This episode is part of a 3-part series on Race, Place, and Health. In this episode, we invite Mr Richard Rothstein, distinguished Fellow of the Economic Policy Institute and acclaimed author of the book, The Color of Law: A Forgotten History of How Our Government Segregated America, and Professor Fernando De Maio, PhD director of research and data use at the AMA's Center for Health Equity, professor of sociology at DePaul University, and co-editor of the recently published book, Unequal Cities: Structural Racism and the Death Gap in America's Largest Cities, to share their expertise on structural racism, neighborhood segregation, and health inequities.
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The Clinical Problem Solvers Antiracism in Medicine Podcast Series aims to equip listeners with the consciousness and tools to practice antiracism in their health professions careers.
Rohan Khazanchi, MPH: What's up, everyone? This is Rohan Khazanchi, and welcome back to episode 11 of the Clinical Problem Solvers: Antiracism in Medicine series. This episode is titled Racism, Redlining and the Path Towards Reconciliation. And this episode is focused on the historical and present-day implications of neighborhood redlining and housing segregation. This will be the first of three episodes interrogating the relationships between race, place, housing, and health, and we're so stoked to dive deep into these critical issues, knowing well that their consequences manifest every day in our clinics and hospitals. As always, our goal in this podcast is to equip our listeners at all levels of training with the consciousness and tools to practice antiracism in their health professions careers. I'm excited to be joined today by my superstar team members, Dr Jenni Tsai and Dr Utibe Essien, who I'll ask to introduce our guests.
Jenny Tsai, MD, M.Ed: Hey, everyone. This is Jenni. I am so thrilled to introduce Professor Fernando De Maio. He's the director of research and data use at the AMA Center for Health Equity. He's also a professor of sociology at DePaul University and co-editor of a new book just published this year titled Unequal Cities: Structural Racism and the Death Gap in America's Largest Cities. On a more personal and somewhat more romantic note, when I met Fernando, I told him he was like the manifestation of my dreams as a medical student. He's doing all the kind of really incisive, critical work that I really yearned for when I first started medical training. And so I continue to learn from him and am just so excited that he's here with us today.
Fernando De Maio, PhD: Thank you so much for having me. And Jenni, that has to be the best introduction I've ever had. So thank you.
Utibe Essien, MD, MPH: As always, big shoes to fill after following Jenni. But I have the distinct honor of introducing Mr. Richard Rothstein, who is a distinguished fellow of the Economic Policy Institute. In 2017, he published an incredible book, which you've all seen me talking about on social media, The Color of Law: A Forgotten History of How Our Government Segregated America. Again, it's now one of a favorite of mine and many of our team members. It's on our shelves and many of our manuscripts citations. Richard, thanks so much for joining us today.
Richard Rothstein: Well, thank you very much. I also got a romantic introduction.
Essien: We aim to please here on the antiracism podcast. So I have the opportunity to start us off with our conversation today. And Richard, I'll start with a question to you. So over the past year and a half, we've seen this renewed enthusiasm for the issue and topic of structural racism, especially in our field of medicine. We've heard words such as redlining, restrictive covenants, predatory lending become a part of discussions in research papers in ways that we've never heard before. And so I was hoping you could help provide some clarity to some of that language and in particular, the two key phrases that you use in your book, both de jure and de facto segregation. Maybe we can start off there.
Rothstein: Well, I'm going to divide that into two separate questions. I'll take the second one first. We have a national myth rationalization that we've all adopted, Blacks and whites, liberals, conservatives, northerners, southerners, Democrats, Republicans. The myth is something like this. It says that the reason we have such a segregated nation, really an apartheid society when it comes to neighborhoods, is because of private activity and personal choices. We're segregated because some bigoted homeowners wouldn't sell, white homeowners wouldn't sell to African Americans in white neighborhoods or landlords wouldn't rent to them or private businesses, real estate agencies, banks, developers excluded African Americans from white neighborhoods. Or maybe we tell ourselves, this has become even more popular lately, that Blacks and whites just like to live with each other, the same race. We feel more comfortable that way. And that's why we're segregated. Or maybe we say it's just a result of income differences. All of these individual, personal, bigoted decisions is why we're segregated. And we give a name to this. We say what we've got is de facto segregation, something that just happened, in fact, by accident, naturally. Once we adopt that view, we have no obligation to do anything about it. It's not a constitutional violation, it's not a legal violation when it was done in the mid-20th century and created a segregated pattern. The reality is that the federal, state and local governments were intimately involved in creating the segregation that we know. More than intimately involved, they structured it, they designed it, they enforced it and they perpetuated it. Segregated neighborhoods are a constitutional violation.
