The Impact of Broadband Redlining on Health Equity

July 21, 2021|6:20 p.m.| ASTHO Staff

Craig SettlesAccess to quality internet may not be the first thing you think of when you think about health equity, but it is something that impacts many communities. The Federal Communications Commission reports that 19 million Americans still lack access to high-speed internet. As the COVID-19 pandemic proved, having access to a healthcare provider over your computer or phone is important if physically getting to your doctor’s office isn’t an option. Communities of color, older adults, people with lower educational levels, and families of low-income are more likely to experience limited digital access.

ASTHO chatted with Craig Settles, a broadband expert with more than 30 years of experience. Since 2006 he has advised communities on broadband solutions. In this interview, Settles discusses ‘broadband redlining’, how pervasive it can be, and why the solutions will need to be community driven.

Listen to the interview here, or read the highlights below. The interview was condensed for clarity.

ASTHO: When people hear about broadband issues when it comes to telehealth, they think about rural.  So, talk a little more about these access challenges that these urban communities experience, and how this does disproportionately impact marginalized communities, and can it contribute to increasing health disparities. 

SETTLES: Right. So, when you look at what's driving the need, there are similar areas in both the rural and the urban need, right? Meaning you have issues with the distance to the doctor's, right—well, there's similar issues in the urban areas as well as the rural.

Now, the rural may be a two, three-hour drive, but in the urban areas, it may be a two-hour bus ride. So, the distance is not the same in the urban areas, but the time it takes to get there is the same.

If I'm working two and three jobs, which is a lot of the working poor of both the rural and the urban—again, that's a need for telehealth, because no one has time to go to the doctor's.

But then, when Obama became president and he created this major stimulus program of which they carved out around 7 billion dollars, there was a heavy bent on putting that money in rural areas.

And, as it progressed—as our issues with broadband progressed, or regressed, depending on how you look at it—that didn't change. That emphasis on the rural part didn't change. And, as a result, people just assumed that the urban areas were fine, that there was no problem there. There was an AT&T store and a Verizon store at every mall, and so forth, so clearly the urban area is just fine.

And that was a problem, and that led to a lot of the disparity. And it is only, I think, because of COVID-19 that it became clear that the pain is very much similar between urban and rural. And they couldn't make the case that it was just the rural area that we have to worry about. Now, all of a sudden, it was New York City and Chicago, and Philadelphia, where they were looking at 50-60% of students in moderate to low-income areas, didn't have broadband. So, they couldn't look at that and say, "well, we're just going to put that money into the rural areas." Now, they had to address the urban area.

ASTHO: For somebody new to this topic, could you define broadband redlining and how that relates to current digital inequalities experienced by these historically marginalized communities today? 

SETTLES:  Sure. I think everyone remembers redlining as it rolled out because the banks wouldn't lend money to African Americans and other people of color, so it was clearly a racial thing.

If I am a provider of services—cable services, internet services, and so forth—I create a formula that says that I'm going to target this and that and this area over here. This is where we're going to market our services. They may look at where people can get 100 cable channels when you find people who will pay $300 for a gigabyte broadband connection. So, they establish certain benchmarks that are based primarily on economics, and basically who can afford a certain level of services.

And so, if you just look at that—Philadelphia, for example. When I wrote about their plan to put wireless all over the city—this was 2005—they had done research in Philly and they could figure out the likelihood of internet penetration just by understanding the economics of a community. Because in the wealthier parts of town, you would have 90-95% internet penetration—but if you went to the poor areas of Philadelphia, you might have 40-50% internet penetration.

So, it's sort of like a known dirty secret of the broadband industry. They go where the money is. They will cherry-pick to their hearts' content. They will give you lots of lip service to "helping our fellow mankind," that whole ritual. But then, they will create these programs, like internet essentials from Comcast, where they create all of these barriers: if you have ever had your service shut off, you can't get internet essentials; if you don't have kids, you don't get the essentials. It has nothing to do, per se, with who has needs. It's like who has needs, but who can survive all of these stupid restrictions. And this is a problem.

ASTHO: Let's talk a little bit about any on-the-ground efforts—and you, I think, touched on this—to implement efficient broadband networks in urban areas that will serve these marginalized communities.

Are there any innovative community pilot programs on your radar that have the potential to increase access to these digital services? 

SETTLES: Well, one of the things is I wrote this guide for libraries, how they can implement telehealth services in their facilities. So, these facilities—schools, libraries, churches, barbershops—are different ways in which you can get telehealth and also broadband to low-income areas. But you still have to build infrastructure. There are examples where libraries can give patrons a laptop or a Chromebook and a hotspot, and they'll have some kind of period of time—it could be a couple of weeks, it could be a couple of months. Those I put in the category of stop-gap measures.

But the partnerships that you establish—they could be with nonprofits, schools, libraries, and so forth. Each of these can provide a place where you can get either limited broadband or longer-term broadband.

I got a note earlier this morning about Detroit. Detroit has created a program that goes neighborhood by neighborhood to build wireless infrastructure and to fund it and so forth. So, it's a tedious process, there's no way around that, but they work within the economic confines of the community.

So, if you can only afford $20 a month, they have to figure out how to deliver broadband to that audience in an economical way that gets the job done.  There was a non-profit wireless ISP—so, they have no profit margin. They have to make money for operations, but because they take away that profit aspect of it all, they can structure deals and provide infrastructure. And you're using schools and libraries to add to that infrastructure that you're building so that you can make the cost per customer affordable. That's what we're seeing happening a lot in some of the less prosperous parts of town.

And what you really need—in Detroit, for example—the project manager for this neighborhood-by-neighborhood deployment of broadband is a preacher. He has a job, obviously, but he's committed to connecting his people, and you need that.

You need local politicians, city councils, those kinds of things, but you need the unofficial leaders to step up. We're talking about the barbershops, the preacher, even the teachers are the ones taking on this role.  I would say that every city, every community, has different needs, they have different politics, different economics, and so forth, so you need something specific for the community. So, no one size fits all.

The development of this blog post is supported by the Health Resources and Services Administration of the U.S. Department of Health and Human Services under grant number 2 UD3OA22890-10-00. Information, content, and conclusions will be those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS, or the U.S. Government.

Janet Oputa is the senior analyst of Clinical to Community Connections at ASTHO
Mattie Quinn, MS, is the director of content development at ASTHO