Historic Residential Redlining and Present-day Diabetes Mortality and Years of Life Lost: The Persistence of Structural Racism

Linde, Sebastian; Walker, Rebekah J.; Campbell, Jennifer A.; Egede, Leonard E.

doi:10.2337/dc21-2563

Cited by 32 publications

(22 citation statements)

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“…Table 2 summarizes results by study design and outcome. Across the 13 studies, 7 were cross-sectional (37)(38)(39)(40)(41)(42)(43), 3 were longitudinal (20,44,45), 2 were qualitative (46,47), and 1 was an RCT (48). Sample sizes ranged from 28 to 182,756.…”

Section: Study Characteristics and Outcomes Of Studiesmentioning

confidence: 99%

“…Structural racism differs from structural inequalities in that it reinforces discriminatory beliefs, values, and distribution of resources on the basis of race and ethnicity (19). Structural racism is antecedent to SDOH and serves as an upstream driver of racial and ethnic disparities in health outcomes in the U.S. (20)(21)(22)(23)(24)(25). Other forms of racism in the U.S. that operate as structural mechanisms of inequalities include systemic racism, or racism that is embedded across all societal systems, and institutional racism, or racism that operates at core institutional levels (19,26).…”

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confidence: 99%

“…Although many policies and practices are no longer legal, the impact of historical laws and practices is still felt through ongoing economic inequalities, and many current practices reinforce disparities in health outcomes for racial and ethnic minorities (20,(27)(28)(29)(30)(31)(32). To effectively address structural racism as an upstream influence of diabetes outcomes, an organizing framework and the evaluation of the evidence for this relationship are needed to develop actionable strategies.…”

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confidence: 99%

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Structural Racism as an Upstream Social Determinant of Diabetes Outcomes: A Scoping Review

et al. 2023

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OBJECTIVE To evaluate the evidence on the role of structural racism as an upstream factor impacting diabetes outcomes, identify current gaps, and recommend areas for future work. RESEARCH DESIGN AND METHODS A reproducible search of Medline and Ovid was used. Structural factors based on the World Health Organization social determinants of health framework (governance, macroeconomic policy, social policy, public policy, and cultural and societal values) had to be included as measured variables or contextual factors discussed as upstream influences. Outcomes included 1) hemoglobin A1c (HbA1c), 2) LDL, 3) BMI, 4) quality of life, 5) self-efficacy, 6) mortality, 7) years of life lost, and 8) self-care behaviors. RESULTS Thirteen articles were included for final synthesis. Ten studies focused on governance, two on social policies, one on public policies, and one on cultural and societal values. Results highlight significant associations between structural racism and poorer clinical outcomes (HbA1c and blood pressure), worse self-care behaviors (diet and physical activity), lower standards of care, higher mortality, and more years of life lost for adults with diabetes. CONCLUSIONS There is a paucity of work investigating the relationship between structural racism and diabetes outcomes. Five areas for future work include 1) more rigorous research on the relationship between structural racism, downstream social determinants, and health outcomes in diabetes, 2) policy assessments specific to diabetes outcomes, 3) research designed to examine pathways and mechanisms of influence, 4) intervention development to mitigate the impact of structural racism, and 5) tracking and monitoring of change over time.

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Section: Study Characteristics and Outcomes Of Studiesmentioning

confidence: 99%

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confidence: 99%

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confidence: 99%

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Structural Racism as an Upstream Social Determinant of Diabetes Outcomes: A Scoping Review

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“…6,7 Recent work has further indicated that residents of historically redlined areas are subject to increased rates of gunshot-related ED visits and injuries, increased odds of preterm birth, and higher rates of diabetes specific mortality and years of life lost (YLL). [8][9][10][11][12][13] Linde et al documented the persistence of these associations, noting that HOLC redlining scores consistently explain 45-56% of the variation in census tract-level diabetes mortality rate and 51-60% of the variation in the census tract diabetes YLL rate between the years of 1990 and 2014 in Seattle, Washington. 13 Finally, historically redlined neighborhoods were shown to be subject to worse COVID-19 outcomes than residents within non-redlined areas.…”

