Healey J. Addressing structural racism in housing to advance racial health equity. HPHR. 2021;30.
Structural racism has influenced housing patterns and led to an inequitable distribution of health-promoting housing resources between Black and white Americans. Housing laws, policies, and practices in American society and its institutions have differentially oppressed, disadvantaged, and neglected Black people and communities. Racial inequities in housing have led to longstanding inequities in health and well-being between Blacks and whites. This article provides a brief overview of the impact historic and continued structural racism has on housing and health inequities in the United States. It also provides a perspective on the use of the Department of Housing and Urban Development’s (HUD) Rental Assistance Demonstration (RAD) program to improve public housing in the country. Though RAD has potential to advance racial equity in housing and health, this article identifies necessary improvements to the program to reach that goal. The article concludes by calling for an explicit focus on addressing structural racism in housing policies and practices in order to decrease health disparities between Black and white Americans.
Structural racism has influenced housing patterns and led to an inequitable distribution of health-promoting housing resources between Black and white Americans. In this article, structural racism is referred to as the “totality of ways in which societies foster racial discrimination, through mutually reinforcing inequitable systems that in turn reinforce discriminatory beliefs, values, and distribution of resources” (Bailey et al., 2017). Housing laws, policies, and practices in American society and its institutions have differentially oppressed, disadvantaged, and neglected Black people and communities. Racial inequities in housing have led to inequities in health and well-being between Blacks and whites (Williams et al., 2019). This article provides a brief overview of the impact historic and continued structural racism has on housing and health in the United States (U.S.). It also provides a perspective on the use of the Department of Housing and Urban Development’s (HUD) Rental Assistance Demonstration (RAD) program to improve public housing in the country. Though RAD has potential to advance racial equity in housing and health, this article identifies necessary improvements to the program to reach that goal. The article concludes by calling for an explicit focus on addressing structural racism in housing policies and practices in order to decrease health disparities between Black and white Americans.
Since the first Africans were forcibly brought to the U.S. under bondage in 1619, structural racism has impacted where Black people live in the country. Enslaved Africans were forced to remain on slaveowners’ property and stripped of human rights, including owning land. When slavery ended 246 years later, the federal government neglected to provide Black Americans with a path to land ownership. Pressure from southern states blocked the passing of legislation intended to provide all formerly enslaved people with forty acres of confederate land (Lee, 2019). Though no law prohibited Blacks from owning land after slavery was abolished, government inaction and public practices made it almost impossible for Black land ownership to be feasible. This resulted in the majority of Blacks being forced to either rent land from previous slaveowners or migrate to northern cities (White and Stuart, 2020). In both northern and southern states, residential segregation enforced through local government policies and private prejudices marginalized Blacks to live in disadvantaged areas unwanted by whites. This race-based geographic exclusion resulted in economically deprived urban “ghettos” (Rothstein, 2015).
Black Americans have largely been denied the benefits that whites have received from government sponsored housing initiatives, such as the National Housing Act of 1934. The purpose of this law was to improve housing standards and conditions by providing a system of federally funded mutual mortgage insurance (U.S. Department of Housing and Urban Development, 1934). Practices of “redlining” in the 1930s by government agencies, private banks, and real estate companies prevented Blacks from accessing the benefits provided by this policy. Redlining was the practice of formally designating areas with majority Black residents as “hazardous” or “declining” for financial investments, and areas with majority white residents as “desirable” or “best” for financial investments (Badger, 2017). This stemmed from the racist belief that the presence of Blacks in a neighborhood undermined property values, furthering segregation as Blacks were excluded from white suburban areas (Rothstein, 2017). Redlining blocked Blacks from accessing mortgages to buy homes and subjected them to predatory loans in order to repair homes. The limited wealth building opportunities available to Black families and neighborhoods compared to their white counterparts led to disinvestment in and deterioration of redlined communities (Badger, 2017). 1930s housing initiatives also included the construction of the first public housing, which was initially built only for white families, and remained segregated by race until the Fair Housing Act of 1968. Black public housing buildings were intentionally built in areas to reinforce patterns of urban poverty and racial segregation (Popkin, 2013). Today, even though Black residents make up only 44% of the 2.3 million people living in public housing, many public housing units in large, urban centers are made up of almost 100% Black renters (Badger, 2015). As the image of public housing became a racist picture of crime, poverty, and waste, President Nixon halted government spending on public housing and undermined public housing desegregation plans (Rothstein, 2012; Salpukas, 1973). This disinvestment in the 1970s led to deteriorating conditions of public housing buildings and a backlog of needed repairs and modernizations. A 2010 HUD study estimated $26 billion in capital need for public housing units, though advocacy groups estimate it has increased upwards of $70 billion since then (U.S. Department of Housing and Urban Development, 2010; Gramlich, 2021)
Government failure to provide adequate public housing resulted in the enactment of new approaches to public housing, such as privatization and voucher programs. However, some of these new housing programs only worsened concentrated poverty and displaced Black families. For example, HUD’s Section 8 Housing voucher program (also known as Housing Choice) implemented in 1974, allows residents to use their public subsidies with private landlords. Yet landlords in many cities and states have the right to reject prospective tenants that use vouchers, restricting many voucher recipients to the same high-poverty and segregated communities where public housing projects are located (Badger, 2015). Additionally, HUD’s Hope IV program (also known as Urban Renewal) that began in 1993, offers grants to private developers to tear down distressed public housing and build new mixed-income units. However, only about half the number of subsidized units have been rebuilt, resulting in a loss of affordable housing stock (Popkin 2004). This flawed policy led to displacement of Black families and increased housing instability (Reid, 2017; Hernandez et al., 2019). This racist history of housing the U.S. has created and reinforced longstanding racial inequities in housing and health.
