The Problematic Role of Public Health in Washington, DC’s, Urban Renewal

The 1949 passage of the Housing Act provided funding for urban renewal programs, in which areas deemed blighted would be condemned and cleared, residents would be relocated, and developers would build anew on the sites.¹ Just after the act was passed, Ralph Johnson, sanitary engineer at the US Public Health Service, wrote of its implications for the public health profession. Johnson identified several roles for health departments, including establishing standards for healthy housing, contributing to the development of general plans, and integrating existing housing quality improvement programs. He concluded that “the active cooperation of health and redevelopment officials can be mutually beneficial” and that renewal represented an “unusual opportunity for benefiting the health of the Nation” that was “especially important to the health profession.”²

Nearly 70 years later, the legacy of urban renewal has not lived up to these optimistic goals. Far more housing units were destroyed than were created to replace those that displaced families lost, thereby disproportionately affecting black and low-income residents; 78% of relocated families were nonwhite.^3,4 Although the role of urban planners in urban renewal’s adverse consequences has been examined extensively,^5-7 the role of public health has received little attention. Several researchers examined the magnitude of the relationship between urban renewal and public health; Fullilove³ researched urban renewal’s adverse health effects, and Lopez⁸ pointed to the public health profession’s role in the program. However, given the scale and impact of urban renewal, further exploration is warranted.

This article builds on the research of Fullilove and Lopez by presenting a case study of Southwest Washington, DC (hereinafter, Southwest). During urban renewal, 99% of the existing buildings were destroyed, displacing 1500 businesses and 23 000 residents, most of whom were not able to return to the expensive new housing that replaced their former homes.⁹ The dense, low-income black community was transformed into a wealthy white enclave: the overall population decreased by 55%, the mean gross rent rose by 392%, the percentage of residents in Southwest who were black was cut in half and the percentage who were white doubled, and the median household income nearly quadrupled.¹⁰ This article describes how a public health rationale was used to justify the urban renewal program and public health tools were used to enact it, despite the adverse long-term implications for health disparities.

The Early Housing Reform Movement

In the mid- to late-1800s, a major housing reform movement developed as public health embraced a broad definition of its mission to eradicate disease and of the sweeping change necessary to address its causes. In a context of massive immigration and industrialization, individuals’ environments, particularly housing, were considered key determinants of health.^11,12 The push to redevelop Southwest originated in this movement. The original street grid in Washington, DC, left block sizes large enough for an alley running through the middle with its own houses fronting onto it, which were mainly populated by poor black people^13,14 (Figure 1). These homes were often in poor condition (Figure 2); by 1952, just before renewal, 43% of dwelling units in Southwest had no inside toilet, 27% had no inside running water, and 70% had no central heating.¹⁷ As a result, alley residents had a disproportionate burden of unhealthy conditions and disease. In 1910, the overall death rate of alley residents was 30.1 per 1000 population (an alarming 373.5 per 1000 population for children aged <1 year)—almost twice as high as that of street residents.^14(p183) The call for alley reform was accordingly justified by a public health rationale. A Washington Post editorial appealing to “clear out the alleys” condemned the “wretched slums” as a “menace to public health” and “breeding places of disease”¹⁸; another editorial (bluntly titled “Slums vs. Health”) urged, “We cannot have a really healthy city until the slum dwellers are moved out of their hatcheries of contagion and decently housed.”¹⁹ Policy makers shared these beliefs; for example, one congressman predicated the need for alley reform on the fact that alley conditions were a “direct cause of an increased death rate here.”²⁰

Figure 1.

Aerial view of alleys in Southwest Washington, DC, mixed in with main streets.¹⁵

Figure 2.

An alley home in Southwest Washington, DC, in 1935 showing poor sanitary conditions.¹⁶

A tension always existed, however, in that rendering alley residents homeless through clearance was unlikely to improve their health. Black residents had few alternative housing options because of segregation, which severely limited the housing stock available to them,¹³ and because of poverty, given intense discrimination in the type of employment and pay available to them.¹⁴ Landlords exploited this captive market by overcharging and forgoing needed maintenance.^14,21,22 Thus, rebuilding healthy and affordable housing was a necessary correlate for residents to benefit from clearance.

