Medical care is sometimes, though not on this blog, viewed as the gold standard to address inequities. However, access to medical care only accounts for an estimated 10-20% of the modifiable factors that affect population health. The other 80-90% of modifiable factors are often referred to as social determinants of health (SDOH). These are the conditions in places where people grow, live, learn, work, play and age. SDOH include things like education, transportation, employment, and broadband internet access. In this post, we focus specifically on our original analysis of redlining the digital divide.
SDOH affect a wide range of health risks and outcomes and are directly related to health inequities. With COVID mortality rates up to six times higher in low-income communities of color than in high-income communities of predominantly White people, we must ask why where we live is still associated with whether we live or die. The answer lies at the intersection of SDOH and our country’s long history of structural racism.
The long arm of historical redlining is associated with contemporary health inequities
The term redlining refers to discriminatory practices that denied access to credit and insurance for borrowers in neighborhoods that had high percentages of people of color. The lasting effects of redlining are plainly visible today in the lack of infrastructure investments in many low-income, communities of color. The Home Owners’ Loan Corporation (HOLC), a federally funded program introduced redlining maps in the 1930s. HOLC created color-coded risk categories for investing in neighborhoods:
- A: “Best” (green)
- B: “Still desirable” (blue)
- C: “Definitely declining” (yellow)
- D: “Hazardous” (red).
Redlined Areas
HOLC outlined in red, areas that had a large portion of African Americans and labeled these areas high risk. Banks encouraged lending in predominantly White and higher-income areas (grades A or B). Through HOLC, banks were able to legally deny mortgage and business loans in redlined neighborhoods (grades C or D). The banks denied African American residents access to capital investment and economic opportunities.
Lasting Effects of Redlining
More than 80 years after the US government assigned HOLC grades, they represent a contemporary public health risk. Some ways in which historical redlining is linked to health inequities in the US are through unstable housing, limited education opportunities, and restricted access to quality health care. Today, residents in formerly redlined neighborhoods suffer from greater poverty and lower life expectancy. Additionally, the people who live in these neighborhoods are more likely to have pre-existing conditions associated with COVID-19 disease. These residents have higher rates of tuberculosis, poorer self-rated health, and greater exposure to alcohol retail outlets.
Access to broadband internet continues to emerge as a health equity indicator during the COVID-19 pandemic
The COVID-19 pandemic has further highlighted stark neighborhood-level inequities in access to health-promoting resources, including broadband internet access. During the pandemic, broadband internet access has become even more essential to many aspects of our lives. It is a tool that we use to connect to medical care (telemedicine) and food. Many people depend on broadband internet access to attend work and school, connect them to job opportunities, and maintain social ties.
Given this, lack of access or reduced internet access (e.g., only accessible through a mobile phone) has the potential to intensify existing health inequities. People without broadband access are in a uniquely vulnerable position. They are often the same ones whose health conditions put them at the highest risk for severe COVID-19. These people are also most likely to be “essential workers” who cannot work remotely.
Does access to broadband internet vary by historical redlining grades?
Redlining represents a historical system that produced inequity. The digital divide between those who do and do not have broadband access is a modern system that adds to racialized health and economic inequity. We wanted to determine whether the historical lack of infrastructure investment translated to the current lack of investment in broadband access in these redlined communities.
Exploring redlining and broadband internet access in Milwaukee
We hypothesized that neighborhoods issued a C or D HOLC grade would be currently associated with poorer broadband access. Our analyses focused on Milwaukee, where studies have shown a long history of structural racism through redlining linked to an increased prevalence of poor health.
We assigned historical redlining grades to current Milwaukee neighborhoods (defined as census tracts) using the 1938 HOLC shapefile and areal weighting methods. We obtained the percentage of households with access to broadband from the 2013-2017 American Community Survey.
A Higher Degree of Redlining is Associated with a Lower Level of Broadband Internet Access
Our analyses included an Analysis of Variance to determine whether current access to broadband was significantly different across neighborhoods that had different historic redlining grades. The bar graph shows the distribution of broadband access across redlining grades in current Milwaukee neighborhoods. This graph shows clear inequities in access to broadband, where grade A or B neighborhoods have much higher access than grade C and D neighborhoods. 82% of the people living in census tracts in “A” neighborhoods had broadband, while only 62% of those in “D” tracts did. This tells us that HOLC ratings are still, at least in part, associated with neighborhoods that have limited access to a resource that is critical for health in the US.
Figure note: The tops of each bar represent the average percentage of households with broadband access in each redlining grade. Labels include the average percentage of households with broadband as well as the standard deviation. Analysis of variance reveals statistically significant differences in broadband access across the grades.
Now what?
For decades, we have seen the toll that structural racism has taken on the US. The long-term effects of redlining are simply one of many examples. We have one of the lowest life expectancies among similar nations with advanced economies [PDF]. While the US prides itself on being the land of opportunity, our findings show that not all Americans have access to the tools they need for success. These tools, especially broadband internet access, have become important access points for basic needs during the current pandemic.
State and local policies addressing broadband access
Broadband internet access is a unique SDOH because just having it is not sufficient to impact health outcomes. One must be able to navigate the internet and download and use the different types of applications. These applications connect people to services such as employment opportunities, medical care, schooling, and even food. Therefore, broadband infrastructure policies should also include strategies to address digital literacy. State and local policies have been used to provide funding to improve broadband infrastructure. Some of these laws include offering tax credits to taxpayers investing in broadband equipment in the state and encouraging local governments to implement multiple infrastructure projects that can be conducted at the same time as broadband installation.
Federal policies addressing broadband access
Recent policies, such as the Federal Communications Commission’s Emergency Broadband Benefit and
the Biden Infrastructure Bill have focused on making sure everyone has access to broadband. This includes offering grants to states for training, broadband equipment, and public internet access for underserved populations.
These policies often focus on increasing broadband access to rural communities, with less focus on urban areas. While high costs of internet subscriptions can be one factor limiting broadband access in urban areas, lack of infrastructure also limits access. In addition to our findings, other studies build the case for more policy focused on urban areas that do not have broadband internet access.
Policies impacting broadband access in Milwaukee
In the case of Milwaukee, the state of Wisconsin offers grant funding for broadband expansion to build broadband infrastructure in underserved communities. This law intentionally targets areas that have not had prior investments in broadband internet access. On the other hand, another Wisconsin law requires local jurisdictions to hold a public hearing prior to constructing, owning, or operating any facility that will provide broadband services. This type of law can have the unintended consequence of delaying broadband internet access to communities most in need.
Creating health equity through structural change
The link between historical redlining and access to broadband internet should inform policy debates and resource allocation. To ensure health equity, we must be intentional in the strategies we use to create structural changes. This will help to increase access to resources needed for a healthy lifestyle regardless of where someone lives. So, that where they live does not determine if they live.
Janelle Armstrong-Brown
Latest posts by Janelle Armstrong-Brown (see all)
Jamie Humphrey