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Redlines and Lead Lines

August 31, 2023

Editor’s Note: Eli Cahan is a resident physician in pediatrics at The Boston Combined Residency Program at Boston Children's Hospital and Boston Medical Center, and an investigative journalist whose work focuses on the intersection of health equity and social justice. -Rachel Y. Moon, MD, Associate Editor, Digital Media, Pediatrics

In one year, Jaylon Wakes transformed from a bouncing-off-walls 5-year-old to a screaming and crying 6-year-old. In the time that followed, Jaylon was suspended 30 times, received 70 unexcused absences, and moved schools. It wasn’t until later that he received a diagnosis; Nakiya Wakes, his mother, told The New York Times: lead poisoning.

Jaylon was one of an estimated 30,000 school children exposed to this neurotoxin. According to The New York Times story, of the 1,300 children evaluated by the city’s lead screening center, 70% required school accommodations. Many of these children struggled in school for years after their initial exposure, The Washington Post reported. On March 21st, 2023, those exposed settled with the state of Michigan, the city of Flint, and others for over $625 million in damages.

“I do not believe that anybody consciously wanted to hurt the people in Flint…[b]ut I do think there is a larger issue that we have to acknowledge,” President Obama said in May 2016, “[w]e’ve got to fix the culture of neglect​."

In the years that followed the Flint Water Crisis, the sequelae of that culture of neglect have increasingly revealed themselves. In cities like Baltimore, Cleveland, and Philadelphia, elevated lead levels are also endemic. And while experts have theorized that the historical legacy of race-based housing segregation—otherwise known as “redlining”—played an essential role in these patterns, so far, quantitative evidence to support those postulates has been limited.

In an article and video abstract being early released this week by Pediatrics, Miranda and colleagues set out to put numbers to this question by estimating the association between racial residential segregation and childhood blood lead levels in North Carolina over a nearly 20-year period (10.1542/peds.2022-058661).

They found that, in the 1990s, each standard-deviation increase in what they call “racial isolation”—a previously validated instrument to measure neighborhood segregation—correlated with 2-3% increase in blood lead levels. These inequities persisted into the 2010s, between 2013-2015, each standard deviation increase in racial isolation conferred a 1-2% increase in blood lead levels.

Moreover, the authors found that neighborhood segregation is increasing—not decreasing. Across the US, between 1990-2015, racial isolation increased by 70%. In other words, the study demonstrates that redlining is not a thing of the past.

“Structural racism is embedded in historical, societal, institutional, and governmental structures,” the authors wrote. “By fostering residential environments inimical to health, [racial residential segregation] serves as a foundation of structural racism and key contributor to preventable racial/ethnic health disparities in the US.”

In her book What the Eyes Don’t See, pediatrician Mona Hanna-Attish—who is credited with flagging the Flint Water Crisis to authorities—wrote that “[p]hysicians need to be trained to see symptoms of the larger structural problems that will bedevil a child’s health and well-being more than a simple cold ever could.”

Accordingly, clinicians interested in understanding—and advocating against—the ongoing legacy of structural racism in the US can read the study by Miranda et al in the September edition of Pediatrics.

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