Race, Racism and Health:
Patterns, Paradoxes and Needed Research
David R. Williams, PhD, MPH
Florence & Laura Norman Professor of Public Health
Professor of African & African American Studies and of
Sociology
Harvard University
African American Mortality
• For the 15 leading causes of death in the United States in
2005, Blacks had higher death rates than whites for:
1. Heart Disease
3. Stroke
8. Flu and Pneumonia
10. Septicemia
15. Homicide
2. Cancer
6. Diabetes
9. Kidney Diseases
13. Hypertension
• Blacks had equivalent rates of accidents and lower death
rates than whites for:
4. Respiratory Diseases
11. Suicide
14. Parkinson’s Disease
Source: NCHS 2007
7. Alzheimer’s Disease
12. Cirrhosis of the liver
Hispanic Mortality
• For the 15 leading causes of death in the United States in
2005, Hispanics had higher death rates than whites for:
6. Diabetes
12. Cirrhosis of the liver
13. Homicide
• Hispanics had equivalent rates of hypertension kidney
disease and lower death rates than whites for:
1. Heart Disease
3. Stroke
4. Respiratory Diseases
8. Flu and Pneumonia
11. Suicide
Source: NCHS 2007
2. Cancer
5. Accidents
7. Alzheimer’s Disease
9. Kidney Disease
10. Septicemia
14. Parkinson’s Disease
Age-Adjusted Mortality rates for 2003-2005
120
1.2
1
1
Rates
80
0.8
60
0.6
0.7
0.8
0.6
40
0.4
20
0.2
0
0
Whites
Blacks
Rates per 10,000 population
Source: National Center for Health Statistics, 2007
American Indians Asian Pacific
Islanders
Hispanics
Minority/White Ratio
100
1.4
1.3
There Is a Racial Gap in Health in Early Life:
Minority/White Mortality Ratios, 2005
B/W ratio
Minority/White Ratio
3
AI/W ratio
API/W ratio
2.5
H/W ratio
2
1.5
1
0.5
0
<1
(1-4)
(5-9)
(10-14) (15-19) (20-24)
Age
There Is a Racial Gap in Health in Mid Life:
Minority/White Mortality Ratios, 2005
B/W ratio
Minority/White Ratio
3
AI/W ratio
API/W ratio
2.5
H/I ratio
2
1.5
a
1
0.5
0
25-29
30-34 35-39
40-44 45-49
Age
50-54 55-59 60-64
There Is a Racial Gap in Health in Late Life:
Minority/White Mortality Ratios, 2005
B/W ratio
Minority/White Ratio
3
AI/W ratio
API/W ratio
2.5
H/W ratio
2
1.5
1
0.5
0
65-69
70-74
75-79
Age
80-84
85+
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
30
12-Month Prevalence of Psychiatric Disorder,
by Race and Nativity Status (%)
US-born
25.6
25
Foreign-born
20
18.6
15
13.1
13.2
11.1
10
8.0
5
0
Caribbean Black
Source: NCS-R, NSAL, NLASS
Latino
Asian
Lifetime Prevalence of Psychiatric Disorder,
by Race and Generational Status (%)
60
54.6
First
50
Second
43.4
Third or later
40
35.3
30.1
30
24.0
23.8
20
19.4
15.2
10
0
Caribbean Black
Latino
Source: Williams et al. 2007; Alegria et al 2007; Takeuchi et al. 2007
Asian
25.6
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.?
