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By Christopher J. King, Bryan O. Buckley, Riya Maheshwari, and Derek M. Griffith

Analysis

Race, Place, And Structural Racism: A Review Of Health And History In Washington, D.C.

ABSTRACT Recent events have amplified the debilitating effects of systemic racism on the health of the United States. In an effort to improve population health and dismantle more than 400 years of racial injustice, retrospective examinations of policies, practices, and events that have sustained and continue to undergird racial hierarchy are necessary. In this historical review we feature Washington, D.C.—a city with a legacy of Black plurality. We begin with an overview of contemporary place-based health and socioeconomic disparities. To express the etiology of the trends and uncover opportunities to undo the damage, we reflect on the national landscape as well as on policies and events that socially, economically, and politically disenfranchised Black residents, yielding stark differences in health outcomes among Washington, D.C., populations. In the spirit of atonement in policy and practice, we hope that this approach will inspire policy makers and practitioners in communities across the nation to conduct similar examinations.

R acism and race-based residential segregation are often measured at a particular point in time. How- ever, it is essential to use a histori- cal analysis to truly understand

their effects on health. Illustrating this, when she was asked about apartheid in South Africa while giving a radio interview in 2004, Nelson Mandela’s daughter Zindzi argued that “racism isnot an event. It is a process.”1 Racismand racial inequities in health are each complex problems. Disagreement about the nature and causes of racial health inequities and the most viable and impactful solutions are common.2 Part of the source of the disagreement is that policies and practices that might not appear to be driven by beliefs and ideologies about race and ethnicity nonetheless have important implications for how societal resources that are critical for health and well-being are allocated.3

Rebecca Blank and colleagues note that al- though some behaviors, policies, and other ac-

tions are intentionally designed to treat specific groups less favorably than others, other such actions have different impacts on population health and well-being even though that was not the intention of the actors.4 It is critical to understand the differential benefits and harms of actions regardless of intention because they have implications for how resources that shape health andwell-beingareallocated.5Recognition of how structural racism is operationalized and its influence on health also is critical. According to Zinzi Bailey and colleagues, structural racism is “the totality of ways in which societies foster racial discrimination throughmutually reinforc- ing systems of housing, education, employment, earnings, benefits, credit, media, health care, and criminal justice. These patterns and practic- es in turn reinforce discriminatory beliefs, val- ues, and distribution of resources.”5

To improve population health, it is imperative to identify and examine the policies, practices, and events that have sustained and continue to

doi: 10.1377/hlthaff.2021.01805 HEALTH AFFAIRS 41, NO. 2 (2022): 273–280 This open access article is distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license.

Christopher J. King ([email protected]), Georgetown University, Washington, D.C.

Bryan O. Buckley, MedStar Health, Columbia, Maryland.

Riya Maheshwari, Georgetown University.

Derek M. Griffith, Georgetown University.

February 2022 41 :2 Health Affairs 273

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undergird racial inequities. In this historical re- view we illustrate how structural racism and historical events socially, economically, and politically disenfranchised Black residents in Washington, D.C., yielding stark differences in health outcomes by race and place. We empha- size not only how race-based residential segre- gation undergirds and helps explain contempo- rary racial disparities in health but also how it grew out of local and federal policies as well as their cultural underpinnings. We also share ex- amples of novel policy solutions to alter the con- text in which health is shaped.

Health Inequities: A Tale Of Race And Place Washington, D.C., is home to nearly 718,000 residents.6 Colloquially known as “Chocolate City,” the city has seen gentrification lead to a downward trend in the population of Black res- idents.7 Black residents now represent nearly 44 percent of the population, compared with more than 70 percent in the 1970s.6,8 White re- presentation is trending upward; that demo- graphic group reflected 42 percent of the total population in 2021 compared with 28 percent in the 1970s. Hispanic or Latino residents repre- sented 12 percent of the population in 2021.6

The median annual household income was $86,420 for the period 2015–19.9 Nearly 60 per- cent of people older than age twenty-five have a bachelor’s degree or higher.10

When compared with those of other cities, the overall health profile of the city is laudable. In prior years the American College of Sports Med- icine American Fitness Index ranked the D.C. area (an area encompassing Washington, D.C., as well as parts of Maryland, Virginia, and West Virginia) as the nation’s healthiest metropolitan area.11 However, when health indicators are stratified by race, a different and compelling narrative unfolds: Black men and Black women inWashington,D.C., canexpect to live seventeen and twelve years less than their White counter- parts, respectively.12 These racial gaps in life ex- pectancy are among the largest in the nation and have persisted for decades.12,13 When compared with White D.C. residents, the percentage of Black residents living with diabetes is nearly six times higher, and the percentages of those living with high blood pressure and dying from heart disease aremore than two times higher.14–16

