KFF Health News undertook a yearlong examination of how government decisions undermine Black health — reviewing court and inspection records and government reports, and interviewing dozens of academic researchers, doctors, politicians, community leaders, grieving moms, and patients. 

During the past two decades there have been 1.63 million excess deaths among Black Americans relative to white Americans. That represents a loss of more than 80 million years of life, according to a 2023 JAMA study.

The video features senior correspondents Fred Clasen-Kelly and Renuka Rayasam, along with Morris Brown, a family care physician in Kingstree, South Carolina.

Learn more about the “Systemic Sickness” series here.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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There was Joshua McCray, 69, a public bus driver who, four years after catching covid-19, still is too weak to drive.

Louvenia McKinney, 77, arrived complaining about shortness of breath.

Ponzella McClary brought her 83-year-old mother-in-law, Lula, who has memory issues and had recently taken a fall.

Morris Brown, the family practice physician who owns the clinic, rotated through Black patients nearly every 20 minutes. Some struggled to walk. Others pulled oxygen tanks. And most carried three pill bottles or more for various chronic ailments.

But Brown called them “lucky,” with enough health insurance or money to see a doctor. The clinic serves patients along the infamous “Corridor of Shame,” a rural stretch of South Carolina with some of the worst health outcomes in the nation.

“There is a lot of hopelessness here,” Brown said. “I was trained to keep people healthy, but like 80% of the people don’t come see the doctor, because they can’t afford it. They’re just dying off.”

About 50 miles from the sandy beaches and golf courses along the coastline of this racially divided state, Morris’ independent practice serves the predominantly Black town of roughly 3,200 people. The area has stark health care provider shortages and high rates of chronic disease, such as diabetes, high blood pressure, and heart disease.

But South Carolina remains one of the few states where lawmakers refuse to expand Medicaid, despite research that shows it would provide medical insurance to hundreds of thousands of people and create thousands of health care jobs across the state.

The decision means there will be more preventable deaths in the 17 poverty-stricken counties along Interstate 95 that constitute the Corridor of Shame, Brown said.

“There is a disconnect between policymakers and real people,” he said. The African Americans who make up most of the town’s population “are not the people in power.”

The U.S. health care system, “by its very design, delivers different outcomes for different populations,” said a June report from the National Academies of Sciences, Engineering, and Medicine. Those racial and ethnic inequities “also contribute to millions of premature deaths, resulting in loss of years of life and economic productivity.”

Over a recent two-decade span, mounting research shows, the United States has made almost no progress in eliminating racial disparities in key health indicators, even as political and public health leaders vowed to do so.

And that’s not an accident, according to academic researchers, doctors, politicians, community leaders, and dozens of other people KFF Health News interviewed.

Federal, state, and local governments, they said, have put systems in place that maintain the status quo and leave the well-being of Black people at the mercy of powerful business and political interests.

Across the nation, authorities have permitted nearly 80% of all municipal solid waste incinerators — linked to lung cancer, high blood pressure, higher risk of miscarriages and stillbirths, and non-Hodgkin lymphoma — to be built in Black, Latinx, and low-income communities, according to a complaint filed with the federal government against the state of Florida.

Federal lawmakers slowed investing in public housing as people of color moved in, leaving homes with mold, vermin, and other health hazards.

And Louisiana and other states passed laws allowing the carrying of concealed firearms without a permit even though gun violence is now the No. 1 killer of kids and teens. Research shows Black youth ages 1 to 17 are 18 times as likely to suffer a gun homicide as their white counterparts.

“People are literally dying because of policy decisions in the South,” said Bakari Sellers, a Democratic former state representative in South Carolina.

KFF Health News undertook a yearlong examination of how government decisions undermine Black health — reviewing court and inspection records and government reports, and interviewing dozens of academic researchers, doctors, politicians, community leaders, grieving moms, and patients.

From the cradle to the grave, Black Americans suffer worse health outcomes than white people. They endure greater exposure to toxic industrial pollution, dangerously dilapidated housing, gun violence, and other social conditions linked to higher incidence of cancer, asthma, chronic stress, maternal and infant mortality, and myriad other health problems. They die at younger ages, and covid shortened lives even more.

Disparities in American health care mean Black people have less access to quality medical care, researchers say. They are less likely to have health insurance and, when they seek medical attention, they report widespread incidents of discrimination by health care providers, a KFF survey shows. Even tools meant to help detect health problems may systematically fail people of color.

All signs point to systems rooted in the nation’s painful racist history, which even today affects all facets of American life.

“So much of what we see is the long tail of slavery and Jim Crow,” said Andrea Ducas, vice president of health policy at the Center for American Progress, a nonprofit think tank.

Put simply, said Jameta Nicole Barlow, a community health psychologist and professor at George Washington University, government actions send a clear message to Black people: “Who are you to ask for health care?”

Past and Present

The end of slavery gave way to laws that denied Black people in the U.S. basic rights, enforced racial segregation, and subjected them to horrific violence.

“I can take facts from 100 years ago about segregation and lynchings for a county and I can predict the poverty rate and life expectancy with extraordinary precision,” said Luke Shaefer, a professor of social justice and public policy at the University of Michigan.

