Dear NASEM Health Equity Policies Committee,

Where you live can better predict your health than your own genes.

Although race/ethnicity is used to highlight differences in and sometimes predict health outcomes, race/ethnicity is a social construct, not a biological construct.

Biological race is neither clearly defined nor supported by genetic findings. Moreover, biological race is not linked to the genes that affect health, according to an article by Ruqaiijah Yearby, then Professor of Law at St. Louis University, in the American Journal of Bioethics (https://salud.to/3RmoCkO)

Because race is a social construct and not a biological construct, the disparities we see in health outcomes across racial/ethnic groups have more to do with where people live than their race/ethnicity.

Thus, differences in health outcomes are related to differences in the environments in which people are born, grow, live, work, play, and age.

This is not surprising given that discriminatory policies and practices created inequitable neighborhoods marked by white advantage and racial disadvantage across various aspects of daily life, to include housing, transportation, education, employment, safety, and social capital.

Today, these inequitable neighborhoods are perpetuated through various structural and political factors—whether intentionally discriminatory or not—that distribute money and power and improve, disrupt, or neglect communities.

Consider the differences between “good” neighborhoods and “bad” neighborhoods.

While some racist policies, like redlining and school segregation, have been outlawed, many have been replaced by classist policies that perpetuate existing racial/ethnic inequities, and others have replaced by distraction policies that are ineffective in combating existing racial/ethnic inequities.

For example, although it is illegal for cities to exclude black and brown people from obtaining housing in white neighborhoods, it is legal for cities to exclude low-income people from obtaining housing in wealthier neighborhoods.

We need stakeholders to understand their influence on policymaking or investment decision-making that simultaneously blocks affordable housing in high-opportunity neighborhoods and concentrates affordable housing in low-opportunity neighborhoods with underperforming schools, inadequate bus service, limited food access, and high crime rates.

A policy can appear unbiased in language and still contribute to racial/ethnic health inequities.

For example, single-family zoning does not appear racist in language, but is classist in both language and practice.

There is no defense grounded in public health, safety, or welfare for requiring a 3,000-ft2 single-family home while prohibiting three 1,000-ft2 homes, according to Jake Wegmann, urban planning and housing scholar (https://salud.to/3R656JC).

The people in the United States need explicitly anti-racist—and anti-classist—policies to stop perpetuating our nation’s legacy of inequity.

Policies should stop cities from perpetuating “good” and “bad” neighborhoods and schools.

To this end, I am submitting a public comment to your NASEM Committee to explore how federal policies can achieve the following:

Stop cities from varying the quality of a child’s education based on the amount of taxable wealth located in the community within which they reside.
Stop cities from concentrating poverty in low-income communities and stop cities from banning different sizes and types of homes in wealthy neighborhoods by addressing single-family zoning; incentivizing inclusionary zoning; and prohibiting cities from declining affordable housing without an appeal.
Stop states and cities from investing in projects that add vehicle capacity, worsen transportation cost burden, and/or worsen location affordability by addressing reliance on level of service as a measure of success; incentivizing investment in transit; and developing equity, safety, and health metrics to determine transportation impacts, measure performance, and score and prioritize projects.
Stop federal agencies from reinforcing existing inequity, and expand requirements to determine if federal agency action/investment will result in inequity to also determine whether federal agency action/investment will ameliorate or reinforce existing inequity.

Even with equitable policy recommendations, harmful narratives may threaten the adoption and implementation of the most equitable policy changes.

Thus, beyond exploring how federal policies create/contribute to racial inequity, the NASEM Committee should also consider how harmful narratives, particularly regarding implicit bias (racial and socioeconomic) and lack of understanding about structural racism, may threaten the adoption and implementation of policies the Committee recommended to promote racial and health equity.