They are as much a violation as the segregation that we eliminated in the 20th century, whether of colleges and universities or lunch counters or buses. The problem is that it's hard to undo once we've done it. If we pass a law prohibiting segregation of restaurants, next day, you can go to any restaurant you want. We pass a law prohibiting the segregation of neighborhoods, the next day, things wouldn't look much different. So that's why we have adopted this rationalization of de facto segregation. It's a very common term. It's used by everyone. Its opposite, the term that describes the reality, is less commonly used by the public, de jure segregation. It means what I described, segregation that was unconstitutionally imposed by federal, state, local governments. And if we understand that segregation was unconstitutional, we created, that would move us forward to understand that we have an obligation, not just an opportunity, but an obligation to redress it, to remedy this constitutional violation, civil rights violation that is the segregation of this society. So it's not just a distinction and description between de facto and de jure segregation. Once we understand we have de jure segregation, changes the way we look at what our obligations are to redress it. Have I taken too much time or should I go on to the other part of your question?
Khazanchi: Not at all. I think we can maybe jump in and we'll circle back as well to you. But I would love to give Fernando a chance to dive in here, too. So you just published, Fernando, a book with your colleague, Dr Maureen Benjamins, titled Unequal Cities: Structural Racism and the Death Gap in America's Largest Cities, and a lot of what you touch on is how our present-day health inequities relate directly to these concepts that Richard has just defined for us. So what I want to ask you is what do de jure and de facto segregation have to do with the crucial public health outcomes that determine the length of our lives.
De Maio: Great, great. Yeah. And thanks again for hosting this conversation. And Richard, it's a pleasure to be in conversation with you. Your book has been very impactful to many of us in public health and social epidemiology. And I think we have several underlying concepts in common, the concept of structural violence being first and foremost with the social and political arrangements that literally harm populations. That's very much a concept that's at the core of our book Unequal Cities, which is essentially an assessment of health inequities and how they vary from place to place. In healthcare and in public health as well, we tend to think of health inequities as big, monolithic, deeply entrenched patterns, and they are, but their variability is really important. It gives us a sense of how different things can be. For a long time, I've been interested in the dynamics of health inequities, how patterns vary, say, between communities in a single city or across cities or across time. For me, that's really important to understand. It gives us a sense that health inequity is not a utopian dream. So in Unequal Cities, we had to look at the 30 largest cities in the United States and looked at Black/ white differences or gaps in life expectancy, premature mortality, death before age 75 and cause-specific mortality for the top 10 causes of death from heart disease and cancer to kidney disease and suicide, plus three causes that aren't in the top 10 but are nevertheless priorities because there are substantial inequities, HIV, homicide and opioid-related mortality. There are lots of different ways of quantifying inequities, and to be sure, there are limitations of our approach. A big one is that we only looked at aggregate differences between two groups, between Blacks and whites. And while this is a valuable lens, it doesn't tell the complete story of health inequity in the United States, of course. And in the book, we also presented data from 2013 to 2017, the most up to date mortality files that were available at the time we wrote the book. In related articles, we're exploring trends over time, plus newer data that's going to look at the effects of COVID and more.