However, concern about the health conditions of the alleys was often motivated by fear of their threat to the rest of the city (ie, concern for wealthy residents, rather than concern for alley residents themselves). An 1896 Washington Post editorial justified its call to clear alley dwellings by noting that “Washington is threatened, morally and physically, by their existence” and arguing that alleys constituted a “danger to the many.”¹⁸ Similarly, a Congressman arguing for legislation condemning alleys emphasized the risk to better-off residents: “They surround the houses of the average citizen and the respectable toilers; they lurk behind the places of the wealthy.…They radiate out insanitary influences.”²⁰ When more powerful stakeholders saw opportunity in clearance, residents’ well-being was vulnerable to sidelining. As the push for alley clearance turned to the process for building replacement housing, private developers vehemently opposed allowing the housing to be built by the local public housing authority.²³ John Ihlder, executive director of the National Capital Housing Authority, continually argued that, given the need for private enterprise to turn a profit, such developers were unlikely to sufficiently meet the need for low-cost housing (a prediction that proved correct).^23,24(p140) However, rejection of public responsibility for decent housing won out.

Congress finally passed the Redevelopment Act in 1945, which created a District of Columbia Redevelopment Land Agency (RLA) with the right to use eminent domain to acquire land and sell it at a low price to private developers. The Redevelopment Act was framed as a public health measure, declaring that the current conditions were “injurious to the public health, safety, morals and welfare.”²⁵ Shortly afterward, Congress passed the Housing Act of 1949, providing further funding and kick-starting urban renewal. Government officials identified the Southwest area for the pilot project, given its dilapidated condition and its symbolic status near the Capitol.²⁶

The Advent of Urban Renewal and the Complicity of Public Health

One of urban renewal’s foundational justifications was public health. The program was controversial from a legal standpoint, because it involved government acquisition and transfer of privately owned buildings, even perfectly sound ones, to private developers, thus entailing government interference with property rights. Thus, as Johnson noted in an article in Public Health Reports, “Cooperation of the local health department is especially important because the basic police power of the State to regulate must be reasonably related to welfare, morals, safety, or health if the regulation is to be held valid.”²⁷ Another public health official concurred: “Improved public health and sanitation [were] usually the main ‘sales arguments’ for slum clearance [and] redevelopment.”²⁸ As to the threat to health in question, urban renewal advocates pointed to “blight”—a nebulous term conceptualized as a metaphorical disease that turned neighborhoods into slums and rendered cities unhealthy.^8,29,30 The 1949 urban renewal legislation stated as its justification that “the health and living standards” of Americans necessitated clearance of blighted areas.¹

Whether urban renewal served public health purposes, however, is questionable; it was substantially co-opted by business and real estate interests to attract higher-income uses. By deeming an area as blighted, a powerful person or institution with an interest in development projects in a neighborhood could conveniently target it for clearance.³⁰ At the time, increasing suburbanization meant the loss of wealthy white residents and their tax revenues; developers and businesses, and often city governments, wished to lure them back with appealing residential neighborhoods and vibrant central business districts.²⁹ Washington, DC, saw the white share of the metropolitan area population drop to lower than 50% and became the first major city in the country to have a majority-black population during the 1950s.²⁴ By the time the Southwest urban renewal program had begun relocating residents, urban renewal was already being critiqued as “negro removal” for its disproportionate displacement of black people.^31,32

One might expect, given the obligation of public health to protect the health of the entire population rather than only well-off segments, that the profession would have protested the use of public health as a justification for such unrelated purposes or pointed to the potential adverse health consequences of such an action. However, there appears to have been little trepidation about its involvement, and no public outcry or discontent emerged.⁸ In fact, not only did the public health profession not protest urban renewal, it supported it and even provided technical support. The Los Angeles City Health Department’s director, for example, wrote in the American Journal of Public Health that it “is natural that health departments should participate” in urban renewal programs.²⁸

