The deadly legacy of redlining — and a mission to reverse it

Editor’s note: The opinions expressed by the author do not necessarily reflect the opinions of the AAMC or its members.

5 to 15. Those were the figures that kept ringing in my ears as my chest tightened and hot tears welled up in my eyes. I was listening to my mentor at Wayne State University School of Medicine (WSUSOM) in Detroit share findings from their health equity research at a small meeting three years ago.

5 to 15. Black Detroiters die 5 to 15 years earlier than their White counterparts as a result of decades of structural racism that has denied resources and opportunities to Black communities. It hurt me to note that despite surviving such violence and upheaval as the transatlantic slave trade and Jim Crow segregation, my community in Detroit was dying prematurely due to the social pathology of multigenerational trauma and injustice.

But I became determined not to succumb to despair.

Instead, after that seminal meeting, I decided to leverage my position as a physician, medical educator, and community organizer to create a WSUSOM course on systemic inequities. The curriculum would teach medical students and residents about the impact of structural injustice on the health of Black Detroiters, empower students to speak up about such inequities, and equip them with advocacy skills in a community–academia collaboration that positioned community partners as the lead.

A group of trainees, community leaders, faculty, and I worked collaboratively to shape the course and identify the legacy of redlining as a critical driver of the lifespan gap in Detroit. In the winter of 2020, we launched our course on that practice and called it “Healing Between the Lines” (HBL).

The history of redlining in the United States illustrates a deeply disturbing reality: When it comes to health, one’s zip code matters more than one’s genetic code.

Begun in the 1930s, redlining was the federal government’s practice of outlining in red the areas on maps with sizable non-White populations to indicate to mortgage lenders that they were not loan-worthy. A quintessentially racist practice, it led to the systematic denial of services, resources, and opportunities that squelched the potential of individuals and communities and increased their vulnerability to natural and human disasters.

Although the Fair Housing Act outlawed redlining in 1968, its legacy persists today as formerly redlined areas remain effectively segregated and continue to experience exclusion from economic and political opportunities. Such neighborhoods often have substandard housing, fewer parks, more exposure to pollutants from such sources as highways, and less access to quality health care and other crucial services. People who live in these neighborhoods also experience generational poverty, increased stress and mental illness, and more engagement with the criminal justice system.

All this means that inhabitants suffer worse health outcomes, including higher rates of such chronic conditions as diabetes and increased morbidity from infectious diseases like COVID-19. For example, a recent study found that Black adults living in historically redlined areas face an 8% higher risk of heart failure than Black adults in non-redlined neighborhoods.

The history of redlining in the United States illustrates a deeply disturbing reality: When it comes to health, one’s zip code matters more than one’s genetic code.

Reversing the effects of redlining

If physicians are going to improve the health of all, they need to be trained in structural competency. That is, they need to understand how health conditions and behaviors are the downstream consequences of such upstream determinants as laws, policies, and regulations.

This philosophy was behind the creation of our HBL course.

HBL participants — roughly 20 per year — meet for two hours every other week for six months. They spend their first two months learning about historical eras and efforts, including the post-Civil War Black codes designed to curtail the power of formerly enslaved people. They also learn to honor the work of prior activists on whose shoulders they stand.

Participants then spend two months learning community activism and partnership skills. In these sessions, trainees learn to listen actively, recognize and work to shed internalized biases, and cultivate cultural humility by adopting a posture of open-mindedness and life-long learning.

Finally, participants spend two months learning how to identify multidisciplinary and community collaborators and build coalitions. And they learn to build authentic — not merely performative — relationships with these partners.

All HBL didactic sessions are led by community leaders. Throughout, we model a community–academic partnership that respects local leaders as experts with lived experience that is on par with professional expertise. 

In addition to these didactics, participants join community activist groups in Justice Circles, monthly sessions that address one of four themes: reproductive health education, transportation, air quality, and returning citizens’ mental health. Then, with guidance from partners at Wayne State University Law School, participants create a policy brief related to their chosen issue.

For example, one brief on the need for robust public transportation to help residents reach health care appointments proposed the creation of a state-level task force to address gaps in existing Medicaid-reimbursed transportation services. Another, on the mental health of people who are incarcerated, urged such moves as the elimination of accumulated health care bills upon individuals’ release. Yet another identified inadequate sexual health education in schools as a key factor in disproportionately high rates of sexually transmitted infections in Detroit compared to the rest of Michigan.

HBL culminates in a half-day virtual symposium where trainees and their partners present their policy briefs to roughly 100 individuals from the worlds of medicine, community activism, legislature, and local government. At the end of our first symposium, state legislators provided crucial feedback to our scholars, and one representative immediately offered to begin translating the briefs into bills. The event also serves to honor the history and culture of Black Detroit through such features as poetry, music, and an ancestral African mindfulness practice.

After the first year, we took a brief hiatus from HBL in part to expand it to include participants from other Wayne State schools, including the School of Social Work and the College of Nursing. We are preparing to admit our second cohort in 2024. Meanwhile, we have been assessing the curriculum and figuring out where it needs to head next.

True measures of success

As we trained participants in how to help heal past injustices, we found that participants were experiencing healing of their own.

The HBL sessions provided a safe space for us to engage in challenging, meaningful conversations that we had never before experienced — and to bring our authentic selves into those conversations.

Several students told us that though they were raised in Detroit, HBL was the first time they had learned about redlining. They shared that they could now better understand the challenging childhood experiences they’d had in their homes, neighborhoods, and schools. They often expressed dismay that they had previously learned so little about the history that informed their current lives. As one participant noted, “This is why I came to medical school. This is the experience I came for.”

All this was particularly meaningful for us because we started working on HBL about two months after the murder of George Floyd, and we launched the course eight months after his murder — while also grappling with the trauma, loss, and disparate devastation of the COVID-19 pandemic.

I am convinced that Healing Between the Lines helped save our lives. It certainly saved mine.

By teaching and coaching student leaders and collaborating with colleagues and community partners, I was able to confront my own racial trauma — and to practice the self-care and community connection necessary for healing. I was able to liberate myself from the despondent bondage of perceived helplessness, hopelessness, and powerlessness, a dangerous mental health cocktail for a COVID-19 frontliner and survivor of pervasive anti-Blackness.

I am convinced that Healing Between the Lines helped save our lives. It certainly saved mine.

The passionate enthusiasm of our trainees as they engaged with the HBL materials, teachers, and experiences — and as they shared life-changing insights and growth — “gave me life.” I rediscovered my own passion for justice work and re-committed myself to developing antiracist medical education throughout the learner continuum.

The effects of the course continue to reverberate. For instance, one student created a task force to review WSUSOM’s medical curriculum and make recommendations to incorporate the role that redlining and other structural injustices play in race-related health disparities.

Hoping to inspire others to incorporate courses similar to HBL, we have presented our work at various local and national conferences. We also plan to create workshops and seminars to help other interested institutions. I am always open to speaking with anyone who wants to develop similar curricula or to have an HBL representative visit their institution. In all our discussions, we note that these programs must be well-funded, resourced, and integrated into the DNA of the institution. In this way, we build the trustworthiness of our institutions, committing to long-term, sustainable partnerships that are community-led, shaped, and implemented.

This is the work we believe is critical if we are to close the unjust 5- to 15-year racial lifespan gap in Detroit. This is what is critical to training and developing our current and future health care workforce if we are to achieve health equity and justice in our nation. This is what is critical if we are to transform a long-standing American nightmare into the American dream in which anyone — regardless of their race, gender, class, or ability — can live their healthiest and best possible lives.


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