The Geography of Health: How Race Based Policies and Real Estate Practices Shaped Today’s Health Inequity Hot Spots

Air Date: Thursday, March 31, 2016

Most US cities have health inequity “hot spots” – neighborhoods and communities with especially poor health outcomes compared to the rest of the city. Scroll down for Q&A

Presentation Slides: The_Geography_of_Health

These areas, characterized by high concentrations of low-income, predominantly minority families and individuals, did not arise by chance but are, instead, the result of decades of disinvestment driven by race-based government policies and real estate practices. Please join us as David Norris, researcher from the Kirwan Institute, explores the link between history and health, with an emphasis on the need to include race as a necessary part of the conversation to correct health disparities.

Real Estate Agents as Agents of Social Change- Redlining ReverseHHS-


7 thoughts on “The Geography of Health: How Race Based Policies and Real Estate Practices Shaped Today’s Health Inequity Hot Spots”

    1. A very short question with a very complex answer! There are several approaches to tackling this difficult issue, but three guiding principles sum up the challenge and guide the search for solutions:

      (a) Health inequity reflects a broader pattern of inequity in other areas – housing, employment, and education, among others – collectively, the social determinants of health. Downstream interventions can address inequities at the service delivery level and should employ creative approaches including community health workers, health care navigators, and patient-centered medical homes, among others. Upstream approaches will require addressing larger, systemic ills in both the health care delivery system and the other social determinants, in parallel. Addressing ONLY health care, or ONLY housing or education or any of the other factors in isolation likely won’t result in substantial, long-term corrections.
      (b) Areas of inequity in our cities did not result from natural processes. Our neighborhoods assumed their current segregated form as the result of deliberate and demonstrably racialized housing and other policy decisions at all levels of government. Since policy choices reflect values, the battle to change policy also must be waged at the level of societal values.
      (c) Inequity hot spots did not emerge overnight; nor will they be fixed through short-term solutions. Efforts to address inequity will require long-term vision and coordinated commitment from several sectors (long-term = longer than an election cycle, or two).

      I think there is reason to hope that we can get there. The move to EMRs puts forward the prospect of data sharing between health care providers and community service organizations to better coordinate care and compliance with treatment regimens, for example. Programs like Harlem Children’s Zone and B’More for Healthy Babies provide models of coordinated education, health care, and service provision. Addressing inequity is less a matter of technique or technology (though those should be employed and leveraged at every opportunity), and more a matter of marshalling and maintaining public and political will…not an easy task, to be sure.


    1. We (Kirwan) have not done hot spot mapping in either DC or Arizona, so I can’t speak specifically to health inequities in those places. In the light of my previous response above, and what we have where we have worked, is that health inequity tracks with inequities in the social determinants. For that, I would point you toward another aspect of Kirwan’s work: opportunity mapping. Opp mapping is a technique developed and employed at Kirwan over the last decade. In a nutshell, we combine approximately 20 indicators at the census tract level into a single index we call the Opportunity Index. Many, if not all, of the indicators in the Opportunity Index are also reflective of social determinants of health. In a collaborative effort with Brandeis University, Kirwan created opportunity maps for the 100 largest metro areas in the U.S., and you can access those online at (click on the “Child Opportunity Maps” link in the header of that page). Opp maps are available for DC and, in Arizona, Tucson and the Phoenix metropolitan area. Where you see low opportunity areas, you can be pretty sure you’ll also see health inequities.


  1. I am an RN and I do Population health, I am also a Realtor. While the points and historical data are interesting there was a period during your talk that I started to wonder if you were going to blame realtor for the disparities. Please keep it points to policy makers. The realtors were a tool for the policy makers


    1. First, thank you for the important work you do, as a nurse AND as a realtor. Though I don’t have any direct experience with the business of real estate, I do have a nurse in the family. My daughter is a NICU nurse at Nationwide Children’s here in Columbus, and it’s a job I couldn’t do. The fact you’re able to balance both careers is impressive.

      I completely agree with you that policy can be a powerful force in shaping the behaviors of people and institutions. But it also needs to be acknowledged that influence is a two-way street: our public policies can shape behavior, but they also reflect the beliefs, attitudes and values of those in society who have economic and political power. And for most of our country’s history, it has been White values – and White biases — that have shaped our policies and institutions, overwhelmingly to the benefit of Whites.

      You’ll recall from the webinar that the Home Owner’s Loan Corporation (HOLC, which soon thereafter morphed into the FHA) came into existence in the 1930’s to provide mortgage insurance to homeowners wishing to refinance their homes in the depths of the Depression. I also showed some examples of the assessor notes used to create the HOLC security maps (redlining maps). Those examples showed two very important things: (1) The form provided by the federal government included spaces for the assessor to explicitly state the percentage of “Negroes” and other “undesirable” races and ethnic groups in neighborhoods, in addition to describing the general state of properties in the neighborhood. That is to say, the federal government actively racialized the assessment process. (2) The form included space at the bottom for the assessor to add clarifying remarks. In all the sets of assessor notes we have examined, the language in these notes is also highly racialized. What is important to remember about this is that the assessors were not sent in from Washington (the fed simply could not have mobilized that sort of workforce in the short time over which the redlining maps were created). Rather, it was mainly local real estate professionals and lenders who completed the neighborhood assessments on which the redlining maps were based.