Starting in the 1930s, the federal government sorted neighborhoods in 239 cities and deemed redlined areas — typically home to Black people, Jews, immigrants, and poor white people — unfit for mortgage lending. That process concentrated Black people in neighborhoods prone to discrimination.

Local governments steered power plants, oil refineries, and other industrial facilities to Black neighborhoods, even as research linked them to increased risks of cardiovascular and respiratory diseases, cancer, and preterm births.

The federal government did not even begin to track racial disparities in health care until the 1980s, and at that time disparities in heart disease, infant mortality, cancer, and other major categories accounted for about 60,000 excess deaths among Black people each year. Elevated rates of six diseases, including cancer, addiction, and diabetes, accounted for more than 80% of the excess mortality for Black and other minority populations, according to “The Heckler Report,” released in 1985. During the past two decades there have been 1.63 million excess deaths among Black Americans relative to white Americans. That represents a loss of more than 80 million years of life, according to a 2023 JAMA study.

Recent efforts to address health disparities have run headlong into racist policies still entrenched in health systems. The design of the U.S. health care system and structural barriers have led to persistent health inequities that cost more than a million lives and billions of dollars, according to the national academies report.

“When covid was first hitting, it was just sort of immediately clear who was going to suffer the most,” Ducas said, “not just because of differential access to care, but who was in a living environment that’s multigenerational or crowded, who is more likely to be in a job where they are an essential worker, who is going to be more reliant on public transportation.”

For example, in spring 2020, the North Carolina health department, led by current Centers for Disease Control and Prevention Director Mandy Cohen, failed to get covid testing to vulnerable Black communities where people were getting sick and dying from covid-related causes at far higher rates than white people.

And Black Americans were far more likely to hold jobs — in areas such as transportation, health care, law enforcement, and food preparation — that the government deemed essential to the economy and functioning of society, making them more susceptible to covid, according to research.

Until McCray, the bus driver in Kingstree, South Carolina, got covid in his mid-60s, he was strong enough to hold two jobs. He ended up on a feeding tube and a ventilator after he contracted covid in 2020 while taking other essential workers from this predominantly Black area to jobs in a whiter, wealthier tourist town.

Now he cannot work and at times has difficulty walking.

“I can tell you the truth now: It was only the good Lord that saved him,” said Brown, the rural physician who treated McCray and many patients like him.

Federal and state governments have spent billions of dollars to implement the Affordable Care Act, the Children’s Health Insurance Program, and other measures to increase access to health care. Yet, experts said, many of the problems identified in “The Heckler Report” persist.

When Lakeisha Preston in Mississippi was diagnosed with walking pneumonia in 2019, she ended up with a $4,500 medical bill she couldn’t pay. Preston works at Maximus, which has a $6.6 billion contract with the federal government to help people sign up for Medicare and Affordable Care Act health plans.

She is convinced that being a Black woman made her challenges more likely.

“Think about how many centuries the same thing has been happening,” said Preston, noting how her mother worked two jobs her entire life without a vacation and suffered from health conditions including diabetes, cataracts, and carpal tunnel syndrome. Today Preston can’t afford to put her 8-year-old son on her health plan, so he’s covered by Medicaid.

“We consistently offer healthcare plans that are on par, if not better, than those available to most Americans through state and federal exchanges,” said Eileen Cassidy Rivera, a Maximus spokesperson.

In email exchanges with the Biden administration, spokespeople insisted that it is making progress in closing the racial health gap. They said officials have taken steps to address food insecurity, housing instability, pollution, and other social determinants of health that help fuel disparities.

President Joe Biden issued an executive order on his first full day in office in 2021 that said “the COVID-19 pandemic has exposed and exacerbated severe and pervasive health and social inequities in America.” Later that year, the White House issued another executive order focused on improving racial equity and acknowledged that long-standing racial disparities in health care and other areas have been “at times facilitated by the federal government.”

“The Biden-Harris Administration is laser focused on addressing the health needs of Black Americans by dismantling persistent structural inequities,” said Renata Miller, a spokesperson for the administration.

The CDC, along with some state and local governments, declared racism a serious public health threat.

U.S. Rep. Alma Adams, a North Carolina Democrat, pushed for “Momnibus” legislation to reduce maternal mortality. Yet federal lawmakers left money for Black maternal health out of the historic Inflation Reduction Act in 2022.

“I come to this space as an elected official, knowing what it is like to be poor, knowing what it is like to not have insurance and having to get up at 3, 4 in the morning with my mom to take my sister to the emergency room,” Adams said.

In the 1960s in North Carolina, Adams and her family would take her sister Linda, who had sickle cell anemia, to the emergency room because they had no doctor and could not afford health insurance. Linda died at the age of 26 in 1971.

“You have to have some sensitivity for this work,” Adams said. “And a lot of folks that I’ve worked with don’t have it.”

Governor’s Veto

The website for Kingstree depicts idyllic images of small-town life, with white people sitting on a porch swing, kayaking on a river, eating ice cream, and strolling with their dogs. Two children wearing masks and a food vendor are the only Black people in the video, even though Black people make up 70% of the town’s population.

But life in Kingstree and surrounding communities is marked by poverty, a lack of access to health care, and other socioeconomic disadvantages that have given South Carolina poor rankings in key health indicators such as rates of death and obesity among children and teens.