The American Public Health Association (APHA) had formed a Committee on the Hygiene of Housing in the 1930s³³ that identified key aspects of housing that influenced health and developed guidelines and an appraisal method for users to evaluate local housing. This method included inspection forms with a set of detailed housing and neighborhood conditions that were individually assigned scores and scaled; it was intended to be a “simple and objective” way to create “a concise and quantitative picture” of housing problems.³⁴ The guidelines penalized neighborhoods with nonresidential uses and higher density, criteria that would help suburban (ie, white, high-income) neighborhoods and hurt urban (ie, black, low-income) neighborhoods.^8,35

As Johnson noted, renewal programs were required to present a general plan to qualify for funding, and the APHA method was “one of the few methods for obtaining objective information for the development of such a plan.”² Indeed, as Lopez showed,⁸ this method played an important role in facilitating urban renewal programs. Planners and other urban officials used the collected data to create supposedly objective justification for which neighborhoods were deemed blighted and targeted for renewal. The Los Angeles City Planning Commission, for example, used the data to create maps and charts highlighting blight; the director of city planning enthused that the APHA’s “contribution…has proved of tremendous value” by “refin[ing] the process to the extent that substandard areas can be ‘pinpointed’ and the precise degree and extent of blighted areas are readily determined.”²⁸ Use of the APHA housing appraisal method was widespread: the Committee happily noted that “the value of such surveys has been outstanding in providing a clear picture of the actual status of the problem areas of our cities…. It is now playing an increasing role as a basis for the work of Housing Authorities, City Planning Boards, and Redevelopment Authorities.”³³ The appearance of scientific objectivity that the APHA’s method provided was particularly instrumental in justifying decisions about targets; the director of city planning at the Los Angeles City Planning Commission noted that “since all the information presented is based upon the standards established by the Association…these exhibits should bear great weight in a court test.”²⁸

Furthermore, the public health profession failed to address the structural causes of unequal housing conditions. The true driver of poor conditions in blighted neighborhoods was segregation (often promoted by government policy) and the accompanying creation of an exploitative dual housing market and starvation of neighborhoods from resources.^3,36,37 Public health professionals were aware of this dual market: in its initial validation of its housing appraisal method, the APHA found that black people paid the same amount as white people for substantially worse housing conditions across every housing cost bracket.³⁴ Johnson noted that the disproportionately high rents for substandard housing relative to its quality were “too well known to merit elaboration.”²⁷ Yet, the APHA continued to support policies that focused on the proximate housing factors affecting health at the expense of the actual determinants patterning them and sometimes even blamed marginalized residents for their neighborhoods’ condition. Milwaukee’s commissioner of health coldly noted that, “The apathy shown by most residents of such areas is a major characteristic of social disorganization. There is a general failure of interest in preventing the continued decline of dwellings.”³⁸ Thus, beyond considerations of equity, this shortsighted approach was unlikely to be successful, because such exploitative patterns would simply reproduce themselves in the next housing available to slum dwellers.

In Washington, DC, government planning and development officials used the APHA method to assess the Southwest neighborhood, noting it to be “frequently used…to make objective determinations of the condition of dwellings as the basis for the initiation of municipal projects.”²⁶ It was on the basis of this method that the RLA justified its decision that the entire area must be destroyed and rebuilt.^39,40 The Supreme Court then espoused the legitimacy of a public health rationale for renewal in the landmark eminent domain case Berman v. Parker, which permitted the seizure of nonblighted buildings in Southwest: “The experts concluded that, if the community were to be healthy, if it were not to revert again to a blighted or slum area, as though possessed of a congenital disease, the area must be planned as a whole.” Indeed, they noted, it was “in the judgment of the District’s Director of Health” that it “was necessary to redevelop [the area] in the interests of public health.”⁴¹ Thus, the use of a public health rationale and of public health tools to target it for renewal paved the way for the razing of Southwest.

