Redlining Heart Failure

In 1933, the Home Owners’ Loan Corporation, a New Deal agency, began color-coding neighborhoods according to “investment risk”: Green outlines for neighborhoods that were “best” for mortgage loans, red for communities where loans were deemed too risky. The policy effectively partitioned entire neighborhoods, leading to segregation and lack of economic opportunity.

The practice was discontinued in the 1940s, but the effects linger. Among other things, a study published in Circulation in July by Amgad Mentias, M.D., an interventional cardiology fellow at Cleveland Clinic, and colleagues finds black adults living in historically redlined areas have a higher risk of heart failure.

The researchers reviewed data from more than 2 million adults in the Medicare Beneficiary Summary Files between 2014 and 2019 with linked residential ZIP codes. Of those, 801,452 self-identified as Black and nearly 1.6 million self-identified as non-Hispanic white.

Black adults living in neighborhoods with the highest proportion of redlining had an 8% higher risk of developing heart failure compared with Black adults in neighborhoods with less redlining. White adults living in historically redlined areas did not have an increased risk of heart failure. Black adults living in neighborhoods with high scores on the Social Deprivation Index were particularly vulnerable. Approximately half of the excess risk appears to be explained by higher levels of socioeconomic distress.

“These findings show us the harm that discriminatory and racist housing policies have had on generations of Black adults and suggest the long-term impact of such policies on cardiovascular health disparities,” said senior author Ambarish Pandey, M.D., a cardiologist and assistant professor in the department of internal medicine at the University of Texas Southwestern Medical Center in Dallas, in an American Heart Association press release.

In another study of redlining’s legacy, researchers from the Louis Stokes Cleveland VHA Medical Center also found that living in a historically redlined neighborhood was associated with a higher prevalence of traditional cardiovascular risk factors and higher cardiovascular risk.

Of 79,997 veterans, those living in redlined areas (the Home Owners’ Loan Corporation defined these as “Grade D”) were more likely to have chronic kidney disease (44.3% vs 20.0% in grade A [“desirable”] areas), heart failure (15.0% vs 12.8%), diabetes (48.9% vs 44.4%), and chronic obstructive pulmonary disease (21.5% vs 19.1%). Across HOLC grades A through D, the prevalence of smoking rose from 27.2% to 31.1% and obesity from 30.0% to 31.3%.

Patients in redlined neighborhoods also had 13% higher risk for all-cause mortality, 14% higher risk of the composite major adverse cardiovascular events, and 15% higher risk of myocardial infarction.

“Decades of discriminatory housing policies have left a lasting imprint on the cardiovascular health of Black communities,” said AHA’s Chief Clinical Science Officer Mitchell Elkind, M.D., in response to the findings from the heart failure study. “This careful and systematic analysis underscores the higher heart failure risk faced by Black adults residing in historically redlined areas, and provides evidence that social determinants of health, such as poverty, education, and access to healthy food, drive this risk.

“The study serves as a stark reminder of the ongoing impact of structural racism and emphasizes the urgent need for restorative actions and targeted investments to promote health equity.”