Some 23% of residents in Williamsburg County, which contains Kingstree, live below the poverty line, about twice the national average, according to federal data.

There is one primary care physician for every 5,080 residents in Williamsburg County. That’s far less than in more urbanized and wealthier counties in the state such as Richland, Greenville, and Beaufort.

Edward Simmer, the state’s interim public health director, said that if “you are African American in a rural zone, it is like having two strikes against you.”

Asked if South Carolina should expand Medicaid, Simmer said the challenges South Carolina and other states confront are worsened by health care provider shortages and structural inequities too large and complicated for Medicaid expansion alone to solve.

“It is not a panacea,” he said.

But for Brown and others, the reason South Carolina remains one of the few states that have not expanded Medicaid — one step that could help narrow disparities with little cost to the state — is clear.

“Every year we look at the data, we see the health disparities and we don’t have a plan to improve,” Brown said. “It has become institutionalized. I call it institutional racism.”

A July report from George Washington University found that Medicaid expansion would provide insurance to 360,000 people and add 18,000 jobs in the health care sector in South Carolina.

“Racism is the reason we don’t have Medicaid expansion. Full stop,” said Janice Probst, a former director of the Rural and Minority Health Research Center in South Carolina. “These are not accidents. There is an idea that you can stay in power by using racism.”

South Carolina’s Republican governor, Henry McMaster, in July vetoed legislation that would have created a committee to consider Medicaid expansion, saying he did not believe it would be “fiscally responsible.”

Expanding Medicaid in the state could result in $4 billion in additional economic output from an influx of federal funds in 2026, according to the July report.

Beyond health care coverage and provider shortages, Black people “have never been given the conditions needed to thrive,” said Barlow, the George Washington University professor. “And this is because of white supremacy.”

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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His mother, Deborah Melvin-Muse, doesn’t display photos of him, the second-youngest of six children. His brother’s birthday was the day after the crash — and he hasn’t celebrated it since. An older brother carries a deep sense of guilt because he was looking after John that morning.

And Cheek Road, in a predominantly Black neighborhood, still lacks sidewalks for children to safely make their way to the local elementary school.

This, despite the years community activists and academic researchers have spent pleading with city leaders for safety improvements along the busy thoroughfare with sloping shoulders where John died. Drivers zoom along Cheek Road in the Merrick-Moore neighborhood, which connects downtown Durham to industrial sites and newer suburban developments.

Melvin-Muse moved her family out of the neighborhood after John’s death. “Now when I go down there, I look and see, you know, nothing really changed,” she said. “It still looks the same.”

Cheek Road has been “identified as needing improvements” by a local metropolitan planning board, said Erin Convery, Durham’s transportation planning manager, in an email.

“The infrastructure that exists is not well implemented,” concluded a May preliminary report produced by University of North Carolina-Chapel Hill students who collected data on speeding, noise, and air quality along Cheek Road. “Poorly marked crosswalks and inadequately positioned bus stops show a need for safety and accessibility improvements,” the report said.

Data was difficult to collect because “there were areas we didn’t want to get out of our cars because of the dangerous conditions,” said Ari Schwartz, one of the researchers.

In the 1940s, Black military veterans returning from World War II helped establish the Merrick-Moore neighborhood. Since then, residents say they have endured everything from noisy industrial trucks and speeding cars to illegal tire dumping and air pollution that threaten their health and safety.

Pedestrian deaths are highest in formerly redlined areas, neighborhoods where Black people lived because of discriminatory federal mortgage lending practices, research shows. The lack of sidewalks, damaged walkways, and roads with high speed limits are concentrated in these neighborhoods, studies show, creating a little-recognized public health crisis.

Governments invest in roads for people driving through such neighborhoods, but not in safety measures — like sidewalks, crosswalks, traffic circles, and speed bumps — that protect people living in them, researchers and advocates say.

“People will talk about vulnerable communities as if there is a problem with these communities, when in fact it is our systems and policies that have created these failings,” said Darya Minovi, a senior analyst at the Union of Concerned Scientists who studies environmental health and justice.

While the share of Black residents in Merrick-Moore has dropped in recent decades, data shows the neighborhood remains more than 80% Black or Hispanic and households there are typically less well-off than in other parts of the city.

“Local government takes money from the neighborhood but does not invest in it,” said Bonita Green, head of the Merrick-Moore Community Development Corporation and a former City Council candidate.

Green said the community group had documented more than 100 auto crashes along Cheek Road during a recent four-year span and at least three pedestrian deaths before 2020. In this fast-growing city of roughly 300,000, students at Merrick-Moore Elementary and others at a nearby high school sometimes walk along the road — where traffic is heavy, drivers are known to disregard the 25-mph speed limit, and the shoulders slope steeply.

When longtime residents like Ponsella Brown see kids walking there or hear about another accident, they remember the death of John Parker, who was in first grade.

“I just cringe,” said Brown, who worked as an administrative assistant at Merrick-Moore Elementary when John died. “Every time it comes up, it’s like really vivid in my mind.”

On the day John died, someone rushed into the office and said a child had been hit by a car on Cheek Road, recalled Brown, who said she ran to the scene.

“I remember the way his head was turned. I remember the spot of blood on his face. Like one speck of blood,” said Brown, who also works for the Merrick-Moore Community Development Corporation and is now a counselor at another school.

