Barbara Ferrer, Ph.D., MPH,
M.Ed
Executive Director
Boston Public Health
Commission
Racial Disparities in Boston, 2008
Health Indicator
Black
Asthma (< 5, hosp)
16.2 per 1000
Birth Weight (Less than 3.3lbs)
3.0% of births
Body Weight (Overweight or Obese)
61%
Breast Cancer (Morality)
38.2 per 100,000
Death Rate (Mortality)
1,035.2 per 100,000
Diabetes (Mortality)
38.4 per 100,000
Drug Related Mortality
27.0 per 100,000
Heart Disease (Mortality)
200.8 per 100,000
High Blood Pressure
30%
HIV/AIDS (Mortality)
12.2 per 100,000
Homicide
31.1 per 100,000
Hospitalization
169.6 per 1,000
Infant Mortality (Mortality)
14.6 per 1,000
Lung Cancer (Mortality)
51.3 per 100,000
Prostate Cancer (Mortality)
72.7 per 100,000
Smoking during pregnancy
3.8%
Suicide (Mortality)
5.0
Teen Birth Rate (15 - 17)
18.9 per 1,000
Uninsured
2.7%
White
4.1
0.8%
50%
19.8
714.2
11.9
29.9
140.0
24%
3.1
n<5
97.2
3.4
48.3
22.2
4.2%
7.1
12.7
1.0%
Infant Deaths per 1,000
Live Births
Infant Mortality by Race/Ethnicity,
1996-2008
16.0
12.0
8.0
4.0
0.0
BOSTON
Black
Latino
White
DATA SOURCE: Boston resident live births and deaths, Massachusetts Department of Public Health
DATA ANALYSIS: Boston Public Health Commission Research and Evaluation Office
Life Expectancy in Years
Life Expectancy by Race
and Ethnicity and Gender,
2003-2008 combined
100.0
78.1
75.0
83.7
80.6
73.5
79.0
50.0
25.0
0.0
DATA SOURCE: Boston Resident Deaths, Massachusetts Department of Public Health
DATA ANALYSIS: Boston Public Health Commission Research and Evaluation Office
81.1
74.8
Percent of Low Birth Weight
Births
Low Birth Weight Births by Maternal Education and
Race/Ethnicity, Boston, MA, 2008
16%
14%
12%
10%
8%
6%
4%
2%
0%
Black
White
13.7%
12.7%
11.6%
9.4%
Less than a High
School Education
8.8%
High School
Graduate
7.8%
At Least Some
College
Maternal Education
NOTE: These data do not include persons whose race/ethnicity and maternal education were not reported.
DATA SOURCE: Boston resident live births, Massachusetts Department of Public Health.
DATA ANALYSIS: Boston Public Health Commission Research and Evaluation Office
6
Racial & Ethnic Disparities
Infant Mortality & Household Income
Per 1,000 Live Births
16.6
11.2
African Americans
with Household
Income $35,000+
White Americans
with Household
Income <$10,000
Prevalence of Smoking
Smoking Prevalence Among Pregnant Women by
Race/Ethnicity, Boston, MA, 2008
5%
4%
4.2%
3.8%
3%
2%
1%
0%
Black
Smokers
White
NOTE: These data do not include persons whose race/ethnicity and smoking status were not reported.
DATA SOURCE: Boston resident live births, Massachusetts Department of Public Health.
DATA ANALYSIS: Boston Public Health Commission Research and Evaluation Office
9
9
Percent of Low Birth Weight
Births
Low Birth Weight Births by Smoking Status and
Race/Ethnicity, Boston, MA, 2008
Black
25%
White
23.5%
20%
15%
10%
12.3%
9.8%
7.9%
5%
0%
Smokers
Non-Smokers
NOTE: These data do not include persons whose race/ethnicity and smoking status were not reported.
DATA SOURCE: Boston resident live births, Massachusetts Department of Public Health.