The infant mortality rate—an internationally recognized indicator of population health and health care quality—is nearly five times higher in Black than in White infants.17,18

Socioeconomic indicators such as income and education reflect similar patterns. A 2013–14 in-

vestigation found that the typical White house- hold in Washington, D.C., had a net worth that was eighty-one times greater than that of the typical Black household.19 When compared with all other races and ethnicities, non-Hispanic Black residents had the lowest percentage of bachelor’s degree attainment at age twenty-five and older in Washington, D.C., in 2015–19.10

A history of local and federal policies that structurally disenfranchised people of color is culpable for a racially divided city (exhibit 1). Later in the article we return to a discussion of the events in exhibit 1. Race-based residential segregation is a key predictor of differences in access to opportunity and social mobility.20

The city is divided into eight municipal units known as wards. Wards east of the Anacostia River are predominantly Black; the profile re- verses toward the west. There is a sixteen-year gap in life expectancy between Ward 8, which is majority Black, and Ward 3, which is majority White, and the infant mortality rate is six times higher in Ward 8 than in Ward 317,18 (exhibit 2) (see the online appendix for a map of life expec- tancy and infant mortality rates by ward).21 The median income is $112,873 in Ward 3 but only $30,910 in Ward 8.17 There are also significant differences in access to food. Only three full-ser- vice grocery stores exist for the 161,503 residents who reside inWards7 and8combined.Ward3, in comparison, has sixteen full-service grocery stores for its 84,869 residents.22

Despite a high rate of health insurance across racial groups in Washington, D.C., there are striking disparities in measures that serve as proxies for delaying or forgoing preventive care. Preventable hospitalizations for ambulatory care–sensitive conditions among Medicare en- rollees are more than two times higher among Black residents thanWhite residents.23Residents from wards with high percentages of Black res- idents disproportionately represent ambulatory care–sensitive hospitalizations.24 Although high morbidity rates and limited access to services may influence the patterns, residents cite other issues such as competing day-to-day survival pri- orities and limited access to behavioral health services.25 Experiences with or perceptions of discrimination, bias, and racism also have also been reported.25 These experiencesmay result in deferral of preventive care and late-stage disease detection.26

Washington, D.C.’s designation as a “federal district” also has had health and health care im- plications, particularly during times of public health crisis. Congress must approve the city’s budget, and during the height of the HIV/AIDS epidemic (1997–2008) the city was not permit- ted to use its own tax dollars for needle exchange

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programs. Although the ban on these programs was lifted in 2007, some epidemiologists posit that the city lost a significant opportunity to reduce HIV transmission rates and deaths, par- ticularly among Black residents, who were dis- proportionately affected by the virus.27,28 Inequi- table federal funding allocations are well documented.29 Most recently, Mayor Muriel Bowser called for parity in the distribution of federal support in the Coronavirus Aid, Relief, and Economic Security (CARES) Act of 2020, as the city received up to $755 million less than states, including states with smaller populations than Washington, D.C., and states whose resi- dents pay less in federal taxes.30,31

The Intersection Of Taxation Without Representation And Race Washington, D.C., does not operate with the same autonomy and representation as US states. The founders believed that if the capital were a state, members of government would be unduly beholden to the state. Since the passage in 1801 of what became known as the Organic Act, res- idents have not had voting rights in Congress and are solely represented by a nonvotingHouse delegate. Because of the District’s growing Black population in the late 1800s, there was wide- spread political will to maintain the status quo. In 1890, according to Sen. John Tyler Mor- ganofAlabama, “after thenegroes came into this

Exhibit 1

Timeline of historical events and policies that have influenced the health of Black residents of Washington, D.C.

SOURCES See notes 19, 25, 35, 38, 40–43, and 47–55 in text. NOTE FHA is Federal Housing Administration.

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District,” it became necessary to “deny the right of suffrage to every human being. It was neces- sary to burn down the barn to get rid of the rats.”32 This statement reflects how race and rac- ism factor into efforts to preserve D.C.’s federal district status and disenfranchise its residents from congressional representation.32,33

As a consequence, residents of a city with a Black plurality have been excluded from shaping national policy and precluded from exercising sovereignty over local affairs. Nonetheless, they pay federal taxes, serve on juries, serve in the military, and contribute to the national econo- my. The slogan “taxation without representa- tion” has become symbolic of the entitlements that residents of states enjoy that Washington, D.C., residents do not.