Traffic on Cheek Road is expected to increase as the population grows in Durham and surrounding areas, according to a separate April report from UNC graduate students. It noted that during the morning school drop-off time, many cars driving on Cheek Road don’t observe the posted speed limits.

Under an equity program meant to reverse the harm done to communities of color, Convery said, Durham officials are considering traffic-calming measures, including traffic circles, speed cushions, and high-visibility crosswalks.

“We’re open to future conversations that will help us achieve zero traffic deaths and injuries,” Convery said.

Yet a 2017 plan that prioritized more than 600 sidewalk projects based on safety, equity, and demand did not include Merrick-Moore Elementary School on Cheek Road, she said.

A strike by Durham school bus drivers this year only heightened concerns about the lack of safe walking routes for the 650 students who attend the elementary school, according to the April report.

Melvin-Muse, now 67, was at work when she got a call that John had been struck by a truck in front of their house. Before she left home that late May morning in 1989, she put her older kids in charge of the younger ones. They passed the time before school riding bicycles near their house, a few blocks from Merrick-Moore Elementary School, when the accident occurred.

John died two months shy of his 7th birthday from “massive head injuries,” according to The (Raleigh) News & Observer, which wrote about his death on Cheek Road at the time. John was buried in Markham Memorial Gardens, according to his obituary in The (Durham) Herald-Sun.

Melvin-Muse said his death sent the family into a tailspin of grief, anger, and regret.

“It caused a big rip in the family,” Melvin-Muse said.

Melvin-Muse and John’s father later divorced. She said she paid for therapy for her other kids, but they still got in trouble at school and two of her children ended up living in a home for kids with behavioral health issues. “It was just a bad time,” she said.

Years after the accident, Melvin-Muse said, she worked up the courage to call the driver who had hit her son. When he answered, he didn’t recognize her name, or John’s, fueling her rage, she recalled.

“I wanted revenge. An eye-for-an-eye kind of thing,” she said. “And I plotted to take him out the same way my son was taken out.”

She went so far as to get a job where he worked, the Durham County tax department, only to find he had left a week before she started.

“God knows what was in my heart and what I planned on doing,” Melvin-Muse said. “God moved him out of that place before I got there.”

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Like most other people living in one of the nation’s oldest public housing projects, Gilliard endured the boarded-up buildings and mold-filled apartments because it was the only place she could afford.

Without working streetlights in parts of Yamacraw, Gilliard relied on the crescent moon’s glow to search for her daughter Desaray in May 2022. She passed yards dotted with clotheslines and power lines, and a broken-down playground littered with juice boxes and red Solo cups.

“I happened to look down, and I knew it was her by her feet, by the shoes she had on,” Gilliard said. She was “barely hanging on and she was covered in blood.”

The year before Desaray died, President Joe Biden called for the federal government to spend tens of billions of dollars to fix dilapidated public housing that he said posed “critical life-safety concerns.” The repairs, Biden said, would mostly help people of color, single mothers like Gilliard who work in low-income jobs, and people with disabilities.

The federal Department of Housing and Urban Development estimates that $115 billion is needed to fund a backlog of public housing repairs. But, two years ago, money to fund those repairs became a casualty of negotiations between the Biden administration and congressional lawmakers over the Inflation Reduction Act. Republicans also have blocked efforts to lift 25-year-old legislation that effectively prohibits the construction of additional public housing, despite the catastrophic public health consequences.

Tenants living in derelict housing face conditions that contribute to higher rates of heart disease, diabetes, asthma, violence, and other life-threatening risks.

The federal government has a long history of discriminatory practices in public housing. In cities across the country after World War II, Black families were barred from many public housing complexes even as the government induced white people to leave them by offering single-family homes in the suburbs subsidized by the Federal Housing Administration. Starting with the Nixon administration, lawmakers slowed investing in new public housing as more Black families and other people of color became tenants.

Today “residents are facing really terrible choices, or terrible options about their future,” said Sarah Saadian, senior vice president of policy for the National Low Income Housing Coalition. “We got here from Congress really failing to live up to its responsibilities of ensuring that people have access to an affordable, stable home.”

In 2022, an art deco luxury apartment building opened down the street. But little has changed in Yamacraw, which is filled with Black families.

Current and former tenants say the Housing Authority of Savannah, the agency that oversees Yamacraw, has ignored the mold, rats, and roaches that infest the units and sicken residents, and the bullet holes in windows and gunshots that ring through the night. Now they fear the city is using the poor state of Yamacraw as justification to push residents out.

In April, an inspection of Yamacraw apartments conducted by HUD, which oversees taxpayer-supported public housing nationwide, found 29 “life-threatening” deficiencies that pose a high risk of death to residents, according to a preliminary report.

The inspection cited 28 deficiencies it called “severe,” meaning they present a high risk of permanent disability, serious injury, or illness. An additional 195 deficiencies were cited as “moderate” because they could cause temporary harm or prompt a visit to a doctor.

Research links structural racism and disinvestment to chronic gun violence, which has taken a heavy toll on Black neighborhoods and kids such as Desaray. A study of gun injuries in four large cities at the height of the covid-19 pandemic found that Black children were 100 times as likely as white youths to suffer a firearm assault.