The Abandonment of Southwest’s Residents

The focus of redevelopment quickly shifted from ensuring acceptable housing conditions for the poor to building luxury housing for the wealthy.²⁴ Profit-oriented private developers in whose hands renewal had been placed soon found uses for Southwest other than low-rent housing. An RLA annual report noted that “no other section of Washington has comparable advantages of location,”⁴² which newspaper editorials and government reports and hearings frequently began to highlight as well.^43-47 Southwest represented, the developer selected to lead the project argued, “a first-class opportunity for private capital investment.”⁴³ Simultaneously, developers and commentators often claimed that higher-income residents and commercial uses would bring a greater tax return to the city, which could repay the city’s eminent domain expenses.^43,45,47 By 1958, a Washington Post article could bluntly state that “one purpose of the redevelopment is to coax high and medium income people into Washington.”⁴⁶ An increasing tension emerged between the initial intention of building housing that would be affordable for Southwest’s low-income residents and this push to “upgrade” the area. One Washington Post editorial described it as a choice between “rais[ing] the character of an entire area” or “ceding in perpetuum the best city land to the lowest income families.”⁴⁸ Another editorial similarly described the ongoing debate as whether “primary consideration [should be given to] keeping rents and sales prices down to the level of most present residents or whether its attractive and unique location along the waterfront, Government buildings and shopping section should not be exploited for higher-income use.”⁴⁵

Governmental officials and RLA staff members eventually argued that the area was now too desirable for the return of displaced residents, while acknowledging that their return had been the original intent.^49,50 As one reporter explained, “Searles [the RLA’s executive director] said it would be a serious mistake to take the ‘most desirable’ parts of cities and rebuild them for lower income groups. If this is done, he declared, ‘the leadership, the wealthy people will leave’ for the suburbs, and deprive the city of their abilities and their tax contributions.”⁵¹ By the mid-1950s, Searles described finding decent housing for displaced residents as a by-product that “happens to be a socially desirable concomitant of this overall plan.”⁴³ Ihlder bitterly noted that “emphasis has been on demolition of slum dwellings…not on improved living conditions for the displaced slum dwellers,” which had become “a secondary consideration.”⁵² Thus, the goal shifted from improving the well-being of Southwest’s residents to clearing space for housing for the wealthy.

The Outcomes for Southwest’s Residents

Southwest’s residents were indeed rehoused in homes with improved conditions (unlike many other cities, where displaced residents came up against housing shortages⁸). For example, a study of relocated residents conducted in the mid-1960s found that none lived in housing that required “major repairs” or was “dilapidated or unfit for use,” compared with almost half before relocation, and 85.7% now lived in good-quality housing, compared with just 22.0% before relocation.⁵³ However, urban renewal had other health implications, which can be understood through Fullilove’s “root shock” model.³ First, the urban renewal process can directly affect health through stress and psychological trauma. Second, displaced residents often moved to communities that had a high concentration of poverty and segregation, which are correlated with poor health outcomes.⁵⁴ Third, urban renewal reduces residents’ access to health-promoting resources as they deal with resettlement and experience disruptions in their networks.

The aforementioned study found that Southwest’s former residents were scattered “as leaves on a windy autumn day.” Only 25% still lived in Southwest, and most did not live near any former neighbors.⁵³ Redevelopment officials usually spoke as if it did not matter where Southwest residents moved, noting that affordable housing could always be built elsewhere.^48,55 For example, an RLA annual report blithely noted that low-income housing was not needed in Southwest because low-cost housing was “for sale under construction just beyond the city limits.”⁵⁶ But there is reason to believe that the concept of community had deep meaning for Southwest residents. In his study on folklife in the alleys, Borchert noted that isolation from the streets outside, substantial face-to-face interaction due to close proximity, and homogeneity of background meant that alleys developed a vibrant and tight-knit community.¹⁴ Residents’ community ties, however, were not replaced in their new neighborhoods: 60% were not aware of any community organization in their new home, and more than one-quarter had not made a single friend in their new neighborhood.⁵³ Social support is known to protect health,^57,58 and the loss of such support among poor residents with limited resources could be particularly jarring. Furthermore, the involuntary loss of such a community could induce psychological trauma; many residents expressed a keen sense of distress about the loss of their homes and communities.⁵⁹