What Has Influenced The Health Of Black D.C. Residents Race and racism have played a critical role in the history and health of the city.We present here a timeline of policies and practices that were de- signed to have differential effects by race and those that have had differential effects despite lacking intent (exhibit 1). This review offers a new vantage point for examining racial inequi- ties and inspires unconventional solutions to achieve racial justice and improve health. 1852: Saint Elizabeths Hospital Founded

Race-based biological fallacies have been en- trenched in the evolution of modern medicine.34

In 1852 Congress appropriated funds for what became known as Saint Elizabeths Hospital, in- tended to serve as the nation’s preeminent lead- ing institution in teaching and research in psy- chiatric care. Although the hospital did admit Black patients, they were segregated in “colored wards” and experienced substandard care in poorly ventilated, overcrowded spaces.35 Be- cause of perceived biological differences, new treatment methods pioneered by the institution, such as psychotherapy, were withheld from Black patients. The story of Saint Elizabeths had a local and national impact: Unequal and unjust treatment shaped Black residents’ nega- tive perceptions about the medical community, and between 1914 and 1933 doctors at the insti- tution published ten influential studies that re- inforced belief systems at the intersection of eu- genics and medicine.35

1862: Taxation And Education The positive correlation between educational attainment and good self-reported health status is well estab- lished.36,37 Because of segregation and communi- ty disinvestment, appropriating tax dollars to fund public education inextricably stymied the social advancement and well-being of Black res- idents of Washington, D.C. The disparity can be seen starkly in education policy and resource allocation stemming from an 1862 law38 desig- nating a portion of taxes paid by Black people for use by Black schools. Those taxes amounted to a mere $410 of support for Black schools in 1863 compared with much higher support for White schools ($65,000), which Black students were not permitted to attend.19

Inequitable access to education would have a ripple effect on Black families for generations to come. For example, during 2015–19, 27 percent of Black residents older than age twenty-five had abachelor’s degree, comparedwith 92percent of Whites.10 These trends have significant health implications. A report recently released by the DC Department of Health highlights correla- tions between level of education and incidence of diabetes, asthma, stroke, and heart disease.17

1934: Redlining And The Federal Housing Administration In the US, homeownership is a vehicle for wealth building.39 Established in 1934, the Federal Housing Administration (FHA) redlined communities to determine the desirability of neighborhoods and promote ra- cial exclusivity in mortgage lending.40 By 1960, the value of FHA-insured property in majority- Black neighborhoods in Washington, D.C., was less than a seventh of that in White suburban jurisdictions.19 The discriminatory practices re- sulted in asset accumulation andwealth building among White homeowners and concentrated poverty among Black homeowners.19 Exclusion-

Exhibit 2

Racial composition and health indicators in Washington, D.C., by ward

Wards

Indicators 1 2 3 4 5 6 7 8 Racial distribution, % Black 21 13 5 45 61 38 92 92 White 58 69 81 31 31 49 3 4 Other 21 18 14 24 8 13 5 4

Life expectancy, years 72–76 � � >76–81 � � � � >81–88 � �

Infant mortality rate per 1,000 live births 0–1.3 � >1.3–5 � � >5–7.1 � � >7.1–12.5 � � �

SOURCES Life expectancy estimates are from the US Small Area Life Expectancy Estimates Project, 2018, as published in DC Health. Health equity report for the District of Columbia 2018 (note 17 in text). For racial distribution data (2021), see note 6 in text. For infant mortality data (2019), see note 18 in text. NOTE Circles indicate the life expectancy and infant mortality category into which any ward falls.

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ary zoning practices were a key driver for differ- ences in the structural conditions of neighbor- hoods east of the Anacostia River. Lack of invest- ment in those communities has sustained lower property values and gaps in resources that facili- tate health and well-being.7,17,19

1940s: Government Seizes Barry Farm At the end of the Civil War, hundreds of free Black families developed Barry Farm, which grew to contain a vibrant community of emerging Black intellectuals and entrepreneurs, including Frederick Douglass.41 Unsettled by their activ- ism, many White residents expressed disdain for the flourishing community of landowners.19

Barry Farm residents were threatened, and there was increased political will to destroy the com- munity.19,41 To construct public housing in the 1940s, the government seized thirty-four acres and demolished homes, businesses, and other assets.41 Suitland Parkway was constructed in 1944, structurally dividing theneighborhood.19,41

The loss of property and homeownership accom- panying the destruction of community assets stripped the Black families who lived there of generational wealth accumulation.