But very quickly, let me give you the top line summary of what we found and how it relates to Richard's book and the deep patterns of segregation in our society. Just looking at life expectancy across the United States, we stand at 78.6 years on average. Between our 30 largest cities, there's a 10-year gap in average life expectancy, from a low of 72.9 in Baltimore to a high of 82.9 in San Francisco and San Jose. Black life expectancy ranges from 70 years in Houston to 78.7 in New York City, while white life expectancy ranges from 75 in Baltimore to more than 85 in Washington, DC, as high as anywhere else in the world. Across the country, we have a four-year gap in life expectancy between Blacks and whites, but this ranges. The highest gap is in Washington, DC, a gap of 12 years. El Paso has no gap in the life expectancy between Black and white residents. My home city of Chicago fairs very poorly in this, with a gap of more than 8 years. This amounts to over 3000 excess Black deaths every year. Critically, and I think this will relate to Richard's notions of the myths that we carry for the explanations of patterns that we see in our society, the gaps that we see are not the products of individual behaviors. They are not the product of lifestyle choices or the behaviors and biology of individuals. But the data reflect there are really deep-rooted structural drivers that are manmade. They didn't appear just by accident. They were created by policy in healthcare, but also in housing, in labor, economic policies of all kinds, that systematically advantaged some groups and systematically disadvantaged others. And it shows up in residential segregation patterns and in our mortality outcomes.
Tsai: I think those are—the word that came to mind was incredible statistics, but really what they are damning, and I think it speaks so much to exactly like you said, these are engineered phenomena. I think something that we've all kind of discussed on this podcast and in our individual work is to think about how these things don't just fall into our laps. I think, Professor Rothstein, your book speaks of that tremendously, and you demonstrate chapter by chapter how state-sanctioned violence in the form of court enforcement, law enforcement in the 1950s, before and after buttress neighborhood segregation. We see this conversation happening today and sometimes even more in our circles in medicine regarding both police violence and differential surveillance, but also inhibited migration of marginalized communities. To what extent do you see a through-line between these moments in history? Especially because, as you mentioned in your book, sometimes the damage is done, and by the time it's reversed or struck down, the patterns that we see, the segregation that we see is already so imposed.
Rothstein: Actually, this goes directly to the first question that you asked me about structural racism. What does that mean? It's not a term that most people understand, and I don't use it for that reason. But what it means is that when you have two groups of people who have different social and economic circumstances, anything that you do, any policy that you implement that applies society wide is going to have different impacts on those two groups simply because the underlying conditions on which you're imposing this, a systematic policy or condition, is going to have different impacts because of their different situation. So for example, we know that African Americans suffer from COVID much more than whites do. On average, the hospitalization rates are higher, the infection rates are higher. Well, that's not because the COVID virus has a racial aspect to it. It's because African Americans and whites are living in such different circumstances that the virus affects them differently. African Americans are living in much more dense neighborhoods. So the possibility of transmission of infection is much greater. They work in jobs that can't be done from home in front of a computer, but that require contact in retail establishments or restaurants or warehouses. So you have this race-neutral virus that isn't programmed to affect African Americans and whites differently, but affects them very differently. And so what we have throughout this society is many, many policies and practices that may be race neutral on their face, but they have different impacts on Blacks and whites, and frequently worse impacts on Blacks than on white as in the case of the COVID virus.
Khazanchi: Yeah, I think that's such an illustrative example, and we've discussed COVID-19 at length on this podcast because of how present it is for all of us in our health care system right now. And it is a clear example that racism and not race is the driver of health inequities and the inequities that we've seen in COVID. Fernando, do you want to jump in?
De Maio: Yeah, if I can just jump in, one of the big lessons of this is that COVID is not the anomaly. The same patterns that we see, the drivers of structural racism affect everything from diabetes to asthma to obesity, cancer and heart disease. They affect population health at large. It's been visible, it's been recognized. It's been in our face because of COVID, but it's been underlying population health in this country for a very, very long time.
Rothstein: Let me add that I think it's important to explain how these things work because most people or almost all people don't understand it, terms like structural racism or don't help eliminate it. So for example, you mentioned, Fernando, asthma. We all know that African American children have asthma at greater rates than white children do. Why? It's not because their lungs are born differently. It's because African American children live in neighborhoods that are more polluted, closer to industrial sites, more trucks driving through the neighborhoods, more dilapidated buildings throwing off dust, more vermin in the environment. And if a child has asthma, that child is more likely than a child who doesn't have asthma—it's not true in every case, you all know that, but on average, more likely to be up at night wheezing. And then coming to school next day drowsy, sleepy from lack of sleep. And if you have two groups of children who are identical in every respect, identical in every respect, same racial composition, same socioeconomic background, same family structure, same everything, except one group has a higher rate of asthma than the other, that group is going to perform more poorly in school simply because it's, on average, sleepier when they're being taught. So that's how structural racism works. As I say, it's not because African American children are born with weaker lungs than white children. It's because once you have two groups of children who are exposed to different socioeconomic conditions, they are going to be affected differently by things that don't seem to have anything to do with race on their face.