Study co-author Jonathan Jay, an assistant professor of community health sciences at Boston University, said most of the country’s gun violence stems from disputes in neighborhoods that lack investment in housing and other public services

“This is about white privilege,” Jay said. “The result is driven by racist policymaking.”

Desaray Gilliard was a high school freshman when she was killed. She loved clothes, music, dancing, and the color pink, her mother said. She planned to go to Italy with her art class. She was excited about learning to drive and getting a job. Desaray had her sights set on attending Ohio State University.

They’d lived in Yamacraw for seven years. The teen’s shooting death remains unsolved.

Gilliard has struggled with thoughts of self-harm, she said. She maintains a memorial with pictures, stuffed animals, and flowers near the spot where she found Desaray’s body.

“I have to remember this is for her,” she said of her middle child’s death, “because nobody else is doing these things for her to keep her memory alive.”

A Broken Promise?

Federally funded public housing must be kept in “decent, safe and sanitary” condition, according to HUD. In 2013, the agency’s then secretary, Shaun Donovan, visited Savannah to announce a program that could give the local housing authority millions of dollars to rehab four public housing complexes, including Yamacraw, which has been among the lowest-rated public housing complexes in Georgia.

The Rental Assistance Demonstration program touted by Donovan did not provide new public money. Instead, it loosened rules to allow local officials to work with private lenders and developers to pay for repairs, transforming public housing complexes into mixed-income developments with Section 8 project-based rental assistance.

Last year, a consultants’ report found a host of problems in Yamacraw, including water leaks and faulty wiring. “The Remaining Useful Life of the Property is estimated to be 0 years,” the consultants wrote. The housing authority wants to demolish Yamacraw and replace it with homes that are “healthier, more energy efficient and accessible,” the report said.

Yamacraw never saw the windfall Donovan promised, current and former tenants said. Even with a housing assistance waitlist of more than 3,000 families in Savannah, records show most of the 315 apartments in Yamacraw sit empty, many with boarded-up doors and windows. Some other public housing developments in the area have been repaired or rebuilt, but except for new roofing added in 2019, Yamacraw has not had a significant renovation in years, according to the consultants’ report.

Rather than repair the units, local officials started a process to tear down the complex, threatening to displace residents who have nowhere else to go in a city where the average two-bedroom apartment rents for more than $1,600 monthly.

Congress has provided less money than was needed over the past 20 years to fix Yamacraw and other public housing complexes nationwide, leaving local agencies in a tough spot, said Earline Davis, executive director of the Housing Authority of Savannah.

The housing authority still plans to demolish Yamacraw and redevelop the property with new affordable housing, she said. Residents fear that they will be pushed out, and that because of its prime location, the redevelopment plans would prioritize apartments that attract people who can afford higher rents.

“Anytime you want to do something to make money — go destroy the historic Black community,” said Georgia Benton, who grew up in Yamacraw. “But ain’t nobody hollerin’ ‘Stop.’”

She and her son LaRay Benton have been fighting the housing authority’s redevelopment plans, which they say could also disrupt the two-century-old First Bryan Baptist Church. Rev. Andrew Bryan, a former enslaved person and ordained minister, founded the church in 1788. He later bought his freedom.

The Bentons and three City Council members went door to door observing the condition of residents’ units. They said plumbing issues caused sewage overflows and leaky faucets, mold tracked across the ceilings, and there were insect and rodent infestations.

Many families said they developed respiratory problems, such as bronchitis and asthma, after they moved in. “It is an unhealthy situation,” LaRay Benton said.

About seven years ago, after his previous Savannah landlord raised the rent, Paris Snead, his wife, and two children found themselves homeless. A nonprofit helped them get into Yamacraw, where rent was $750 a month.

It’s been years since they left. Snead said he still takes a daily allergy pill because he believes he was exposed to mold in his unit, which caused allergy-like symptoms.

“The walls sweat like working men,” Snead said of his former apartment. “The walls will, literally, from the top to the bottom, leak water.”

“When you’re homeless, and you want to be able to have a place for your kids, I mean, you’ll make a home wherever you can,” he said.

Snead said he showed Yamacraw’s management the leaking walls, but they didn’t act.

“The management team there did more to evict people and cause problems than they did to help families and ensure they had a place to stay,” Snead said.

HUD, which conducts periodic inspections at public housing complexes, declined an interview request. The agency referred questions to the Housing Authority of Savannah.

The housing authority’s redevelopment plans have been delayed by HUD’s lengthy approval process, said Savannah Mayor Van R. Johnson II, who appoints people to a five-member board of commissioners that helps oversee the city’s public housing.

He said he met with HUD acting Secretary Adrianne Todman and other HUD officials about housing issues in Savannah.

“People don’t deserve to live like that,” Johnson said.

If Yamacraw is demolished and rebuilt, he said, current tenants will have a chance to return because the homes will be affordable to people with low incomes.

Nobody else is doing these things for her to keep her memory alive.

Detraya Gilliard

‘The Worst Experience of My Life’

Yamacraw’s struggles are rooted in century-old policies that have made it difficult for many Black neighborhoods to thrive.

In the 1930s, the federal government’s Home Owners’ Loan Corp. made color-coded maps for Savannah and 238 other cities and labeled redlined areas — usually places where Black people, Jews, immigrants, and Catholics lived — as undesirable for investment.