1950s–1970s: ‘White Flight’ During the 1950s through the 1970s, “White flight” was a trend experienced in cities across the country, includingWashington,D.C., asWhiteAmericans took advantage of federal affordable housing policies that facilitated their migration to subur- ban communities.40 During the thirty-year peri- od, 308,000White residents, or60percent of the city’s White population, left the city.42 The exo- dus had a substantive impact on municipal reve- nue, which led to a decline in social services and quality of life. Moreover, the structural condi- tions caused by vacant and abandoned proper- ties left Black residents especially vulnerable to the impending crack cocaine epidemic.40,43

1960s–1970s: Urban Renewal Urban re- newal or gentrification has been linked to poor health for Black and low-income residents.44,45 In the 1960s Washington, D.C., experienced urban renewal, including in predominantly Black neighborhoods in Southwest, where many Black-owned businesses and homes were de- stroyed and thousands of Black residents were displaced in the process.19 Urban renewal not only led to the dissolution of emerging Black communities but also kept thousands of resi- dents from accumulating assets and generating wealth.

1980s–1990s: Crack Epidemic Residential segregation and discriminatory practices left Black residents especially vulnerable to the crack cocaine epidemic of the 1980s and 1990s. In 1986 Congresspassed theAnti–DrugAbuseAct,which included mandatory sentences for cocaine pos-

session (including the derivative known as crack) by quantity. Possession of more than five grams of crack would result in a five-year mini- mum sentence for first-time offenses, whereas possession of 500 grams of powder cocaine car- ried the same sentence.43 This era would be known for mass incarceration and racial dispar- ities in arrests and sentencing because crackwas relatively inexpensive, and small amounts were both more accessible and more pervasive in Black and poor communities than in wealthier andWhiter areas. Cocaine in its powder form, in contrast, was both more costly and more often used by affluent White people.43

With Black men in particular disproportion- ately affected by the crack epidemic, it had a profound impact on families. Some researchers suggest that the epidemic was a key contributor to the modern-day Black-White gaps in educa- tion, housing, and income.46

2001–23: Closure Of Hospitals And Ser- vice Lines Recent closures of hospitals and spe- cialty care service lines in Black communities have restricted access to convenient and timely medical care. From 2001 to 2020 closures were the outcome of the institutions’ extensive histo- ries of fiscal challenges, partially because of pay- er mix, as well as a proliferation of trends in mergers, acquisitions, and consolidation.25,47–55

Shuttering of health care services stressed the city’s health care ecosystem, resulting in long wait times for neighboring facilities and trans- portation barriers for patients.47–55

▸ DISTRICT OF COLUMBIA GENERAL HOSPI-

TAL (2001): After almost 200 years, inpatient services and trauma wards at DC General Hospi- tal closed in 2001. The public hospital was known for its culturally nuanced care, and it served as the medical home for the disenfran- chised, low income, and uninsured. It was also instrumental in medical education.48,49

▸ PROVIDENCE HOSPITAL (2019): Providence Hospital closed in 2019 after having served the community for nearly 160 years. The hospital provided inpatient and emergency department services. Shuttering of obstetrics and behavioral health services exacerbated preexisting specialty care gaps for city residents.17,50 With the hospital having been located in Ward 5, Black residents were likely to be disproportionately affected, as theymake up 55 percent of residents inWard 5.56

▸ UNITED MEDICAL CENTER (2020–23): Lo- cated in Ward 8, United Medical Center is the only hospital east of the Anacostia River.25 Many services have recently shuttered, including a skilled nursing facility and obstetrics ward,52

and there are plans to close the hospital by 2023.51 The closures were the result of a conflu- ence of factors, including declining patient vol-

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ume, inability to compete with more attractive and centralized medical establishments, and events that negatively affected the hospital’s brand and community perception.52–54 The ab- sence of prenatal services east of the Anacostia River creates another obstacle in a citywide effort to reduce high rates of infant andmaternal mor- tality.55

The Path Forward In this article we have illustrated how contempo- rary health inequities in Washington, D.C., are born from events that took place during the past two centuries. Many articles have documented racial inequities by race and place, as well as the role that race-based residential segregationplays in stymieing access to opportunity.20,57,58 These trends grew out of a legacy of slavery and Jim Crow segregation, as well as events and policies that may appear to have little to do with health. There are data supporting the notion that state- hood for the District of Columbia would have health benefits for its residents. For example, Thomas LaVeist found a strong relationship be- tween political representation and Black-White inequities in infant mortality in a national sam- ple of US residents at the city level.58

The COVID-19 pandemic is a noteworthy re- minder of how inequitable practices leave com- munities especially vulnerable in the face of a public health emergency. Extensive evidence elucidates the relationship between community deprivation and likelihood of delaying care or having apreventable readmission.59,60 The recent closure of hospitals and specialty care services located in the city’s Black neighborhoods repre- sents a seemingly cyclical burden for residents and should be a concern for the city’s entire health care infrastructure. Interventions that solely focus on health be-

havior will not close the chasm in racial health inequities. And although attention is increasing- ly being paid to social determinants of health in efforts to advance population health, outcomes cannot be fully realized without racial justice, which requires unconventional approaches to identify and dismantle norms that are deep

seated in policies, systems, and structures. Citywide efforts are under way inWashington,