De Maio: Right, right. We have lots of conversations, I think, in medicine and public health and the related fields about the importance of naming racism and structural racism in particular. This past year, I published a paper with Aletha Maybank and Nancy Krieger, and we avoid looking at the systematic marginalization and exclusion of the word racism in many of our top journals. And we thought that was a really harmful act, that without naming the problem, and it's our collective responsibility to explain it, to define it, to communicate it in effective ways to physicians, to health care systems, to the public at large and really detail, with data and with narratives, all the ways through which racism impacts our health. It gets under our skin through bodily processes, through labor policies, through education policies. To be sure, I think that's one of the greatest challenges that we have in health equity work, in medicine and public health, in all our fields over the coming years. And certainly, I really appreciate the importance of centering really the analysis of the deep roots of segregation as part of that story of health inequities.
Tsai: Mr Rothstein or Richard, we encourage first names, but I'm having a little difficulty. I think from the get go, you talked about this myth of personal behaviors and private agreements driving a lot of segregation. And I think your book lays out tremendously and with example after example of how that's just not true. On this topic of being specific about structural racism and examples of that so that we have a shared vocabulary and we aren't being vague about what we're referring to, can you quickly choose one of your many anecdotes to kind of poke a hole in that myth to share with our readers, actually, it wasn't just people choosing to live amongst people that seemed more like them. They were actually directed specific and explicit measures put forth by the Federal Housing Association and other powers that makes this very clearly de jure segregation?
Rothstein: Sure. I'll describe one policy that I think you're probably asking me to go into detail about, a very powerful policy followed by the federal government to ensure that African Americans and whites could not live near one another in any metropolitan area of the country. In the mid-20th century, up until the mid-20th century, working class and middle-class African Americans and whites all lived in urban areas. We didn't have suburbs. They all lived in urban areas. The reason why is that we were a manufacturing economy, and factories had to be located near deep water ports and railroad terminals to get their final products and to get their parts and shipped their final products. And workers, as well as bankers and other surface industries that serviced these manufacturing plants all had to be located in the same central area. People didn't have cars to drive to work. They either walked to work or took shared streetcar rides. Well, in the 1940s, and especially ramped up after World War II, the federal government embarked on a program to suburbanize the entire white working class and middle-class population to get them out of cities into single-family homes in the suburbs. This was a federal policy to suburbanize whites and to prohibit African Americans from joining them. It was a policy of the Federal Housing Administration and Veterans Administration. And you know about it even if you can't name it. Every metropolitan area in the country has suburbs that were created for then working class and lower middle-class families in the 1940s. The most famous of them is probably Levittown, east of New York City. 17 000 homes in one place, the developer William Levitt proposed to build.
He couldn't build it because no bank would be crazy enough to lend him the money to buy the land to construct a development of 17 000 homes. As I say, we weren't a suburban country at that time. Not only did the banks refused to lend money to something so speculative that nobody had bought but they thought it might be crazy to want to live there. Nobody lived out in the suburbs, they lived in the urban areas. The only way that Levitt could build this subdivision—and this was true everywhere in the country. I don't want to imply that this was unique, suburbs like this were developed everywhere. The only way he could develop it was by going to the Federal Housing Administration and Veterans Administration, submitting his plans, the architectural designs, the materials that were going to be used, the layout of the streets, and a federally required commitment never to sell a home to an African American. The Federal Housing Administration and Veterans Administration even required that Levitt placed a clause in the deed of every home prohibiting resale to African Americans or rental to African Americans. This was a federal requirement. It wasn't the action of rogue bureaucrats working in the Federal Housing Administration or Veterans Administration. It was written out in the federal policy manual that was distributed to appraisers all over the country, whose job it was to evaluate applications of developers for federal bank guarantees. The manual said you couldn't recommend for a federal bank guarantee a project that was going to include African Americans. The manual went so far as to say that you couldn't recommend for a federal bank guarantee a development that was all white, but it was going to be located near where African Americans were living, because in the words of the manual, that would run the risk of infiltration by inharmonious racial groups.
