dr david williams on health disparities
TRANSCRIPT
A Time For Action:the Enigma of Social Disparities in Health and How to Effectively
Address Them
David R. Williams, PhD, MPHFlorence & Laura Norman Professor of Public Health
Professor of African & African American Studies and of Sociology
Harvard University
There Is a Racial Gap in Health in Early Life:Minority/White Mortality Ratios, 2000
0
0.5
1
1.5
2
2.5
3
<1 1-4 5-14 15-24
Age
Min
orit
y/W
hite
Rat
io
B/W ratioAmI/W ratioAPI/W ratioHisp/W ratio
There Is a Racial Gap in Health in Mid Life:Minority/White Mortality Ratios, 2000
0
0.5
1
1.5
2
2.5
25-34 35-44 45-54 55-64
Age
Min
orit
y/W
hite
Rat
io
B/W ratioAmI/W ratioAPI/W ratioHisp/W ratio
There Is a Racial Gap in Health in Late Life:Minority/White Mortality Ratios, 2000
0.0
0.2
0.4
0.6
0.8
1.0
1.2
1.4
1.6
65-74 75-84 85+
Age
Min
orit
y/W
hite
Rat
io
B/W ratioAmI/W ratioAPI/W ratioHisp/W ratio
Immigration and Health • Hispanics and Asian Americans tend to have equivalent
or better health status than whites
• Immigrants of all racial/ethnic groups tend to have better health than their native born counterparts
• With length of stay in the U.S., the health advantage of immigrants declines
• Latinos and Asians differ markedly in their levels of human capital upon arrival in the U.S.
• Given the low SES profile of Hispanic immigrants and their ongoing difficulties with educational and occupational opportunities, the health of Latinos is likely to decline more rapidly than that of Asians and
to be worse than the U.S. average in the future
Lifetime Prevalence of Psychiatric Disorder, by Race and Generational Status (%)
Source: Williams et al. 2007; Alegria et al 2007; Takeuchi et al. 2007
19.4
35.3
30.1
24.0
54.6
43.4
25.6
15.2
23.8
0
10
20
30
40
50
60
Caribbean Black Latino Asian
First
Second
Third or later
Challenges
What are the relevant factors and what is the relative contribution of each to shaping the relationship between migration status/generational status and health for racial/ethnic minority populations?
What interventions, if any, can reverse the downward health trajectory of immigrants with length of stay in the U.S.?
Age-Adjusted Heart Disease Death Rates for Blacks and Whites, 1950-2000
100
200
300
400
500
600
700
1950 1960 1970 1980 1990 2000
YEAR
Dea
th R
ates
per
100
,000
Pop
ulat
ion White
Black
Age-Adjusted Cancer Death Rates for Blacks and Whites, 1950-2000
100
150
200
250
300
1950 1960 1970 1980 1990 2000
YEAR
Dea
th R
ates
per
100
,000
Pop
ulat
ion White
Black
Diabetes Death Rates 1955-1998
12.610.4
8.611.7 11.9
17.0
24.4
46.4
52.8
24.3
0.0
10.0
20.0
30.0
40.0
50.0
60.0
1955 1975 1985 1995 1996-98Year
Dea
ths
per
100
,000
Pop
ula
tion
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
4.5
5.0
Am
In
d/W
Rat
io
White
Am Ind
Am Ind/W Ratio
Source: Indian Health Service; Trends in Indian Health 2000-2001
Life Expectancy at Birth, 1900-2000
0
10
20
30
40
50
60
70
80
90
1900 1950 1970 1990 2000
WhiteBlack
Year
Age
60.8
71.7
64.1
76.1
69.1
77.671.9
47.6
69.1
33.0
The Persistence of Racial Disparities
• We have FAILED! • In spite of:
-- a War on Poverty-- a Civil Rights revolution-- Medicare & Medicaid-- the Hill-Burton Act-- Major advances in medical research &
technology We have made little progress in reducing the elevated
death rates of blacks and American Indians relative to whites.
Understanding Elevated Health Risks
“Has anyone seen the SPIDER that is spinning this complex web of causation?”
Krieger, 1994
SAT Scores by Income
Source: (ETS) Mantsios; N=898,596
Family Income Median ScoreMore than $100,000 1129
$80,000 to $100,000 1085
$70,000 to $80,000 1064
$60,000 to $70,000 1049
$50,000 to $60,000 1034
$40,000 to $50,000 1016
$30,000 to $40,000 992
$20,000 to $30,000 964
$10,000 to $20,000 920
Less than $10,000 873
SES: A Key Determinant of Heath
• Socioeconomic Status (SES) usually measured by income, education, or occupation influences health in virtually every society.
• SES is one of the most powerful predictors of health, more powerful than genetics, exposure to carcinogens, and even smoking.
