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 1.5 1 0.5 0 <1 1-4 Age 5-14 15-24 B/W ratio AmI/W ratio API/W ratio Hisp/W ratio

There Is a Racial Gap in Health in Mid Life: Minority/White Mortality Ratios, 2000
2.5 Minority/White Ratio 2 1.5 1 0.5 0 25-34 35-44 Age 45-54 55-64 B/W ratio AmI/W ratio API/W ratio Hisp/W ratio

There Is a Racial Gap in Health in Late Life:
Minority/White Mortality Ratios, 2000

1.6 1.4 1.2 1.0 0.8 0.6 0.4 0.2 0.0 65-74 75-84 Age 85+

Minority/White Ratio

B/W ratio AmI/W ratio API/W ratio Hisp/W ratio

Immigration and Health
• Hispanics and Asian Americans tend to have equivalent or better health status than whites • Immigrants of all racial/ethnic groups tend to have better health than their native born counterparts • With length of stay in the U.S., the health advantage of immigrants declines • Latinos and Asians differ markedly in their levels of human capital upon arrival in the U.S. • Given the low SES profile of Hispanic immigrants and their ongoing difficulties with educational and occupational opportunities, the health of Latinos is likely to decline more rapidly than that of Asians and to be worse than the U.S. average in the future

60

Lifetime Prevalence of Psychiatric Disorder, by Race and Generational Status (%)
54.6 First 43.4 Second Third or later 35.3 30.1 23.8 24.0 15.2 25.6

50

40

30 19.4

20

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 Death Rates per 100,000 Population 600 500 400 300 200 100 1950 1960 1970 1980 1990 2000

White Black

YEAR

Age-Adjusted Cancer Death Rates for Blacks and Whites, 1950-2000
300 Death Rates per 100,000 Population 250

White Black

200

150

100 1950 1960 1970 1980 1990 2000

YEAR

Diabetes Death Rates 1955-1998
60.0 Deaths per 100,000 Population 50.0 40.0 30.0 20.0
17.0 24.3 24.4

White Am Ind Am Ind/W Ratio
46.4

5.0 4.5
52.8

4.0 3.0 2.5 2.0 1.5 1.0 0.5 0.0 Am Ind/W Ratio 3.5

10.0 0.0

12.6

10.4

11.7 8.6

11.9

1955

1975

1985 Year

1995

1996-98

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

Life Expectancy at Birth, 1900-2000
90 80 70 60 69.1 60.8 47.6 33.0 76.1 71.7 64.1 White Black 69.1 77.6 71.9

Age

50 40 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
More than $100,000 $80,000 to $100,000 $70,000 to $80,000 $60,000 to $70,000 $50,000 to $60,000 $40,000 to $50,000 $30,000 to $40,000 $20,000 to $30,000 $10,000 to $20,000 Less than $10,000
Source: (ETS) Mantsios; N=898,596

Median Score
1129 1085 1064 1049 1034 1016 992 964 920 873

SES: A Key Determinant of Heath
• Socioeconomic Status (SES) usually measured by income, education, or occupation influences health in virtually every society. • SES is one of the most powerful predictors of health, more powerful than genetics, exposure to carcinogens, and even smoking. • The gap in all-cause mortality between high and low SES persons is larger than the gap between smokers and non-smokers. • Americans who have not graduated from high school have a death rate two to three times higher than those who have graduated from college. • Low SES adults have levels of illness in their 30s and 40s that are not seen in the highest SES group until after the ages of 65-75.

30 25

Percentage of Persons in Poverty Race/Ethnicity
25.3 26.6 21.5 16.1 9.3 10.7 16.8

Poverty Rate

20 15 10 5 0 White Black AmI/AN NH/PI Race
U.S. Census 2006

Asian

Hisp. Any

2+ races

Racial/Ethnic Composition of People in Poverty in the U.S.
2+ races, 2.6%

Hisp. Any 23.9% Asian, 3.6% NH/PI, 0.17% Black 23.1% White 46.1%

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

Relative Risk

Family Income in 1980 (adjusted to 1999 dollars)
9-year mortality data from the National Longitudinal Mortality Survey

Added Burden of Race
• Race and SES reflect two related but not interchangeable systems of inequality • SES accounts for a large part of the racial differences in health • BUT, there is an added burden of race, over and above SES that is linked to poor health.