And I have in my book, The Color of Law, a photograph of a wall created in Detroit the developer was required to construct in order to separate his all- white development from an African American city. And unless he did that, the Federal Housing Administration wouldn't guarantee his development. So he built the wall. Well, this had enormous consequences because the country was suburbanized in this way for whites only, the homes were inexpensive. Levittown, for example, homes sold for about $8000 apiece. In today's money, that's $100 000. White working-class families could buy those homes and pay less than their monthly mortgage payments and amortized mortgage that the Federal Housing Administration, Veterans Administration guaranteed, pay less than their monthly housing charges than they were paying for rent in apartments in urban areas. Black families, as I say, were prohibited from doing this. Well, over the next couple of generations, those homes added value. They increased in value not only in Levittown, but these suburbs all over the country, they all would sell for $100 000. You can't buy a home in these suburbs for $100 000 today. They sell for 200, 300, 400, 500 thousand dollars. In some places, a million dollars or more. A 100-thousand-dollar home selling for a million dollars or more. The white families who bought those homes gained wealth from the appreciation in the value of their homes. They used that wealth to send their children to college. They used it to take care of temporary emergencies, medical maybe or temporary unemployment. They used this to subsidize their retirements, and they used it to bequeath wealth to their children and grandchildren, who then had down payments for their own homes. African Americans were prohibited from doing this. So we now have an enormous wealth gap in this country.
On average, African American incomes are about 60% the white income, 60, 70%. That's a big disparity. I don't have the time to go into the causes of that. But you'd think that if there was a 60% income gap, there'd be a 60% wealth gap as well. Families can save the same amount of money from the same incomes. But in reality, while African American incomes are 60% of white incomes, on average, African American household wealth is about 5% the white wealth. And that enormous disparity between a 60% income ratio and the 5% wealth ratio is entirely attributable to unconstitutional federal housing policy that was practiced in the mid-20th century and whose effects endure today. The wealth gap underlies not only the health disparities that we were talking about before, the concentration of African Americans in less healthy neighborhoods that contribute in large part to differences in health outcomes, contribute to differences in school achievement, as I described before, in the case of asthma, contribute to mass incarceration and police abuse of African Americans. I'm not saying that police would never abuse an African American if we hadn't imposed this kind of segregation on them. But when you concentrate the most disadvantaged young men in single neighborhoods without access to good jobs or the transportation to get to them or schools that aren't overwhelmed with the social and economic problems of the children, it's inevitable that the police are going to not only engage in confrontations with them, but adopt tactics of control, disaffected the marginalized populations not only in this country, but throughout the world. And let me say this, the wealth gap that contributed so much as a result of this single policy to the racial inequality we have today is also responsible for something that's very frightening and dangerous.
And that is the enormous political polarization that we have in this country today. It's frightening, it's dangerous, probably as great as we've had at any time since the 1850s. It's not entirely racial, but we all know that the political polarization largely tracks racial lines. How can we ever expect to develop and protect the common identity that's necessary to preserve this democracy? If so many African Americans and whites live so far from each other, they have no ability to empathize with each other, no ability to identify with each other's life experiences. So the consequences of this policy practiced in the 1940s and 1950s are enormous, and they persist even without reinforcement. They are reinforced by some ongoing discrimination, but that's not the main cause. They persist because it takes action as affirmative to undo it as the action that created it.
Essien: Wow. Well, when we asked you to join us, Richard, on the pod, I think we knew we were going to get educated. That was a really powerful word just to remind us that none of this is new. We have the legacy, we have the history of these laws and policies that have brought us to where we are today. And you mentioned that a lot of this has been inconsistent and it's not necessarily been anything—unless we have affirmative changes, affirmative decisions that are being made, we can't actually change it. And so I wanted Fernando to get your thoughts about that. I think you've written a lot about what kind of structural reforms can be done. One of your pieces earlier this year talked about the structurally competent healthcare system. In your book, you talk about certain cities, like you mentioned El Paso, that don't have those racial disparities. So what do you imagine are some of the potential paths forward, especially to addressing the racial disparities that have come from these wealth gaps that were just described?
