How Redlining Continues to Affect Health and Life Expectancy in Marginalized Communities

Heart disease, type 2 diabetes (T2D), high blood pressure (HBP), and obesity rates are significantly higher in communities previously affected by historic redlining, according to data presented at the American Heart Association Scientific Sessions 2024. The findings bring awareness to the impact and consequences of structural racism on social determinants of health, such as access to healthy foods, leading to increased rates of chronic illness.

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What is redlining?

Redlining is a historical practice that denied individuals in urban and Black-populated neighborhoods access to credit, preventing them access to proper housing and other necessary resources. This was led by the Home Owner’s Loan Corporation, which sought to offer low-interest mortgage loans to help individuals recover from the Great Depression. However, there were restrictions to who was eligible for these loans.¹

“It was a process that the Home Owner’s Loan Corporation (HOLC) used in order to grade neighborhoods,” Rebekah Walker, PhD, associate professor and division chief of Population Health at University at Buffalo, NY, said in a Pharmacy Times® interview. “They grade them into 4 categories. The fourth category was colored red. That's where the term redlining comes from. And individuals living in that neighborhood were limited in their access to credit, mortgage, being able to obtain a mortgage, and so that really set in place a lot of socioeconomic factors for individuals in those neighborhoods.”²

As a result of redlining, tax revenue was decreased in these communities, leading to reduced investments in schools and government services. This lack of funding had a trickle-down effect, limiting access to quality education and, by extension, health education. Simultaneously, the absence of robust government programs left communities with inadequate infrastructure, resulting in poorer living conditions. These compounded disadvantages perpetuated cycles of inequity and led to their continued prevalence across multiple generations.¹

Redlining started in 1933 and was legal until it was prohibited by the Fair Housing Act of 1968.¹

How does redlining impact health?

Emerging evidence suggests that historic redlining continues to influence present-day health and mortality outcomes, both directly and through its effects on social risk factors that mediate these outcomes. To better understand the contemporary health implications of redlining, researchers analyzed data from over 11,000 US Census tracts across 38 states, focusing on whether limited access to healthy foods contributes to increased rates of heart disease, T2D, and other cardiovascular risk factors. Food access was measured at the census tract level by examining the proportion of healthy food suppliers relative to unhealthy ones.^1,3

The findings revealed a clear association between historic redlining and health outcomes, highlighting how limited food access plays a critical role in this relationship. In redlined communities, approximately 11.8% of individuals had type 2 diabetes, 31.9% had high blood pressure, 6% experienced heart disease, and 31.8% were affected by obesity.^1,3

“What we found was that the food access when there was less [sic] access to healthy food, that the relationship between historic redlining and these cardiometabolic diseases was explained through that pathway,” Walker said. “So, what it would suggest is that if we can introduce interventions that focus on improving food access at a neighborhood level, that we would be able to decrease the prevalence of the cardiometabolic diseases and mitigate some of that impact of structural racism on cardiometabolic outcomes.”²

Targeted interventions to improve access to healthy foods at the neighborhood level could help reduce the burden of conditions such as diabetes, high blood pressure, and heart disease, offering a pathway to addressing the lingering effects of structural racism on health outcomes. However, the broader implications of redlining extend beyond disease prevalence, touching on mortality and life expectancy.

Does redlining affect life expectancy?

Understanding the long-term effects of historic redlining is critical, as these systemic practices continue to shape health outcomes in measurable ways. Beyond increasing the prevalence of chronic diseases such as diabetes, heart disease, and obesity, redlining may also influence life expectancy in impacted communities.