• The gap in all-cause mortality between high and low SES persons is larger than the gap between smokers and non-smokers.
• Americans who have not graduated from high school have a death rate two to three times higher than those who have graduated from college.
• Low SES adults have levels of illness in their 30s and 40s that are not seen in the highest SES group until after the ages of 65-75.
Percentage of Persons in Poverty Race/Ethnicity
9.3
25.326.6
16.1
10.7
21.5
16.8
0
5
10
15
20
25
30
White Black AmI/AN NH/PI Asian Hisp.Any
2+ races
Race
Pov
erty
Rat
e
U.S. Census 2006
Racial/Ethnic Composition of People in Poverty in the U.S. 2+ races, 2.6%
Hisp. Any 23.9%
AmI/AN, 1.6%
NH/PI, 0.17%
White46.1%
Black23.1%
Asian, 3.6%
U.S. Census 2006
Relative Risk of Premature Death by Family Income (U.S.)
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
<10K 10-19K 20-29K 30-39K 40-49K 50-99K 100+K
Rel
ativ
e R
isk
Family Income in 1980 (adjusted to 1999 dollars)
9-year mortality data from the National Longitudinal Mortality Survey
Added Burden of Race
• Race and SES reflect two related but not interchangeable systems of inequality
• SES accounts for a large part of the racial differences in health
• BUT, there is an added burden of race, over and above SES that is linked to poor health.
Percent of persons with Fair or Poor Health by Race, 1995
Race/Ethnicity Percent
Racial Differences
B-W H-W B-H
White 9.1 8.2 6.0 2.2
Black 17.3
Hispanic 15.1
Poor=Below poverty; Near poor+<2x poverty; Middle Income = >2x poverty but <$50,000+
Source: Parmuk et al. 1998
Percent of Women with Fair or Poor Health by Race and Income,
1995
Household Income
White Black Hispanic
Poor 30.2 38.2 30.4
Near Poor 17.9 26.1 24.3
Middle Income 9.2 14.6 13.5
High Income 5.8 9.2 7.0
SES Difference 24.4 29.0 23.4
Poor=below poverty; Near Poor=<2x poverty; Middle Income=>2x poverty but <$50,000; High Income=$50,000+
Source: Pamuk et al. 1998
Infant Death Rates by Mother’s Education, 1995
02468
101214161820
<HighSchool
High School SomeCollege
Collegegrad. +
Education
Dea
ths
per
1,00
0 po
pula
tion
0
0.5
1
1.5
2
2.5
3
B/W
Rat
io
WhiteBlackB/W Ratio
Infant Mortality by Mother’s Education, 1995
9.9
6.5
5.14.2
17.3
14.8
12.311.4
6 5.9 5.44.4
5.7 5.5 5.14
12.7
7.9
5.7
0
2
4
6
8
10
12
14
16
18
20
<12 12 13-15 16+
Years of Education
Infa
nt M
orta
lity
NH White Black Hispanic API AmI/AN
Why Race Still Matters1. All indicators of SES are non-equivalent across race.
Compared to whites, blacks receive less income at the same levels of education, have less wealth at the equivalent income levels, and have less purchasing power (at a given level of income) because of higher costs of goods and services.
2. Health is affected not only by current SES but by exposure to social and economic adversity over the life course.
3. Personal experiences of discrimination and institutional racism are added pathogenic factors that can affect the health of minority group members in multiple ways.
Race/Ethnicity and Wealth, 2000Median Net Worth
Income White Black HispanicAll $79,400 $7,500 $9,750
Excl. Hm. Eq. 22,566 1,166 1,850
Poorest 20% 24,000 57 500
2nd Quintile 48,500 5,275 5,670
3rd Quintile 59,500 11,500 11,200
4th Quintile 92,842 32,600 36,225
Richest 20% 208,023 65,141 73,032
Orzechowski & Sepielli 2003, U.S. Census
Wealth of Whites and of Minorities per $1 of Whites, 2000
Household IncomeWhite B/W
Ratio
Hisp/W
Ratio
Total $ 79,400 9¢ 12¢
Poorest 20% $ 24,000 1¢ 2¢
2nd Quintile $ 48,500 11¢ 12¢
3rd Quintile $ 59,500 19¢ 19¢
4th Quintile $ 92,842 35¢ 39¢
Richest 20% $ 208,023 31¢ 35¢
Source: Orzechowski & Sepielli 2003, U.S. Census
Race and Economic Hardship 1995African Americans were more likely than whites to experience the following hardships 1:
1. Unable to meet essential expenses
2. Unable to pay full rent on mortgage
3. Unable to pay full utility bill
4. Had utilities shut off
5. Had telephone shut off
6. Evicted from apartment1 After adjustment for income, education, employment status, transfer payments, home ownership, gender, marital status, children, disability, health insurance and residential mobility.
