A Time For Action:

the Enigma of Social Disparities

in Health and How to Effectively
Address Them

David R. Williams, PhD, MPH

Florence & 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

3
Minority/White Ratio

2.5
2 B/W ratio
AmI/W ratio
1.5
API/W ratio
1 Hisp/W ratio
0.5
0
<1 1-4 5-14 15-24
Age
 There Is a Racial Gap in Health in Mid Life:
Minority/White Mortality Ratios, 2000

2.5
Minority/White Ratio

2
B/W ratio
1.5
AmI/W ratio
1 API/W ratio
Hisp/W ratio
0.5

0
25-34 35-44 45-54 55-64
Age
 There Is a Racial Gap in Health in Late Life:
Minority/White Mortality Ratios, 2000

1.6
1.4
Minority/White Ratio

1.2
1.0 B/W ratio
AmI/W ratio
0.8
API/W ratio
0.6
Hisp/W ratio
0.4
0.2
0.0
65-74 75-84 85+
Age
 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,
60
by Race and Generational Status (%)
54.6
First
50
Second
43.4
Third or later
40
35.3
30.1
30
25.6
23.8 24.0
19.4
20
15.2

10

0
Caribbean Black Latino Asian

Source: Williams et al. 2007; Alegria et al 2007; Takeuchi et al. 2007

 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
700

White
Death Rates per 100,000 Population

600
Black
500

400

300

200

100
1950 1960 1970 1980 1990 2000

YEAR
 Age-Adjusted Cancer Death Rates for
Blacks and Whites, 1950-2000
300

White
Death Rates per 100,000 Population

Black
250

200

150

100
1950 1960 1970 1980 1990 2000

YEAR
 Diabetes Death Rates 1955-1998
60.0 White 5.0
Am Ind 4.5
Deaths per 100,000 Population

50.0 Am Ind/W Ratio 52.8

4.0
46.4
3.5

Am Ind/W Ratio
40.0
3.0
30.0 2.5
2.0
24.3 24.4
20.0
1.5
17.0
1.0
10.0 12.6 11.7 11.9
10.4
8.6 0.5
0.0 0.0
1955 1975 1985 1995 1996-98
Year

Source: Indian Health Service; Trends in Indian Health 2000-2001

 Life Expectancy at Birth, 1900-2000
90
80 76.1 77.6
69.1 71.7 69.1 71.9
70
60.8 64.1
60
47.6
Age

50 White
40 Black
33.0
30
20
10
0
1900 1950 1970 1990 2000
Year
 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

Family Income Median Score

More 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
Source: (ETS) Mantsios; N=898,596
 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
30

25 26.6
25.3
20 21.5
Poverty Rate

15
16.1 16.8

10
10.7
9.3
5

0
White Black AmI/AN NH/PI Asian Hisp. 2+ races
Any
Race
U.S. Census 2006
 Racial/Ethnic Composition of People in
Poverty in the U.S.
2+ races, 2.6%

Hisp. Any
23.9%

White
Asian, 3.6% 46.1%

NH/PI, 0.17%
Black
23.1%
AmI/AN, 1.6%

U.S. Census 2006

 Relative Risk of Premature Death by
Family Income (U.S.)
4.0
3.5
3.0
2.5
Relative Risk

2.0
1.5
1.0
0.5
0.0
<10K 10-19K 20-29K 30-39K 40-49K 50-99K 100+K

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
Racial Differences
Race/Ethnicity Percent 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
White Black Hispanic
Income
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
20
Education, 1995 3
Deaths per 1,000 population

18
16 2.5
14 2

B/W Ratio
12 White
10 1.5 Black
8 B/W Ratio
6 1
4 0.5
2
0 0
<High High School Some College
School College grad. +
Education
 Infant Mortality by Mother’s Education,
1995
20
NH White Black Hispanic API AmI/AN
18
17.3
16
14 14.8
Infant Mortality

12 12.7 12.3
11.4
10
9.9
8
7.9
6 6.5
6 5.7 5.9 5.5
4 5.1 5.4 5.1 5.7
4.2 4.4 4
2
0
<12 12 13-15 16+
Years of Education
 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.
 Race/Ethnicity and Wealth, 2000
Median Net Worth
Income White Black Hispanic
All $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
White B/W Hisp/W
Household Income Ratio 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 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

 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
 MLK Quote

“..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]

 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
White Black
Record
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 Discrimination
In 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
 Determinants of Health in the U.S.

