Editor’s Note: Ha Le (she/hers) is a resident physician in pediatrics at UCSF, whose passions include medical education, social justice, and narrative medicine. -Rachel Y. Moon, MD, Associate Editor, Digital Media, Pediatrics
I was a first-year medical student when the COVID-19 pandemic and resulting inequities reiterated that the diagnosis and pathophysiology are not the only determinants of health. Structural racism, defined as how societal systems create and reinforce racial discrimination, also plays a critical role. The Black-White disparity in mortality due to COVID-19 is an example of how structural racism exacerbates healthcare disparities.
While there is growing literature on the impacts of structural racism on health, few consider the broad impacts of past practices on the present.
Lorraine Reese Blatt and colleagues at the University of Pittsburgh and Michigan State University sought to address this deficiency in their article being early released in Pediatrics this week entitled, “Historical Structural Racism in the Built Environment and Contemporary Children’s Opportunities" (10.1542/peds.2023-063230).
The authors investigated the impact of historical structural racism in the built environment (SRBE) on children’s contemporary educational, socioeconomic, and health opportunities. Focusing on Allegheny County in Pennsylvania, an area with a history of great racial inequity, they studied 4 SRBE measures:
- Redlining, which refers to the 1930–1960s practice of rating neighborhoods from most desirable to hazardous. These grades favored the more affluent, majority White neighborhoods and prevented people who lived in communities of color and/or were low income from obtaining mortgages, becoming homeowners, and building wealth.
- Blockbusting, defined by the authors as the period from 1950 to 1980 when families of color began to move into urban neighborhoods and real estate companies used “panic-selling” as a strategy to urge White families’ movement from the cities to suburbs.
- Freeway displacement, which considers the negative impact of US interstate construction as communities, primarily those from low-income and minoritized backgrounds, were forced to relocate so that these freeways and highways could be built.
- Urban renewal, which involves the demolition and redevelopment of neighborhoods initially occupied by primarily Black communities, displacing the residents.
Blatt and colleagues, using data from the 2015 Child Opportunity Index 2.0, found that:
- Redlining and blockbusting were negatively associated with children’s education, socioeconomic status, and health.
- Urban renewal was negatively associated with educational and socioeconomic opportunities.
- When all four SRBE measures were modeled together, the negative associations with education, socioeconomic status, and health increased. Notably, the negative impact on children’s opportunities was greater with the four SRBEs grouped than when redlining was considered as the only independent variable.
These results reflect the long-lasting impact of historical racist policies, particularly those related to restructuring the urban environments of communities that were Black, minoritized, and low-income.
Prior studies have provided glimpses into the ways in which these policies may impact health. For instance, redlining has been linked to current air pollution disparities across racial and ethnic lines. However, as Blatt and colleagues note, most of this prior work “has been limited in scope in considering only the impacts of redlining.” This study’s results demonstrate the need to expand our lens when studying the impact of historical practices on current-day healthcare disparities—especially if we hope to use the data to effect change for more just and equitable health practices and interventions.
What is most striking about this article, however, is the implication of the enduring consequences of past actions on today’s youth. Not only does this recognition suggest that we as pediatricians need to refine our approaches when assessing the social drivers of health, but it also places a greater weight on our current advocacy work. Our present-day political and social practices (such as gentrification) will likely have longstanding impacts for generations to come.
Years since the start of the COVID-19 pandemic and currently on my next stage of pediatric training, I continue to find more reiterations of how health can be determined even before a patient enters the hospital or an outpatient clinical site. Blatt and colleagues present one such powerful example, and I highly encourage all pediatricians to read this article available in Pediatrics.