De Maio: Great, great. A lot of what Richard was just describing also reminds me of, I think, one of the best books that I've read and has informed my work, and that's a book by Richard Wilkinson called Unhealthy Societies. It was published back in the mid-1990s. It was kind of the seminal work in social epidemiology that started all of our work around the income inequality hypothesis, where we were using tools mostly from economics to measure inequities in income and wealth and how they correlate with health outcomes. And it's raised a lot of interesting questions that I think are very much mirrored where Richard explores in his book as well. Is income inequality what we call a determinant of health or is it itself a consequence of deeper lying root causes? And so we have to think about things like neoliberalism, capitalism, the power of markets, the power of welfare systems, things that most public health schools and certainly most medical programs don't engage with in systematic and structured ways. That's really where our Unequal Cities analysis really landed in the structural roots, at the city level and larger, that drive the patterns that we see in our epidemiology. And it's frankly a huge challenge. We're just starting to scratch the surface of this. With some of our cross-sectional findings that I mentioned before, we looked at really the effects of income inequality and racial segregation using tools like the index of concentration at the extremes and the Gini coefficient. And in general, we found that inequities in income and mortality go hand in hand. When we looked at policies, we found very mixed results.
We looked at data that scored cities along a continuum, awarding gold, silver, bronze, or no stars if they had a range of health equity promoting policies from inclusionary zoning regulations to boost affordable housing stock, into tobacco policies, universal access to pre-kindergarten and more. As you might expect, across the board, there was a gradient. Across the board, the cities with the gold stars tended to have much lower levels of overall mortality. And that's the good news. But even among the gold star cities, we had devastating levels of inequities in terms of mortality rates, life expectancy, excess deaths, all of the IP indicators. That's the bad news and the real challenge before us, what needs to change in terms of public policy, in terms of health system policy, labor, housing to specifically target the elimination of health inequities as an overarching goal. In the long run, that's what we hope to do. We hope to see health equity research having a synergy between quantitative social epidemiology, the kind of work that features in our book, with other perspectives like legal epidemiology, the kind of work that features in books like Daniel Dawes, The Political Determinants of Health, and also where books like Richard's, The Color of Law, have been so influential. And so this kind of merging in synergy between the traditional epidemiology that's in a comfort zone for public health and medicine and branching out to these related fields that could really inform the causes of the causes.
Khazanchi: Yeah. Richard, I'd love to turn to you. I think this totally mirrors some of the discussion that you had in The Color of Law, which was that you alluded similarly to remedies as a path forward from the legacy of segregation and towards a future which understands healing and reconciliation as our final goal. So related to what Fernando talked about, what do you think are some of the paths we can take or advocate for, even beyond the walls of our clinics or hospitals or healthcare systems, recognizing that, as Fernando so astutely pointed out, we can move the needle, but even with many of these policies, we might not get all the way there. There might be more needed beyond this, but just curious to hear what you think about possible remedies for our past harms.
Rothstein: Well, we need to move the needle, and that will be very incremental and small. And I don't engage in utopian thinking. We know what the policies are to create equality, a more equal society and a non-segregated society. What's missing is not policy ideas. What's missing is a new civil rights movement that's going to create the political environment where those policies have to be implemented. Some of them are quite radical, it seems, although quite necessary and required under our constitution. Some of them are very incremental. But the political environment doesn't exist for any of them. So I resist talking too much about remedies because I want to talk more about how we create that new civil rights movement. But let me give you some examples. I mentioned the suburbs and how they were created by an unconstitutional policy. I'll use again the example of Levittown, because that's one that I think people are most familiar with. Those homes sold for $100 000 in the late 1940s, early 1950s on a segregated basis. They now sell for 300, 400, 500 thousand dollars. Levittown, as a result of the Fair Housing Act, which was passed in 1968, it said in effect, "Okay, African Americans, you now are allowed to live in Levittown. We're no longer going to prohibit you from living there." And as a result, Levittown is now about 1% African American, maybe 2%. I haven't looked at the 2020 census data yet, but maybe 2%. In a broader neighborhood in Nassau County, east of New York City, that's about 12%, 15% African American. The federal government should be buying up homes in Levittown at market rates as they come for sale, 300, 400 thousand dollars, and reselling them to qualified African Americans at deeply discounted prices.