Life Expectancy at Birth, 1900-2000
90
76.1
80
70
60.8
Age
60
50
40
71.7
69.1
77.6
69.1
71.9
64.1
47.6
White
Black
33.0
30
20
10
0
1900
1950
1970
Year
1990
2000
Age-Adjusted Heart Disease Death Rates
for Blacks and Whites, 1950-2004
Death Rates per 100,000 Population
750
White
Black
600
450
300
150
0
1950
1960
1970
1980
YEAR
1990
2000
2004
Age-Adjusted Cancer Death Rates for
Blacks and Whites, 1950-2004
Death Rates per 100,000 Population
300
White
Black
250
200
150
100
50
0
1950
1960
1970
1980
YEAR
1990
2000
2004
Age-Adjusted Stroke Death Rates for
Blacks and Whites, 1950-2004
Death Rates per 100,000 Population
250
White
Black
200
150
100
50
0
1950
1960
1970
1980
YEAR
1990
2000
2004
Diabetes Death Rates 1955-1998
5.0
White
Am Ind
Am Ind/W Ratio
50.0
4.5
52.8
46.4
4.0
3.5
40.0
3.0
30.0
2.5
20.0
2.0
24.4
24.3
1.5
17.0
10.0
12.6
1.0
10.4
11.7
11.9
0.5
8.6
0.0
0.0
1955
1975
1985
Year
Source: Indian Health Service; Trends in Indian Health 2000-2001
1995
1996-98
Am Ind/W Ratio
Deaths per 100,000 Population
60.0
Heart Disease Death Rates Mississippi 1996-2000
White Women, Ages 35+
CDC, Heart Disease and Stroke maps
Heart Disease Death Rates Mississippi 19962000
Black Women, Ages 35+
CDC, Heart Disease and Stroke maps
Heart Disease Death Rates Mississippi 1996-2000
Women
WHITE
CDC, Heart Disease and Stroke maps
BLACK
Race and the Burden of Breast Cancer
Compared to white women, black women are less
likely to get breast cancer, BUT they are more
likely to:
-- get breast cancer when young
-- be diagnosed at an advanced stage
-- have aggressive forms of breast cancer that are
resistant to treatment
-- have triple negative tumors: grow quickly, recur
more often, kill more frequently (Hispanic women
also)
-- die from breast cancer
Chlebowski et al. 2005, JNCI; CA Study
Race and Major Depression
Blacks have lower current and lifetime rates of major
depression than Whites, BUT depressed Blacks
are more likely than their White counterparts to:
-- be chronically or persistently depressed
-- have higher levels of impairment
-- have more severe symptoms
-- not receive treatment
Williams et al. 2007; Archives of Gen. Psychiatry
Mortality Rate
Neonatal Mortality Rates (1st Births), U.S.
16
14
12
10
8
6
4
2
0
White
Black
Mexican
Puerto Rican
15-19yrs. 20-29yrs. 30-34yrs.
Maternal Age
Geronimus & Bound, 1991; National Linked
Birth/Death Files, 1983
Racial/Ethnic Disparities in Health:
More than just Socioeconomic Status
Hazard Ratio
Black-White Mortality Hazard Ratios
Unadjusted
SES adjusted
3
2.5
2
1.5
1
0.5
0
18-25 25-44 45-64 65-74
Age
Franks et al., 2006; 1990-1992 NHIS linked to NDI through 1995
>75
Race and Prostate Cancer
Health Professionals Study
• 51,529 U.S. male health professionals, aged
40-75, followed from 1986 to 2002:
• Compared to whites, blacks had elevated
multivariate risk of
- incident cancer 1.49 (1.13-1.96)
- high grade cancer 1.75 (1.11-2.77)
Non-significant risk for
- fatal cancer 2.04 (0.90-4.62)
Giovannucci et al., 2007 Int. J. Cancer
Meharry vs Johns Hopkins
A 1958 – 65, all Black, cohort of Meharry Medical
College MDs was compared with a 1957- 64, all
White, cohort of Johns Hopkins MDs. 23-25
years later, the Black MDs were more likely to
have:
 higher risk of CVD (RR=1.65)
 earlier onset of disease
 incidence rates of diabetes & hypertension
that were twice as high
 higher incidence of coronary artery disease
(1.4 times)
 higher case fatality (52% vs 9%)
Thomas et al., 1997 J. Health Care for Poor and Underserved
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
Black
17.3
Hispanic
15.1
6.0
Poor=Below poverty; Near poor+<2x poverty; Middle Income = >2x poverty but <$50,000+
Source: Parmuk et al. 1998
2.2
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
20
18
16
14
12
10
8
6
4
2
0
3
2.5
2
1.5
1
0.5
0
<High High School Some
School
College
Education
College
grad. +
B/W Ratio
Deaths per 1,000 population
Infant Death Rates by Mother’s Education,
1995
White
Black
B/W Ratio
Infant Mortality by Mother’s Education,
1995
20
NH White
18
Hispanic
API
AmI/AN
17.3
16
Infant Mortality
Black
14
14.8
12
12.7
12.3
11.4
10
9.9
8
7.9
6
6 5.7
4
6.5
5.9 5.5
5.1
5.4 5.1 5.7
4.2
4.4 4
2
0
<12
12
13-15
Years of Education
16+
Racial/Ethnic Disparities in Health:
More than simplistic genetic hypotheses
What is Race?
