1930s 'Redlining' Connected to Poor Health Outcomes Today

New study from UH Harrington Heart & Vascular Institute shows link between historical redlining and increase in contemporary cardiometabolic health risk factors

Sadeer Al-Kindi, MD

A new study from University Hospitals (UH) Harrington Heart & Vascular Institute further proves that people living in areas that were subjected to housing discrimination decades ago now suffer from higher rates of poor health outcomes, including heart disease, kidney failure and diabetes. The findings were published this month in the Journal of the American College of Cardiology.

In the 1930s, the federal government created the Home Owners’ Loan Corporation (HOLC), in part to stabilize the housing market during the Great Depression and offer home mortgage refinance services to some homeowners in default and expand home buying opportunities for some citizens. The HOLC created maps of nearly 200 U.S. cities that color-coded neighborhoods to denote potential lending risk: A (“best” or green), B (“still desirable” or blue), C (“definitely declining” or yellow) and D (“hazardous” or red), with the latter deemed as a “redlined” neighborhood. Majority Black neighborhoods were “redlined” into the hazardous category more frequently, meaning people living there were more likely to be denied a loan to buy or renovate a home. These housing practices were not outlawed until the 1960s.

“Earlier studies have shown that Black adults living in previously redlined areas had a lower cardiovascular health score than Black adults living in neighborhoods given a grade of A,” said Sadeer Al-Kindi, MD, cardiologist at UH Harrington Heart & Vascular Institute and co-author of the study. “Our study is the first to examine the national relationship between redlined neighborhoods and cardiovascular diseases. It supports the results of previous related studies while additionally showing that historic redlining is associated with an increased risk of comorbidities and a lack of access to appropriate medical care today.”
 
The authors linked 1930s redlining maps with current neighborhood maps and examined the prevalence of cardiovascular risk factors and disease by neighborhood category (A through D, A=lowest risk to D=highest risk). They obtained the prevalence of cardiovascular disease from CDC data. The study encompassed more than 11,000 HOLC-graded census tracts that included more than 38.5 million people across the country.

Results show an overall increase in rates of obesity, diabetes, high blood pressure and smoking across the grading spectrum from A to D. Nearly twice the amount of adults ages 18 to 64 years old were without health insurance in D-graded areas compared to those with an A. Furthermore, they discovered that neighborhoods with a better grade had more routine health visits and better cholesterol screening as compared to neighborhoods with a worse grade.
 
“Our group at UH Harrington Heart & Vascular Institute wanted to study redlining in this way to better understand the socio-environmental underpinning of health inequities. Such understanding can provide unprecedented new information with which one can attempt to solve the current epidemic in chronic non-communicable diseases,” said Sanjay Rajagopalan, MD, Chief of the Division of Cardiovascular Medicine and Chief Academic and Scientific Officer of UH Harrington Heart & Vascular Institute; as well as the Herman K. Hellerstein, MD, Chair in Cardiovascular Research. “UH is committed to improving the health of all people in Northeast Ohio by advancing science and human health and this study provides a foundation for programs like ACHIEVE GreatER.”
 
ACHIEVE GreatER, announced last year, is an initiative funded thanks to a transformative $18.2 million federal grant from the National Institutes of Health. Through ACHIEVE GreatER, UH will provide cardiovascular care to people living in the Cuyahoga Metropolitan Housing Authority (CMHA). More than half of CMHA units fall into a previously redlined category. 
 
“ACHIEVE GreatER has an ultimate goal of reducing cardiovascular complications and hospitalizations by improving blood pressure, lipids and glucose targets for Black patients at risk of heart health issues,” said Dr. Rajagopalan, who is also the principal investigator of Cleveland’s ACHIEVE GreatER team.
 
Community health workers, nurses, dieticians, and pharmacists will be deployed into CMHA communities, providing personalized diet and exercise advice and health services like screenings for blood pressure, cholesterol, and average blood sugar. The ACHIEVE GreatER research team will study the impact of these interventions.
 
“Studying topics like redlining helps us better understand the root cause of healthcare disparities. This gives us the information and motivation to make an impactful change through initiatives like ACHIEVE GreatER,” said Issam Motairek, MD, lead author of the redlining study.
 
“The mission of University Hospitals is to heal, to teach and to discover. With our redlining study, we have confirmed a problem that needs addressed. Now, armed with this crucial information, we have an opportunity to heal and a duty to act,” said Mehdi Shishehbor, DO, MPH, PhD, President of UH Harrington Heart & Vascular Institute, and Angela and James Hambrick Chair in Innovation.
 
While this study links historical housing discriminatory practices with modern day cardiometabolic disease and risk factors, the authors look forward to future studies that examine micro-level neighborhood characteristics, which make redlined neighborhoods more susceptible to disease.
 
To read the full study, “Historical Neighborhood Redlining and Contemporary Cardiometabolic Risk” in the Journal of the American College of Cardiology, click here.