For example, the rationale that affordable housing or duplexes will degrade the health, safety, and welfare of residents perpetuates segregation, the concentration of opportunity in white, wealthy neighborhoods, and the denial of opportunity in low-income neighborhoods, particularly those of color which, due to historic public disinvestment, are traditionally low-income.

This rationale is rooted in racist/classist beliefs, and these beliefs must be dismantled to obtain consensus for solutions to promote racial and health equity.

Similarly, lack of understanding about and/or failure to acknowledge historic and structural racism and discrimination results in the blaming of individuals rather than institutions thus leads to downstream efforts to change individual behavior rather than upstream efforts to change institutions.

For example, many decisionmakers blame low-income families for not having enough money to move out of “bad” neighborhoods without any regard for their professional and political role in shaping the quality of neighborhoods.

Low-income people, particularly low-income people of color, are often blamed as being the problem, despite the underlying problem of unfair policies and practices that create inequitable neighborhoods.

Thus, workforce development programs are often suggested as solutions to lift families out of poverty so they can move into “good” neighborhoods.

However, this reinforces the narrative that low-income people don’t deserve “good” neighborhoods unless they make more money.

This also reinforces the narrative that midstream solutions targeting a very small portion of the population are more important than systemic changes to improve living conditions for entire neighborhoods.

At best, these attitudes and beliefs result in misplaced culpability and insufficient solutions to achieve racial equity and justice. At worst, these attitudes and beliefs perpetuate a legacy of systemic exclusion that entrenches racial/ethnic disadvantage and contributes to worse social, economic, and health inequities over generations.

Another problem with temporary solutions that address individual social needs is they distract from other more meaningful solutions that could improve the system in which those social needs arise.

Workforce development, for example, is often pushed as a primary solution to address various inequities associated with segregation and subsequent disinvestment.

However, despite higher education achievement, the black-white the wage gap persists and the homeownership gap is larger today than in 1968 when housing discrimination was blatantly legal.

Nationwide, homeownership rates are lower for black college graduates (56.4%) than white high school dropouts (60.5%) (https://salud.to/3KJ65Nv).

Additionally, college didn’t help close the wage gap between 2000 and 2018 (https://salud.to/3pPBZy6).

In fact, Latinos with a college degree earned roughly the same proportion of white wages in 2018 (82.0%) as they did in 2000 (82.8%), and black people with a college degree earned a smaller proportion of white wages in 2018 (79.0%) than they did in 2000 (82.8%) (https://salud.to/3pPBZy6).

Although important, workforce development is a midstream strategy and insufficient to address upstream inequities.

Furthermore, the Moving to Opportunity literature suggests that even if families are given the opportunity to move to a better neighborhood, the move is often temporary and is to the detriment of adolescent children and to important family social networks which are important for emergency childcare, transportation, and various other daily disruptions (Moving to Opportunity: The Story of an American Experiment to Fight Ghetto Poverty).

While these families typically move to neighborhoods with less crime, they often miss out on the dual benefit of also obtaining better access to opportunity. Moreover, there are numerous hidden rules among classes and compounding barriers that factor into a family’s decision to uproot and move (https://salud.to/3AXj1vy).

Additionally, even if a person moves to a better neighborhood and gets a better job, inadequate bus service and costly private vehicle ownership can threaten their employment security, thus economic security, with some people being one flat tire or one late bus away from getting fired.

Ultimately, America should not have “good” and “bad” neighborhoods to begin with, and America should not have “good” and “bad” schools.

People living in poverty do not deserve “bad” neighborhoods, and the people who currently live in “bad” neighborhoods cannot possibly be to blame for decades of public disinvestment in housing, transportation, education, employment, safety, social capital, and general economic development.

People of color and people living in poverty deserve adequate housing, quality schools, and safe transportation options.

I urge this Committee to explore how federal policies allow cities to perpetuate “good” and “bad” neighborhoods and schools, particularly across different racial/ethnic and socioeconomic status groups.

Sincerely,

Dr. Amelie G. Ramirez, Director, Salud America!