Bauman 1998; SIPP
Racism: Potential Mechanisms• Institutional discrimination can restrict economic
attainment and thus differences in SES and health.• Segregation creates pathogenic residential
conditions.• Discrimination can lead to reduced access to
desirable goods and services.• Internalized racism (acceptance of society’s
negative beliefs) can adversely affect health.• Racism can lead to increased exposure to
traditional stressors (e.g. unemployment). • Experiences of discrimination may be a neglected
psychosocial stressor.
Perceived Discrimination:
Experiences of discrimination may be a neglected psychosocial
stressor
“..Discrimination is a hellhound that gnaws at Negroes in every waking moment of their lives declaring that the lie of their inferiority is accepted as the truth in the society dominating them.”
Martin Luther King, Jr. [1967]
MLK Quote
Discrimination Persists
• Pairs of young, well-groomed, well-spoken college men with identical resumes apply for 350 advertised entry-level jobs in Milwaukee, Wisconsin. Two teams were black and two were white. In each team, one said that he had served an 18-month prison sentence for cocaine possession.
• The study found that it was easier for a white male with a felony conviction to get a job than a black male whose record was clean.
Source: Devan Pager; NYT March 20, 2004
Percent of Job Applicants Receiving a Callback
Criminal Record
White Black
No 34% 14%
Yes 17% 5%
Source: Devan Pager; NYT March 20, 2004
Recent Review• 115 studies in PubMed between 2005 and 2007
• Broader outcomes (fibroids, breast cancer incidence, Hb A1c, CAC, stage 4 sleep, birth weight, sexual problems)
• Studies of effects of bias on health care seeking and adherence behaviors
• Some longitudinal data
• Attention to the severity and course of disease
• International studies:
-- national: New Zealand, Sweden, & South Africa
-- Australia, Canada, Denmark, the Netherlands, Norway, Spain, Bosnia, Croatia, Austria, Hong Kong, and the U.K.
• Discrimination accounts, in part, for racial/ethnic disparities in health
Williams & Mohammed, in press
Every Day DiscriminationIn your day-to-day life how often do the following things happen to
you?• You are treated with less courtesy than other people.• You are treated with less respect than other people.• You receive poorer service than other people at restaurants or
stores.• People act as if they think you are not smart.• People act as if they are afraid of you.• People act as if they think you are dishonest.• People act as if they’re better than you are.• You are called names or insulted.• You are threatened or harassed.
Everyday Discrimination and Subclinical Disease
In the study of Women’s Health Across the Nation (SWAN):
-- Everyday Discrimination was positively related to subclinical carotid artery disease (IMT; intima-media thickness) for black but not white women
-- chronic exposure to discrimination over 5 years was positively related to coronary artery calcification (CAC)
Troxel et al. 2003; Lewis et al. 2006
Arab American Birth Outcomes
• Well-documented increase in discrimination and harassment of Arab Americans after 9/11/2001
• Arab American women in California had an increased risk of low birthweight and preterm birth in the 6 months after Sept. 11 compared to pre-Sept. 11
• Other women in California had no change in birth outcome risk pre-and post-September 11
Lauderdale, 2006
Discrimination and Disparities in Health Discrimination accounts for some of the racial
differences in: -- self-reported physical and/or mental health in the
U.S. (Williams et al, 1997; Ren et al, 1999; Pole et al, 2005), Australia (Larson et al, 2007), South Africa (Williams et al. 2008) & New Zealand (Harris et al. 2006)
-- birth outcomes (Mustillo et al. 2004) -- health care trust (Adegmembo et al, 2006) -- sleep quality and physical fatigue (Thomas et al.
2006)
Discrimination and Health Behaviors
Recent studies indicate that experiences of discrimination are associated with:
• Delays in seeking treatment
• Lower adherence to treatment regimes
• Lower rates of follow-up
• Poorer perceived quality of care
• Alcohol, tobacco and other drug use
Van Houteven et al. 2005, Banks & Dracup, 2006; Wagner & Abbott 2007; Wamala et al. 2007
Policy Area: Stress & Resources
Social status determines the types of stressors and level of exposure to stressors for social groups, as well as, the availability (and efficacy?) of resources to cope with stress
Stress and Health
• Stressors can lead to altered functioning of neuroendocrine and other pathways that can adversely affect health.
• Stressors and the negative emotional states created by them can lead to health behaviors such as impaired sleep patterns, decreased physical activity, increased substance use and food consumption that all increase risk of chronic disease.
Cohen, Kessler, & Gordon 1995; Marmot & Brunner 2001
Medical Care10%
Genetics20%
Environment20%
Behavior50%
U.S. Surgeon General, 1979
Determinants of Health in the U.S.
