Structural Racism, the Social Determination of Health, and Health Inequities: The Intersecting Impacts of Housing and Mass Incarceration

Abstract

Public health researchers have directed increasing attention to structural racism and its implications for health equity. The conceptualization of racism as historically rooted in systems, structures, and institutions of US society has important implications for addressing social determinants of health (SDOH). It requires theorizing SDOH as embedded in and expressions of racially oppressive historical structures that are manifested in and maintained by policies, programs, and practices in multiple domains that dynamically intersect to reinforce and reproduce in new ways: race inequities in health.

We develop this argument using housing, a SDOH recognized as reflecting longstanding racist practices and policies that, among other things, have restricted the affordable housing options of Black people to segregated neighborhoods with limited resources. We argue that understanding and addressing the health inequities resulting from structural racism associated with housing requires simultaneously understanding and addressing how housing intersects with mass incarceration, another SDOH and manifestation of structural racism.

We suggest that unless these intersections are intentionally analyzed and confronted, efforts to address the impacts of housing on racial health disparities may produce new forms of health inequities. (Am J Public Health. 2023;113(S1):S58–S64. https://doi.org/10.2105/AJPH.2022.307116)

Public health researchers are directing increasing attention to structural racism and its implications for advancing health equity. Structural racism is not a new concept. Twenty-five years ago, for example, Williams¹ presciently argued that race differences in health provide a measure of the consequences of our history of racist oppression. It is this history, and its ongoing manifestations, that the concept of structural racism seeks to capture.

Although varied, definitions direct attention beyond individual demonstrations of racism to focus on systemic racial exclusion from power and its consequences.² Racism is recognized as historically rooted in systems, structures, and institutions in multiple domains of US society and embedded in the policies, practices, programs, and operating logic producing and maintaining these domains, and the system of racial oppression more generally, at any given historical moment.³

This framing has important implications for conceptualizing and addressing the social determinants of health (SDOH). Bailey et al. argue that structural racism shapes “the distribution of the social determinants of health.”^3(p1461) But accounting for structural racism also requires moving beyond the distribution of these determinants. It suggests as well the importance of recognizing and theorizing about the determination of SDOH.⁴ Not only are SDOH distributed differentially because of structural racism, they have different meanings and implications for Black people than for White people because they are determined by and represent a contemporary manifestation of this racism.

Also important to this conceptualization is understanding how these processes operate and intersect across different domains, potentially reinforcing or challenging one another.⁵ This framing has critical implications for promoting health equity, which we illustrate here by discussing examples of how housing intersects with mass incarceration—each recognized as SDOH determined by structural racism—in producing health inequities.

DETERMINATION OF HOUSING

Much recent attention has focused on analyzing housing as a SDOH in the United States, with a particular interest in the health consequences associated with the shortage of affordable housing and the cost burdens and instability it produces. In no state in the country will a minimum wage job affordably cover the rent of a 1-bedroom apartment.⁶ Public housing and rental assistance are typically funded at levels that meet the needs of just 20% of those with eligible income.⁷ This unmet need for affordable rental housing contributes to increasing the rates of homelessness and crowded and unstable housing arrangements, with well-documented health consequences.⁸ Low-income renters who do find housing often experience significant cost burdens,^9,10 which are associated with many adverse health-related outcomes.^11–13 Housing instability—via evictions and other forced moves—is also associated with poor health outcomes.^14–17

These experiences are not racially neutral; access to stable, affordable housing is distributed by race.¹⁰ Twenty percent of Black households are extremely low-income renters, as compared with 6% of White households.¹⁸ Furthermore, Black renters comprise a disproportionate share of those evicted.¹⁹ The associated health outcomes are also distributed by race,¹⁰ but situating affordable and stable housing in a structural racism framework directs attention beyond the distribution of these SDOH by race to the context that has produced this distribution: its determination. In this regard, the structural racism underlying residential segregation is critical.

Research documents that racial exclusion was essential to the project of suburban development in the late 19th and early 20th centuries,^20–22 including through racially restrictive deed covenants and the professionalization of realtors, whose standards influenced government policies and programs.^22,23 Although various government policies have contributed to residential segregation, New Deal housing policy is considered particularly significant.²⁴ To increase access to affordable housing for unemployed workers through the construction of public housing, the Public Works Administration was known to tear down existing housing to replace it with segregated projects, in some instances turning what were once racially integrated neighborhoods into segregated ones.²⁵

Even after local authorities took over public housing construction, US Housing Authority guidelines required public housing to reflect the neighborhood racial composition and cautioned against integrating communities by constructing projects for White families in predominantly Black neighborhoods.^25,26 Racially restrictive covenants excluded Black people from the Federal Housing Administration (FHA)–backed opportunities. Additionally, FHA underwriting guidelines standardized the valuation of homes in terms of “neighborhood risk,” signified in large part by neighborhood racial composition, a practice known as redlining.²⁴ Passage of the Fair Housing Act in 1968 made redlining illegal, opening the housing market to Black people but did so on “predatory and exploitative terms.”^27(p18) Previously excluded from homeownership because they were too “risky” to lend to, “risky” buyers became a source of profit in an era of FHA-insured home mortgages meant to encourage home ownership in predominantly Black neighborhoods.²⁷

