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The Intersection of Structural Racism and Obesity

The first workshop’s second session was dedicated to the intersection of structural racism and obesity. Stephanie Navarro Silvera, professor of public health at Montclair State University, moderated and provided opening remarks, which were followed by presentations on housing and education and a discussion with the session’s two speakers.

Silvera proposed that racism provides a social and institutional framework for how people live, eat, and die. She likened it to an iceberg, suggesting that most efforts to address racism chip away at the top of the iceberg and appear to be making significant progress. But those efforts do not penetrate the submerged, most dangerous portion of the iceberg. Silvera explained two lenses through which she views issues of structural inequality: large “P” policy, which includes broad federal, state, and local laws that may or may not be specific to health (e.g., voting rights, housing, education, and health care); and small “p” policy, which includes organizational practices and policies that influence human behaviors, as well as large “P” policy, through funding availability, enforcement, intention, and equitability of policy application.

Silvera informed the audience that the session would explore the history of institutionalized racism in housing and education, and its influence on current behaviors and food and activity environments. Inequities and segregation persist in both residential environments and the educational system, she observed, and are related to obesity because, for example, geographic access to supermarkets in urban areas has been documented to vary according to income and race (often both). According to Silvera, the interconnectedness of housing’s impact on socioeconomic resources and the corresponding impacts on education and occupation, and ultimately health, manifest not only at an individual level but also at a generational level. Circling back to her initial statement about racism, she stressed that the environment into which one is born and the resources available affect one’s health at birth and throughout the lifespan, as well as educational attainment and income through a succession of interconnected systems that influence how people live, eat, and die.

HOUSING DISCRIMINATION AND DISPARITIES

Roland Thorpe Jr., professor in the Department of Health, Behavior, and Society at The Johns Hopkins University, deputy director of the Hopkins Center for Health Disparities Solutions and founding director of the Center’s Program for Men’s Health Research, and codirector of the university’s Alzheimer’s Disease Resource Center for Minority Aging Research, discussed the interplay of housing with structural racism and obesity.

Thorpe opened with a quote from a 2020 article in The Atlantic, “Sometimes racial data tell us something we don’t know. Other times we need racial data to confirm something we already seem to know.”¹ From Thorpe’s perspective, this quote inspires conversation about the broader systems that influence reality and also highlights that sometimes sufficient data exist to confirm a problem, which in turn propels action toward solutions.

Thorpe described pathways through which housing discrimination operates and through which structural racism influences housing disparities. The first is physical housing conditions, such as lead in a home. The second is housing affordability and stability, he continued, adding that a higher rent burden (i.e., a higher proportion of income spent on housing) has been linked to hypertension and poor self-rated health, and also consumes financial resources that otherwise could go toward health-related expenses. He explained that housing instability encompasses such outcomes as being behind on rent or mortgage payments, frequent moves, homelessness, eviction, foreclosure, displacement, and overcrowding. The third pathway is residential racial segregation, which he identified as a fundamental determinant of health, but one that has garnered little discussion with regard to its impact on housing.

Thorpe expounded on two pathways linking residential racial segregation to health: resource deprivation and risk exposure. Noting that segregation creates differential access to health-supporting resources, he pointed to associations between segregation and lower availability of full-service restaurants and supermarkets; fewer opportunities to access high-quality medical care; and fewer health clinics, physicians, and pharmacies (Bower et al., 2014; Gaskin et al., 2012a,b; LaVeist, 2011; Morland et al., 2002; Morrison et al., 2000). Moving on to the risk exposure pathway, Thorpe explained that segregation creates differentials by race in the health risk profiles of communities in which Black people and other minorities often live. Exposure to environmental toxins (e.g., lead paint in a home) often is greater in highly segregated areas, he stressed, as is the targeted availability

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¹https://www.theatlantic.com/ideas/archive/2020/04/coronavirus-exposing-our-racial-divides/609526 (accessed January 11, 2021).

of such hazardous products as tobacco, alcohol, and illegal drugs. He added that highly segregated areas are typically characterized by concentrated poverty, which tends to lead to high crime, low-quality housing, and a stressful environment.

