https://www.nytimes.com/2020/08/14/opinion/sunday/blm-residential-segregation.html

Disclosures

The hosts and guests report no relevant financial disclosures.

Citation

De Maio F, Rothstein R, Khazanchi R, Tsai J, Krishnamurthy S, Ogunwole M, Fields NF, Nolen L, Onuoha C, Watkins A, Williams J, Paul D, Essien UR. “Episode 11: Racism, Redlining, and the Path Towards Reconciliation.” The Clinical Problem Solvers Podcast. https://clinicalproblemsolving.com/episodes. October 12, 2021.

Show Transcript

ARM Ep 11 TRANSCRIPT V1