Ultimately, little evidence of improvement in health outcomes emerged: the aforementioned study found that 43% of relocated residents were seriously affected by illness or disability after the move, which was no improvement from prerelocation.⁵³ This finding was unsurprising because moving residents did little to address, and even exacerbated, structural inequalities. For example, a higher percentage of residents (62%) were unemployed compared with prerelocation (52%).⁵³ The communities east of the river where Southwest residents moved became highly segregated.⁶⁰ Racial residential segregation is described as a “fundamental cause” of poor health because of its wide-ranging impact on residents’ abilities to access health-promoting resources.⁵⁴ Indeed, these communities still have substantial health disparities today.⁶¹

Conclusion

During Southwest’s redevelopment, the public health profession was complicit in enabling a program that counteracted its responsibilities to the public by jeopardizing the health of the most marginalized. Public health professionals predicated health on a narrow set of technical housing and neighborhood conditions, neglecting other important aspects such as community and ignoring the role of structural forces creating housing disparities. Developers’ financial motivations, along with cities’ desire to lure back higher-income residents and their tax dollars after suburbanization, led them to seize the opportunity of demolishing low-income housing and removing “unworthy” residents from a location that was desirable to the wealthy. In such a situation, the public health profession would be expected to act as advocates for the marginalized. Instead, however, public health provided the legal rationale for the urban renewal program and legitimized and facilitated the targeting of marginalized neighborhoods by creating a supposedly impartial and scientific way to justify such targeting, thereby harming vulnerable populations and perpetuating inequality.

The public health profession’s puzzling unquestioning support is less surprising when placed in the context of its increasing detachment from a social reform orientation as it professionalized and adopted a science-based identity. During the first half of the century, public health developed a close relationship with medicine, focusing on individual explanations for disease at the cost of attention to the broader social and environmental context. Efforts to understand morbidity and mortality sought links between microorganisms and disease in the laboratory, examining a one-to-one relationship between disease agent and host rather than on the environment in which people lived. Preventive approaches were accordingly also individualistic, emphasizing personal hygiene and modifiable risk factors such as smoking.^8,62-64 At the same time, the field began to limit the scope of its domain. The coalition of forces that had previously worked together to address public health concerns increasingly splintered and developed into separate professional fields with more defined services.^8,12,62 Although public health professionals still viewed housing as a public health concern,²⁸ this narrow scope meant that they focused on technical activities (eg, inspections) without paying attention to the social and economic context, abandoning the advocacy component of its mission necessary to address this context. Southwest residents themselves could thus be viewed as responsible for their poor housing and poor health, leaving public health professionals with less sympathy and less recognition that their fate was unjust, while social issues such as poverty and segregation were seen as outside public health’s scope of responsibility.⁸

The case of Southwest raises questions that are still relevant today: Who deserves equitable access to the resources that enable health (eg, housing), and what role should the public health profession play in policy that affects the social determinants of health? Displacement through public housing transformation initiatives, gentrification, and eviction are pressing concerns for low-income black residents of Washington, DC, and cities nationwide. As public health continues to define the extent of its identity as activist versus scientific and address the social determinants of health, we must further assess the field’s role in programs that contributed to displacement and segregation to better understand the consequences of withdrawal from an active commitment to equity and identify potential guidelines for navigating today’s challenges. These historical lessons of these past failures, along with explicit attention to anti-racism, should also be incorporated into public health training curriculums to ensure that the same mistakes are not repeated by the next generation of public health leaders. Public health’s complicity in the mistreatment of Southwest’s residents reminds us of the public health profession’s obligation to advocate for the rights of the marginalized to equitable access to health.