Racial segregation in the United States distinguishes how people experience this country, Thorpe declared. He noted that minorities tend to live in more geographically distinct communities compared with Whites, which impacts housing. Not only does racial segregation lead to differential environmental and social risk exposures that exist within a long-standing system of structural racism, but other discriminatory practices, such as redlining, have perpetuated housing disparities. Thorpe highlighted the Homeowners Loan Act of 1933, whose objective was to help refinance nonfarm home mortgages at risk of foreclosure. This was to be accomplished by creating a Home Owners’ Loan Corporation (HOLC) to buy upside-down mortgages from banks and issue low-interest, federally backed 15-year amortized home mortgage loans that would reduce homeowners’ monthly payments. Banks would not issue loans to homeowners in certain areas in the city, he continued, which were designated with red lines on HOLC maps and corresponded to the areas where large proportions of Black people lived. The result was that Black Americans were systematically denied these loans, illustrating the point with the high proportion of redlined areas on a 1930 HOLC map of Macon, Georgia. He next showed a recent map of Macon, pointing out that even though the Fair Housing Act of 1968 outlawed redlining, the areas categorized as declining or hazardous on this map correspond to the previously redlined areas. Most (91 percent) of the redlined neighborhoods continue to be inhabited predominantly by minorities and 73 percent of these neighborhoods are low to moderate income (Jan, 2018). Most White people live in the neighborhoods categorized as “best” or “desirable,” he continued, which correspond directly to the areas designated as such in the 1930 HOLC map.

Turning to the potential influence of structural racism on diseases including obesity, Thorpe next presented a conceptual framework of pathways through which neighborhoods shaped by structural racism may contribute to racial/ethnic inequities in SARS-CoV-2 exposure and COVID-19 morbidity and mortality (Figure 3-1) (Berkowitz et al., 2021).

He cited attributes of low-resource neighborhoods—including pollution, limited walkability, lower-quality housing stock, low access to nutritious foods, less accessible health care, and overpolicing and crime-related stress—and pointed out that those attributes are also potential contributors to obesity. He added that during the COVID-19 pandemic, the same neighborhoods tended to have limited ability to practice social distancing because of crowded housing conditions, had fewer resources that were open and accessible, and had limited protective social environments.

The problems of structural racism, housing disparities, and obesity are at the systems level and are inextricably linked, Thorpe stressed, but he argued that these problems can be addressed with new, different approaches. He ended his presentation by listing four opportunities for achieving greater equity in health and health care for vulnerable populations, with an emphasis on reducing housing disparities. The first is improving housing affordability for people of color, perhaps through zero-interest loans. The second is providing people of color with not just living but thriving wages, a concept he noted is currently undefined but a ready topic for discussion. The third is investing in underresourced communities based on residents’ meaningfully solicited inputs on how best to make those investments. The fourth is forming cross-sector partnerships to facilitate health equity in housing and communities.

EDUCATION, SEGREGATION, AND STRUCTURAL INEQUALITY

J. Alexander Navarro, assistant director of the University of Michigan Center for the History of Medicine, discussed connections among institutionalized racism, housing, and segregation in the U.S. education system. One cannot understand inequality in education, he proposed, without understanding the role played by the courts in resegregating the country’s schools during

the past 70 years. The role of these court decisions is also important in the context of spatial U.S. geographic and residential patterns that reflect decades of legal segregation in housing. Segregation in education is described more accurately by the phrase “de jure” rather than “de facto,” he pointed out, because it is the result of legal segregation in housing versus an occurrence that exists in reality but lacks legal recognition.

Navarro reviewed a series of court cases he sees as key influences on education in the United States. In Brown v. Board of Education (1954), he began, the Supreme Court ruled that school segregation is unconstitutional, a decision that overturned the Plessy v. Ferguson (1896) ruling upholding the constitutionality of racial segregation under the “separate but equal” doctrine. In the Brown decision, the Court ruled that separate facilities are inherently unequal and therefore violate the Equal Protection Clause of the 14th Amendment. The following year, the Court’s Brown II (1955) ruling that school districts must desegregate “with all deliberate speed” placed responsibility for desegregation with local school boards. Although grievances are typically redressed immediately in cases of civil rights violations, he explained, this clause was problematic because it left room for school districts to resist desegregation. Many places refused to desegregate or did the bare minimum, Navarro recounted, which he described as evident based on the poor state of desegregation into the 1960s.

Navarro moved on to discuss Green v. New Kent County (1968), which he characterized as possibly the most important of the cases he would be discussing. Virginia had strongly resisted integration efforts even after the Brown decision, he noted for context, and began to relent only after passage of the 1964 Civil Rights Act tied federal funding to desegregation. Prior to the 1968 ruling, New Kent County students could choose to attend the county’s (previously all-)White school or (previously all-)Black school under a “freedom of choice” plan. Students could change schools only after sending paperwork to a state-run board; otherwise they were automatically assigned to the school they had attended previously. Despite this administrative requirement, several hundred Black students opted to transfer to the White school. Once there, Navarro continued, they faced opposition and harassment, and a resulting court case made it to the Supreme Court. The Court ruled that the freedom of choice plan was ineffective; that “the time for mere ‘deliberate speed’ has run out”; and that school boards have an affirmative duty to dismantle and eliminate racially unitary school systems, a component of the ruling that Navarro characterized as critically important.