The researchers’ analysis of life expectancy did produce statistically significant, associations between historic redlining practices and present-day diabetes mortality and years of life lost (YLL) rates. This was determined by 2-way T tests and spatial autocorrelation models, which assessed mean differences in mortality rates across different HOLC rating areas. They focused on diabetes-specific causes of death, as individuals with diabetes represent a population with chronic medical burdens that may be at elevated risk due to exposure to historic structural racism.³

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In areas with a 1-unit higher HOLC grade were associated with a 20.9% higher mortality rate in 1990 and an 18.5% higher mortality rate in 2014 for all causes of death. Areas graded as C or D indicated worse conditions and were associated with a 95.4% higher mortality rate compared to areas graded A or B, with statistical significance (P < .01). Additionally, mortality and YLL rates decreased across both low and high HOLC rating areas for diabetes and all-cause mortality. However, these disparity gaps persisted over the 25-year period, with significant differences across all outcomes, years, and causes.³

“And so, what does that really mean for us today? It means that even though we look at redlining as historic, they still have impact today,” Leonard Egede, MD, MS, FACP, professor and department chair of medicine at the University at Buffalo, said in an interview with Pharmacy Times. “And then even as we look at some of the contemporary measures, that tells us that there are still things happening today that have an impact on how people actually live and function, but I think the most important part is its impact on mortality. So, when your left expenditure is affected, it means it has long term impact on people's lives.”⁴

What is the path forward?

Addressing the lasting impact of historic redlining is crucial for tackling ongoing health disparities that continue to affect marginalized communities. These discriminatory practices not only shaped the physical landscape of neighborhoods but also set in motion a cycle of inequality that persists today. Reform will require a dynamic approach that involves increasing health care access, improving education, developing housing initiatives, and fostering economic empowerment.⁵

Food access is a critical aspect of this process, too, as diet is a significant indicator of overall health outcomes and risk of chronic disease. Walker stressed the importance of addressing the underlying factors that lead to limited food access, suggesting that removing barriers preventing people from accessing food in other areas could help address health outcomes.⁵

“Changing where bus lines run, improving the way that bus lines can get people to other areas, addressing some of the socioeconomic disparities that we see through things like financial incentives, cash incentives, that would be able to provide the funds that are necessary to purchase healthier food,” Walker said.²

Financial incentives and improving public transportation are just 2 examples of how targeted interventions can help individuals access the resources they need, particularly in areas where health food options are scarce. However, Egede mentions that addressing these health disparities requires more than just temporary fixes—it demands a deeper, systemic change in how policies are designed and implemented.

“We have argued that at some point we can't ignore the past,” Egede said. “We actually have to account for the past, but a lot of these things are tied to policy. So, policies are tied to housing, transportation, food, employment, education, and we believe that the more we learn about these pathways, the more we're able to change outcomes, and that policies really think about underlying poverty as a driver of some of these outcomes. But policies that change how neighborhoods are supported and [providing] the resources will make a huge difference.”⁴

The consequences of redlining extend far beyond higher rates of chronic diseases, significantly impacting life expectancy in affected communities. These disparities reflect a legacy of systemic inequities that continue to shape the lived experiences of individuals in affected communities. The path forward lies in reshaping policies that address the historical injustices of redlining and creating environments that foster equity and opportunity.

REFERENCES

1. Heart disease more common in past redlined areas linked to limited access to healthy foods. News release. American Heart Association. November 11, 2024. Accessed January 10, 2025. https://newsroom.heart.org/news/heart-disease-more-common-in-past-redlined-areas-linked-to-limited-access-to-healthy-foods#:~:text=Research%20Highlights%3A,outlawed%20practice%20known%20as%20redlining

2. Gerlach A. The impact of redlining on contemporary food access and cardiometabolic risk. Pharmacy Times. November 17, 2024. Accessed January 10, 2025. https://www.pharmacytimes.com/view/the-impact-of-redlining-on-contemporary-food-access-and-cardiometabolic-risk

3. Linde S, Walker R, Campbell J, et al. Historic residential redlining and present-day diabetes mortality and years of life lost: the persistence of structural racism. Diabetes Care. 2022. doi:10.2337/dc21-2563

4. Gerlach A. History to health: the lasting effects of redlining on life expectancy. Pharmacy Times. November 17, 2024. Accessed January 10, 2025. https://www.pharmacytimes.com/view/history-to-health-the-lasting-effects-of-redlining-on-life-expectancy

5. Egede L, Walker R, Campbell J, et al. Modern day consequences of historic redlining: finding a path forward. J Gen Intern Med. 2023. doi:10.1007/s11606-023-08051-4