“Pure races in the sense of genetically
homogenous populations do not exist in the
human species today, nor is there any
evidence that they have ever existed in the
past… Biological differences between
human beings reflect both hereditary factors
and the influence of natural and social
environments. In most cases, these
differences are due to the interaction of
both.”
American Association of Physical Anthropology, 1996
Hypertension,
7 West African Origin Groups (%)
33
35
30
25
20
15
25
24
26
19
14
16
10
5
0
ia
al
an
r
r
b
e
u
r
g
R
U
n
Ni
n
o
o
o
er
ero
m
m
a
C
Ca
ca
i
a
Jam
St
Source: International Collaborative Study of Hypertension in Blacks, 1995
ia
c
u
.L
os
d
a
b
Bar
is
o
n
i
Ill
Prevalence of Diabetes,
6 West African Origin Groups
age-adjusted prevalence
12
10.8
10.6
10
8.2
8.1
8
6.2
6
4
2
2
.S
.
U
.K
.
U
Ba
rb
ad
os
uc
ia
St
.L
ai
ca
Ja
m
N
ig
er
ia
0
Source: Cooper et al., 1997; International Collaboration Study of Hypertension in Blacks
Research Opportunity
As research on the human genome moves
forward, there will be increasing need for
comprehensive, detailed, and rigorous
characterization of the risk factors/resources in
the psychological, social, and physical
environment that may interact with biological
predispositions to affect health risks.
Why Race Still Matters
1. 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.
Wealth of Whites and of Minorities
per $1 of Whites, 2000
White
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¢
Household Income
Source: Orzechowski & Sepielli 2003, U.S. Census
Race and Economic Hardship 1995
African 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 apartment
1 After
adjustment for income, education, employment status, transfer payments,
home ownership, gender, marital status, children, disability, health insurance and
residential mobility.
Bauman 1998; SIPP
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
Child and Adult SES and Hypertension
Pitt County, NC Men
8
7
Odds Ratios
6
5
Low/Low
Low/High
High/Low
High/High
4
3
2
1
0
Age Adjusted
James et al. 2006; AJPH
Multivariate
Adjusted
Racism and Health: Mechanisms
• Institutional discrimination (segregation) can restrict SES
attainment and group differences in SES and health.
• Segregation can create pathogenic residential conditions.
• Discrimination can lead to reduced access to desirable
goods and services.
• Internalized racism (acceptance of society’s negative
characterization) can adversely affect health.
• Racism can create conditions that increase exposure to
traditional stressors (e.g. unemployment).
• Experiences of discrimination may be a neglected
psychosocial stressor.
Residential Segregation is an example of
Institutional Discrimination that has
pervasive adverse effects on health
Racial Segregation Is …
1. Myrdal (1944): …"basic" to understanding racial
inequality in America.
2. Kenneth Clark (1965): …key to understanding racial
inequality.
3. Kerner Commission (1968): …the "linchpin" of U.S.
race relations and the source of the large and
growing racial inequality in SES.
4. John Cell (1982): …"one of the most successful
political ideologies" of the last century and "the
dominant system of racial regulation and control" in
the U.S.