Swann v. Charlotte-Mecklenburg (1971) was a turning point, according to Navarro, because the Supreme Court ruled that district courts can use three powerful tools to influence school district policies: (1) racial quotas can be used as a starting point for the development of integration plans; (2) courts can redraw district lines as an interim corrective measure; and

(3) courts can mandate and enforce busing plans for school districts to facilitate transportation of both Black and White students to opposite-race schools for integration purposes. This third provision was widely unpopular, Navarro explained, because of the burden it placed on students who were bused long distances (many of whom were Black). He also noted that this was the last time the Supreme Court was unanimous on a school segregation case.

Navarro next pointed to San Antonio v. Rodriguez (1973), which stemmed from the practice in Texas of deriving school district funding mainly from local property taxes and guaranteeing only a small proportion of that funding from the state. According to Navarro, this practice resulted in major disparities in school district funding, which led the San Antonio Independent School District to argue that children have a fundamental, constitutional right to education and that the Texas funding plan discriminated against children living in poverty. The district court agreed with the school district, but the Supreme Court struck down the lower court’s decision in ruling that (1) a federal, constitutional right to education does not exist; therefore (2) unequal school funding is not illegal; and (3) poverty does not make for a suspect class—that is, courts cannot view people who are poor as subjects of discrimination because of poverty itself. Navarro explained that this case set the stage for considering school segregation in light of residential housing and therefore funding patterns, and a rapid shift in segregation in education followed.

The following year, Milliken v. Bradley (1974) featured a plaintiff’s allegation that de facto school segregation in Detroit resulted from de jure housing policies. This was the first time a plaintiff had attempted to link segregation with housing policies, he pointed out, and the district court agreed that policies influencing geographic and residential housing patterns had contributed to school segregation. The district court ordered Detroit schools and 53 adjacent suburban school districts to desegregate, Navarro said, which was realistically achievable only by busing suburban children into the city and vice versa because of the way housing patterns had developed. But the Supreme Court disagreed with forced busing across school district lines, despite having ruled 3 years earlier (Swann, 1971) that districts could impose busing to facilitate integration. The Supreme Court suggested that the racial makeup of school districts resulted from housing patterns and not policies, Navarro elaborated, and that children in the suburbs could not be forced to bus across county lines to desegregate a different (i.e., the city of Detroit’s) school system. According to Navarro, this essentially meant that a Detroit-only desegregation plan was the only solution, but he questioned the feasibility of that approach given that Detroit at the time was rapidly becoming a majority Black city.

Navarro fast-forwarded to 1991 to review Oklahoma City Schools v. Dowell, a case that spanned a decades-long series of events in which

Oklahoma City attempted desegregation via neighborhood zoning and then busing. After integration was achieved in the late 1970s, the busing mandate was removed, and resegregation ensued, yet a district court ruled that any segregation had resulted from neighborhood housing patterns, not from school district discriminatory practices. The Supreme Court agreed that because the school district had complied with the original desegregation plan and the vestiges of de jure segregation had been removed, schools did not need to continue with court-mandated desegregation plans. According to Navarro, the ruling effectively communicated that school segregation based on racialized housing patterns was legal. In light of this decision, he maintained, school resegregation has increased dramatically since 1991.

Navarro discussed a final case, Parents Involved in Community Schools v. Seattle (2007), which developed as a result of the practice of using race as a tiebreaker for admission to competitive high schools in Seattle, intended to ensure some level of diversity in those schools. The Supreme Court agreed with the parents that the practice was unconstitutional and that students cannot be classified on the basis of race despite diversity goals. Furthermore, the Court ruled that because Seattle was never under a desegregation order, the state had no compelling interest in using race for school admission. In short, he said, this ruling indicated that segregation based on housing patterns was not illegal.

Navarro shifted to describing the current state of school segregation, referencing data indicating that more than half of U.S. students attend a racially concentrated school (García, 2020; Schaeffer, 2021). Racialized poverty is a “double whammy” for students of color, he contended, because poor students of color fare worse than poor White students. Students of color are twice as likely to live in poverty as their White counterparts, he pointed out, and are at least five times as likely to live in an area of concentrated poverty, with associated negative social and health effects (Creamer, 2020; Kneebone and Holmes, 2016; National Equity Atlas, 2019). Even though school integration has been recognized as one of the best paths to achieving racial equity, he asserted, school resegregation has accelerated in recent decades, and he reiterated that it is tied directly to residential segregation.

