The legacy of structural racism: Associations between historic redlining, current mortgage lending, and health

Structural racism, which is embedded in past and present operations of the U.S. housing market, is a fundamental cause of racial health inequities. We conducted an ecologic study to 1) examine historic redlining in relation to current neighborhood lending discrimination and three key indicators of societal health (mental health, physical health, and infant mortality rate (IMR)) and 2) investigate sustained lending disinvestment as a determinant of current neighborhood health in one of the most hypersegregated metropolitan areas in the United States, Milwaukee, Wisconsin. We calculated weighted historic redlining scores from the proportion of 1930s Home Owners' Loan Corporation residential security grades contained within 2010 census tract boundaries. We combined two lending indicators from 2018 Home Mortgage Disclosure Act data to capture current neighborhood lending discrimination: low lending occurrence and high cost loans (measured via loan rate spread). Using historic redlining score and current lending discrimination, we created a 4-level hierarchical measure of lending trajectory. In Milwaukee neighborhoods, greater historic redlining was associated with current lending discrimination (OR = 1.73, 95%CI: 1.16, 2.58) and increased prevalence of poor physical health (β = 1.34, 95%CI: 0.40, 2.28) and poor mental health (β = 1.26, 95%CI: 0.51, 2.01). Historic redlining was not associated with neighborhood IMR (β = -0.48, 95%CI: -2.12, 1.15). A graded association was observed between lending trajectory and health: neighborhoods with high sustained disinvestment had worse physical and mental health than neighborhoods with high investment (poor physical health: β = 5.33, 95%CI: 3.05, 7.61; poor mental health: β = 4.32, 95%CI: 2.44, 6.20). IMR was highest in 'disinvested' neighborhoods (β = 5.87, 95%CI: 0.52, 11.22). Our findings illustrate ongoing legacies of government sponsored historic redlining. Structural racism, as manifested in historic and current forms of lending disinvestment, predicts poor health in Milwaukee's hypersegregated neighborhoods. We endorse equity focused policies that dismantle and repair the ways racism is entrenched in America's social fabric.

Abstract P873: Structural Racism in Columbus, Ohio Associated With Stroke Prevalence

Introduction: Racial disparities exist in stroke and stroke outcomes. However, the fundamental cause for these disparities are not biological differences, but structural racism. Using the Home Owners’ Loan Corporation (HOLC) ‘redlining’ scores, as indicator of structural lending practices from middle of the last century, we hypothesize that census tracts with high historic redlining are associated with higher stroke prevalence.

Methods: Weighted historic redlining scores (HRS) were calculated using the proportion of 1930s HOLC residential security grades contained within 2010 census tract boundaries of Columbus, Ohio. Stroke prevalence (adults >=18) was obtained at the census tract-level from the CDC’s 500 Cities Project. Sociodemographic factors, as measured by census tract level information (American Community Survey 2014-2018), were considered mediators in the causal association between historic redlining (measured in 1936) and stroke prevalence (measured in 2017) and were not controlled for in regression analysis. The functional form of the association was non-linear, so stroke prevalence within quartiles of the HRS were compared using linear regression instead of a continuous score.

Results: Higher HRS, representing greater redlining, were associated with greater prevalence of stroke when comparing the highest to the lowest quartile of HRS (Figure). Census tracts in the highest quartile of HRS had 1.48% higher stroke prevalence compared to those in the lowest quartile (95% CI: 0.23-2.74). No other interquartile differences were observed.

Conclusions: Historic redlining practices are a form of structural racism that established geographic systems of disadvantage and consequently, poor health outcomes. Our findings demonstrate disparate stroke prevalence by degree of historic redlining in census tracts across Columbus, Ohio. While ecologic, this study demonstrates the need to acknowledge that racism, not race, drive stroke disparities.