“The houses are occupied by the lowest class negro tenants,” a government surveyor wrote.

Yamacraw was opened in 1941 as segregated public housing for Black people. Today a health clinic occupies the original administrative building, designed to look like a plantation house.

Despite its problems, Johnson said, some of the city’s most prominent doctors, lawyers, and ministers grew up in Yamacraw.

Former and current tenants said the apartments slowly descended into disrepair.

Each year more than 10,000 public housing apartments across the U.S. become uninhabitable.

Some lawmakers have used the poor state of public housing as justification to refuse lifting a moratorium passed during the Clinton administration that prohibits the construction of additional units, even as the nation’s rental prices — and evictions — soar.

The argument that public housing “doesn’t work” is disingenuous, said Saadian, with the National Low Income Housing Coalition.

“The federal government really failed to invest in public housing, to keep it in good condition, and to keep those communities thriving,” Saadian said, “and in many cases, actively contributed to those communities declining.”

Instead of repairing public housing and building more high-quality units, federal lawmakers promised to provide housing vouchers, commonly known as Section 8, which helps people with low incomes rent privately owned homes. But most people who qualify for vouchers never receive them. Those who do often struggle to find landlords who will accept them, rendering them sometimes worthless.

Three years ago, LaTonya Atterbury was living in hotels north of Atlanta when she was offered a unit in Yamacraw for $511 a month. In August 2021, she moved in with her niece, now 29, and her niece’s son, now 8, relieved to have more stable housing.

But within the first week, she said, a neighbor’s son broke her window and the housing authority charged her $60 to fix it. She said her bathroom is covered in mold and mildew. One day, months after she moved in, Atterbury noticed a hole in her second-story window and saw a bullet on the floor, and realized there had been a shooting overnight. No one was injured, she said, but the bullet hole was only recently fixed — about 2½ years after the incident.

“It’s been the worst experience of my life,” Atterbury said. “Sitting here will make you very depressed.”

Atterbury said she and other residents remain in Yamacraw at least in part because the housing authority has promised vouchers to move elsewhere. Three years later, she is still waiting.

Demolishing and rebuilding Yamacraw could take years.

Davis, the housing authority’s executive director, said her agency has repeatedly told tenants they would be relocated to other public housing complexes or given a Section 8 voucher during construction if they have no lease violations. But residents say they routinely receive lease violations for harmless acts such as broken blinds. LaRay Benton said one resident was cited and fined $75 for leaving a stroller on her front porch while she took her baby inside.

A Mother’s Search

Researchers said that the presence of abandoned buildings can contribute to violent crime by making people feel unsafe and creating a sense of disorder. Studies suggest that razing abandoned buildings and improving green space can reduce it.

“No gun policy is going to work if we don’t fix social infrastructure,” said Jonathan Metzl, director of the Department of Medicine, Health, and Society at Vanderbilt University. “We need investments to make sure communities feel safe. This is not just a public health problem. This is a race problem. This is a democracy problem.”

In recent years, shooting victims or their relatives, including Desaray’s mother, have filed at least three lawsuits against the Housing Authority of Savannah. Those ongoing lawsuits allege the agency failed to take added security measures in its public housing complexes — some of which had fallen into disrepair — despite gun violence and other crimes.

“I don’t know how we can prevent shootings,” Davis said.

Davis declined to comment on the lawsuits. She would say only that her agency has installed cameras in Yamacraw, worked with police, and asked residents to report crime. The actions came after Desaray’s death.

Johnson, Savannah’s mayor, said police have investigated the Desaray Gilliard case, but there are people “who know what happened” and will not talk to officers.

Around 9 p.m. on a Friday night two years ago, Gilliard went looking for her daughter for the second time that night. Desaray missed an 8 p.m. curfew and wasn’t answering her phone.

Gilliard waited for about 30 minutes at a bench near a park in the middle of the complex, hoping Desaray would find her. Then she started to retrace her steps.

Gilliard called 911 after she saw her daughter’s body.

When the police arrived, they made their way through the darkened complex with flashlights, Gilliard said. An officer pulled up Desaray’s shirt and saw a bullet hole in her chest. Gilliard said she later learned from a funeral director that her daughter had been shot three times. She has yet to receive an autopsy report from the police.

Gilliard said “nothing has changed before, since, or after” her daughter’s death.

“It’s been very difficult,” she said. “Sometimes I wanted to give up. I even thought about committing suicide.”

About a month after Desaray died, Gilliard said someone tried to break into her apartment. A couple of weeks later, her request to move to a new complex was finally granted and Gilliard left Yamacraw.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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On nearly every day of 2024 so far, a burst of gunfire has hit at least four people somewhere in the country. Some days, communities have endured four or five such shootings.

The nation’s top doctor called on policymakers to consider gun safety measures such as bans on assault weapons and high-capacity ammunition magazines and universal background checks for all firearm purchases. His advisory also urges a “significant increase” in funding for research on gun injuries and deaths, as well as greater access to mental health care and trauma-informed resources for people who have experienced firearm violence.

In 2022, more than 48,000 people were killed by guns in the U.S., or about 132 people a day, and suicides accounted for more than half of those deaths, according to data from the Centers for Disease Control and Prevention. An additional 200-plus Americans seek emergency care for firearm injuries each day, according to estimates from Johns Hopkins University research. No federal database records nonfatal gun injuries.