Policy Area: Health Care
There are racial & ethnic differences in access to care
and the quality of care
The Effect of Race and Sex on Physicians'Recommendations for Cardiac Catheterization
• 720 physicians viewed recorded interviews
• Reviewed data about a hypothetical patient
• The physicians then made recommendations about that patient's care
The Effect of Race and Sex on Physicians'Recommendations for Cardiac Catheterization
• Women (OR =0.60) and blacks (OR =0.60) were less likely to be referred for cardiac catheterization than men and whites, respectively.
• Black women were significantly less likely to be referred for catheterization than white men (OR= 0.4)
Schulman et. al., NEJM 1999;340:618.
STUDY CHARGE • Assess the extent of racial and ethnic differences in healthcare that are not otherwise attributable to known factors such as access to care (e.g., ability to pay or insurance coverage);
• Evaluate potential sources of racial and ethnic disparities in healthcare, including the role of bias, discrimination, and stereotyping at the individual (provider and patient), institutional, and health system levels; and,
• Provide recommendations regarding interventions to eliminate healthcare disparities.
Race and Medical Care
• Across virtually every therapeutic intervention, ranging from high technology procedures to the most elementary forms of diagnostic and treatment interventions, minorities receive fewer procedures and poorer quality medical care than whites.
• These differences persist even after differences in health insurance, SES, stage and severity of disease, co-morbidity, and the type of medical facility are taken into account.
• Moreover, they persist in contexts such as Medicare and the VA Health System, where differences in economic status and insurance coverage are minimized.
Institute of Medicine, 2003
Ethnicity and AnalgesiaChart review of 139 patients with isolated long-bone
fracture at UCLA Emergency Department (ED):• All patients aged 15 to 55, had the injury within 6
hours of ER visit, had no alcohol intoxication.• 55% of Hispanics received no analgesic compared
to 26% of non-Hispanic whites.• Simultaneous adjustment for sex, primary language,
insurance status, occupational injury, time of presentation, total time in ED, fracture reduction and hospital admission, Hispanic ethnicity was the strongest predictor of no analgesia.
• After adjustment for all factors, Hispanics were 7.5 times more likely than non-Hispanic whites to receive no analgesia.
Source: Todd, et al. 1993
Reducing Inequalities -IHealth Care
• Improve access to care and the quality of care– Give emphasis to the prevention of illness– Provide effective treatment– Develop incentives to reduce inequalities in the
quality of care
Care that Addresses the Social context
• Effective health care delivery must take the socio-economic context of the patient’s life seriously
• The health problems of vulnerable groups must be understood within the larger context of their lives
• The delivery of health services must address the many challenges that they face
• Taking the special characteristics and needs of vulnerable populations into account is crucial to the effective delivery of health care services.
• This will involve consideration of extra-therapeutic change factors: the strengths of the client, the support and barriers in the client’s environment and the non-medical resources that may be mobilized to assist the client
Nurse Family Partnership• Nurses make prenatal and postnatal visits to pregnant
women.• Nurses enhance parents’ economic self-sufficiency by
addressing vision for future, subsequent pregnancies, educational and job opportunities.
• Three randomized control trials (Elmira, NY; Memphis, TN; Denver, CO)
• Improved prenatal behaviors, pregnancy outcomes, maternal employment, relationships with partner.
• Reduces child abuse and neglect, subsequent pregnancies, welfare and food stamp use
• $17,000 return to society for each family served
Olds 2002, Prevention Science
Needed Interventions
Policies to reduce inequalities in health must also address fundamental non-
medical determinants.
Guiding Principles
1. Health Policy must be re-defined to include policies in all sectors of society that have health consequences.
2. Policies which improve average health may have no impact on social inequalities in health.
3. We need policies that improve health overall and targeted interventions to address social inequalities.
4. Major gains are possible through strategies that tackle health problems that occur most frequently.
5. Families with children should be a priority.
Needed Behavioral Changes
• Reducing Smoking
• Improving Nutrition and Reducing Obesity
• Increasing Exercise
• Reducing Alcohol Misuse
• Improving Sexual Health
• Improving Mental Health
Reducing Inequalities IReducing Negative Health Behaviors?
*Changing health behaviors requires more than just more health information. “Just say No” is not enough.
*Interventions narrowly focused on health behaviors are unlikely to be effective.
*The experience of the last 100 years suggests that interventions on intermediary risk factors will have limited success in reducing social inequalities in health as long as the more fundamental social inequalities themselves remain intact.