5. Massey and Denton (1993): …"the key structural
factor for the perpetuation of Black poverty in the
U.S." and the "missing link" in efforts to understand
urban poverty.
How Segregation Can Affect Health
1. Segregation determines SES by affecting 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 medical
care and to high-quality care.
Source: Williams & Collins , 2001
Segregation and Employment
• Exodus of low-skilled, high-pay jobs from
segregated areas: "spatial mismatch" and
"skills mismatch"
• Facilitates individual discrimination based
on race and residence
• Facilitates institutional discrimination based
on race and residence
Race and Job Loss
Economic Downturn of 1990-1991
Racial Group
Net Gain or Loss
BLACKS
59,479 LOSS
WHITES
71,144 GAIN
ASIANS
55,104 GAIN
HISPANICS
60,040 GAIN
Source : Wall Street Journal analysis of EEOC reports of 35,242 companies
Race and Job Loss
Percent Black
Company
Work Force
Losses
Reason
Sears
16
54
Closed distribution centers in
inner-cities; relocated to
suburbs
Pet
14
35
Two Philadelphia plants
shutdown
Coca-Cola
18
42
Reduced blue-collar workforce
American
Cyanamid
11
25
Sold two facilities in the South
Safeway
9
16
Reduced part-time work; more
suburban stores
Source: Sharpe, 1993: Wall Street Journal
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
Segregation and
Neighborhood Quality
Municipal services (transportation, police, fire,
garbage)
Purchasing power of income (poorer quality, higher
prices).
Access to Medical Care (primary care, hospitals,
pharmacies)
Personal and property crime
Environmental toxins
Abandoned buildings, commercial and industrial
facilities
Segregation and
Housing Quality
Crowding
Sub-standard housing
Noise levels
Environmental hazards (lead, pollutants, allergens)
Ability to regulate temperature
Segregation and
Health Behaviors
Recreational facilities (playgrounds, swimming pools)
Marketing and outlets for tobacco, alcohol, fast foods
Exposure to stress (violence, financial stress, family
separation, chronic illness, death, and family turmoil)
Segregation and Medical Care -I
• Pharmacies in segregated neighborhoods are less
likely to have adequate medication supplies
(Morrison et al. 2000)
• Hospitals in black neighborhoods are more likely
to close (Buchmueller et al 2004; McLafferty,
1982; Whiteis, 1992).
• MDs are less likely to participate in Medicaid in
racially segregated areas. Poverty concentration is
unrelated to MD Medicaid participation (Greene et
al. 2006)
Segregation and Medical Care -II
• Blacks are more likely than whites to reside in
areas (segregated) where the quality of care is low
(Baicker, et al 2004).
• African Americans receive most of their care from
a small group of physicians who are less likely
than other doctors to be board certified and are
less able to provide high quality care and referral
to specialty care (Bach, et al. 2004).
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
Segregation: Distinctive for Blacks
• Blacks are more segregated than any other group
• Segregation varies by income for Latinos &
Asians, but high at all levels of income for blacks.
• Wealthiest blacks ( > $50K) are more segregated
than the poorest Latinos & Asians ( < $15,000).
• Middle class blacks live in poorer areas than
whites of similar SES and poor whites live in
better areas than poor blacks.
• Blacks show a higher preference for residing in
integrated areas than any other group.
Source: Massey 2004
100
90
80
70
60
50
40
30
20
10
0
90
82
81
80
Source: Massey 2004; Iceland et al. 2002; Glaeser & Vigitor 2001
80
77
C
le
.
U
.S
ve
la
nd
k
N
ew
ar
go
C
hi
ca
or
k
N
ew
Y
ke
e
M
ilw
au
it
D
et
ro
A
fr
th
So
u
85
66
ica
Segregation Index
American Apartheid:
South Africa (de jure) in 1991 & U.S. (de facto) in
2000
Percentage
Proportion of Black & Latino Children in Poorer
Neighborhoods Than Worst Off White Children
100
90
80
70
60
50
40
30
20
10
0
Black
Latino
86%
76%
69%
74%
57%
44%
All Metro Areas 5 Metro Areas 5 Metro Areas
High Segr.