The Office of the Surgeon General does not set or carry out gun policy, but historically its reports and warnings have nudged policymakers and lawmakers to act.

Murthy, a physician, told KFF Health News he hoped to convey the broader toll of gun violence on the nation and the need for an urgent public health response. He cited soaring gun deaths among children and teens and noted that “the mental health toll of firearm violence is far more profound and pervasive than many of us recognize.”

“Every day that passes we lose more kids to gun violence,” Murthy said, “the more children who are witnessing episodes of gun violence, the more children who are shot and survive that are dealing with a lifetime of physical and mental health impacts.”

Firearm-related homicides over the past decade and suicides over the past two decades have driven the sharp rise in gun deaths, the advisory says.

Guns are the leading cause of death for children and teens, with higher death rates among Black and Hispanic youths. Researchers from Boston University found that during the height of the covid pandemic, Black children were 100 times as likely as white children to experience gun injuries. Hispanic and Asian children also saw major increases in firearm assault injuries during that time, that study showed.

Joseph Sakran, executive vice chair of surgery at John Hopkins Hospital in Baltimore and chief medical officer for Brady United Against Gun Violence, said the surgeon general’s declaration is a “historic moment that sounds the alarm for all Americans.”

But Sakran added: “It cannot stop here. We have to use this as another step in the right direction. No one wants to see more children gunned down.”

Murthy has long said gun violence should be framed as a health issue. He argued that the approach has been successful in combating significant societal problems, citing tobacco control efforts that took hold following the then-surgeon general’s landmark 1964 report concluding that smoking cigarettes causes lung cancer and other diseases.

“We saved so many lives, and that’s what we can do here, too,” Murthy said.

Murthy’s move is one of several recent Biden administration actions designed to combat gun violence, as most gun-related measures remain political nonstarters in Congress. Federal officials have allowed states to use Medicaid dollars to pay for gun violence prevention, and the White House has called on hospital executives and doctors to gather more data about gunshot injuries and to routinely counsel patients about the safe use of firearms.

While available data points to tragic outcomes across American communities, government officials and public health researchers have long been stymied by sparse federal funding devoted to gun violence research and the scope of its health effects.

“I’ve been studying gun violence for about 33 years now and there’s still some really basic and fundamental questions I can’t answer,” said Daniel Webster, a gun violence researcher at Johns Hopkins University.

“To really understand gun violence, you need to do more than just look at publicly available surveillance data,” he said. “You need to actually do in-depth studies involving the populations at highest risk for shooting or being shot.”

A Brady analysis found that of the 15 leading causes of death in the U.S., firearm injuries received the third-lowest amount of federal research funding through the National Institutes of Health for each person who died. The only causes of death that garnered less research funding through NIH were poisonings and falls, according to the analysis.

Sonali Rajan, an adjunct associate professor of epidemiology at Columbia University who researches the effects of gun violence on children, said political leaders and others need to reframe the debate on gun violence from crime to public health.

“We are raising a whole generation of children for whom exposure to gun violence is normal,” Rajan said.

In Michigan, “we had a kid survive the Oxford High School shooting only to go to Michigan State University and see another mass shooting,” she said. “It is unbelievably shameful.”

Serving as President Joe Biden’s surgeon general since 2021, Murthy has, at times, caused political controversy with his views on gun violence.

Over a decade ago, former President Barack Obama nominated Murthy to be the nation’s top doctor. But Murthy’s support for a federal ban on the sale of assault weapons and ammunition and additional restrictions on gun purchases drew the ire of the National Rifle Association, as well as Republicans and some Democrats in Congress. The U.S. Senate narrowly confirmed Murthy to the job in December 2014, more than a year after his nomination.

Murthy has previously issued advisories on social isolation and loneliness, youth mental health, and the well-being of health workers. He said gun violence comes up in many of his conversations with young people about the mental health challenges they’re facing.

“Fears around gun violence have really pervaded so much of the psyche of America in ways that are very harmful to our mental health and well-being,” Murthy said.

Many other causes of death are treated differently as to understanding the problems and developing solutions, Webster said. But “that’s generally not what we’ve done with gun violence. We’ve oversimplified it and overpoliticized it.”

As Sakran put it: “As we look at firearm injuries, there’s arguably no public issue that’s as urgent.”

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In an interview with KFF Health News, SSA Commissioner Martin O’Malley said that in the coming days he would propose changes to help people avoid crushing debts that have driven some into homelessness and caused financial hardships for the nation’s most vulnerable — the poorest of the poor and people with disabilities or persistent medical conditions or who are at least age 65.

O’Malley, who took office in December, said that “addressing the injustice we do to too many Americans because of overpayments, the rather cruel-hearted and mindless way that we recover those overpayments,” is among his top priorities.

He said he has concrete steps in mind, such as establishing a statute of limitations, shifting the burden of proof to the agency, and imposing a 10% cap on clawbacks for some beneficiaries.

“We do have the ability and we do have the authority to address many of these injustices,” he said, suggesting that the SSA won’t have to wait for congressional action.

The pledge comes after an investigation by KFF Health News and Cox Media Group television stations revealed that SSA routinely reduces or halts monthly benefit checks to reclaim billions of dollars in payments it sent to beneficiaries then later said they should not have received.

