Separate and Unequal: Race, the Mortgage Market, and Health

On Monday, December 7, Assistant Professor at Emory University, Abigail Sewell, PhD, visited the UC San Francisco (UCSF) School of Nursing’s Department of Social and Behavioral Sciences and presented as a guest speaker. Her talk entitled “Separate and Unequal: Race, the Mortgage Market, and Health” provided faculty and students in the School of Nursing with critical knowledge and gave the opportunity for dialogue with a question and answer period following the talk as well as a formal reception with Dr. Sewell.

Racial Segregation

Dr. Sewell’s talk centered on the current state of segregation. She led with the fact that despite legislation, racial segregation still exists in almost every domain. Specifically, Dr. Sewell illuminated health effects of racial residential segregation, which she affirms are at times negative and at other times positive. Dr. Sewell developed her own multi-level, root-cause, conceptual model called the racism-race reification process, which posits that structured forms of racial bias have an effect by changing the neighborhoods in which we live. After detailing her model, she presented data that tests this model from the city of Chicago.

Because economic status and living conditions are shaped by racial segregation and Chicago is deeply divided by race and class, the city is a prime location to study the health effects of racism and segregation, especially because, as Dr. Sewell further asserts, the city’s failure to implement affordable housing compounded inequality in a way that led to the nationalization of fair housing legislation. Dr. Sewell applied four main sociological approaches to observations of neighborhood, specifically health effects – political economic theories of race and racism; structural race theory; political economic theories of health and health care; and social structure and personality theory. Dr. Sewell began her talk with this succinct statement:

Health, in many ways, reflects both the chance to live well and an opportunity to live more. Racial residential segregation however curtails one’s chances at living well and living more.” – Abigail A. Sewell, PhD

Mortgage Practices

Dr. Sewell advocates for adopting place stratification theories of segregation to the neighborhood level to centralize racial disparities in entry into the housing market as a key organizing force of racial disparities in health. She highlighted that racial disparities and mortgage access can dictate 1) how racial dissimilar and isolated neighbors are and 2) what kinds of goods, services, and opportunities are available in which neighborhoods.

The focus of her lecture was specifically on understanding the link between lending disparities and asthma—a key dimension of racial disparities among children. Dr. Sewell challenged the audience to consider this further by asking, “What do banking practices have to do with youth having trouble breathing?” While symptoms of asthma improve over time, there is no cure. Research indicates that the health effects of segregation, including neighborhood quality and marginalized social status, holds true in the case of asthma. Including hazardous physical conditions of the living environment, such as waste management practices, poorly maintained housing, streets, and play areas, to low levels of collective efficacy in neighborhood, translating to a lack of mutual trust and social cohesion among neighbors and to a myriad of spatial arrangements where blacks are segregated from whites to neighborhood poverty, and the absence of affluence and wealth at the neighborhood level and to being black, Latino, and poor. Dr. Sewell pointed out that despite this, there have been no studies conducted linking lending disparities to asthma.

Racism-Race Reification Process (R3p)

Dr. Sewell developed a model that documents that there are institutional aspects of racial discrimination that are codified and manifested in neighborhoods and communities—the Racism-Race Reification Process (R3p), Dr. Sewell’s model of race, institutions, and illness. The first part of her conceptual model holds that institutional structures of racism are created from an ideology of race and manifested in how institutional gatekeepers interact with and react to marginalized people and communities marginalized by the ethno-racial status of the people who live there. Dr. Sewell notes that resource deprivation rooted in institutionalized racism in turn is linked to racial differences in illness. Lastly, she affirms that racial health disparities are propagated by way of the deterioration of neighborhood quality and the ghettoization of racially marginalized people in disadvantaged neighborhoods. Dr. Sewell focused on the key component, which she notes is the racist relational structure, which develops from the actions and inactions of institutionalized gatekeepers. It is a neighborhood-level mechanism that affects health both indirectly and directly. Dr. Sewell presented this compelling cyclical cause-and-effect analysis demonstrating the effects racism has on every element involved in community and neighborhood health.

Dr. Sewell’s presentation illuminated the nature of the housing market and the types of home buying occurring during the recession, including foreclosure. She also detailed pathways that people follow into loans. Access to mortgage lending is good for neighborhoods. Yet, she attested that not all forms of access lend to positive outcomes. Dr. Sewell characterizes her research and findings as “the Home Mortgage Disclosure Act meets American Apartheid” and “Being Black, Living in the Red.” She pointed out that we generally assume that the political economy of neighborhoods matters, however, we do not know much regarding its actual intersection with racial health disparities.


Dr. Sewell concluded her presentation with remarks on implications of the study toward understanding the implications of the long-term recession on minority health. After describing the states of her analysis, Dr. Sewell detailed her results. She summarized that “without considering any control variables, the only measure of racial mortgage discrimination that differentiates health is racialized credit privateness. That is, in areas where minorities are more likely than whites to be provided credit that is not regulated by the federal government, asthma is more prevalent. These findings support a direct health effect of racist relational structures, primarily through racial differences in private credit.” Dr. Sewell revealed her data including developed “neighborhood typologies.” She stressed that the mortgage market must be seriously considered as a health risk for minorities. In her final remarks, she affirms, “Segregation is bad for health. But studies show that while living in segregation at the city level is bad for health, studies indicate that living in segregated neighborhoods within a city is not uniformly bad for one’s health. What’s missing is a historicized appreciation of how spaces come to be segregated.” Dr. Sewell’s future research will focus on this critical context. The lively question and answer period included exchanges regarding policy’s potential, additional environmental factor consideration, expansion of this analysis to other cities, and results stemming from the application of this model on modern suburban areas.