Maybe something closer to $100 000. That's a narrowly targeted remedy for a very specific constitutional violation. It's not some magic idea, it's a narrowly targeted remedy to a very specific constitutional violation. But we're nowhere near having the political environment in which that can be accomplished. There are many other things that are much smaller that can be done. For example, the biggest program that we have now for subsidizing housing for low-income families, disproportionately African American, is a low-income housing tax credit. It's a federal program tax credit that's distributed to states who then distribute it to non-profit organizations who then sell them to developers to build housing for low-income families. That program reinforces segregation because developers would much rather build low-income housing in existing low-income neighborhoods. Land is cheaper there. They don't have to hold 100 community meetings explaining why you're bringing Black people into someone's neighborhood. It's not hard to advertise a vacancy. You just put a sign in the window and a low-income person will walk by and see a for rent sign. Well, that can be reversed easily by placing a priority on the use of these tax credits in higher opportunity communities. Another thing needs to be done also, though, and we should prohibit the use of this credit for creating segregated developments in other communities that's concentrating low-income families in segregated projects than simply being located outside of segregated neighborhoods. The problem is that the housing in many communities—I don't know if it's true in Pittsburgh, where you are, where this is hosted.
But in many communities, housing is now becoming increasingly unaffordable even to working class and middle-class families, not only to low-income families. And we have no subsidy for housing for middle class families. When the private sector is unable to create housing for under current market conditions, we need to insist that any new developments have housing that's available not only for marketable families and not only for low-income families with the low-income housing tax credit, but also for moderate income families who require a subsidy and for which there is none available. Now like I say, there is no political support for those kinds of ideas today, even obvious, though, they may be, as they constitutionally require remedy for unconstitutionally created de jure segregation. That's why I'm much more focused on how do we create a new civil rights movement? And let me say that I am working with and helping a group of national civil rights leaders create something that they call the new movement to redress racial segregation. And the idea is to create local groups, not advocate national policy, pie in the sky national policy, but local groups that are going to, like the civil rights movement of the 1960s, take direct action in their local communities to advance small steps towards these segregation that hopefully will build towards a national movement that will make national policy more possible. I think that they are planning—they're hiring staff now to send to local communities where there's interest. I think they're planning to launch in January of 2022.
And when it launches, what they are going to do is examine the responses they get to the launch, see where they're concentrated, where we have a collection of both African American and whites wanting to become members of this new movement, and they will send staff to help them research the segregation of their own community and design a strategy to redress it.
De Maio: If I can just jump in, Richard. You've got me thinking of the remarkable impact that the fight against racial segregation in hospitals and health systems had in and how important it was within the 1960s civil rights movement and perhaps of the potential that this new wave of health equity work, this activism that's around COVID, but other conditions as well, will contribute in a similar way moving health systems to think of not just who lives and dies within the walls of the hospital, but the responsibilities of health systems to their communities at large. So we go from thinking about hunger as an individual-level social need to thinking about food security in a community to the supermarket redlining that influences that. And the same thing with housing security and the policies that severely limit opportunities for all.
Rothstein: I have a friend and colleague. Her name is Layla Morsy, M-O-R-S-Y, and she's actually a professor in Australia at Flinders University, who is writing a book similar to mine about segregation in the medical system, going back to the early 1900s, and documenting that the segregation of medical care was as vicious as the segregation of housing that I've described, and how its ongoing effects also contribute to the health inequities that we find today. I will put her in touch with you as she works on this. I've seen some drafts of early work that she's done. It's phenomenal stuff. It shocks even me, about the segregation of medical care, the history of it and how unconstitutional as well as unlawful it was and what its ongoing consequences are.