D.C., to facilitate progress. In 2015 the DCOffice ofHealth Equitywas established. Guided by nine key drivers—education, employment, income, housing, transportation, food environment, medical care, outdoor environment, and com- munity safety—the office applies a health equity and health-in-all-policies lens across govern- ment agencies.61 In 2020 the Council of the Dis- trict of Columbia unanimously passed the Racial Equity Achieves Results (REACH) Amendment Act, which created an Office of Racial Equity; a racial equity advisory board; and a commission to facilitate a coordinated approach for racial equity, social justice, and economic inclusion.62

The city also employs Racial Equity Impact Assessments to uncover whether or how a racial group might be negatively affected by imminent legislation or an organizational policy.63 Nor- malizing such assessments can help maintain operational awarenessof howvestigesof thepast persist within and across institutions and social systems. Policies that promote racial equity and help

level the playing field are also necessary. For example, in a commitment to breaking the cycle of poverty, the DC Council recently approved the ChildWealthBuildingAct of 2021,which puts up to $1,000 per year into a trust fund for low-in- come children. After children reach age eigh- teen, those funds can be used for college, buying a home or business, investing in a business, or making a contribution to a retirement fund.64

Conclusion Achieving racial justice in Washington, D.C., would make an important statement about the nation’s commitment to life, liberty, and the pur- suit of happiness. The pathway forward requires operational awareness that the injustices being pursued and eliminated are intersectional and historically rooted. Therefore, unconventional practices are needed to identify and dismantle systems, policies, processes, and cultural norms that perpetuate racial inequities. ▪

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NOTES

1 Zinzi Mandela: growing up in the anti-apartheid movement. NPR [se- rial on the Internet]. 2004 Apr 29 [cited 2021 Oct 28]. Available for

download from: https://www.npr .org/templates/story/story.php? storyId=1862300

2 Came H, Griffith D. Tackling racism

as a “wicked” public health problem: enabling allies in anti-racism praxis. Soc Sci Med. 2018;199:181–8.

3 Williams DR, Rucker TD. Under-

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278 Health Affairs February 2022 41 :2 Downloaded from HealthAffairs.org on February 22, 2022.

standing and addressing racial dis- parities in health care. Health Care Financ Rev. 2000;21(4):75–90.

4 Blank RM, Dabady M, Citro CF, ed- itors. Measuring racial discrimina- tion. Washington (DC): National Academies Press; 2004.

5 Bailey ZD, Krieger N, Agénor M, Graves J, Linos N, Bassett MT. Structural racism and health in- equities in the USA: evidence and interventions. Lancet. 2017; 389(10077):1453–63.

6 DC Health Matters. 2021 demo- graphics. Summary data for city: District of Columbia [Internet]. Washington (DC): DC Health Mat- ters; [updated 2021 Jan; cited 2021 Dec 15]. Available from: https:// www.dchealthmatters.org/index .php?module=demographicdata &controller=index&action=index

7 Kellogg A. D.C., long “Chocolate City,” becoming more vanilla. NPR [serial on the Internet]. 2011 Feb 15 [cited 2022 Jan 3]. Available from: https://www.npr.org/2011/02/15/ 133754531/d-c-long-chocolate-city- becoming-more-vanilla

8 Urban Institute. Washington, DC: our changing city [Internet]. Washington (DC): Urban Institute; [cited 2021 Dec 15]. Available from: https://apps.urban.org/features/ OurChangingCity/demographics/ #history

9 DC Health Matters. Median house- hold income [Internet]. Washington (DC): DC Health Matters; [updated 2021 Jan; cited 2021 Dec 16]. Avail- able from: https://www.dchealth matters.org/indicators/index/view? indicatorId=315&localeId=130951

10 DC Health Matters. People 25+ with a bachelor’s degree or higher [In- ternet]. Washington (DC): DC Health Matters; [updated 2021 Jan; cited 2021 Dec 16]. Available from: https://www.dchealthmatters.org/ indicators/index/view?indicatorId= 340&localeId=130951&locale ChartIdxs=1|2|4

11 American Fitness Index. 2016 ACSM American Fitness Index: actively moving America to better health [Internet]. Indianapolis (IN): Amer- ican College of Sports Medicine; 2016 [cited 2021 Dec 15]. Available from: https://americanfitnessindex .org/wp-content/uploads/2014/02/ acsm_afireport_2016_FINAL.pdf

12 Roberts M, Reither EN, Lim S. Contributors to the black-white life expectancy gap in Washington D.C. Sci Rep. 2020;10(1):13416.