Housing impacts physical and mental health and well-being in a variety of ways that interact with each other. The safety and quality of home environments, such as the presence of lead, mold or pests, or the lack of proper heating or cooling, can result in negative health outcomes such as asthma, brain damage, or cardiovascular events (Taylor, 2018). Additionally, housing affordability and instability (such as moving frequently due to falling behind on rent or being evicted) are associated with depression, anxiety, substance use, teen pregnancy, psychological trauma, and suicide (Taylor, 2018). Neighborhood context of housing is also an important determinant of health. For instance, physical characteristics such as the presence of parks, grocery stores, and public transportation, are correlated with improved health, as well as social characteristics of neighborhoods, like safety and social capital (Taylor, 2018).
The impact of structural racism in housing policies and practices disadvantages Blacks from accessing housing resources that promote health and wealth. Research shows that redlined neighborhoods are associated with poorer mental health, lower life expectancy, greater preterm births, prevalence of chronic diseases, higher risk of COVID-19, and more late-stage cancer diagnoses (Krieger et al., 2020a; Krieger et al., 2020b; Richardson et al., 2021). Historic exclusion of Blacks from home ownership pathways has contributed to a gap where almost twice the proportion of whites own homes compared to Blacks (U.S. Census Bureau, 2020). This racial discrimination has impacted generational wealth accumulation for Black families, which contributes to half of all Black households being classified as “rent-burdened” compared to only one-third of whites. (Swope and Hernandez, 2019) Studies show that experiencing financial strain in paying for housing causes people to forego health-promoting goods such as food, heating and cooling, medical care and prescriptions, or education (Taylor, 2018). This contributes to Blacks experiencing higher rates of negative physical and mental health outcomes compared to whites (Bailey et al., 2017).
To address racial health gaps and improve health equity, it is important to recognize racism and housing as critical determinants of health and well-being. This article references health equity as every person being able to exercise and utilize their human right to access health-promoting opportunities and resources. This requires the just removal of barriers to being healthy and the implementation of pathways to being healthy for marginalized populations.
Ensuring public housing remains available, affordable, and stable while improving physical, social, and contextual housing conditions is critical to improve racial health equity. A new initiative aimed at doing this in larger, urban areas is the Department of Housing and Urban Development’s (HUD) Rental Assistance Demonstration (RAD) program that began under President Obama in 2012. RAD allows local housing authorities to convert public housing buildings to project-based Section 8 housing and either retain property ownership or transfer it to other entities. The goal of this program is to generate additional funding sources to address the unsafe and unhealthy state of many public housing buildings. Though the RAD intervention has some flaws, it has been regarded by housing policy-makers and advocates as a way to preserve affordable housing, while tackling the backlog of urgently needed renovations (Reid, 2017).
Because RAD has been in use for only about 10 years, there is not yet a large body of research on the positive and negative impacts of the intervention. However, in the places where RAD has been implemented, research shows the program has provided some health benefits to residents. RAD has effectively addressed the physical conditions of public housing buildings in need of rehabilitation, providing residents with improved unit aesthetics and layout, modern appliances, and mold abatement, all of which contribute to better health outcomes (Hernandez et al., 2019). Additionally, social conditions in RAD housing have been improved through the implementation of on-site managers who facilitate connections between residents and with social services. This has positively impacted health by increasing resident access to health-promoting resources and social networks (Hernandez et al., 2019). RAD programs also promote the health of tenants by preserving housing stability and affordability.