De Maio: Yeah, vital. And I'm so happy to say that that's a topic and an issue that the American Medical Association and many others across medicine are really doing some deep listening around and searching around and learning around the effects of the closure of Black medical schools as a result of the Flexner Report and the real consequences that's had for community health for generations over time. That's something we're just beginning to grapple with and understand. So I'm sure all of us would welcome your colleague's book.
Tsai: Yeah, absolutely. And I think it's something that we think about as trainees, as people who are residents. We, I think, see that in our teaching hospitals and it's a big part of our training that kind of sticks in your mind. These were excellent and practical and specific recommendations. Mr. Rothstein, a.k.a. Richard, we usually end our episodes—and I know you have to leave pretty soon. We ask our speakers to share a tip for those on the call and for those that are listening, something specific that they can take to the clinics or the hospital wards tomorrow. So when I wake up and put on my maybe clean scrubs and swing my stethoscope across my neck and I enter the hospital, what is something I can do where I can say, "My friend Richard wanted me to do this or wants me to know this."? It might be a little bit more challenging as somebody who is a housing and education policy scholar, but what is an important takeaway or recommendation or something that we can do on the ground tomorrow to make this world a better place?
Rothstein: Jennifer, I apologize, but I can't answer that question. It's beyond my competence. I want to say one thing to you, though. In addition to being a physician, you're a citizen. And I think the most important thing you can do is align yourself with other citizens in whatever profession they are, because this is going to take a community effort. And I hope you will sign up with this link that I give you and work not only with other physicians and medical professionals, but with realtors and developers and teachers and citizens in all walks of life to address this because this cannot be done within a single sector. As you know, my view is that the primary cause of health disparities is the segregation of African Americans in less well-resourced communities, and that's not something that can be addressed inside the hospital alone.
Khazanchi: Yeah, I love that. And I think so much of our conversations on this podcast have kind of come back to this core message, which this work really starts in our backyard. It's there in our backyard. It needs to be done in our backyard. And so I love that both of you have done such a critical job of bringing this back to what we can be doing in our own communities. And Fernando, I'd love to turn to you and ask a similar question to what we asked Richard, which is, and our listeners take their headphones off and they walk into their clinics after hearing this episode, what is one takeaway that you would offer them as something they can do starting tomorrow?
De Maio: Yeah, the main takeaway is to listen to Richard's very wise words. But I think you know this, is to approach this with humility, to work with others. Jonathan Metzl and others talk about structural interventions and structural humility, and I'm heartened by everything that I've heard on this podcast and the conversations that we've had that there is really the potential to make a huge impact for the better. To name and dismantle systems that cause harm, to not tolerate things just because that's the way they've been done before, but to look across all aspects of our work, in my work as an educator, in a classroom at university or your work as a physician, to look at the systems that we work under and really root out which ones are harmful and which ones move us towards more just and equitable societies. So thanks again for this wonderful conversation. It has been such a pleasure.
Essien: So we just want to thank you all so much, again, for taking the time. We're so, so grateful to have Richard Rothstein, author of The Color of Law. Fernando de Maio, author of Unequal Cities, to join with us today to share on this topic. We spent a lot of the last hour or so talking about policies, talking about big picture ideas, but in so many ways, this topic that we shared on today is personal. I think about my grandmother, who died a couple of years ago, and living in the same thatched-roof hut that my father grew up in eastern Nigeria. I think about his journey along with my mom's to the US and the challenges that they had trying to look for a home in the suburbs of New York City as thick-accented immigrants to the US. And then my experience just last year looking for my first home. And again, I think we all listening have similar stories regardless of the city that we're in today, not to mention our patients and their experiences. And so we're so grateful that you brought these lessons to us, reminders to work with folks outside of our daily spaces to address these issues for our communities. As Rohan mentioned, we have a full three-part series on the topic of racism and housing. We're really looking forward to future conversations. And again, just much gratitude to you, Richard and Fernando, for taking the time to connect with us today.
Rothstein: Thank you very much. It's a pleasure to meet all of you, and I hope to work with you in the future.
De Maio: Thanks again. [music]
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