Handunge V. Purpose built communities to promote health equity and address the impacts of racialized residential segregation. Harvard Public Health Review. 2021; 30.
Structural racism is the “totality of ways in which societies foster racial discrimination, through mutually reinforcing inequitable systems that in turn reinforce discriminatory beliefs, values, and distribution of resources, which together affect the risk of adverse health outcomes” (Bailey et al., 2017). In the United States, racialized residential segregation is a form of structural racism that creates areas of concentrated urban poverty and exacerbates the Black-white wealth gap and health gap. The belief that concentrated poverty is a driver of “bad” neighborhoods (i.e., high in crime, low employment and graduation rates), is what led Tom Cousins, a real estate developer from Georgia, to develop the Purpose Built Communities (PBC) intervention (Franklin & Edwards, 2012). In this essay, I argue that Purpose Built Communities (PBCs) are important evidence-based interventions that promote racial and socioeconomic equity in public health. However, I conclude that there is opportunity for intervention improvement, and that concurrent action will be necessary to eliminate racial inequities in public health.
Following the Great Depression in the 1930s, racist public policies and private actions deprived Black Americans of wealth-generation opportunities. These policies and practices including demolishing racially integrated communities and segregating public housing, subsidizing housing developments in the suburbs for deeds that prohibited sale to African Americans, and denying low-cost mortgages in African American communities through the widespread practice of redlining, produced racialized residential segregation in the U.S. (Gross, 2017). Additionally, this residential segregation, accompanied with severe lack of investment in Black communities, continues to shape socioeconomic conditions for Black Americans at the individual, household, and neighborhood levels (Williams & Collins, 2001). While redlining was made illegal through the Fair Housing Act of 1968, one in four Black Americans and one in six Hispanic Americans currently live in high-poverty neighborhoods (where the poverty rate is greater than or equal to 30%) compared to only one in thirteen white Americans (National Low Income Housing Coalition, 2020). Additionally, while the average white person in metropolitan areas lives in neighborhoods that are 75% white, most Black Americans live in neighborhoods that are more racially diverse (Bailey et al., 2017).
In his work, Dr. David Williams highlights racial residential segregation in the U.S. as a “fundamental cause” of the stark health disparities between Black and white Americans (Williams & Collins, 2001). Residential segregation has created predominantly Black neighborhoods with less access to health-related goods (e.g., grocery stores, quality housing, transportation), healthcare, and wealth generating opportunities. Such socioeconomically disadvantaged neighborhoods are associated with lower health outcomes (e.g., poorer self-reported health, adverse mental health, increased rates of chronic disease) and studies have found that living in a historically redlined neighborhood is associated with higher risk of pre-term birth, late-stage diagnosis of breast and lung cancer, and lower life expectancy at birth (Krieger, 2020a, 2020b; Richardson, 2021). Thus, systematic segregation and disinvestment in Black communities in the U.S. perpetuates both health and wealth inequities, by relegating many Black Americans to neighborhoods characterized by concentrated poverty.
The Purpose Built Communities (PBC) intervention has the potential to address Black-white health and socioeconomic inequities in the U.S. The aim of the Purpose Built Communities (PBC) organization is to stymie the intergenerational poverty that stems from racialized residential segregation, through improving neighborhood conditions in high poverty areas. PBCs are a place-based, long-term intervention that have four essential components: 1) mixed-income housing which aims to deconcentrate poverty while keeping housing affordable for low-income residents; 2) a “cradle-to-college” investment in education for children, including early childhood education in a child’s life as early as 6 weeks old 3) services and facilities (e.g., grocery stores, banks, gyms, financial literacy classes) to support families and increase neighborhood cohesion; and 4) a “community quarterback” organization which oversees coordinated efforts throughout the neighborhood (Purpose Built Communities, 2021). By attracting residents across the income spectrum, investing in children and low-income residents, increasing health promoting resources and social cohesion, PBCs aim to improve the overall health and well-being of the neighborhood.