Situating housing in this structural racism framework highlights the importance of considering how both affordable housing and stable housing (which are SDOH) are distributed differently by race. It is also important to consider the context in which these SDOH occur because the context is shaped by structural racism and gives these SDOH different meanings for Black residents than for White residents. In the 1990s, for example, risky subprime loans were differentially marketed (distributed) to poor Black clients, who represented a unique niche for such loans because of residential segregation. However, residential segregation also structured the impact (meaning) of these loans, with Black and Hispanic neighborhoods bearing the brunt of the foreclosure crisis.²⁸ Similarly, even for low-income Black renters who do live in an affordable and decently maintained building, that building is more likely to be located in a high-poverty, racially segregated neighborhood²⁹ that is surrounded by abandoned housing,³⁰ more exposed to pollutants,³¹ and further from grocery stores stocked with healthy foods³² than the decent and affordable buildings lived in by their White counterparts. Also, homeownership does not represent the same path to wealth accumulation for Black owners as it has for White owners,^33,34 nor does it bring them the same health advantages.³⁵

DETERMINATION OF MASS INCARCERATION

Locating the affordable housing crisis in the racist history and interests that produced residential segregation has important implications for understanding and addressing health inequities. Also critical is another contemporary form of structural racism that has structured and given meaning to housing access and affordability and the context in which it occurs: mass incarceration. Comprising less than 5% of the world’s population, the United States accounts for 20% of those incarcerated.³⁶ In any given year, more than 600 000 people enter US prisons and more than 10 million enter jails; about a quarter of them will be rearrested in the same year.³⁷ Many have not been convicted of a crime; they sit behind bars because they cannot afford the bail that would release them.³⁷ When released, many will join the more than 4.3 million people currently under probation or parole.³⁸ The consequences of arrest, incarceration, or community supervision will follow most throughout their lifetime because each leaves a (virtually permanent) public record that can be used to exclude them from resources critical for healthy living.³⁹ Further affected by mass incarceration are the nearly 113 million people, or 50% of adults, who have had a family member incarcerated for at least 1 year or the 6.5 million with an immediate family member currently incarcerated.⁴⁰

These experiences with the criminal legal system are not racially neutral. Black people are incarcerated at almost 5 times the rate of White people³⁷; and non-Hispanic Black people comprise 38% of those on parole and 30% of those on probation.³⁸ They are 50% more likely to have had a family member incarcerated and 3 times more likely to have had a family member incarcerated for more than a year.⁴⁰ Entry into the criminal legal system typically begins with a police encounter, not necessarily with a crime. When driving, Black drivers are more likely than are White drivers to be stopped, and when stopped, searched by police.⁴¹ Black people are also more likely to be subject to “stop and frisk” policing practices.⁴²

The disproportionate distribution of Black people under the scrutiny of the criminal legal system cannot be explained by race differences in the perpetration of crimes. Instead, consistent with a structural racism framing, it is the product of the history of racial oppression that mass incarceration signifies.⁴³ This history is embedded in policies and practices designed to preserve White privilege, including in the US Constitution, which, to reconcile slavery with founding principles of liberty and equality, defined a slave as “three-fifths of a man.”^44–46 When the Thirteenth Amendment ended slavery, it did so with 1 exception: “as a punishment for crime.” Southerners then worked to ensure that all expressions of Black freedom were prohibited, first through Black Codes, then via Jim Crow laws.^44,46 Policing practices took shape in this context, with police responsible for enforcing these laws.⁴⁶

Scholars differently locate the emergence of the current form—mass incarceration—that this racist history takes (e.g., as part of the President Johnson administration’s “war on poverty”⁴⁷ or the President Nixon administration’s “war on drugs”⁴⁴). What is abundantly clear, however, are its powerful impacts on life: whereas Black people of all socioeconomic backgrounds are subject to the suspicious gaze of those who assume their criminality, and many experience mass incarceration through their connection to incarcerated family members, these impacts are most profound in low-income, racially segregated urban neighborhoods.⁴⁸

Mass incarceration is increasingly recognized as a SDOH in its own right,^49–51 operating at multiple levels^52,53 and among the formerly incarcerated,^49,50 their children and romantic partners,^54,55 and their communities.⁵⁶ Here, we highlight examples of how it intersects with housing, with subsequent implications for health equity.