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confidence: 99%

“…[8][9][10][11][12][13] Linde et al documented the persistence of these associations, noting that HOLC redlining scores consistently explain 45-56% of the variation in census tract-level diabetes mortality rate and 51-60% of the variation in the census tract diabetes YLL rate between the years of 1990 and 2014 in Seattle, Washington. 13 Finally, historically redlined neighborhoods were shown to be subject to worse COVID-19 outcomes than residents within non-redlined areas. 14,15 While the mechanisms between historical redlining and health outcomes have not been well examined, evidence suggests that historic redlining operates upstream to suppress social advancement by limiting potential to achieve higher income.…”

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Modern Day Consequences of Historic Redlining: Finding a Path Forward

et al. 2023

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There is emerging evidence that structural racism is a major contributor to poor health outcomes for ethnic minorities. Structural racism captures upstream historic racist events (such as slavery, black code, and Jim Crow laws) and more recent state-sanctioned racist laws in the form of redlining. Redlining refers to the practice of systematically denying various services (e.g., credit access) to residents of specific neighborhoods, often based on race/ethnicity and primarily within urban communities. Historical redlining is linked to increased risk of diabetes, hypertension, and early mortality due to heart disease with evidence suggesting it impacts health through suppressing economic opportunity and human capital, or the knowledge, skills, and value one contributes to society. Addressing structural racism has been a rallying call for change in recent years—drawing attention to the racialized impact of historical policies in the USA. Unfortunately, the enormous scope of work has also left people feeling incapable of effecting the very change they seek. This paper highlights a path forward by briefly discussing the origins of historical redlining, highlighting the modern-day consequences both on health and at the societal level, and suggest promising initiatives to address the impact.

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Individual-Level Exposure to Residential Redlining in 1940 and Mortality Risk

Linde,

Egede

2024

JAMA Intern Med

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ImportanceHistoric redlining, the practice by the Home Owners’ Loan Corporation (HOLC) of systematically denying credit to borrowers in neighborhoods that were inhabited by primarily African American individuals, has been associated with poor community outcomes, but the association with individual risk of death is not clear.ObjectiveTo examine if exposure to residential redlining practices by HOLC in 1940 is associated with increased risk of death later in life.Design, Setting, and ParticipantsThe study linked individuals who resided within HOLC-graded neighborhoods (defined as Census Enumeration Districts) in 1940 with administrative death records data. The study estimated hazard ratios as well as age-specific life expectancy gaps (at age 55, 65, and 75 years) for HOLC grading exposure. This was done using methods that adapted standard parametric survival analysis to data with limited mortality coverage windows and incomplete observations of survivors. The analysis sample consisted of 961 719 individual-level observations across 13 912 enumeration districts within 30 of the largest US cities (based on 1940 population counts) across 23 states. Data were analyzed between December 1, 2023, and September 4, 2024.Main Outcome and MeasuresThe exposure was HOLC grade based on historic HOLC maps, with A representing “best” or creditworthy areas; B, “still desirable”; C, “definitely declining”; and D, “hazardous” areas not worthy of credit (ie, redlined), and the main outcome was age at death from the Social Security Numident file.ResultsThe 961 719-person individual sample had a mean (SD) age of 19.26 (9.26) years in 1940 and a mean (SD) age at death of 76.83 (9.22) years. In a model adjusted for sex (52.48% female; 47.52% male), race and ethnicity (7.36% African American; 92.64% White), and latent place effects, a 1-unit lower HOLC grade was associated with an 8% (hazard ratio, 1.08 [95% CI, 1.07-1.09]) increased risk of death. At age 65 years, these hazard differentials translated into an estimated life expectancy gap of −0.49 (95% CI, −0.56 to −0.43) years for each 1-unit decrease of the HOLC grade.ConclusionThis study found that individuals who resided within redlined neighborhoods in 1940 had lower life expectancy later in life than individuals who resided within other HOLC-graded areas.

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Historic Residential Redlining and Present-day Diabetes Mortality and Years of Life Lost: The Persistence of Structural Racism

Cited by 32 publications

References 14 publications

Structural Racism as an Upstream Social Determinant of Diabetes Outcomes: A Scoping Review

Structural Racism as an Upstream Social Determinant of Diabetes Outcomes: A Scoping Review

Modern Day Consequences of Historic Redlining: Finding a Path Forward

Individual-Level Exposure to Residential Redlining in 1940 and Mortality Risk

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