In some cases, years passed before the government discovered its mistake and then imposed debts that sometimes have reached tens of thousands of dollars on people who cannot afford to pay. KFF Health News and Cox Media Group discovered that more than 2 million people a year have been hit with overpayment demands.

Most overpayments are linked to the Supplemental Security Income program, which provides money to people with little or no income, who are disabled, blind, or at least age 65. Others are connected to the Social Security Disability Insurance program, which aids disabled workers and their dependents.

O’Malley said the agency plans to cease efforts to claw back years-old overpayments and halt the practice of terminating benefits for disabled workers who don’t respond to overpayment notices because they did not receive them or couldn’t make sense of them.

“We’re not fulfilling congressional intent by putting seniors out of their homes and having them live under a bridge when they didn’t understand our notice,” O’Malley said.

Denise Woods lives in her Chevy, seeking a safe place to sleep each night at strip malls or truck stops around Savannah, Georgia. Woods said she became homeless in 2022 after the SSA — without explanation — determined it had overpaid her and demanded she send back roughly $58,000. Woods didn’t have that amount on hand, so the agency cut off her monthly disability benefits to recoup the debt.

The agency later restored some of her benefit allowance: She gets $616 a month. That’s not enough to cover rent in Savannah, where even modest studio apartments can run $1,000 a month.

In January, she fell ill and landed in intensive care with pneumonia. “I signed a [Do Not Resuscitate form] and a nurse asked, ‘Do you know what this means?'” Woods said. “I told her there was no reason to revive me if my heart stops. They have already ruined my life. I’m beyond exhausted.”

After KFF Health News and Cox Media Group published the series “Overpayment Outrage,” hundreds of disability beneficiaries came forward with troubling accounts, including how the government sent them overpayment notices without explanation and threatened to cut off their main source of income with little warning.

Members of Congress publicly demanded that SSA fix the problems. Democratic Sen. Ron Wyden of Oregon said he would meet monthly with agency officials “until it is fixed.”

Sens. Gary Peters and Debbie Stabenow, both Michigan Democrats, sent a letter dated Feb. 29 to the SSA, saying many overpayments were caused by the agency. They asked officials to explain what is causing the problems.

“It’s absolutely critical that the agency is accurately administering these benefits,” Peters said in written response to an interview request. “I’ve heard from too many people across Michigan who have faced financial hardship after the agency sent them incorrect payments.”

The agency recovered $4.9 billion of overpayments during the 2023 fiscal year, with an additional $23 billion in overpayments still uncollected, according to its latest annual financial report.

O’Malley said he wants to address overpayment clawbacks as part of a larger effort to address SSA’s “customer service crisis.” He did not provide specifics but said he anticipated plans would be implemented this year.

Officials have long acknowledged that the federal disability system is dogged by lengthy delays and dysfunction. Some people become homeless or grow sicker while waiting for an initial decision on an application, which took an average of over seven months in 2023, according to a letter signed by dozens of members of Congress.

O’Malley said the agency terminates disability benefits for some people who don’t contact the SSA after receiving a clawback letter.

“To be honest, a lot of problems [are caused by] our notices being hard to read,” O’Malley said. “In fact, one might argue that the only thing that’s really clear about the notice is to call the 800 number.”

The agency’s toll-free number, O’Malley said, is on his fix-it list, too.

Callers complain of lengthy hold times and often are unable to reach an agent for help, according to congressional members, disability attorneys, and others.

O’Malley pointed to a 27-year low in staffing. “We’ve been unpacking many of these customer service challenges,” he said. “There’s not one of them that hasn’t been made worse by the short staff.”

Still, he said, the overpayment process is unfair. Beneficiaries often must produce evidence to show they did not receive extra money, O’Malley noted.

“One would assume that in a country where people are innocent until proven guilty,” he said, “that the burden should fall more on the agency than on the unwitting beneficiary.”

(WSB-TV, Atlanta)

Advocates for the poor and disabled said they are hopeful O’Malley will stick to his commitments.

“Overpayments have long plagued our clients and caused severe hardship,” said Jen Burdick, an attorney with Community Legal Services of Philadelphia, which represents clients who have received overpayment notices. “We are heartened to see that SSA’s new commissioner is taking a hard look at overpayment policy reforms and optimistic and hopeful his administration will provide these folks some long-needed relief.”

Mike Pistorio is worried that change won’t come fast enough for him.

A letter dated Sept. 21, 2023, that he received from the Social Security Administration says he was overpaid $9,344. The letter alleges Pistorio — a disabled 63-year-old who said he has four stents in his heart — received too much money on behalf of his children, who are now adults.

Pistorio said that he doesn’t understand why he owes the government money and that the SSA has not answered his questions. He said he and his wife live in fear of being evicted from their home because they depend on his $1,266 monthly disability benefits to pay rent.

“What makes me mad is none of this is my fault,” said Pistorio, who lives in Middletown, Pennsylvania, and worked as a plumber until his health faltered. “The stress of this has made my diabetes go up.”

Pistorio said the agency has offered to deduct $269 a month from his benefits to pay off his debt — an amount he says he cannot afford.

“I have told them ‘I will lose my housing,’” Pistorio said.