House & Williams 2000; Lantz et al. 1998; Lantz et al. 2000
Changes in Smoking Over Time -I
Successful interventions require a coordinated and comprehensive approach:
• The active involvement of professionals and volunteers from many organizations (government, health professional organizations, community agencies and businesses)• The use of multiple intervention channels (media, workplaces, schools, churches, medical and health societies)
Warner 2000
Changes in Smoking Over Time -2
The use of multiple interventions – • Efforts to inform the public about the dangers of cigarette smoking (smoking cessation programs, warning labels on cigarette packs)• Economic inducements to avoid tobacco use (excise taxes, differential life insurance rates)• Laws and regulations restricting tobacco use (clean indoor air laws, restricting smoking in public places and restricting sales to minors)
Even with all of these initiatives, success has been only partial
Warner 2000
Moving Upstream
Effective Policies to reduce inequalities in health must address fundamental
non-medical determinants.
WHY?
WHY?
WHY?
Centrality of the Social Environment
An individual’s chances of getting sick are largely unrelated to the receipt of medical care
Where we live, learn, work, play and worship determine our opportunities and chances for being healthy
Social Policies can make it easier or harder to make healthy choices
SES and Health Risks
SES is linked to:
*Exposures to health enhancing resources *Exposures to health damaging factors *Exposure to particular stressors *Availability of resources to cope with stress
Health practices (smoking, poor nutrition, drinking, exercise, etc.) are all socially patterned
Making Healthy Choices Easier
Factors that facilitate opportunities for health:
• Facilities and Resources in Local Neighborhoods
• Socioeconomic Resources
• A Sense of Security and Hope
• Exposure to Physical, Chemical, & Psychosocial Stressors
• Psychological, Social & Material Resources to Cope with Stress
Redefining Health Policy
Health Policies include policies in all sectors of society that affect opportunities to choose health, including, for example,
• Housing Policy
• Employment Policies
• Community Development Policies
• Income Support Policies
• Transportation Policies
• Environmental Policies
Policy Implications
Since the socio-political environment and SES is a key determinant of health,
improving social and economic conditions is critical to improving health
and reducing health disparities
Policy Area
Place Matters!
Geographic location determines exposure to risk factors and resources
that affect health.
Racial Segregation Is …1. …"basic" to understanding racial inequality in
America (Myrdal 1944) .
2. …key to understanding racial inequality (Kenneth Clark, 1965) .
3. …the "linchpin" of U.S. race relations and the source of the large and growing racial inequality in SES (Kerner Commission, 1968) .
4. …"one of the most successful political ideologies" of the last century and "the dominant system of racial regulation and control" in the U.S (John Cell, 1982).
5. …"the key structural factor for the perpetuation of Black poverty in the U.S." and the "missing link" in efforts to understand urban poverty (Massey and Denton, 1993).
How Segregation Can Affect Health
1. Segregation determines quality of education and employment opportunities.
2. Segregation can create pathogenic neighborhood and housing conditions.
3. Conditions linked to segregation can constrain the practice of health behaviors and encourage unhealthy ones.
4. Segregation can adversely affect access to high-quality medical care.
Source: Williams & Collins , 2001
Segregation: Distinctive for Blacks• Blacks are more segregated than any other
racial/ethnic group.
• Segregation is inversely related to income for Latinos and Asians, but is high at all levels of income for blacks.
• The most affluent blacks (income over $50,000) are more highly segregated than the poorest Latinos and Asians (incomes under $15,000).
• Thus, middle class blacks live in poorer areas than whites of similar SES and poor whites live in much better neighborhoods than poor blacks.
• African Americans manifest a higher preference for residing in integrated areas than any other group.
Source: Massey 2004
Residential Segregation and SES
A study of the effects of segregation on young African American adults found that the elimination of segregation would erase black-white differences in
Earnings High School Graduation Rate Unemployment
And reduce racial differences in single motherhood by two-thirds
Cutler, Glaeser & Vigdor, 1997
Racial Differences in Residential Environment
• In the 171 largest cities in the U.S., there is not even one city where whites live in ecological equality to blacks in terms of poverty rates or rates of single-parent households.
• “The worst urban context in which whites reside is considerably better than the average context of black communities.” p.41
Source: Sampson & Wilson 1995
Proportion of Black & Latino Children in Poorer Neighborhoods Than Worst Off White Children
76%86%
57%
44%
74%69%
0102030405060708090
100
All Metro Areas 5 Metro AreasHigh Segr.
5 Metro AreasLow Segr.
Neighborhood
Per
cent
age
BlackLatino
American Apartheid:South Africa (de jure) in 1991 & U.S. (de facto) in
2000
82 81 80 80 7766
8590
0102030405060708090
100
South
Afr
ica
Detro
it
Milw
aukee
New Y
ork
Chicago
Newar
k
Clevela
ndU.S
.