Low Segr.
Neighborhood
Acevedo-Garcia et al., 2008
Research Implications: Distinctive
Patterns?
• What effects do these distinctive residential
environments have on normal physiological
processes?
• How are normal adaptive and regulatory systems
affected by the harsh residential environment of
blacks?
• Due to biological adaptations to their residential
environments, should we not expect to find some
biological profiles that are different and some
distinctive patterns of interactions (between biological
and psychosocial factors) for African Americans?
Internalized Racism:
One response of stigmatized
populations is to accept as true the
larger societal beliefs about their
inferiority
Internalized Racism & Health: Understudied
• The experimental manipulation of a stigma of
inferiority (stereotype threat) leads to increases in
blood pressure among blacks
• Internalized racism has been positively associated
with psychological distress and substance abuse in
several studies of African Americans
• Internalized racism has been positively associated
with the risk of overweight and abdominal obesity
in studies of Black women in the Caribbean and
the U.S.
Blascovich et al. 2001; Taylor & Jackson, 1990; Taylor et al. 1991; Tull et al. 1999; Chambers et al. 2004
Perceived Discrimination:
Experiences of discrimination may be a
neglected psychosocial stressor
Race, Criminal Record, and Jobs
• 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.
Devah Pager, 2003; Am J Sociology
Percent of Job Applicants Receiving a
Callback
Criminal Record
White
Black
No
34%
14%
Yes
17%
5%
Devah Pager, 2003; Am J Sociology
“..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]
Paradies’ Review
• Identified 138 empirical studies
• 65% (n=89) published between 2000-2004
• 86% in U.S., but 20 studies from Europe, Canada,
Australia/New Zealand and the Caribbean
• After adjustment for confounders, discrimination
tends to be associated with poor health
• Similar to the literature on stress, consistent
inverse association more often found for measures
of mental health than physical health
Paradies, 2006: International Journal of Epidemiology
Recent Review
• 95 studies in MEDLINE between 2005 and 2007
• Broader range of outcomes (e.g. uterine myomas, hemoglobin
A1c, CAC, less stage 4 sleep & breast cancer incidence)
• Attention to the effects of bias on health care seeking and
adherence behaviors
• Some longitudinal data
• Focus on the severity and course of disease
• Growth in international studies (e.g. national studies in New
Zealand, Sweden, and South Africa; studies from Australia,
Canada, Denmark, the Netherlands, Norway, and the U.K.)
Williams & Mohammed, under review
Discrimination and Disparities in
Health
Perceptions of discrimination have been
shown to account for some of the racial
differences in:
-- self-reported physical health in the U.S.
(Williams, et al., 1997; Ren, et al., 1999)
and New Zealand (Harris et al. 2006)
-- birth outcomes (Mustillo et al. 2004).
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
Every Day Discrimination
In your day-to-day life how often have any of the following things
happened 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; intimamedia 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
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
Prevalence
Prevalence of Substance Use according to
Racial Discrimination and Race/Ethnicity
100
90
80
70
60
50
40
30
20
10
0
Smoking
Alcohol
Marijuana
Cocaine
Crack
African
American
African
American
White
White
None
Any
None
Any
Racial Discrimination in Years 7 and 15
Discrimination and Diabetes
• A study of 848 diabetic patients found that
perceived health care discrimination was
associated with worse glycemic control (A1c),
more diabetes symptoms, and worse physical
functioning.
• (Higher levels of discrimination were associated
with lower ratings of the interpersonal qualities of
care, e.g. “friendliness and courtesy,” “respect”).
• Discrimination may adversely affect severity &
course of disease by affecting patients’ levels of
self-care.
Source: Piette et al. 2006, Patient Ed & Counseling
Discrimination and Health: New Zealand
• National study of 4,108 Maori and 6,269 whites
• A 5-item scale captured ethnically motivated physical
or verbal attack, unfair treatment (due to ethnicity) in
health care, getting a job, at work, or in housing.
