Health in All Policies (HiAP) is a framework that emphasizes the importance of integrating health considerations into all areas of policymaking. A critical aspect of this approach is the recognition that public health is largely impacted by policies outside of the health sector. By recognizing that housing, education, and transportation policies can perpetuate health disparities, HiAP aims to address these barriers and promote equity.

Racial and Ethnic Residential Segregation as a Social Determinant of Health

Racial and ethnic residential segregation (RERS) exemplifies the multidimensional and overlapping nature of systemic issues affecting health. RERS refers to the isolation of poor and/or racial minorities in communities that are separated from those of other socioeconomic groups (Hahn, 2017).

Racist policies related to residential segregation in America trace back to the 1800s, when Indigenous peoples were forcibly removed from the lands of which they are stewards. Federal laws such as the Indian Removal Act of 1830, the Indian Appropriations Act of 1851, and Jim Crow laws of the late 19th and early 20th centuries established and reinforced racial segregation. Beginning in 1933 under the New Deal, the Federal Housing Administration (FHA) subsidized suburban housing for middle- and lower-middle-class whites while prohibiting sales to African Americans (NPR, 2017).

Redlining—refusing to insure mortgages in or near Black neighborhoods—furthered segregation efforts initiated by the FHA (NPR, 2017). These and other policies have perpetuated de facto segregation in the U.S. and have had lasting impacts on BIPOC (Black, Indigenous, and People of Color) communities. As recently as 2020, the U.S. Department of Housing and Urban Development (HUD), under the Trump administration, suspended the Affirmatively Furthering Fair Housing (AFFH) rule which “mandated that localities receiving federal assistance take meaningful action to address decades of discriminatory policies leading to racially segregated and under-resourced communities,” (NLIHC, 2020).

RERS Pathways Associated with Negative Health Outcomes

1. Environment: Neighborhoods where BIPOC populations often purchase homes are frequently situated near government-funded projects such as highways and hazardous waste facilities (Colorado Coalition for the Homeless, 2020).  The American Lung Association reports that marginalized racial and ethnic groups face higher exposure to pollutants (2023). Medicaid recipients in predominantly African American communities have an increased risk of premature death due to particle pollution (American Lung Association, 2023). Additionally, ambient air pollution contributes to hypertension during pregnancy, low birth weights, preterm births, and negative impacts on fetal lung and brain development (WHO, 2024).
2. Housing: Discriminatory housing policies result in higher eviction rates, low homeownership rates, and increased housing instability for BIPOC populations (Colorado Coalition for the Homeless, 2020). Black and African American Coloradans experience housing instability at more than three times the rate of white Coloradans (Colorado Children’s Campaign, 2023). Despite making up only 5.3% of the population, Black Coloradans constituted 23.5% of Metro Denver’s unhoused population in 2020, while Indigenous populations report the lowest homeownership rates of any racial group (Colorado Coalition for the Homeless, 2020).
3. Transportation: Access to transportation is crucial for reaching employment, education, healthcare, and food resources. Racially segregated neighborhoods often have inadequate access to public transportation, leading marginalized populations to spend a disproportionately higher share of their household income on transportation (Hahn, 2017). Furthermore, government transportation investments frequently prioritize white and suburban neighborhoods, resulting in inner-city highways that create physical barriers to minority neighborhoods and contribute to poor air quality (Urban Institute, n.d.).
4. Food and Nutrition: Segregated neighborhoods often have limited access to full-service grocery stores and an abundance of fast food and alcohol outlets (Colorado Coalition for the Homeless, 2020). In 2021, one-fifth of Black Coloradans reported experiencing food insecurity, and Black children are three times more likely to face hunger compared to their white peers (Colorado Children’s Campaign, 2023).
5. Health Care: Healthcare services in segregated neighborhoods often reflect upstream inequities. Predominantly Black communities are more likely to be designated as primary care provider shortage areas, offering fewer ambulatory services and limited access to physicians (Arcaya & Schnake-Mahl, 2017). Inequities in healthcare experiences exacerbate health outcomes. Black women are three times more likely to die from pregnancy-related causes than white women, and in Colorado, Black infant mortality rates are nearly seven times higher than those of white infants (Colorado Children’s Campaign, 2023). The COVID-19 pandemic highlighted inequities, with Indigenous populations experiencing a 36.7% increase in mortality, followed by Black (29.7%) and Asian (29.4%) populations, compared to less than an 18.5% mortality increase among white populations (U.S. Census, 2023).
6. Education: Nationally, school districts serving students of color receive less funding (Colorado Children’s Campaign, 2023) leading to inequitable social and economic conditions that worsen academic achievement gaps (National Academies, 2020). Accessible and high-quality education is linked to increased economic mobility, health literacy, and better health outcomes (Tulane University, 2021).
7. Interpersonal Violence: Residential segregation can concentrate social and economic disadvantages that foster conditions for higher rates of interpersonal violence (CEPR, 2023). States with higher segregation indices tend to report increased rates of firearm homicides in Black communities (CEPR, 2023). Exposures to interpersonal violence and racism have been classified as adverse childhood experiences (ACEs). ACEs are associated with lifelong physical and mental health risks.