13 Harper S, MacLehose RF, Kaufman JS. Trends in the black-white life expectancy gap among US states, 1990–2009. Health Aff (Millwood). 2014;33(8):1375–82.

14 DC Health Matters. Adults with dia- betes [Internet]. Washington (DC): DC Health Matters; [updated 2021 Jan; cited 2021 Dec 16]. Available from: https://www.dchealthmatters

.org/indicators/index/view? indicatorId=81&localeId=130951 &localeChartIdxs=1%7C2%7C4

15 DC Health Matters. High blood pressure prevalence [Internet]. Washington (DC): DC Health Mat- ters; [updated 2021 Jan; cited 2021 Dec 16]. Available from: https:// www.dchealthmatters.org/ indicators/index/view?indicatorId= 253&localeId=130951&locale ChartIdxs=1%7C2%7C4

16 DC Health Matters. Age-adjusted death rate due to coronary heart disease [Internet]. Washington (DC): DC Health Matters; [updated 2021 Jan; cited 2021 Dec 16]. Avail- able from: https://www.dchealth matters.org/indicators/index/view? indicatorId=99&localeId=130951 &localeChartIdxs=1%7C2%7C3

17 DC Health. Health equity report for the District of Columbia 2018 [In- ternet]. Washington (DC): DC Health; 2019 Feb 9 [cited 2021 Dec 15]. Available from: https://dchealth .dc.gov/publication/health-equity- report-district-columbia-2018

18 DC Health Matters. Infant mortality rate [Internet]. Washington (DC): DC Health Matters; [updated 2021 Jan; cited 2022 Jan 6]. Available from: https://www.dchealthmatters .org/indicators/index/view? indicatorId=9671&localeTypeId=27

19 Kijakazi K, Atkins RMB, Paul M, Price A, Hamilton D, Darity WA Jr. The color of wealth in the nation’s capital [Internet].Washington (DC): Urban Institute; 2016 Nov 1 [cited 2022 Jan 6]. Available from: https:// www.urban.org/research/ publication/color-wealth-nations- capital/view/full_report

20 Williams DR, Collins C. Racial resi- dential segregation: a fundamental cause of racial disparities in health. Public Health Rep. 2001;116(5): 404–16.

21 To access the appendix, click on the Details tab of the article online.

22 D.C. Hunger Solutions. Still minding the grocery gap in D.C.: 10th anni- versary grocery store report [Inter- net].Washington (DC): D.C. Hunger Solutions; c 2020 [cited 2022 Jan 6]. Available from: https://www .dchunger.org/wp-content/uploads/ 2021/01/StillMindingGroceryGap .pdf

23 DC Health Matters. Preventable hospital stays: Medicare population [Internet]. Washington (DC): DC Health Matters; [updated 2018 Aug; cited 2022 Jan 6]. Available from: https://www.dchealthmatters.org/ indicators/index/view?indicatorId= 384&localeId=130951

24 Government of the District of Co- lumbia, Department of Health. Dis- trict of Columbia health systems plan 2017 [Internet]. Washington (DC): The Department; 2017 Sep 19 [cited 2021 Dec 15]. Available from: https://dchealth.dc.gov/sites/

default/files/dc/sites/doh/ publication/attachments/DC%20 Health%20Systems%20Plan%20 2017_0.pdf

25 Georgetown University. New Georgetown report highlights health disparities and calls for racial equity in the District of Columbia [Inter- net]. Washington (DC): Georgetown University; 2020 Jun 2 [cited 2021 Dec 15]. Available from: https:// provost.georgetown.edu/new- georgetown-report-highlights- health-disparities-and-calls-for- racial-equity-in-the-district-of- columbia/

26 Lee C, Ayers SL, Kronenfeld JJ. The association between perceived pro- vider discrimination, healthcare uti- lization, and health status in racial and ethnic minorities. Ethn Dis. 2009;19(3):330–7.

27 Ruiz MS, O’Rourke A, Allen ST. Impact evaluation of a policy inter- vention for HIV prevention in Washington, DC. AIDS Behav. 2016; 20(1):22–8.

28 Ban lifted on D.C. needle exchange. NPR [serial on the Internet]. 2007 July 2 [cited 2021 Dec 15]. Available from: https://www.npr.org/ templates/story/story.php?storyId= 11664095

29 Gillette H. Between justice and beauty: race, planning, and the fail- ure of urban policy in Washington, D.C. Philadelphia (PA): University of Pennsylvania Press; 1995.