Environment
20%
Behavior
50%

Genetics
20%

Medical Care
10%

U.S. Surgeon General, 1979

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 Analgesia
Chart 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 -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 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
• Health Policy must be re-defined to include policies
in all sectors of society that have health
consequences.
• Policies which improve average health may have no
impact on social inequalities in health.
• We need policies that improve health overall and
targeted interventions to address social inequalities.
• Major gains are possible through strategies that
tackle health problems that occur most frequently.
• 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 I
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.
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

100
90
80 86% Black
70
Percentage

76% 74% Latino

60 69%
50 57%
40
44%
30
20
10
0
All Metro Areas 5 Metro Areas 5 Metro Areas
High Segr. Low Segr.
Neighborhood
 American Apartheid:
South Africa (de jure) in 1991 & U.S. (de facto) in
2000
100 90
90 85 82 81 80 80 77
80
Segregation Index

70 66
60
50
40
30
20
10
0
a

nd

.
k
e

go
it

S
ic

ke

or

ar
ro

U.
ica

la
fr

w
au

Y
t

ve
A

De

Ne
Ch
w
ilw

le
th

Ne

C
u

M
So

Source: Massey 2004; Iceland et al. 2002; Glaeser & Vigitor 2001
 Reducing Inequalities II
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 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.
 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
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
0.62
0.61
0.6
0.59
Cents 0.58
0.57
0.56
0.55
0.54
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

3. Excess Deaths (Blacks) 59,000 66,000

4. Infant Mortality
Black/White Ratio, Males 1.9 2.1
Black/White Ratio, Females 2.0 2.3
6. 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
80
White Black
76.1 76.3 76.5
75.3 75.3 75.4 75.6 75.6 75.9
75
Life Expectency (Year)

70 69.5 69.3 69.1 69.1 69.1 69.3 69.6

68.9 68.8

65

60
1984 1985 1986 1987 1988 1989 1990 1991 1992
Year

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 19.5 16.4 35.9

Islander
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

 Determinants of Family Structure

• 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.

Bishop 1980; Testa et al. 1993; Wilson & Neckerman 1986

 % 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 Rates
Country 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
Source: UNICEF (United Nations’ Children’s Fund), 2000
 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 40
Larry 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
• Religious institutions can provide support, intimacy, a
sense of connectedness and belonging
• Religious beliefs and values can provide systems of
meaning to interpret and re-interpret stress
• Religious beliefs can provide feelings of strength to cope
with adversity
• By encouraging moderation in all things and reducing
risk taking behavior, religious involvement can reduce
exposure to stress.
• Religious participation can discourage negative health
behaviors (tobacco, alcohol, drugs, risky sexual
practices)
• 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 20
by Religious Attendance
70
63.5 63.4
60.1 57.9 60.1
60 56.1
52.4
50 46.4
Age

40
White
Black
30

20

10

0
Never <1 week 1/week > 1/week

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
Commission Leadership
Mark McClellan
Physician 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.
Alice Rivlin
Former 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.
Commissioners
Katherine Baicker
Professor of Health Economics, Department of Health Policy and Management,
Harvard University

Angela Glover Blackwell

Founder and Chief Executive Officer, PolicyLink

Sheila P. Burke
Faculty Research Fellow and Adjunct Lecturer in Public Policy, Kennedy School of
Government, Harvard University

Linda M. Dillman
Executive Vice President of Benefits and Risk Management, Wal-Mart Stores, Inc.

Sen. Bill Frist

Schultz Visiting Professor of International Economic Policy, Princeton University

Allan Golston
U.S. Program President, The Bill & Melinda Gates Foundation
Commissioners

Kati Haycock
President, The Education Trust

Hugh Panero
Co-Founder and Former President and Chief Executive Officer, XM Satellite Radio

Dennis Rivera
Chair, SEIU Healthcare

Carole Simpson
Leader-in-Residence, Emerson College School of Communication and Former Anchor,
ABC News

Jim Towey
President, Saint Vincent College

Gail L. Warden
Professor, University of Michigan School of Public Health and President Emeritus,
Henry Ford Health System
Commission will Focus on Non-Medical
Pathways to Improve Health

Economic & Social

Opportunities and Resources

Living & Working Conditions

in Homes and Communities

Medical Personal
Care Behavior

HEALTH
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 campaign
www.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
• Health officials and organizations cannot
improve health by themselves
• Improving health and reducing inequalities in
health is not just about more health programs, it
is about a new path to health
• All policy that affects health is health policy
• 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
• Inequalities in health are created by larger
inequalities in society.
• SES and racial/ethnic disparities in health reflect
the successful implementation of social policies.
• Eliminating them requires political will for and a
commitment to new strategies to improve living
and working conditions.
• Our great need is to begin in a systematic and
comprehensive manner, to use all of the current
knowledge that we have.
• 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