Maori were 10 times more likely than whites to report
discrimination in 3 or more settings.
• Perceived discrimination made an incremental
contribution over and above SES in explaining
disparities in poor self-rated health, low physical
functioning, psychological distress, and self-reported
cardiovascular diseases
Harris et al., 2006, Lancet
Discrimination and Health: South Africa
• National study of 4,351 adults
• All black groups 2 to 4 times more likely than whites
to report chronic and acute racial discrimination
• All black groups had higher levels of psychological
distress than whites
• Perceived discrimination made an incremental
contribution over and above SES in accounting for
racial disparities in psychological distress
• Discrimination unrelated to poor self-rated health
Williams et al., 2008, Social Science & Medicine
Challenges
•
•
•
•
Measuring Discrimination
Thinking carefully about exposure
Capturing life course exposure
Conceptual clarity re discrimination and
stress
• Attributional Ambiguity
• Dealing with Denial
Subjective Nature of Discrimination
1. There can be shared response bias between the measure
of discrimination and the measure of health when both
rely on self-reports.
2. In mental health studies there may be confounding
between reports of discrimination and health, based on
selective recall as a function of current mental health.
3. How can we improve the accuracy of reports based on
individual perceptions?
4. Are there simple cues to memory that can be utilized?
5. What are the key confounding factors that should also be
assessed for statistical adjustment (social desirability,
neuroticism, self-esteem, other?)?
Social Desirability
1. Asking repeatedly about “racial discrimination” or
experiences “because of your race” could produce demand
characteristics in which respondents believe that it is
desirable to the interviewer to report such experiences. This
could lead to over-reporting of discrimination.
2. Respondents may vary in their thresholds of what
constitutes discrimination and fail to report incidents that
are not perceived as serious.
3. But, does “unfair treatment” really capture racial
discrimination?
4. Does “unfair treatment” evoke the same experiences for
whites as for blacks and other minorities?
5. Are there race of interviewer effects?
Assessing Life Course Exposure
1. Research on stressful life events indicates that the falloff
in reporting stressors occurs at the rate of 5% per month.
2. How can we overcome errors due to forgetting?
3. Prior research has used past month, past year, past 3
years, and lifetime time frames for reports of
discrimination, but they have not used them
simultaneously. How can we best capture lifetime
exposure?
4. How can we measure well the timing of exposure?
5. How can we, quickly but effectively, facilitate the
accurate reconstruction of past events?
Historical Trauma (HT) -I
• Intergenerational effects of racism, genocide, &
assimilation on American Indian health
• Cumulative & collective psychological wounding over
the life-span and across generations
• Similar to studies of other generational group traumas,
such as, the Jewish Holocaust, or the internment of
Japanese Americans in concentration camps
• HT may contribute to unresolved grief, substance
abuse, physical and mental illnesses, suicide,
homicide, problematic gambling behaviors, domestic
violence, child abuse & low SES in American Indians
Whitbeck et al. 2004
Historical Trauma -II
• Scales with good psychometric properties
have been developed to assess HT
• Prevalence levels of HT are high in
American Indians
• Recent empirical studies have found an
inverse association between HT and health.
• Clinical interventions to address HT have
also been developed.
Whitbeck et al 2004; Braveheart 2003;
Attributional Ambiguity
•
Full knowledge is usually lacking about any specific
interpersonal transaction
•
Ambiguity and uncertainty regarding the attribution
of negative experiences could themselves lead to
worry and rumination that is health damaging
•
How can we assess ambiguity in the perceptions of
discrimination?
•
Importance of capturing all exposures regardless of
attribution
Dealing with Denial
1. Reporting discrimination can adversely affect selfesteem and feelings of control.
2. Some individuals cope with discrimination by
minimizing or even denying its occurrence.
3. Some research has found that minority group
members who report never having an experience of
discrimination also report the highest levels of
illness.
4. Is there a way to operationalize denial in the context
of large epidemiological studies?