30 Executive Office of the Mayor [In- ternet]. Washington (DC): The Of- fice. Press release, Mayor Bowser calls on Congress to provide equal funding for DC in next coronavirus relief bill; 2020 Jul 21 [cited 2021 Dec 15]. Available from: https:// mayor.dc.gov/release/mayor- bowser-calls-congress-provide- equal-funding-dc-next-coronavirus- relief-bill

31 Volou K, Khan S. Mayor Bowser: DC gets $725M less in coronavirus relief funds than states. WUSA9 [serial on the Internet]. 2020 Mar 26 [cited 2021 Dec 15]. Available from: https://www.wusa9.com/article/ news/health/coronavirus/dc-mayor- announces-inequity-in-senate- approved-stimulus-package/65- 3e9717c3-89a5-43e7-aec5-ca1205c2e 673

32 Jaffe HS, Sherwood T. Dream city: race, power, and the decline of Washington, D.C. New York (NY): Simon & Schuster; 1994.

33 Berenson T. Here’s why Washington D.C. isn’t a state. Time [serial on the Internet]. 2016 Apr 15 [cited 2021 Dec 15]. Available from: https:// time.com/4296175/washington-dc- statehood-history/

34 Jackson JP, Weidman NM, Rubin G. The origins of scientific racism. J Blacks High Educ. 2005/2006; 50(Winter):66–79.

35 Summers M. Madness in the city of

February 2022 41 :2 Health Affairs 279 Downloaded from HealthAffairs.org on February 22, 2022.

magnificent intentions. New York (NY): Oxford University Press; 2019.

36 Ross CE, Wu C. The links between education and health. Am Sociol Rev. 1995;60(5):719–45.

37 Ross CE,Wu C-L. Education, age, and the cumulative advantage in health. J Health Soc Behav. 1996;37(1): 104–20.

38 U.S. Congress. An Act Providing for the Education of Colored Children in the Cities of Washington and Georgetown, District of Columbia, May 21, 1862 [Internet].Washington (DC): US Congress; [cited 2022 Jan 6]. Available from: https://www .visitthecapitol.gov/exhibitions/ legislative-highlights/act-providing- education-colored-children-cities- washington-and

39 Turner TM, Luea H. Homeowner- ship, wealth accumulation, and in- come status. J Hous Econ. 2009; 18(2):104–14.

40 Rothstein R. The color of law: a forgotten history of how our gov- ernment segregated America. New York (NY): Liveright; 2018.

41 Shoenfeld S. The history and evolu- tion of Anacostia’s Barry Farm [In- ternet]. Washington (DC): D.C. Pol- icy Center; 2019 Jul 9 [cited 2022 Jan 4]. Available from: https:// www.dcpolicycenter.org/ publications/barry-farm-anacostia- history/

42 Zickuhr K. Discriminatory housing practices in the District: a brief his- tory [Internet]. Washington (DC): D.C. Policy Center; 2018 Oct 24 [cited 2022 Jan 4]. Available from: https://www.dcpolicycenter.org/ publications/discriminatory- housing-practices-in-the-district-a- brief-history/

43 Vagins DJ, McCurdy J. Cracks in the system: 20 years of the unjust federal crack cocaine law [Internet]. Washington (DC): American Civil Liberties Union; 2006 Oct [cited 2021 Dec 15]. Available from: https://www.aclu.org/other/cracks- system-20-years-unjust-federal- crack-cocaine-law

44 Mehdipanah R, Marra G, Melis G, Gelormino E. Urban renewal, gen- trification, and health equity: a re- alist perspective. Eur J Public Health. 2018;28(2):243–8.

45 Gibbons J, Barton MS. The associa- tion of minority self-rated health with Black versus White gentrifica- tion. J Urban Health. 2016;93(6): 909–22.

46 Evans WN, Garthwaite C, Moore TJ. The White/Black educational gap, stalled progress, and the long-term consequences of the emergence of crack cocaine markets. Rev Econ Stat. 2016;98(5):832–47.

47 Jamison P. A pregnant woman went to the “hospital from hell” short of

breath. Six hours later, she was dead. Washington Post [serial on the In- ternet]. 2017 Dec 24 [cited 2021 Dec 15]. Available from: https://www .washingtonpost.com/local/dc- politics/a-pregnant-woman-went-to- the-er-short-of-breath-six-hours- later-she-was-dead/2017/12/24/ 08642e6e-e4d8-11e7-ab50- 621fe0588340_story.html

48 Stolberg SG. After two centuries, Washington is losing its only public hospital. New York Times [serial on the Internet]. 2001 May 7 [cited 2021 Dec 15]. Available from: https://www.nytimes.com/2001/ 05/07/us/after-two-centuries- washington-is-losing-its-only-public- hospital.html

