Gabriel L. Schwartz

Residential racial segregation is hypothesized to cause inequities in cardiovascular disease (CVD). Yet existing work is largely associational and has rarely tested the longitudinal effects of childhood segregation on later CVD. Here, we leverage quasi-random urban planning decisions in Northern US cities prior to the Great Migration as an instrument for segregation as Black families moved north, providing a natural experiment. We specifically followed Ananat’s work showing railroad track configurations serve as an instrument for segregation at the metropolitan area level. We linked Ananat’s data to the birthplaces of participants in the Panel Study of Income Dynamics (1968-1994, n = 871 Black and 1418 White), following them through 2023. Race-stratified accelerated failure time models used an instrumental variables design and cluster bootstrapping, progressively adjusting for other railroad features, socioeconomic status, and birth year. Estimates suggest childhood residential segregation causally delays the onset of CVD or hypertension for White people, but speeds it up for Black people, though CIs and instrument strength varied across model specifications. Non-instrumented models directly adjusting for confounders yielded strongly attenuated results in the same direction. Segregation is likely a cause of Black–White CVD inequities, not just a correlate. Causal designs across the life course are needed.

Fatal police violence is a public health problem in the United States, with large racial and spatial inequities that remain understudied. Indigenous people, for example, experience some of the highest rates of fatal police violence of any racial/ethnic group. Residents of American Indian/Alaska Native (AIAN) reservations may be at particular risk, given geographically specific police surveillance, jurisdictional mazes, and structural disinvestment. Yet little quantitative work has examined fatal police violence against Indigenous peoples in the United States, including by reservation geography. We examined whether AIAN people experience higher rates of fatal police violence in and around reservations at the population level. We analyzed data on all AIAN people killed by police (n = 203, 2013–2024) from the Mapping Police Violence database. We first summarized their geographic distribution and characteristics using descriptive statistics. We then estimated rate ratios using quasi-Poisson regression models with population offsets, comparing AIAN peoples’ fatal police violence rates in and around reservations versus farther away. We find that fatal police violence against AIAN people is strongly concentrated in and around reservations: 73% of AIAN deaths occurred on or within 10 miles of reservations, despite only 39 to 51% of the AIAN population living there. Those areas’ residents were 1.60 to 5.84 times more likely to be killed by police than those living farther away, depending on location and choice of population offsets. Sensitivity analyses indicated these elevated risks could not plausibly be explained away by differential racial/ethnic misclassification. A coordinated public health response to police violence is urgently needed in Indian Country.

Housing insecurity is now widespread among US youth. Evidence is limited, however, on how that is affecting their mental health. Longitudinal analyses examining specific, policy-modifiable forms of housing insecurity are especially lacking. We thus estimated associations between two housing exposures (eviction and family inability to pay housing bills) and youth mental health over time, including sleep disturbances. To do so, we analyzed all available waves of the Adolescent Brain and Cognitive Development Study, a national cohort of US youth (2016-2021, n = 11 868, aged 9-13 years). Models adjusted for individual-level fixed effects and time-varying sociodemographic characteristics. Results show eviction and inability to pay rent/mortgage were both associated with worse mental health, including more severe internalizing, externalizing, and sleep disturbance symptoms. In models including both housing exposures, eviction associations were attenuated, while estimates for inability to pay were effectively unchanged. Given the prevalence of families having difficulty paying housing bills, findings suggest a large pool of young people whose mental well-being may be adversely affected. If these associations reflect cause, government efforts to prevent evictions (eg, right to counsel in housing court) or lower housing cost burden (cash assistance, public housing, zoning reform, etc.) would have important benefits for young people’s psychological wellness.

Housing quality is a powerful determinant of health. When US renters’ housing conditions deteriorate, state policies known as “implied warranties of habitability” are meant to force landlords to ameliorate pathogenic habitability violations, allowing renters to sue or withhold rent until repairs are completed. No research, however, has tested whether these policies work—whether they succeed at protecting population health. At issue is whether warranties are effective when bringing legal action is so onerous for renters in practice. We thus use generalized difference-in-differences models to estimate warranties’ effects on renters’ general and respiratory health, including event study and triple-difference models that employ homeowners as negative controls. Health outcome data from the National Health Interview Survey (1993-2018) was limited to the 10 states that did not have a warranty at baseline and had sufficient pre-implementation data. We found null associations near 0 for nearly all outcomes. It is unclear whether this is because (A) our sample mostly included states with weak policies, (B) US renters are not guaranteed lawyers in civil court, or (C) a completely different, more proactive rental inspection approach is needed. Regardless, results suggest policies must change if we are to realize the public health promise of healthier housing.

Background and Objectives: Housing insecurity is rising among older adults, especially for racially minoritized people. Few studies have evaluated whether healthcare institutions are meeting that challenge. Using data from a large California medical system, we examined how often older patients are (A) identified as housing insecure and then (B) referred to social services, as well as inequities in those rates. Research Design and Methods: We analyzed electronic health records (2013–2022) for 119,127 older adults (55+) receiving primary or emergency care. We used a natural language processing model to identify housing insecurity and social services referrals/connections from unstructured notes, with referrals also captured via structured data. Trends in identification were compared to eviction and homelessness trends in the general population. Racial inequities in referrals were evaluated using logistic regression. Results: 0.6% of encounters (n = 6,253) screened positive for housing insecurity. Positive screening trends were nonlinear, with initial increases followed by declines to baseline (roughly tracking regional eviction trends). Only 7% of patients identified as housing insecure were referred to social services, and connections were more likely in primary than emergency care (odds ratio [OR] = 2.04, 95% confidence interval [95% CI]: 1.41–2.96). Asian patients had lower odds of referral than non-Hispanic White patients (OR = 0.51, 95% CI: 0.28–0.95). Discussion and Implications: We identified urgent unmet needs for housing intervention among older patients. Healthcare systems must do more to ensure older patients, especially racially minoritized older adults, are screened for housing insecurity and connected to housing services.

Epidemiologists are increasingly asking questions about the effects of policies on health and health disparities, generally using quasi-experimental methods. Researchers have developed a burgeoning body of rigorous methodological work focused on addressing potential inference challenges arising from modeling choices, study design, data availability, and common sources of bias in policy evaluations using observational data. However, epidemiologists have paid less attention to the measurement and operationalization of policy exposures. The field of legal epidemiology offers rigorous, formalized methods to address challenges in measuring policy, yet disciplinary divides have impeded the communication of these approaches from lawyers to epidemiologists. In this article, we use terminology familiar to epidemiologists to describe the field of legal epidemiology and how challenges in measuring policy exposures can compromise causal inference, with a particular focus on addressing information bias and consistency assumptions. Laws and regulations can address or enforce structural inequities, and understanding challenges to their characterization and measurement can enhance epidemiologic research on their health and health equity effects. This article is part of a Special Collection on Methods in Social Epidemiology.