Historic ‘Redlining’ May be Affecting Veteran Cardiovascular Health More Than a Century Later


The practice has biologic, epigenetic, and structural implications on people living in these once-segregated areas.

Living in historically redlined neighborhoods was found to be associated with a 13% higher risk for all-cause mortality and major adverse cardiovascular events (MACE), according to the results of a study published in JAMA Network Open. The association is independent of traditional cardiovascular risk factors.

Credit: santoelia - stock.adobe.com.

Credit: santoelia - stock.adobe.com.

“Even close to a century after this practice was discontinued, redlining appears to still be adversely associated with adverse cardiovascular events,” the study authors wrote in the article. “This underscores the idea that one’s surrounding environment is a powerful estimator of health.”

The findings show that patients in redlined neighborhoods had a 14% higher outcome of MACE (hazard ratio [HR], 1.139; 95% CI, 1.083-1.198; P < .001) and 13% higher rate of all-cause mortality (HR, 1.129; 95% CI, 1.072-1.190; P < .001). Further, these veterans were more likely to be minoritized populations and had increased risk of hypertension, diabetes, obesity, smoking, and having unhealthy cholesterol levels.

In the 1930s, The Home Owners’ Loan Corporation (HOLC) created redlining, which is a color-coded grading system for neighborhoods based on the racial and ethnic make-up. The grading system was used to estimate risk of foreclosure, but it ultimately dissuaded investment in redlined neighborhoods and worsened residential segregation.

“Neighborhoods were rated and thus color-coded as (A [best [green]), B (still desirable [blue]), C (definitely declining [yellow]), and D (hazardous [red]),” the study authors wrote.

In the 1940s, the practice of redlining was stopped; however, people in redlined neighborhoods experienced markedly worse access to care, adverse environmental exposures, health risk factors, and outcomes. Even today, studies show that people in these neighborhoods experience worse health and risk of cardiovascular outcomes, but the extent is unknown.

Investigators conducted an individual-level longitudinal analysis of 79,997 veterans with atherosclerotic cardiovascular disease to understand whether redlining is associated with adverse cardiovascular outcomes. Among patients, 7% lived in grade A neighborhoods, 20% in group B, 42% in group C, and 31% in grade D.

Limitations included a mostly male (and veteran exclusive) population who have access to insurance and health care services; small cohort size in relation to overall patient population; not accounting for change in location; and residential confounding, which could impact the findings.

Redlined neighborhoods may not receive proper investments (leading to increased environmental exposures and noise pollution that may be associated with poor cardiovascular outcomes) and people have reduced access to recreational land space, healthy foods, and tree cover, which may be associated with increased stress responses that can inflame the arteries and cause MACE, according to the study. These residents could also have poor health outcomes due to financial insecurity, fewer resources, and poor educational opportunities.

The study calls attention to the adverse sequelae of residential discrimination, specifically with cardiovascular outcomes, and shares how it is important to identify neighborhood characteristics associated with risk. Increasing greenspaces, incentivizing taxes on tobacco, improving access to nutritious food, and making health care delivery more accessible may improve cardiovascular outcomes.

“Future studies should incorporate individual social determinants of health and neighborhood social risk for comprehensive assessment of cardiovascular health,” the study authors wrote.


Deo, S, Motairek I, Nasir K, et al. Association Between Historical Neighborhood Redlining and Cardiovascular Outcomes Among US Veterans With Atherosclerotic Cardiovascular Diseases. JAMA Netw Open. 2023;6(7):e2322727. doi:10.1001/jamanetworkopen.2023.22727

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