This discussion offers a limited perspective on the social determinants of health (SDOH) and populations affected by RERS, merely illustrating how policies can shape daily life. Individuals with lived experiences and in-depth perspectives must lead policy change discussions, as their insights are vital for driving meaningful progress.

Colorado Legislation

The following several pieces of Colorado legislation, while not exclusively health-focused, may directly or indirectly impact RERS and associated health outcomes:

• SB21-169: Restrict Insurers’ Use of External Consumer Data – Became Law
• HB22-1414 (Proposition FF): Healthy Meals for All Public School Students – Adopted
• HB22-1095: Physician Assistance Collaboration Requirements – Lost
• HB24-1339: Disproportionately Impact Community Air Pollution – Lost
• HB24-1313: Housing in Transit-Oriented Communities – Became Law
• HB24-1388: Transfers to the Nurse Home Visitor Program Fund – Became Law
• SB24-094: Safe Housing for Residential Tenants – Became Law
• SB24-184: Support Surface Transportation Infrastructure Development – Became Law
• SB24-001: Continue Youth Mental Health Services Program – Became Law
• HB24-1262: Maternal Health Midwives – Became Law
• HB24-1075: Analysis of Universal Health-Care Payment System – Lost

Nurses play a crucial role in advocating for health considerations across all policy areas, not just those directly related to healthcare. By leveraging their unique expertise and critical thinking, nurses can effectively educate stakeholders about the implications of various policies on health outcomes. This holistic approach ensures that health is prioritized in decision-making processes, ultimately leading to improved health systems and community well-being.

References

American Lung Association. (2023). Disparities in the impact of air pollution. https://www.lung.org/clean-air/outdoors/who-is-at-risk/disparities

Arcaya, M. & Schnake-Mahl, A. (2017). Health in the segregated city. New York University Furman Center. https://furmancenter.org/research/iri/essay/health-in-the-segregated-city

Center for Economic and Policy Research (CEPR). (2023). Racial segregation and gun violence in black communities. https://cepr.net/racial-segregation-and-gun-violence-in-black-communities/#:~:text=Residential%20segregation%20facilitates%2C%20concentrates%2C%20and,problem%20in%20the%20United%20States.

Colorado Coalition for the Homeless. (2020). Race, ethnicity, and homelessness: Issue brief 2020. https://www.coloradocoalition.org/sites/default/files/2020-10/Issue%20Brief-Race%20Ethnicity%20and%20Homelessness_final.pdf

Colorado Children’s Campaign. (2023). Black children and families in Colorado are still experiencing the effects of systemic racism. https://www.coloradokids.org/black-children-and-families-in-colorado-are-still-experiencing-the-effects-of-systemic-racism/

Hahn, Robert. (2017). Racial and ethnic residential segregation as a root social determinant of public health and health inequity: A persistent public health challenge in the United States. Poverty and Race Research Action Council. https://www.prrac.org/racial-and-ethnic-residential-segregation-as-a-root-social-determinant-of-public-health-and-health-inequity-a-persistent-public-health-challenge-in-the-united-states-2/

National Public Radio (NPR). (2017). A ‘forgotten history’ of how the U.S. government segregated America. https://www.npr.org/2017/05/03/526655831/a-forgotten-history-of-how-the-u-s-government-segregated-america

National Academies of Sciences, Engineering, and Medicine. (2020). The impacts of racism and bias on Black people pursuing careers in science, engineering, and medicine: Proceedings of a workshop. The National Academies Press. https://doi.org/10.17226/25849.

National Low Income Housing Coalition (NLIHC). (2020). Leading civil rights & housing groups condemn President’s effort to gut fair housing, use of incendiary racial rhetoric for political gain. https://nlihc.org/news/leading-civil-rights-housing-groups-condemn-presidents-effort-gut-fair-housing-use-incendiary

Tulane University School of Public Health and Tropical Medicine (Tulane University). (2021). Education as a social determinant of health. https://publichealth.tulane.edu/blog/social-determinant-of-health-education-is-crucial/

Urban Institute (UI). (n.d.). Structural racism explainer collection. https://www.urban.org/racial-equity-analytics-lab/structural-racism-explainer-collection/causes-and-consequences-separate-and-unequal-neighborhoods

United States Census Bureau (US Census). (2023). Males and the Hispanic, American Indian and Alaska Native populations experienced disproportionate increases in deaths during pandemic. https://www.census.gov/library/stories/2023/06/covid-19-impacts-on-mortality-by-race-ethnicity-and-sex.html

World Health Organization (WHO). (2024). Experts warn of serious health impacts from climate change for pregnant women, children, and older people. https://www.who.int/news/item/05-06-2024-experts-warn-of-serious-health-impacts-from-climate-change-for-pregnant-women–children–and-older-people#:~:text=Ambient%20air%20pollution%20increases%20the,foetal%20brain%20and%20lung%20development