To understand whether the PBC intervention promotes racial and socioeconomic equity in public health, it is useful to review the redevelopment outcomes of East Lake, Georgia, which serves as the PBC organizational model. In 1995, before implementing the PBC intervention, East Lake had a 30% high school graduation rate, a median income of $4,500, a 13% employment rate, and a crime rate 18 times that of the national average. In 2021, twenty-five years into the PBC intervention, 98% of students in East Lake graduate on time, the median income for residents receiving public assistance is 5 times the median in 1995, and the violent crime rate is nearly zero (Shoy, 2021). Additionally, the neighborhood school (Drew Charter School), which includes a majority of students who are Black and who receive free and reduced lunch, performs similarly to other top public schools in Atlanta, including those that are in majority middle and upper income, and more white neighborhoods (U.S. News & World Report, n.d.; Public School Review, n.d.). This demonstrates that investment in education through the PBC model is effective in improving racial and socioeconomic equity.
The redevelopment of East Lake illustrates the positive outcomes associated with broad intentional investment at the neighborhood level, which has been systematically prevented for generations in many communities of color. Although there is limited information on the PBC intervention’s impact on the Black-white wealth gap and health outcomes, the components and goals of the intervention are evidence-based. For instance, greater neighborhood social cohesion is associated with better cardiovascular health and mental health outcomes. Additionally, increased access to healthy foods and exercise resources is associated with lower BMI and better diets (Diez Roux & Mair, 2010). Moreover, quality housing and education are both drivers of better health (Swope & Hernández, 2019). Finally, studies have shown that early childhood education has a high return on investment and improves both socioeconomic and health outcomes for recipients and their children (Heckman 2019 as cited in The Heckman Equation, 2019). Thus, the PBC intervention advances racial and socioeconomic equity in public health by directly targeting some of the negative neighborhood impacts of racialized residential segregation. It boosts neighborhood investment, increases access to health-promoting resources, and improves quality of education and housing for low-income residents. By focusing on concentrated areas of poverty with a majority non-white population, the PBC organization centers its efforts on neighborhoods that have been most impacted by structural racism in the U.S., thus promoting racial equity.
Additional strengths of the PBC model include its place-based, multifaceted approach, racial equity lens and community-engaged process. PBCs are neighborhood level interventions that use a holistic framework to incorporate housing, education, and health & wellness, instead of taking a more siloed approach to targeting issues as larger federal programs (e.g., WIC, SNAP) often do. PBCs require collaboration between multiple sectors (government, nonprofits, private sector, and residents) and incorporate a “quarterback” organization to oversee coordination (Center for Promise, 2014). While the PBC intervention is wide in scope, the multipronged approach ensures that the maximum benefit will be gained from each individual component of the intervention. Additionally, the openness to partnerships across sectors enables the quarterback organization to focus on community-specific needs and assets rather than using a one-size fits all approach.
The PBC model also incorporates a racial equity lens and a community-engaged process (Center for Promise, 2014). Using a racial equity lens is important as this indicates that the PBC organization acknowledges the legacy of state-sanctioned discrimination against Black individuals and disinvestment in Black communities in the U.S. By acknowledging this history, the PBC organization understands that concentrated poverty was intentionally created through government policies that segregated Black populations from white populations. To address these harms, the organization involves community residents in the planning and implementation process. I believe that community-based interventions cannot be successful without community input and support. Thus, a community-engaged process is necessary for intervention success.
While the PBC model promotes a community-engaged approach and racial equity lens, it is unclear whether this engagement is meaningful across neighborhoods. In the East Lake intervention, tensions between original residents and the East Lake Foundation (ELF) leaders led tenants to bring an injunction against the ELF and vote to get rid of its involvement in the redevelopment project (Goldstein, 2017). Additionally, it is unclear how accessible PBCs are to original residents. In the case of East Lake, residents who did not meet working requirements or who had a felony record (13%) were not eligible to return, and only about 25% of the original residents returned to the redeveloped neighborhood (Yu, 2015). When considering racial justice, the exclusion of those with a felony record is important to examine as mass incarceration disproportionately impacts Black men and women (Alexander, 2010). Without more information on displacement rates and outcomes for displaced families, it is harder to assess the potential negative impacts of PBCs.