      In other words, both federal policy makers and local real estate and banking professionals were complicit in promoting the practice of redlining.

      Scholars disagree on whether the redlining maps were used on a case-by-case basis to decide mortgage loan applications, but they make very clear that this is how the assessors (realtors and lenders) knew and assessed their own communities, and that personal knowledge guided, in part, their lending and selling practices as well as determining the level to which the federal government would guarantee mortgages.

      It’s also true that redlining alone did not segregate our cities; segregation was already in place, and so we need to ask how those patterns became established. For a complete answer to that complex question, I recommend that you watch the videos I mentioned in the webinar, “Race: The Power of an Illusion”, and especially episode 3, “The House We Live In” ( But what redlining did do was to institutionalize — and therefore legitimize — segregation in real estate policy and practice.

      Realtors of the day also were guided by policy and educational materials put forth by the real estate industry itself. The National Association of Real Estate Boards (now the National Association of Realtors) explicitly advocated for, and trained realtors to employ, racialized preferences in practice. I have attached an article that lays out this history and more, and actually ends on a hopeful note for the role of realtors in moving housing equity forward. But to go forward, we have to face realistically where we’ve been. This excerpt from the article summarizes NAREB’s role and that of local boards in promoting racial preferences in real estate practice.

      (In what follows, the author unfortunately misidentifies NAREB as the National Association of Real Estate BROKERS. The NAREB he means to refer to, and the precursor of today’s NAR, was the National Association of Real Estate BOARDS, not Brokers. NAREB the Brokers came into being in the 1940’s, and comprises specifically minority brokers.)

      “Like many other institutions, the National Association of Real Estate Brokers* (sic; should be “Boards”) (NAREB) maintained explicit racially discriminatory policies for several decades. The FHA and NAREB’s discriminatory policies were exacerbated by blockbusting practices of brokers, which in turn aggravated apprehension of integrated living. Physical separation increased racial stereotypes.
      “After the US Supreme Court outlawed statutory racial restrictions in 1917, real estate boards resolved to nevertheless prevent nonwhites from living in white neighborhoods. The Chicago Real Estate Board decided they would only sell property to blacks on blocks with blacks, and only after such blocks were filled solidly, to contiguous blocks. In 1921, the Chicago Real Estate Board voted to expel “any member who rented or sold property on a white block to blacks.” Chicago’s work became a model for other Boards and NAREB. Restrictions included Japanese buyers. For example, the Board of Portland, Oregon, put in its Code of Ethics that “[n]o member of the Board will directly or indirectly sell or be a party to the sale of Portland residential property to persons of the Negro or Oriental races now inhabited almost exclusively by white persons.”
      “In response to actions by local boards around the country (underlining mine), NAREB revised its Code of Ethics in 1924, including the introduction of Article 34. From 1924 through 1950, under Article 34, a broker was forbidden from “introducing into a neighborhood a character of property or occupancy, members of any race or nationality . . . whose presence will clearly be detrimental to property values in that neighborhood.” “Thirty-two states adopted ‘model real estate licensing acts’ that authorized state commissions to revoke the licenses of agents who violated NAREB’s Code of Ethics.” Therefore, legally and by its Code of Ethics, NAREB members were required to enforce segregation. Those who did not were considered traitors. According to one account:
      ‘Even in neighborhoods without restrictive covenants, the [Baltimore Board’s] standard real estate sales contract decreed that ‘at no time, shall the land included in said agreement or any part thereof, any building erected thereon, be occupied by any negro or negroes, or persons of negro or African extraction or descent, in whole or in part.’
      “Therefore, just as federal lending was synonymous with racial discrimination, so racial discrimination was with being a licensed realtor.”

      Before I close, I also must point out that the actions of individual realtors, like all of us, are sometimes guided in part by the unconscious biases that our society has conditioned us to hold. Numerous studies clearly demonstrate that whites are often shown more and higher-value properties, are offered better rental rates, are subjected to fewer credit checks, and even are able to schedule more appointments with realtors than are blacks and other minorities.

      I hope, in all of this, you don’t hear me “blaming” realtors for today’s segregated neighborhoods but, rather, a call to responsibly examine both past institutions and individual practices & values, to understand how each influences and shapes the other. We can’t hope to undo the damage of structural racism until we understand and acknowledge how it got us here, and how we can change policy & practice to move forward.


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