Seg
rega
tion
In
dex
Source: Massey 2004; Iceland et al. 2002; Glaeser & Vigitor 2001
Reducing Inequalities IIAddress Underlying Determinants of Health
• Improve conditions of work, re-design workplaces to reduce injuries and job stress
• Enrich the quality of neighborhood environments and increase economic development in poor areas
• Improve housing quality and the safety of neighborhood environments
Improving Residential Circumstances
Policies to reduce racial disparities in SES and health should address the concentration of economic disadvantage and the lack of an infrastructure that promotes opportunity that co-occurs with segregation and exists on many American Indian reservations.
That is, eliminating the negative effects of segregation on SES and health requires a major infusion of economic capital to improve the social, physical, and economic infrastructure of disadvantaged communities.
Source: Williams and Collins 2004
Neighborhood Renewal and Health - I
• A 10-year follow-up study of residents in 5 neighborhood types in Norway found that changes in neighborhood quality were associated with improved health.
• The neighborhood improvements: a new public school, playground extensions, a new shopping center with restaurants and a cinema, a subway line extension into the neighborhood, a new sports arena & park, and organized sports activities for adolescents.
• Residents of the area that had experienced these dramatic improvements in its social environment reported improved mental health 10 years later
• This effect was not explained by selective migration
Dalgard and Tambs 1997
Neighborhood Renewal and Health - II
• Neighborhood improvement in a poorly functioning area in England was linked to improved health and social interaction.
• Improvements: housing was refurbished (made safe & sheltered from strangers), traffic regulations improved, improved lighting & strengthening of windows, enclosed gardens for apartments, closed alleyways, and landscaping. Residents involved in planning process.
• One year later:
– Levels of optimism, belief in the future, identification with their neighborhood, trust in other neighbors, and contact between the neighbors had all increased.
– Symptoms of anxiety and depression had declined.
Halpern, 1995
Neighborhood Change and Health
• The Moving to Opportunity Program randomized families with children in high poverty neighborhoods to move to less poor neighborhoods.
• It found, three years later, that there were improvements in the mental health of both parents and sons who moved to the low-poverty neighborhoods.
Leventhal and Brooks-Gunn, 2003
Reducing Inequalities IIIAddress Underlying Determinants of Health
• Improve living standards for poor persons and households
• Increase access to employment opportunities
• Increase education and training that provide basic skills for the unskilled and better job ladders for the least skilled
• Invest in improved educational quality in the early years and reduce educational failure
Increased Income and Health
• A study conducted in the early 1970s found that mothers in the experimental income group who received expanded income support had infants with higher birth weight than that of mothers in the control group.
• Neither group experienced any experimental manipulation of health services.
• Improved nutrition, probably a result of the income manipulation, appeared to have been the key intervening factor.
Kehrer and Wolin, 1979
Income Change and Health
• A natural experiment assessed the impact of an income supplement on the mental health of American Indian children.
• It found that increased family income (because of the opening of a casino) was associated with declining rates of deviant and aggressive behavior.
Costello et al. 2003
Health Effects of Civil Rights Policy• Civil Rights policies narrowed black-white economic gap
• Black women had larger gains in life expectancy during 1965 - 74 than other groups (3 times as large as those in the decade before)
• Between 1968 and 1978, black males and females, aged 35-74, had larger absolute and relative declines in mortality than whites
• Black women born 1967 - 69 had lower risk factor rates as adults and were less likely to have infants with low-birth weight and low APGAR scores than those born 1961- 63
• Desegregation of Southern hospitals enabled 5,000 to 7,000 additional Black babies to survive infancy between 1965 to 1975
Kaplan et al. 2008; Cooper et al. 1981; Almond & Chay, 2006; Almond et al. 2006
Economic Policy is Health Policy
In the last 50 years, black-white differences in health have narrowed and widened with black-white differences in income
Changes in Mortality Rates per 100,000 Population, Age 35-74, Between 1968 and 1978 (Men)
Year White Black
1968 2,119.7 2,919.8
1978 1,738.2 2,331.8
Change -381.5 -588.0
% Change 18.0 20.1
Cooper et al., 1981b
Changes in Life Expectancy at Birth Between 1968 and 1978 (Women)
Year White Black
1968 75.0 67.9
1978 77.8 73.6
Change 2.8 5.7
% Change 3.7 8.4
Cooper et al., 1981b
Median Family Income of Blacks per $1 of Whites
0.54
0.55
0.56
0.57
0.58
0.59
0.6
0.61
0.62
Cents
1978 1980 1982 1984 1986 1988 1990 1992 1994 1996
Year
Source: Economic Report of the President, 1998
Health Status Changes, 1980-1991
Indicator 1980 1991
1. Excess Deaths (Blacks) 59,000 66,0002. Infant Mortality
Black/White Ratio, Males 1.9 2.1Black/White Ratio, Females 2.0 2.3
3. Life Expectancy Black/White Gap, Males 6.9 8.3 Black/White Gap, Females 5.6 5.8
Source: NCHS, 1994.