A strength of RAD is that it provides flexibility for housing authorities to adapt the program to their local housing market needs. Additionally, RAD incorporates equity by providing protections to current tenants, giving them the right to return to the building after temporarily relocating for repairs. Though there have still been some complaints about tenant displacement at RAD sites, this clause has been largely successful at preventing the displacement of residents that occurred during previous HUD public housing policies (Burrowes and Ladet, 2018; Reid, 2017). Incorporating legal aid services into the program could help residents better understand and utilize their tenant rights. Further, to ensure tenant protections are being enforced, HUD should increase government oversight and evaluation of the RAD program. A report by the U.S. Government Accountability Office (2018) stated that HUD does not effectively monitor issues like increases in rent or displacement of residents. Though both Democrats and Republicans, including former HUD Secretary Ben Carson, have supported increasing the cap on the number of units eligible to be transferred to the private sector under the RAD program (which has increased to 38% of public housing stock), government oversight procedures must first be improved before expansion continues (Cohen, 2018).
Although RAD has effectively improved physical and social public housing conditions, the intervention could do more to address contextual conditions, meaning the presence of positive or adverse health resources in the surrounding neighborhood (Swope and Hernandez, 2019). At one RAD site, residents reported that neither safety nor their connection to the surrounding community was improved after the RAD intervention was implemented, both of which impact health (Hernandez et al., 2019). Due to the issues of structural racism previously discussed, Black communities are disproportionately afflicted by adverse health context issues such as presence of violence and crime, environmental hazards, liquor stores, fast-food outlets, as well as a lack of supermarkets, green spaces, and healthcare services (Swope and Hernandez 2019). These neighborhood characteristics are linked to a greater incidence of health issues such as asthma, stress, obesity related health outcomes, and negative birth effects (Swope and Hernandez 2019). To improve racial equity in housing and health, it is important for RAD to address housing context.
RAD could be amended to improve neighborhood context by boosting capital investment and economic opportunity in the community. For example, it could be required that public housing building rehabilitation include transforming adjacent or nearby vacant lots or abandoned buildings into community spaces or retail locations. Incorporating policies to improve the built environment surrounding public housing communities, in coordination with RAD’s tenant displacement protections, could help improve neighborhood and resident health while preventing gentrification. Residential segregation makes it possible to target communities with the RAD intervention based on geography to specifically improve health in Black neighborhoods.
A potential challenge to using the RAD program to improve racial equity is America’s unfettered capitalism, which has contributed to white Americans accumulating seven times the wealth of Black Americans (Lee, 2019). Some critics have argued that the privatization of public housing, such as the RAD program, creates conflicting interests because there is no money to be made in creating housing for the poor (Taylor 2019). Additionally, it has been highlighted that the private institutions the government delegates responsibilities to through RAD (such as real estate companies and banks), have a history of racism in their profit-seeking behavior (Taylor 2019). To address these issues and utilize RAD to improve racial equity in housing and health, RAD partnerships must ensure an equitable distribution of power between public, private and community stakeholders. This shared power will necessitate inclusion of resident input into RAD program activities, specifically Black residents who have been neglected due the racist actions discussed in this article. Though RAD program guidelines include resident participation throughout the process, level and effectiveness of community engagement have varied across projects (Reid, 2017). Improved oversight of the RAD program could also increase meaningful community engagement. Advancing racial equity in housing and health requires all sectors connected to this work to explicitly identify and tackle systemic racism against Black Americans.
Structurally racist public and private housing policies and practices continue to harm Black people in the U.S. Public housing initiatives, like the RAD program, are important to improve the health and well-being of communities of color who have been marginalized and neglected. However, public housing policies must incorporate a racial equity lens. This will ensure programs do not further disadvantage historically marginalized communities and are working to decrease the gaps in housing related health outcomes between Black and white Americans. An explicit and coordinated national plan to dismantle structural racism in housing would contribute to improved access to health-promoting housing resources for Black people and communities, advancing health equity in the U.S.
Julia A. Healey is a Master of Public Health student in the Social & Behavioral Sciences Department at the Harvard T.H. Chan School of Public Health. Prior to graduate school, she worked at the Lown Institute health care think tank and served as an AmeriCorps member at the Boston Alliance for Community Health. Julia’s public health interests are in health equity, structural social determinants of health, and health communications.