Percent of persons with Fair or Poor Health by Race, 1995
Race/Ethnicity White Black Hispanic Percent 9.1 17.3 15.1 Racial Differences B-W H-W B-H 8.2 6.0 2.2

Poor=Below poverty; Near poor+<2x poverty; Middle Income = >2x poverty but <$50,000+ Source: Parmuk et al. 1998

Percent of Women with Fair or Poor Health by Race and Income, 1995
Household Income Poor Near Poor Middle Income High Income SES Difference White 30.2 17.9 9.2 5.8 24.4 Black 38.2 26.1 14.6 9.2 29.0 Hispanic 30.4 24.3 13.5 7.0 23.4

Poor=below poverty; Near Poor=<2x poverty; Middle Income=>2x poverty but <$50,000; High Income=$50,000+ Source: Pamuk et al. 1998

Infant Death Rates by Mother’s Education, 1995 3 20
Deaths per 1,000 population 18 16 14 12 10 8 6 4 2 0 <High High School Some School College Education College grad. + 2.5 B/W Ratio 2 1.5 1 0.5 0 White Black B/W Ratio

20 18 16 Infant Mortality 14 12 10 8 6 4 2 0

Infant Mortality by Mother’s Education, 1995
NH White
17.3 14.8 12.7 9.9 7.9 12.3

Black

Hispanic

API

AmI/AN

11.4

6 5.7

6.5

5.9 5.5

5.1

5.4 5.1 5.7

4.2

4.4 4

<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 All
Excl. Hm. Eq. Poorest 20% 2nd Quintile 3rd Quintile 4th Quintile Richest 20%

White $79,400
22,566 24,000 48,500 59,500 92,842 208,023

Black $7,500
1,166 57 5,275 11,500 32,600 65,141

Hispanic $9,750
1,850 500 5,670 11,200 36,225 73,032

Orzechowski & Sepielli 2003, U.S. Census

Wealth of Whites and of Minorities per $1 of Whites, 2000
White Household Income B/W Ratio Hisp/W Ratio

Total Poorest 20% 2nd Quintile 3rd Quintile 4th Quintile Richest 20%
Source: Orzechowski & Sepielli 2003, U.S. Census

$ 79,400 $ 24,000 $ 48,500 $ 59,500 $ 92,842 $ 208,023

9¢ 1¢ 11¢ 19¢ 35¢ 31¢

12¢ 2¢ 12¢ 19¢ 39¢ 35¢

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 Record
No

White
34%

Black
14%

Yes

17%

5%

Source: Devan Pager; NYT March 20, 2004

• 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

Recent Review

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; 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

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 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

Needed Interventions
Policies to reduce inequalities in health must also address fundamental nonmedical 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 highquality 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 blackwhite 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 70 60 50 40 30 20 10 0

Percentage

86% 76% 69% 74% 57% 44%

Black Latino

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 80 70 60 50 40 30 20 10 0
ic a A fr

90

85

82

81

80

80

Segregation Index

77 66

k

nd

ilw au ke e

or k

go

it

Ch ica

Ne w ar

De t

Ne w

So u

Source: Massey 2004; Iceland et al. 2002; Glaeser & Vigitor 2001

M

C le

th

ve la

Y

U. S

ro

.

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 lowpoverty 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 1968 1978 Change % Change
Cooper et al., 1981b

White 2,119.7 1,738.2 -381.5 18.0

Black 2,919.8 2,331.8 -588.0 20.1

Changes in Life Expectancy at Birth Between 1968 and 1978 (Women)
Year 1968 1978 Change % Change
Cooper et al., 1981b

White 75.0 77.8 2.8 3.7

Black 67.9 73.6 5.7 8.4

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 3. 4. Excess Deaths (Blacks) Infant Mortality Black/White Ratio, Males Black/White Ratio, Females Life Expectancy Black/White Gap, Males Black/White Gap, Females 1980 59,000 1.9 2.0 6.9 5.6 1991 66,000 2.1 2.3 8.3 5.8

6.

Source: NCHS, 1994.

U.S. Life Expectancy at Birth, 1984-1992
80 White

75
Life Expectency (Year)

75.3

75.3

75.4

75.6

75.6

75.9

76.1

Black 76.5 76.3

70

69.5

69.3

69.1

69.1

68.9

68.8

69.1

69.3

69.6

65

60 1984 1985 1986 1987 1988
Year
NCHS, 1995

1989

1990

1991

1992

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 All White, non-Hispanic Asian or Pacific Islander Black, non-Hispanic Hispanic Poor 20.5 11.1 19.5 39.9 40.3 Near Poor Economically Vulnerable 22.7 43.2 19.7 16.4 28.1 31.7 30.8 35.9 68.0 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

Country
Spain Italy Mexico France Ireland Germany United States United Kingdom Sweden

% Children Child Poverty (%) 1 Parent HH 1 Parent Other
2 3 4 8 8 10 19 20 21 32 22 28 26 48 51 55 46 7 12 20 26 6 14 6 16 13 2

Source: UNICEF (United Nations Children’s Fund), 2000

Child Poverty Rates
Country Netherlands Spain Sweden Canada Italy United States Australia France United Kingdom Poland Before Taxes 16.0 21.1 23.4 24.6 24.6 26.7 28.1 28.7 36.1 44.4 After Taxes 7.7 12.3 2.6 15.5 20.5 22.4 12.6 7.9 19.8 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 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

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 60 50
56.1 46.4 60.1 57.9 63.5 52.4 63.4 60.1

Age

40 30 20 10 0 Never <1 week 1/week > 1/week

White Black

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 Care

Personal 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 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

Coming Soon

– –

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