U.S. Life Expectancy at Birth, 1984-1992
75.3 75.3 75.4 75.6 75.6 75.9 76.1 76.3 76.5
69.5 69.3 69.1 69.1 68.9 68.8 69.1 69.3 69.6
60
65
70
75
80
1984 1985 1986 1987 1988 1989 1990 1991 1992
Year
Lif
e E
xpec
ten
cy (
Yea
r)
White Black
NCHS, 1995
Policy Area
Reducing Childhood Poverty
Challenges and Opportunities
Early Life
• Brain circuits in fetal and early childhood periods are affected by exposure to stress
• Toxic stress during this period, such as poverty, abuse, or parental depression, can adversely affect brain architecture and lead to elevated levels of cortisol and adrenaline
• When stress hormones are activated too often and for too long, they can damage the hippocampus
• This can lead to impairments in learning, memory and the ability to regulate stress responses
National Scientific Council on the Developing Child
Childhood Poverty, U.S., 1996 Percent of Children Under Age 18
Income Poor Near Poor Economically Vulnerable
All 20.5 22.7 43.2
White, non-Hispanic 11.1 19.7 30.8
Asian or Pacific Islander
19.5 16.4 35.9
Black, non-Hispanic 39.9 28.1 68.0
Hispanic 40.3 31.7 72.0
Source: U.S. Census Bureau (Pamuk et al. 1998)
Family Structure and SES
Compared to children raised by 2 parents those raised by a single parent are more likely to:
• grow up poor• drop out of high school• be unemployed in young adulthood• not enroll in college • have an elevated risk of juvenile delinquency and
participation in violent crime.
McLanahan & Sandefur 1994; Sampson 1987
• Economic marginalization of males (high unemployment & low wage rates) is the central determinant of high rates of female-headed households.
• Marriage rates are positively related to average male earnings.
• Marriage rates are inversely related to male unemployment.
Determinants of Family Structure
Bishop 1980; Testa et al. 1993; Wilson & Neckerman 1986
Source: UNICEF (United Nations Children’s Fund), 2000
% Children Child Poverty (%)
Country 1 Parent HH
1 Parent Other
Spain 2 32 12
Italy 3 22 20
Mexico 4 28 26
France 8 26 6
Ireland 8 48 14
Germany 10 51 6
United States 19 55 16
United Kingdom 20 46 13
Sweden 21 7 2
Source: UNICEF (United Nations’ Children’s Fund), 2000
Child Poverty RatesCountry Before Taxes After Taxes
Netherlands 16.0 7.7
Spain 21.1 12.3
Sweden 23.4 2.6
Canada 24.6 15.5
Italy 24.6 20.5
United States 26.7 22.4
Australia 28.1 12.6
France 28.7 7.9
United Kingdom 36.1 19.8
Poland 44.4 15.4
Policy Matters
Investments in early childhood programs in the U.S. have been
shown to have decisive beneficial effects
The High/Scope Perry Preschool Study to
Age 40Larry Schweinhart
High/Scope Educational Research Foundation
www.highscope.org
High/Scope Perry Preschool 123 young African-American children, living in poverty
and at risk of school failure.
Randomly assigned to initially similar program and no-
program groups.
4 teachers with bachelors’ degrees held a daily class of 20-
25 three- and four-year-olds and made weekly home visits.
Children participated in their own education by planning,
doing, and reviewing their own activities.
Results at Age 40 Those who received the program had better academic
performance (more likely to graduate from high school)
Program recipients did better economically (higher
employment, annual income, savings & home ownership)
The group who received high-quality early education had
fewer arrests for violent, property and drug crimes
The program was cost effective: A return to society of $17
for every dollar invested in early education_____________________________________________________________________Schweinhart & Montie, 2005
Building on Resources We Need to Better Understand How Resilience Factors and Processes Can Affect Health and how to Build on the Strengths and Capacities of Communities
Religion & Health: Potential Mechanisms
1. Religious institutions can provide support, intimacy, a sense of connectedness and belonging
2. Religious beliefs and values can provide systems of meaning to interpret and re-interpret stress
3. Religious beliefs can provide feelings of strength to cope with adversity
4. By encouraging moderation in all things and reducing risk taking behavior, religious involvement can reduce exposure to stress.