DATA ANALYSIS: Boston Public Health Commission Research and Evaluation Office
10
10
Racial & Ethnic Disparities
Infant Mortality & Prenatal Care
Per 1,000 Live Births
12.7
7.1
African Americans White Americans
First Trimester Prenatal Care After
Prenatal Care
1st Trimester or
None
DATA SOURCE: Infant Mortality Statistics from the 2003 Period Linked Birth/Infant Death Data Set, National vital
statistics reports; vol. 54, no. 16. Hyattsville, MD; National Center for Health Statistics, 2006

Race has no clear biologic or genetic
basis…“there are no characteristics, no traits,
not even one gene that turns up in all
members of one so-called race, yet is absent
from others” (L. Adelman. Race and Gene
Studies)

The meanings of racial designations- White,
Black, Asian- are subject to historical, cultural
and political forces; “race justified social
inequalities as natural”.
Racial & Ethnic Disparities
Infant Mortality & Nativity, 2003
16
14
Per 1,000 Live Births
12
13.8
10
8
6
9.3
4
2
0
Foreign Born
United States Born
Black Women
DATA SOURCE: Infant Mortality Statistics from the 2003 Period Linked Birth/Infant Death Data Set, National
vital statistics reports; vol. 54, no. 16. Hyattsville, MD; National Center for Health Statistics, 2006
WHAT ABOUT RACISM ?
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Differences in socio-economic status and
environmental conditions
Differences in exposure to “stress”
Differences in access to health care services
Differences in diagnostic testing, treatment,
and the quality of care received within the
health care system
Differences in health behaviors
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Exposure to waste disposal sites
Exposure to air pollutants
Exposure to “unregulated” job sites
(housecleaning, sweat shops, farms)
Exposure to sub-standard housing
(quality, density, location)
Exposure to alcohol and tobacco
products and unhealthy foods
Exposure to violence
Hospitalizations per 1,000 Population
Asthma Hospitalizations of Children Under
Age 5 by Neighborhood, Boston, 2005-2007
15.2
16.0
12.7
12.0
11.0
9.1
8.8
8.0
7.9 8.4
10.2 10.1
7.9
7.2
5.5
4.0
3.1
3.7
4.3
0.0
*Includes the North End
†Includes Chinatown
DATA SOURCE: Acute Care Hospital Case Mix files, Massachusetts Division of Health Care Finance and Policy
DATA ANALYSIS: Boston Public Health Commission Research Office
4.8
Figure 30.22 Homicides, 2006-2008 Combined
NOTE: Data are presented as age-adjusted rates. Neighborhoods are defined by zip codes.
DATA SOURCE: Boston resident deaths, Massachusetts Department of Public Health
DATA ANALYSIS: Boston Public Health Commission Research and Evaluation Office
MAP CREATED BY: Boston Public Health Commission Research and Evaluation Office
Figure 30.15b Obese Adult Residents, 2006-2008 Combined
NOTE: Body Mass Index (BMI) is calculated from self-reported weight and height. An adult who has a BMI of 30 or higher is considered obese. These data do not
include persons of 'Other' or unknown race/ethnicity.
Neighborhoods are defined by zip codes.
DATA SOURCE: Boston Behavioral Risk Factor Survey, 2006 and 2008, Boston Behavior Surveillance System (BBRFSS), Boston Public Health Commission DATA
ANALYSIS: Boston Public Health Commission Research and Evaluation Office
MAP CREATED BY: Boston Public Health Commission Research and Evaluation Office
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Understanding the biologic impacts of
social stress (Wadhwa et al. 2001., Culhane
et al. 2001., Kramer et al. 2001 )
Theory of allostatic load (Michael Lu. 2002,
Rich-Edwards. 2001)
“ ..a woman’s chronic exposure to racism creates an
allostatic load ..altering the endocrine milieu in
which the placenta is established….” (RichEdwards. 2001)
Stress
Photo: http://www.lam.mus.ca.us/cats/encyclo/smilodon/
Allostasis:
Maintain Stability through Change
McEwen BS. Protective and damaging effects of stress mediators. N Eng J Med. 1998;338:171-9.
Allostastic Load
McEwen BS. Protective and damaging effects of stress mediators. N Eng J Med. 1998;338:171-9.