HOUSING–MASS INCARCERATION INTERSECTION

One manifestation of mass incarceration is federal and state laws that have created a new category of citizens who—by virtue of their criminal record, especially when for a drug-related crime—do not have the rights or access to resources accorded other citizens. Access to affordable housing is among such rights they lose. Federal regulations require housing authorities to ban public housing or vouchers for at least 3 years for applicants who have been, or who have a household member who has been, evicted from federally assisted housing for a drug-related crime in the past 3 years. Federal regulations also require housing authorities to set standards prohibiting admission to or permitting eviction from households if a member is using drugs.⁵⁷ Although the regulations leave room for housing administrations’ discretion in implementation, most local polices are more restrictive than federal law requires.^58,59 Landlords, too, use criminal background checks in determining who to rent to.

Undoubtedly, these policies contribute to rates of homelessness among formerly incarcerated people that are nearly 10 times those among the general public.⁶⁰ When combined with policies that criminalize homelessness, they can create a “revolving door” between incarceration and the community^60,61 that can exacerbate any existing, and may provoke new, health problems as people move through this door.⁶² These policies also create communities in which the systematic exclusion of some members from access to affordable housing shapes the meaning of having such access for others. In this context, it can be difficult to develop and maintain long-term stable relationships and the health benefits they can bring.⁶³ Relatedly, residents who seek to fill housing gaps exacerbated by criminal legal policies by providing a place for friends, family, or acquaintances to stay put their own health and housing in jeopardy.⁶⁴ They risk eviction or losing a voucher if a guest has a warrant against them or brings drugs or attention from the police or landlords—or just because strict housing policies prohibit guests from staying for more than 14 days.⁵⁸

Mass incarceration also intersects with housing to further shape life in racially segregated, low-income neighborhoods through harsh policing tactics and heavy surveillance that have become increasingly part of the daily lives of residents.⁶⁵ When implemented in neighborhoods where a legacy of structural racism has segregated low-income Black people with limited access to housing and where there is heavy police surveillance, policies that define drug crimes as deserving stricter penalties than other crimes virtually ensure that residents will be noticed gathering on street corners. Suspicious police officers will assume they are and sometimes may find them selling drugs⁶⁶ even as their White counterparts, who self-report equivalent rates of drug selling,⁶⁷ conduct their business unobserved behind the locked doors of their homes. Highly surveilled contexts can also lead to housing instability for those returning from prison or jail who, to ensure that their residences comply with strict parole and probation stipulations, avoid otherwise stable situations for more precarious ones.^68,69

This same heavy police presence in combination with assumptions of Black criminality can turn everyday items, such as cell phones and toys, into “dangerous objects,” justifying the killing of their owners. Even witnessing these forms of policing affect the health of community residents.^70,71 A home in some contexts may provide a place to escape from external stressors (i.e., provide ontological security), which Padgett⁷² theorizes is a central mechanism through which housing can benefit health. However, the homes of those living in racially segregated, heavily policed spaces are subject to surveillance and even raiding by police, child welfare services, and probation or parole officers—diminishing any sense of security and further jeopardizing stability, health, and well-being.^68,73,74

As housing gains increasing attention as a SDOH and expanding access to affordable housing a strategy for promoting health equity,⁷⁵ it is critical to account not only for the implications of a structural racism framework for understanding the determination of this SDOH but also for how housing intersects with mass incarceration—another SDOH and manifestation of structural racism. Otherwise, our efforts run the risk of exacerbating, if not creating new forms of, health inequities.

As an example, consider “evidence-based” calls that promote tenant based–housing voucher programs to improve health but do not address the exclusion from these programs of those with criminal records.⁷⁵ These programs may extend access to safe, stable, and affordable housing and the health benefits that accompany it, but for whom and with what implications for those who remain excluded? At minimum, criminal records should not determine access to housing, or any other rights and benefits of citizens. Still, if criminal records no longer dictate housing access, will potential health benefits be fully realized if the neighborhoods in which housing is located continue to be racially segregated and oversurveilled? As decision makers contemplate policies to expand access to affordable housing, it is critical to recognize and consciously ask how that access is given meaning by a context where structural racism has produced residential segregation as well as mass incarceration and how best to challenge the structural racism at their cores. Also critical are solutions that enhance the ability of residents themselves to do the challenging.

CONCLUSIONS

We conclude with 2 thoughts. First, in keeping with the special issue theme, “structural racism and public health,” we have focused on structural racism, but we acknowledge that it simultaneously intersects with systems of gender and class oppression. Promoting health equity also requires intentionally recognizing and addressing these forms of oppression. Second, in a dynamic and complex conceptualization that recognizes the historically rooted and currently manifesting structures of oppression undergirding different policy domains that have produced health inequities, it is difficult to anticipate all the impacts of efforts to address them—often referred to as “unintended consequences.” The stronger our theory and methods are in understanding and analyzing the oppressive systems and structures at the heart of SDOH, and the more intentional our efforts to recognize and challenge these systems of oppression (and the new forms they will take if unchallenged), the better we will be at advancing health equity.