Financing must also be considered to understand the potential for sustainable impact of PBCs on racial and socioeconomic equity. PBCs are financed through a combination of sources. Affordable housing is supported through avenues such as “Low Income Housing Tax Credits” and “HUD project-based rental assistance,” and charter schools can typically be financed through public funding. However, community-based supportive programs, such as recreation, afterschool programs, and financial literacy classes are funded through philanthropic funds (Franklin & Edwards, 2012). As the organization expands to new communities, there is the possibility of donation cannibalization when multiple PBCs are in proximity to each other (Shoy, 2021). Additionally, philanthropic funds are less sustainable (i.e., grant funding may run out, grants may not renew).
Scalability is another important factor when considering the extent of impact PBCs can have in American society. In the twelve years since the inception of the PBC organization, 28 PBC neighborhoods have been developed (about two neighborhood interventions per year). Each PBC neighborhood requires a long-term commitment of over a decade. In using the size of East Lake (~15,000 people) as a reference point, the PBC organization directly impacts over 400,000 Americans. While this is substantial, as of 2013, 13.8 million people live in concentrated poverty in the U.S. (Florida, 2015). Based on this, the PBC organization serves just 3% of individuals living in concentrated poverty. Thus, even if five PBCs are added each year, with over 800 distressed neighborhoods, it would take over 150 years to reach everyone (Purpose Built Communities, 2019). While the PBC organization does not seek to be the sole solution for concentrated poverty, it is important to note that this organization alone is unlikely to reach all U.S. neighborhoods in need.
Therefore, I argue that the PBC organization should take a few additional steps to better ensure that PBC interventions are implemented in a manner that promotes racial and social justice, and increases sustainability. Firstly, the PBC model should have more explicit requirements for community-engagement to ensure that the original residents in PBC communities have significant decision-making power throughout the entire process. Secondly, the organization should expand inclusion criteria so that more original residents, including those impacted by the carceral system, can stay and benefit from the redevelopment. The PBC organization could also leverage its influence to advocate for policy changes with the department of Housing and Urban Development that would reduce barriers to obtaining quality housing for individuals with a felony record. Thirdly, the organization could provide additional financial and social supports to individuals and families that are displaced and are unable to return to the redeveloped neighborhood. Fourthly, the PBC organization should work with communities to find more sustainable financing mechanisms to support programs and facilities long-term. Lastly, the PBC organization should publish reports for outcomes in each community, including data on resident retention, to be transparent about the positive and negative impacts of redevelopment. These community-specific reports could also build evidence to support the PBC model.
In this essay, I have primarily focused on racial equity as it relates to Black Americans. PBCs have the potential to promote racial equity related to other non-white U.S. groups as well. However, history, culture, and individual and group autonomy should inform any PBC efforts. For instance, while indigenous groups in the U.S. also face high rates of poverty, indigenous sovereignty and the history of settler colonialism in the U.S. should inform PBC efforts. Nevertheless, PBCs are an evidence-based intervention that aim to combat intergenerational poverty at the neighborhood level. They create healthier neighborhoods and increase opportunity and resources for low-income communities of color. Beyond the positive changes that PBCs bring to residents, the model also provides additional benefits and direction for health equity work. For instance, PBCs contribute to the literature on place-based interventions and how to successfully address poverty at the neighborhood level.
Additionally, the success of the PBC organization can be used to build public support for policies that address the negative impacts of residential segregation and the larger legacy of discriminatory practices impacting Black communities. With enough evidence, perhaps there is potential for the PBC organization to secure government funding and increase scalability to reach more neighborhoods in the short-term. Finally, given that every neighborhood has unique needs and assets, the PBC model highlights the importance of implementation science and community-engaged methods in understanding how to successfully adapt interventions to community-specific contexts. Thus, the PBC organization should continue to strive towards an ethical and inclusive approach in their redevelopment efforts and be active in both advocacy and research to reduce racial and socioeconomic inequities in public health. However, given limited scalability, it is equally important to focus on other pathways to concurrently promote racial and socioeconomic equity in public health (e.g., promoting inclusionary zoning, abolishing prisons and reforming the criminal punishment system, increasing access to quality healthcare, and enacting socioeconomic interventions such as reparations for African enslavement) until racialized health inequities and wealth gaps are eliminated from American society.
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Veronica Handunge is a Masters student in the Health and Social Behavior program at the Harvard T.H. Chan School of Public Health. Veronica has a BA in Neuroscience & Behavior, and Business Management from Columbia University.