Allostatic Load
McEwen BS, Lasley EN. The end of stress: As we know it. Washington DC: John Henry Press. 2002
Stressed vs. Stressed Out
• Stressed
– Increased cardiac output
– Increased available glucose
– Enhanced immune
functions
– Growth of neurons in
hippocampus & prefrontal
cortex
• Stressed Out
– Hypertension &
cardiovascular diseases
– Glucose intolerance &
insulin resistance
– Infection & inflammation
– Atrophy & death of neurons
in hippocampus & prefrontal
cortex
 Individual
behavior exists within a
social context
 Internalized racism can affect
health behavior
 Health behavior alone does not
account for unequal burden of
disease and death
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Disparities consistently found across a wide
range of disease areas and clinical services
Disparities are found even when clinical
factors, such as stage of disease
presentation, co-morbidities, age, and
severity of disease are taken into account
Disparities are found across a range of
clinical settings, including public and
private hospitals, teaching and nonteaching hospitals, etc.
Disparities in care are associated with
higher mortality among minorities (e.g.,
Bach et al., 1999; Peterson et al., 1997;
Model of Social Determinants of Health
Inequities
Socioeconomic
Status
Environmental
Exposure
Stress
Racism
Health Behaviors
Access To Health
Services
Access to Testing
and Screening
Health
Outcomes
Boston’s efforts to address racial and
ethnic inequities in health
www.bphc.org/disparities
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Evidence based foundation: data collection,
analysis and dissemination of relevant
information
Community capacity building and coalition
development are the pillars of the work
Inequities considered as a central issue and
elimination strategies are integrated into
core public health functions
Working upstream with non-traditional
partners is required to address root causes
of inequities
Funding is directed to support efforts to
eliminate inequities
Develop institutional competency to
engage in sustained efforts to
eliminate inequities
 Support/build community capacity
to lead and engage in efforts to
eliminate inequities
 Identify partnership opportunities to
enhance and promote efforts to
eliminate inequities
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Providing employee education and training
opportunities (core competencies and
leadership development)
Integrating elimination of inequities in every
program (logic models, goals, objectives,
activities and evaluation)
Identifying and changing internal policies that
may perpetuate inequities (ARAC)
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Reduce low birth weight rates among Boston residents
and reduce the gap in low birth weight rates between
Black and White Boston residents by 25%.
Reduce obesity rates among Boston residents and
reduce the gap between White and Black/Latino
combined obesity/overweight rates by 30% for children
and youth and by 20% for adults.
Reduce Chlamydia rates among Boston residents 15
through 24 years of age and reduce the gap in
Chlamydia rates between Black, Latino, and White
residents 15 through 24 years of age by 25%.
Building Community Capacity
• $3 million investment to 54
community and health institutions
to address health disparities
• Key Project Areas: Data Collection,
Health Systems, Raising Public
Awareness, Workforce Diversity,
Patient Education, Violence
Prevention and Trauma Response,
and Food Access/Obesity
Prevention
Building Partnerships -- Policy
and Advocacy
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Legislative advocacy and voter education:
- Violence Prevention Bill
- CORI reform
- Re-entry Bill
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Active engagement with State efforts such as Disparities
Council, Governor Patrick administration, and Executive Office
of Health and Human Services, and the MA Department of
Public Health
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Board of Health regulatory authority
- tobacco control
- permitting and inspecting
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Promote a diverse workforce and leadership
team
Establish institutional and personal cultural
competence
Build and sustain diverse partnerships
Collect appropriate data to understand the
challenge, measure progress and establish
accountability
Work “upstream” to address root causes of
health inequities in health outcomes
◦ Strongly oppose discrimination and
racism in all settings
◦ Support affordable, healthy housing
◦ Promote local opportunities for safe
exercise and recreational activities
◦ Promote local opportunities for
healthy, quality affordable foods
◦ Invest in public education and job
training
 Focus
on policies that are good
for health, not just health policies
 Fund efforts promoting
community health
 Build strategic partnerships