Navarro cited as a key issue to keep in mind that the Equal Protection Clause of the 14th Amendment has become a double-edged sword. It was a powerful tool in the past, he observed, but he believes it has become weaponized and now ensures that institutions can make race-blind decisions even when attempting to address racially mediated systemic problems. In addition, he argued, the courts do not reliably provide remedies as they did for plaintiffs between the late 1950s and early 1970s. The connections between racialized residential patterns and school segregation are well known, he maintained, but he stressed that the courts have routinely refused in recent

decades to address these connections in a meaningful way. He reiterated his assertion that “de facto” school segregation is a misnomer, and that the phenomenon instead results from legal segregation and residential patterns. These conditions were initially bolstered by Jim Crow–era policies, he added, and have been fueled more recently by policies that privilege private capital, private development, and urban renewal programs that he asserted are aimed at affluent populations and seek to protect White sensibilities regarding “who gets to live where.”

Finally, Navarro shared his belief that school reform alone is a dead end. He contended that such programs as schools of choice, voucher programs, and charter schools fail to address the root problem, characterizing them as conservative, “pseudo free market approaches” to public education. He contended that introducing competition among schools does not work because public education is not a commodity, and treating it as such feeds into the notion that de facto school segregation results from market forces and from who buys homes in which neighborhoods and communities. In closing, he argued for viewing public education as infrastructure rather than as a commodity.

PANEL AND AUDIENCE DISCUSSION

Following the two presentations summarized above, Silvera moderated a discussion with the speakers, which was followed by a round of audience questions. Topics addressed included ideas for effecting systemic change by intervening on root causes, such as housing and education, and by promoting multisector involvement and community engagement.

Effecting Systemic Change by Intervening on Root Causes

Silvera observed that racialized segregation in housing and education are so deeply entrenched that they may not be recognized as consequences of policies, and she asked the speakers for suggestions about where to intervene to address the root causes of these issues. Thorpe suggested that it is necessary first to acknowledge the existence of structural racism, and then to apply both federal-level and local municipality–level approaches simultaneously to address political determinants of health.

Navarro predicted that the current Supreme Court, with its conservative makeup, is unlikely to produce a court-based solution to these issues any time soon. He agreed with Thorpe that both federal and local actions are important. He cited housing voucher programs and the Internal Revenue Service’s low-income housing tax credit program as examples of federal programs that are ineffective in addressing structural inequality in housing because they focus on keeping people in high-poverty areas instead

of moving them to high-opportunity areas. He suggested examining local zoning and housing ordinances, which he said have racial implications regarding “who gets to afford to live where,” and cautioned against incentivizing gentrification that displaces current inhabitants. He appealed for increasing access to capital for communities of color, alleging that these populations have been denied access to the home-buying market under racialized policies operating under the guise of other issues, such as using credit score as a proxy for race.

Effecting Systemic Change through Multisector Involvement and Community Engagement

Addressing a participant’s question about who is responsible for driving changes to address structural racism, Thorpe called out people who are in positions that maintain the structures involved, such as government officials and corporate decision makers. In terms of obesity solutions, he mentioned building grocery stores in food deserts as a way to both address food insecurity and provide employment for community residents, as well as using government or corporate capital to fund schools in establishing urban gardens that can be used to teach students while producing fresh produce for the community. Silvera underscored her belief that all policy is health policy given the multisectoral influences on health, and that all politics are local, which is the level at which she said policy has a direct impact on individuals and communities.

Navarro observed that when cities undergo urban renewal, much of that capital is directed to large developers and corporations. He proposed allocating a proportion of capital to community-based organizations owned and operated by residents, who he said typically lack the connections needed to secure a seat at the table when capital is being distributed. Silvera agreed and emphasized the value of amplifying community voices to better understand challenges and cocreate solutions that will be a good fit for the community, such as ensuring that foods provided to improve food access are culturally and ethnically appropriate.

Thorpe built on Silvera’s statement about health in all policies, pointing out that sectors tend to work in silos, but that partnering on seemingly unrelated but interconnected issues could leverage expertise and resources to achieve greater benefit relative to working independently. Navarro mentioned the Flint water crisis as an example of a health issue with broader systemic influences, stemming from a decades-earlier White flight out of Detroit, the city’s deindustrialization, and remaining residents’ loss of water access due to unpaid water bills. These events made such a crisis inevitable, he contended, rather than the result of a series of unforeseen consequences.