49 Cohn V. D.C. General Hospital. Washington Post [serial on the In- ternet]. 1988 Sep 20 [cited 2021 Dec 15]. Available from: https://www .washingtonpost.com/archive/ lifestyle/wellness/1988/09/20/dc- general-hospital/ce5ee21e-b512- 4a81-b688-46e815129d77/

50 Arnold J. Providence Hospital closes after 158 years: “I think it will put a lot of people in jeopardy.” WUSA9 .com [serial on the internet]. 2019 May 1 [cited 2021 Dec 16]. Available from: https://www.wusa9.com/ article/news/i-think-it-will-put-a-lot- of-people-in-jeopardy-providence- hospital-closes-after-158-years/65- 9c9a17e2-92b5-4a35-bb23-bde 122906ab7

51 Jamison P. As part of budget vote, D.C. lawmakers opt to close city’s public hospital within four years. Washington Post [serial on the in- ternet]. 2019 May 14 [cited 2022 Jan 6]. Available from: https://www .washingtonpost.com/local/dc- politics/dc-lawmakers-vote-to-close- citys-public-hospital-within-four- years/2019/05/14/85415b92-765d- 11e9-b3f5-5673edf2d127_story.html

52 Reed T. United Medical Center will permanently close obstetrics unit. Washington Business Journal [serial on the Internet]. 2017 Dec 13 [cited 2021 Dec 15]. Available from: https://www.bizjournals.com/ washington/news/2017/12/13/ district-owned-united-medical- center-opts-to.html

53 Weil JZ, Fadulu L. At a troubled D.C. hospital, fewer patients and looming cuts in funding, services. Washing- ton Post [serial on the Internet]. 2021 May 11 [cited 2021 Dec 15]. Available from: https://www .washingtonpost.com/local/dc- politics/umc-dc-hospital-united- medical-center/2021/05/11/ aca0af8c-adf9-11eb-ab4c- 986555a1c511_story.html

54 Barthel M. The skilled nursing fa- cility at UMC closed due to corona- virus. Now it’s shutting down per-

manently. DCist [serial on the Internet]. 2020 Jul 7 [cited 2021 Dec 15]. Available from: https://dcist .com/story/20/07/07/umc-nursing- facility-closed-coronavirus/

55 Ieronimo C. D.C.’s high maternal mortality rate shows an urgent need for hospital access. Diamondback [serial on the Internet]. 2019 Nov 19 [cited 2021 Dec 15]. Available from: https://dbknews.com/2019/11/19/ washington-dc-maternal-mortality- pregnancy-health-care-united- medical/

56 DC Health Matters. Race data for Ward 5 [Internet].Washington (DC): DC Health Matters; [updated 2021 Jan; cited 2022 Jan 6]. Available from: https://www.dchealthmatters .org/?module=demographicdata &controller=index&action=index &id=131492&sectionId=940

57 LaVeist T, Pollack K, Thorpe R Jr, Fesahazion R, Gaskin D. Place, not race: disparities dissipate in south- west Baltimore when blacks and whites live under similar conditions. Health Aff (Millwood). 2011;30(10): 1880–7.

58 Laveist TA. Segregation, poverty, and empowerment: health consequences for African Ameri- cans. Milbank Q. 1993;71(1):41–64.

59 Patel SA, KrasnowM, Long K, Shirey T, Dickert N, Morris AA. Excess 30- day heart failure readmissions and mortality in Black patients increases with neighborhood deprivation. Circ Heart Fail. 2020;13(12):e007947.

60 Morris AA, McAllister P, Grant A, Geng S, Kelli HM, Kalogeropoulos A, et al. Relation of living in a “food desert” to recurrent hospitalizations in patients with heart failure. Am J Cardiol. 2019;123(2):291–6.

61 DC Health. Office of Health Equity [Internet]. Washington (DC): DC Health; [cited 2021 Dec 15]. Avail- able from: https://dchealth.dc.gov/ page/office-of-health-equity

62 Council of the District of Columbia. D.C. Law 23-181. Racial Equity Achieves Results (REACH) Amend- ment Act of 2020 [Internet]. Washington (DC): DC Council; [cit- ed 2021 Dec 10]. Available from: https://code.dccouncil.us/us/dc/ council/laws/23-181

63 Council Office of Racial Equity. Ra- cial Equity Impact Assessments [In- ternet]. Washington (DC): CORE; [cited 2021 Dec 15]. Available from: https://www.dcracialequity.org/ racial-equity-impact-assessments

64 Council of the District of Columbia. B24-0236—Child Wealth Building Act of 2021 [Internet]. Washington (DC): DC Council; [cited 2021 Dec 15]. Available from: https://lims .dccouncil.us/Legislation/B24-0236

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