Neighborhood Quality & Disease Prevention During the COVID-19 Pandemic
By Matthew McCurdy and Ijeoma Egekeze
Renowned physician and epidemiologist, Dr. Camara Jones, defines racism as, “a system of structuring opportunity and assigning value based on the social interpretation of how one looks (which is what people call race), that unfairly disadvantages some individuals and communities, unfairly advantages other individuals and communities, and saps the strength of the whole society through the waste of human resources.”[1]
Structural racism chooses winners and losers and, as the COVID-19 pandemic has shown, often the results of losing are disease and death. In the United States, structural racism manifests itself in many ways including housing policy and Black neighborhood quality. Discriminatory housing policies and disinvestment practices have led to the development of Black segregated, under-resourced communities. The conditions of these neighborhoods contribute to poorer chronic health outcomes, leading to increased risk for COVID-19 susceptibility, severity, and mortality.
Neighborhood Quality, Government Policy, and Health Outcomes
Research has shown that the resources available in a neighborhood – also known as neighborhood quality – have an impact on individual stress and chronic health conditions.[2] Low-resource neighborhoods lack access to affordable, healthy foods (or food deserts) and are not in close proximity to primary care facilities for chronic disease management, reliable alternatives to public transportation, as well as safe streets and green spaces for clean air and physical activity. Other neighborhood risk factors include exposure to environmental toxicants, hazardous work environments, or heavily trafficked highways – all of which contribute to racial disparities in respiratory health outcomes.[3] Additionally, individuals in low-resource, population-dense communities are forced to travel longer distances to access basic resources and visit health care providers. Population density and distant health care providers can significantly reduce opportunities for social isolation and social distancing. Neighborhood quality impacts COVID-19 hospitalization and death rates in Black communities, and the absence of critical resources and services in Black communities is a direct result of redlining and other discriminatory policies that have segregated metropolitan areas and drained resources from Black neighborhoods.
Sign with American flag "We want white tenants in our white community," directly opposite the Sojourner Truth homes, a U.S. federal housing project in Detroit, Michigan. A riot was caused by white neighbors' attempts to prevent African American tenants from moving in.
U.S. federal government, 1942
In the early 1930s, President Roosevelt implemented the New Deal – a set of social programs designed to bring the U.S. out of the Great Depression. Among these programs was a push to make homeownership more feasible for Americans through low interest, federally backed housing loans. The loans and subsequent homeownership proved to be a gateway to the middle class for many white Americans; however, lenders and the Federal Housing Authority explicitly denied African Americans access to these loans or refused to lend or insure in areas that were predominately African American (redlining).[4] When Black people could find somewhere to live, they were often driven to less-favorable housing options, like government rental public housing, neighborhoods near industrial pollutants, and low-income, resource depleted neighborhoods that lacked health-promoting infrastructure.[5] Policies like Jim Crow in the Southern states further entrenched segregation and disinvestment in African American communities. This policy-driven structural racism contributed to the adverse conditions within the neighborhood environment experienced by many African American residents. The legacy of these decisions remains today and can be seen in the health and wellbeing of Black people living in these communities. Across the country, we have already seen that the epidemic has widened housing disparities, impacting Black people’s ability to maintain stable housing.[6]
Underlying Health Conditions & COVID-19 Susceptibility
Factors affecting neighborhood quality also determine a person’s proximity to health care providers, as well as his or her ability to manage chronic conditions. Asthma, chronic obstructive pulmonary disease (COPD), diabetes, chronic kidney disease, heart disease, and hypertension are among the most common pre-existing conditions affecting COVID-19 patients. These specific health conditions disproportionately impact African American communities and negatively impact a person’s lungs, increasing his or her susceptibility to contracting COVID-19. With limited access to affordable health care providers and few available hospitals and community health centers, Black patients are more likely to die from asthma than any other racial or ethnic group.[7] To date, low-income families receiving housing assistance develop asthma at rates higher than the general population due to exposure to lead hazards and asbestos, inadequate ventilation and temperature control, mold exposure, and crowded living environments.[8] The impact of disparities in respiratory health can be seen in Chicago, Illinois, one of the nation’s epicenters of asthma-related deaths and one of the first major cities to report high rates of COVID-19 prevalence among African American people.[9]
Additional Considerations to Address COVID-19 & Neighborhood Quality
Disaggregated Data
Recently, an increased demand for disaggregated COVID-19 incidence, prevalence, and mortality data has prompted 40 states to publish data on the gender, age, and racial and ethnic backgrounds of COVID-19 patients. However, in order to stop the spread of COVID-19, we need this data from all states at the county or city level. Access to detailed disaggregated data would allow researchers, public health departments, local and state governments, and other health professionals tailor their responses to the communities most affected by the pandemic.
