Historical Redlining and Present-Day Nonsuicide Firearm Fatalities

Dholakia, Ayesha MD
Burdick, Kendall J. MD
Kreatsoulas, Catherine MSc, PhD
Monuteaux, Michael C. ScD
Tsai, Jennifer MD, MEd
Subramanian, S. V. PhD
Fleegler, Eric W. MD, MPH

¹Department of Pediatrics, Boston Children's Hospital, and Department of Pediatrics, Boston Medical Center, Boston, Massachusetts (A.D., K.J.B.)
²Harvard T.H. Chan School of Public Health, Boston, Massachusetts (C.K.)
³Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts (M.C.M.)
⁴Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, and St. Joseph's Medical Center in Stockton, Stockton, California (J.T.)
⁵Harvard Center for Population and Development Studies, Cambridge, Massachusetts, and Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts (S.V.S.)
⁶Department of Emergency Medicine, Massachusetts General Hospital, and Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, Massachusetts (E.W.F.).

Financial Support: In part by the Fred Lovejoy Housestaff Research and Education Fund.

Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M23-2496.

Reproducible Research Statement:Study protocol and statistical code: See the Supplement. Data set: Freely available at the Gun Violence Archive, Esri's ArcGIS Living Atlas of the World, http://statefirearmlaws.org, and the Centers for Disease Control and Prevention's Web-based Injury Statistics Query and Reporting System.

Corresponding Author: Ayesha Dholakia, MD, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115; e-mail, [email protected].

Author Contributions: Conception and design: A. Dholakia, E.W. Fleegler, M.C. Monuteaux, S.V. Subramanian.

Analysis and interpretation of the data: K.J. Burdick, A. Dholakia, E.W. Fleegler, C. Kreatsoulas, M.C. Monuteaux, S.V. Subramanian, J. Tsai.

Drafting of the article: K.J. Burdick, A. Dholakia, E.W. Fleegler, J. Tsai.

Critical revision for important intellectual content: K.J. Burdick, A. Dholakia, E.W. Fleegler, C. Kreatsoulas, M.C. Monuteaux, S.V. Subramanian, J. Tsai.

Final approval of the article: K.J. Burdick, A. Dholakia, E.W. Fleegler, C. Kreatsoulas, M.C. Monuteaux, S.V. Subramanian, J. Tsai.

Provision of study materials or patients: A. Dholakia.

Statistical expertise: C. Kreatsoulas, M.C. Monuteaux, S.V. Subramanian.

Obtaining of funding: A. Dholakia, E.W. Fleegler.

Administrative, technical, or logistic support: A. Dholakia, E.W. Fleegler, J. Tsai.

Collection and assembly of data: K.J. Burdick, A. Dholakia, E.W. Fleegler, C. Kreatsoulas.

This article was published at Annals.org on 23 April 2024.

Annals of Internal Medicine 177(5):p 592-597, May 2024. | DOI: 10.7326/M23-2496

Background:

Redlining began in the 1930s with the Home Owners' Loan Corporation (HOLC); this discriminatory practice limited mortgage availability and reinforced concentrated poverty that still exists today. It is important to understand the potential health implications of this federally sanctioned segregation.

Objective:

To examine the relationship between historical redlining policies and present-day nonsuicide firearm fatalities.

Design:

Maps from the HOLC were overlaid with incidence of nonsuicide firearm fatalities from 2014 to 2022. A multilevel negative binomial regression model tested the association between modern-day firearm fatalities and HOLC historical grading (A [“best”] to D [“hazardous”]), controlling for year, HOLC area-level demographics, and state-level factors as fixed effects and a random intercept for city. Incidence rates (IRs) per 100 000 persons, incidence rate ratios (IRRs), and adjusted IRRs (aIRRs) for each HOLC grade were estimated using A-rated areas as the reference.

Setting:

202 cities with areas graded by the HOLC in the 1930s.

Participants:

Population of the 8597 areas assessed by the HOLC.

Measurements:

Nonsuicide firearm fatalities.

Results:

From 2014 to 2022, a total of 41 428 nonsuicide firearm fatalities occurred in HOLC-graded areas. The firearm fatality rate increased as the HOLC grade progressed from A to D. In A-graded areas, the IR was 3.78 (95% CI, 3.52 to 4.05) per 100 000 persons per year. In B-graded areas, the IR, IRR, and aIRR relative to A areas were 7.43 (CI, 7.24 to 7.62) per 100 000 persons per year, 2.12 (CI, 1.94 to 2.32), and 1.42 (CI, 1.30 to 1.54), respectively. In C-graded areas, these values were 11.24 (CI, 11.08 to 11.40) per 100 000 persons per year, 3.78 (CI, 3.47 to 4.12), and 1.90 (CI, 1.75 to 2.07), respectively. In D-graded areas, these values were 16.26 (CI, 16.01 to 16.52) per 100 000 persons per year, 5.51 (CI, 5.05 to 6.02), and 2.07 (CI, 1.90 to 2.25), respectively.

Limitation:

The Gun Violence Archive relies on media coverage and police reports.

Conclusion:

Discriminatory redlining policies from 80 years ago are associated with nonsuicide firearm fatalities today.

Primary Funding Source:

Fred Lovejoy Housestaff Research and Education Fund.

Redlining began in the 1930s with the Home Owners' Loan Corporation; this discriminatory practice limited mortgage availability and reinforced concentrated poverty that still exists today. This study examines the relationship between historical redlining policies and present-day nonsuicide firearm fatalities.