Addressing Racism as a Public Health Crisis: A Starting Point to UnDesign Current Systems

The whole world has changed since the NYC Health Department exhibited Undesign the Redline in 2018, but the relevance of the project has only grown. The project, detailed in a newly published report, provided a concrete way for a local health department to engage with residents, community partners, and government employees about structural racism. Since 2018, two events stand out. First, the COVID-19 pandemic, with its disproportionate impact on Black and Latino Americans as well as Alaskan Natives, American Indians, and Asian Americans. Then came the murder of George Floyd, which reinvigorated activism against police violence, bringing structural and institutional racism into the international limelight. Together these triggered a collective reckoning with racist policies. Still, it remains a challenge to go beyond rhetoric and make visible in everyday experience how such policies work to harm health. The example of redlining makes clear how a policy can create conditions under which universal threats of a virus, violence, or other harms are more lethal in some communities than others.

Created and curated by Designing the WE, a social impact design studio, Undesign the Redline is a traveling interactive exhibit exploring antecedents and subsequent harms of redlining. It aims to promote understanding of and opposition to the lack of public and private investment in redlined neighborhoods. From January through September 2018, NYC Health Department staff offered tours of the exhibit to City government employees, faith-based leaders, architects, city planners, health service providers, educators, students, and Bronx residents. Exhibit content included reproductions of the Home Owner’s Loan Corporation (HOLC) original color-coded maps, a historical timeline of relevant policies, practices, and organizing efforts, and real-world applications of how consequential disparities can be “undesigned.” The NYC Health Department paired the curated panels with maps showing geographic disparities in NYC, such as rates of high school graduation, asthma hospitalizations, infant mortality rates, and life expectancy. The maps make a powerful visual statement. Nearly a century later, present-day health burdens continue to track with historical redlining.

My colleagues and I humbly acknowledge that this work was challenging as government employees. For staff that grew up in the South Bronx, intersectional identities as “government employee” and “community resident” created unique complexities and opportunities. We offer this work as a tangible example of how a local health department can engage in difficult conversations about structural racism among staff, partners, and residents. Mounting and staffing Undesign the Redline brought Health Department staff into very close proximity to the experiences of people in the neighborhood that we serve, showing how government can alter its approach to public health practice. We learned along with our visitors.

The first lesson was that in the present-day South Bronx, by many indicators the definition of a “distressed” neighborhood reflects bad policies, not bad people. But perhaps more important, this project highlighted how disinvestment in some neighborhoods made possible disproportionally more investment in others. For example, redlining also simultaneously created green- and blue-lined neighborhoods where banks made mortgages and other long-term investments. We found ourselves, as government employees, participating in an honest dialogue that included people who have been harmed by the system of redlining, and people who have benefited from it. Some participants had lived through events detailed in the exhibit. Some had internalized the narrative that their communities suffered because of residents’ own poor decisions and challenged alternatives to personal responsibility. These conversations were raw, sometimes tense, and mutually enlightening. At the end of a tour one resident reflected, “I lived this!!!! Thank you for telling the truth.”

Our call to action to other local health departments and organizations is to join us in naming structural racism as a root cause of health inequities, and in making explicit the connection between racist policies and practices and consequential health outcomes. This project had reverberating impacts. A staff person in graduate school inspired her class to visit the exhibit following her push to expand the discussion of the “War on Drugs” to include identifying elements of systemic racism embedded in policies and the unresolved intergenerational trauma of drug use.

Difficult conversations need a starting point; a way to understand that the goal is assuming responsibility, and not blame. This work begins with learning from and alongside the people we serve, and with telling the truth. Only from there can we begin to undesign what has been built. To learn more, read our Practice Full Report, “Making Injustice Visible: How a Health Department Can Demonstrate the Connection Between Structural Racism and the Health of Whole Neighborhoods” in the Journal of Public Health Management and Practice September/October 2021 issue.