Capturing Exposure
• Perceived discrimination is not a magic bullet that
captures all relevant race-related risk in the
environment
• Must be adequately assessed (comprehensively;
chronic & enduring features; traumatic events)
• Think of relevant exposure and lag times
• Discrimination is only one type of relevant stress
• Must be understood within the context of other
stressors
Williams et al 2003; AJPH
We need a more integrated science to
better elucidate how multiple
dimensions of the social environment,
combine, additively and interactively, to
affect the onset of illness and the
progression of disease processes
Cumulative Biological Risk
We need to identify the biological pathways by which
social adversities affect health.
Many biological risk factors (B.P., cholesterol, glucose,
fibrinogen) are often patterned by SES.
Chronic exposure to stressors can lead to physiological
dysregulation across multiple physiological systems of
the body. Allostatic load captures the cumulative
burden of this physiological wear and tear on the
human organism that increases the risk of disease.
Seeman et al. 2003
Allostatic Load and Inequalities in Health
• In a study of high-functioning elderly, a summary
measure of allostatic load (16 biological indicators
of cardiovascular risk [6], hormones [4],
inflammation [4], and renal function and lung
function) was inversely related to SES.
• This summary measure of biological dysregulation
explained one third of educational differences in
morbidity. The cumulative measure of biological
risk (allostatic load) explained more variance than
the individual biological indicators.
Seeman et al.2003
Life-Course Approaches
Individuals and groups disadvantaged with exposure to
a pathogenic factor, tend to be exposed to multiple risk
factors.
Social adversities and stressors tend to co-occur and
cumulate over the life course.
We need to better understand how adult health is
affected by certain critical events earlier in life, as well
as, by the accumulation of health risks over the life
course.
Evidence for Action
How can we effectively intervene
to reduce social inequalities in
health?
Reducing Inequalities -I
Health 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 socioeconomic 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
Determinants of Health in the U.S.
Environment
20%
Behavior
50%
Genetics
20%
Medical Care
10%
U.S. Surgeon General, 1979
Needed Behavioral Changes
• Reducing Smoking
• Improving Nutrition and Reducing Obesity
• Increasing Exercise
• Reducing Alcohol Misuse
• Improving Sexual Health
• Improving Mental Health
Reducing Inequalities II
Reducing 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.
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
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
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.
Reducing Inequalities III
Address 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 cooccurs with segregation.
That is, eliminating the negative effects of
segregation on SES and health is likely to require
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.
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 III
Address 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
Policy Area
Reducing Childhood Poverty
Challenges and Opportunities
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 noprogram groups.
 4 teachers with bachelors’ degrees held a daily class of 2025 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
Research Opportunities
• We currently do not know whether policies that
address improving socioeconomic circumstances
are best implemented at the federal, state or local
level and what optimal forms such policies should
take.
• We need to rigorously evaluate the extent to which
policies in multiple sectors of society have
consequences for health and health disparities.
Research Opportunities: Multiple
Levels
• Which community-based interventions show the
greatest promise?
• How can we more actively support individuals,
families, and communities to make choices that
promote health?
• Are there specific interventions targeted at the broader,
social, political and economic determinants of health
that would have larger health enhancing effects on
disadvantaged (socioeconomic and racial/ethnic)
populations than their higher status peers?
• How can we best build on the strengths and capacities
of disadvantaged populations?
Conclusions
•
•
•
•
Racial Disparities in health are created by larger
inequalities in society, of which racism is one
determinant.
Social inequalities in health reflect the successful
implementation of social policies.
We need to examine how exposure to institutional and
individual forms of racism relate to each other, and
combine with other risks factors and resources, and
cumulate over the life course, to affect health
We need to identify how innate & acquired biological
factors interact with conditions in the psychological,
social and physical environment to affect health risks.
A Call to Action
“The only thing necessary for the triumph
[of evil] is for good men to do nothing.”
Edmund Burke, British Philosopher
www.macses.ucsf.edu
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•
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