5. Religious participation can discourage negative health behaviors (tobacco, alcohol, drugs, risky sexual practices)
6. Religious institutions can generate stress: time demands, role conflicts, social conflicts, criticism
Religion and Adolescent Risk Behavior• Religious high school seniors are less likely than their
non-religious peers to– Carry a weapon (gun, knife, club) to school– Get into fights or hurt someone– Drive after drinking– Ride with driver who had been drinking– Smoke cigarettes– Engage in binge drinking (5 or more drinks in a
row)– Use marijuana
• Religious seniors were more likely to– Wear seat belts– Eat breakfast, green vegetables and fruit– Get regular exercise– Sleep at least 7 hours per night
Wallace and Forman 1998; Monitoring the Future Study
U.S. Life Expectancy at Age 20by Religious Attendance
0
10
20
30
40
50
60
70
Never <1 week 1/week > 1/week
White
Black
Age
56.1
46.4
60.1 57.963.5
52.4
63.460.1
Hummer et al. 1999
Commission Overview
David R. Williams, Ph.D.Executive Staff Director, Commission to Build a Healthier America
Commission Goals and Objectives
• Raise awareness of shortfalls in Americans’ health and highlight promising interventions beyond medical care to improve health and longevity
• Recommend policy interventions – public and private – to improve Americans’ health both in the near and longer term
• Inspire confidence and public will to take meaningful steps
towards improved health for all Americans
Alice RivlinFormer U.S. Cabinet official, and an expert on the budget. First woman to hold the position of Director of the Office of Management and Budget and was founding director of the Congressional Budget office. Currently, Director of Greater Washington Research Program at Brookings Institution.
Commission Leadership
Mark McClellanPhysician and economist who helped develop and then effectively implemented Medicare prescription drug benefit. Former CMS Administrator (2004) and FDA Commissioner (2002). Director of the Engelberg Center for Health Care Reform, Senior Fellow in Economic Studies and Leonard D. Schaeffer Director's Chair in Health Policy Studies at the Brookings Institution.
Commissioners
Katherine BaickerProfessor of Health Economics, Department of Health Policy and Management, Harvard University
Angela Glover BlackwellFounder and Chief Executive Officer, PolicyLink
Sheila P. BurkeFaculty Research Fellow and Adjunct Lecturer in Public Policy, Kennedy School of Government, Harvard University
Linda M. DillmanExecutive Vice President of Benefits and Risk Management, Wal-Mart Stores, Inc.
Sen. Bill FristSchultz Visiting Professor of International Economic Policy, Princeton University
Allan GolstonU.S. Program President, The Bill & Melinda Gates Foundation
Commissioners
Kati HaycockPresident, The Education Trust
Hugh PaneroCo-Founder and Former President and Chief Executive Officer, XM Satellite Radio
Dennis RiveraChair, SEIU Healthcare
Carole SimpsonLeader-in-Residence, Emerson College School of Communication and Former Anchor, ABC News
Jim ToweyPresident, Saint Vincent College
Gail L. WardenProfessor, University of Michigan School of Public Health and President Emeritus, Henry Ford Health System
Commission will Focus on Non-Medical Pathways to Improve Health
HEALTHHEALTH
Economic & SocialOpportunities and Resources
Living & Working Conditionsin Homes and Communities
MedicalCare
PersonalBehavior
HEALTH
Commission Activities will Garner National Attention
• Commission Launch– February 28, 2008, Washington, DC
• State Chartbook, Issue Briefs
• Qualitative Research and Polling
• Field Hearings and Special Events
• Final Report
www.commissiononhealth.org
• Key features now available:– Commission resources: Overcoming
Obstacles to Health report, charts– Leadership perspectives/Blogs– Multimedia personal stories– Commission information and activities– News releases– Commission news coverage– Relevant news articles
• Coming Soon– Interactive tool to demonstrate how
changing a factor such as average educational attainment at the county level could affect mortality rates
– Chartbook with state-level data on health shortfalls
– Issue briefs
commissiononhealth.org
A Resource for Public Health Professionals
Because There’s More to Health than Health Care
www.macses.ucsf.edu
A 7-part documentary series & public impact campaignwww.unnaturalcauses.org
Produced by California Newsreel with Vital Pictures
Presented on PBS by the National Minority Consortia of Public Television
Impact Campaign in association with the Joint Center Health Policy Institute
Conditions for HEALTH
H - Housing
E – Education & Environment
A - Access
L - Labor
T – Transportation
H – Hope and Happiness
Conclusions -I
1. Health officials and organizations cannot improve health by themselves
2. Improving health and reducing inequalities in health is not just about more health programs, it is about a new path to health
3. All policy that affects health is health policy
4. Health officials need to work collaboratively with other sectors of society to initiate and support social policies that promote health and reduce inequalities and health
Conclusions -II
1. Inequalities in health are created by larger inequalities in society.
2. SES and racial/ethnic disparities in health reflect the successful implementation of social policies.
3. Eliminating them requires political will for and a commitment to new strategies to improve living and working conditions.
4. Our great need is to begin in a systematic and comprehensive manner, to use all of the current knowledge that we have.
5. Now is the time
A Call to Action
“The only thing necessary for the triumph [of evil] is for good men to do nothing.”
Edmund Burke, British Philosopher