Reducing COVID-19 to Protect the People Most at Risk
Local governments and public health departments should implement outreach programs to assure that communities most at risk are receive support services, especially those serving as essential workers, experiencing homelessness or housing insecurity, those who are unemployed or furloughed, or those impacted by mass incarceration. Cities like San Francisco have taken steps to ensure that people without stable housing options are able to reduce their risk of contracting the virus by moving them to temporary locations for self-isolation, restricting movement in and out of public shelters, and implementing a moratorium on evictions. Most incarcerated men and women do not have safe alternatives for social isolation. For example, in New York City, prisons lack access to clean water, soap, and hand sanitizer. Some states, like Washington, have begun to commute sentences or release people convicted of non-violent offenses to home confinement with electronic monitoring.
Access to COVID-19 Testing
Although the CARES Act[10] allowed for free COVID-19 testing, communities of color have not experienced a significant increase in access to COVID-19 testing and there are hospitals that continue to charge patients for COVID-19 testing services.
Rebuilding Health Care Infrastructure & Recent Health Policy Reforms
To address gaps in health care coverage, new laws like the Families First Coronavirus Response Act and the Coronavirus Aid, Relief, and Economic Security (CARES) Act have provided new opportunities to rebuild state and local public health infrastructure.
Improving Access to Healthy Housing Options
There are some proven innovative methods at the intersection of housing and health. Governments, foundations, and other stakeholders have developed solutions that integrate housing and an understanding of the social determinants of health. Place-based efforts, like those taken on by Purpose Built Communities, have shown improvement in African American health outcomes by intentionally investing in the resources that make-up neighborhood quality like stable mixed-income housing, education, and green spaces. Other communities have created housing mobility programs that move African Americans out of low-income, under resourced communities to non-poverty neighborhoods. While those programs have shown promise for helping individual health outcomes, much more progress needs to be made in investing in low-income, African American communities across the country to improve collective outcomes.
References:
[1] Camara Phyllis Jones. (2002). Confronting Institutionalized Racism. Phylon (1960-), 50(1/2), 7-22. doi:10.2307/4149999
[2] Diez Roux, A.V. and Mair, C. (2010), Neighborhoods and health. Annals of the New York Academy of Sciences, 1186: 125-145. doi:10.1111/j.1749-6632.2009.05333.x
[3] Celedón, J. C., Roman, J., Schraufnagel, D. E., Thomas, A., & Samet, J. (2014). Respiratory health equality in the United States. The American thoracic society perspective. Annals of the American Thoracic Society, 11(4), 473–479. https://doi.org/10.1513/AnnalsATS.201402-059PS
[4] Rothstein, Richard. The Color of Law: A Forgotten History of How Our Government Segregated America. First edition. New York; London: Liveright Publishing Corporation, a division of W.W. Norton & Company, 2017.
[5] Margaret T. Hicken Margaret T. Hicken, Lindsey Burnside, Dominique L. Edwards, and Hedwig Lee, January 2019: 5. Black-White Health Inequalities by Intentional Design: The Lasting Health Impact of Racial Residential Segregation Racism: Science & Tools for the Public Health Professional. https://doi.org/10.2105/9780875533049ch05.
[6] Greene, Solomon, and Alanna McCargo. “New Data Suggest COVID-19 Is Widening Housing Disparities by Race and Income.” Urban Institute, 2 June 2020, www.urban.org/urban-wire/new-data-suggest-covid-19-widening-housing-disparities-race-and-income.
[7] Centers for Disease Control and Prevention, Most Recent Asthma State or Territory Data, March 24, 2020, https://www.cdc.gov/asthma/most_recent_data_states.htm.
[8] Ganesh, Bhargavi, Scally, Corianne Payton, Skopec, Laura, & Zhu, Jun. The Relationship between Housing and Asthma among School-Age Children. The Urban Institute. October 2017. https://www.urban.org/sites/default/files/publication/93881/the-relationshi-between-housing-and-asthma_1.pdf
[9] Thometz, Kristen. Study: ‘Alarming’ Racial Disparities Persist Among Kids with Asthma, WTTW Chicago. May 1, 2018, https://news.wttw.com/2018/05/01/study-alarming-racial-disparities-persist-among-kids-asthma.
[10] H.R. 748, the Coronavirus Aid, Relief, and Economic Security (CARES) Act, CARES Act, Congress.gov, https://www.congress.gov/bill/116th-congress/house-bill/748/text
