Center for Health Equity November, 12-13, 2007 Louisville, Kentucky

Social Disparities in Health: Challenges and Opportunities 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

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

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

Diabetes Death Rates Source: Indian Health Service; Trends in Indian Health

Life Expectancy at Birth, Year Age

SAT Scores by Income Source: (ETS) Mantsios; N=898,596 Family IncomeMedian Score More than $100, $80,000 to $100, $70,000 to $80, $60,000 to $70, $50,000 to $60, $40,000 to $50, $30,000 to $40, $20,000 to $30, $10,000 to $20, Less than $10,000873

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

Percentage of Persons in Poverty Race/Ethnicity Poverty Rate U.S. Census 2006

Racial/Ethnic Composition of People in Poverty in the U.S. U.S. Census 2006

Relative Risk of Premature Death by Family Income (U.S.) Relative Risk Family Income in 1980 (adjusted to 1999 dollars) 9-year mortality data from the National Longitudinal Mortality Survey

Percent of persons with Fair or Poor Health by Race, 1995 Race/EthnicityPercent Racial Differences B-W H-W B-H White Black17.3 Hispanic15.1 Poor=Below poverty; Near poor+ 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 WhiteBlackHispanic Poor Near Poor Middle Income High Income SES Difference Poor=below poverty; Near Poor= 2x poverty but <$50,000; High Income=$50,000+ Source: Pamuk et al. 1998

Race/Ethnicity and SES Race and SES reflect two related but not interchangeable systems of inequality In national data, the highest SES group of African American women have equivalent or higher rates of infant mortality, low birth- weight, hypertension and overweight than the lowest SES group of white women

Infant Death Rates by Mothers Education, 1995

Infant Mortality by Mothers Education, 1995

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 IncomeWhiteBlackHispanic All $79,400$7,500$9,750 Excl. Hm. Eq. 22,566 1,166 1,850 Poorest 20% 24, nd Quintile 48,500 5,275 5,670 3 rd Quintile 59,500 11,50011,200 4 th Quintile 92,842 32,60036,225 Richest 20% 208,023 65,14173,032 Orzechowski & Sepielli 2003, U.S. Census

Wealth of Whites and of Minorities per $1 of Whites, 2000 Household Income White B/W Ratio Hisp/W Ratio Total $ 79,400 9¢12¢ Poorest 20% $ 24,000 1¢2¢2¢ 2 nd Quintile $ 48,500 11¢12¢ 3 rd Quintile $ 59,500 19¢ 4 th 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 societys negative beliefs) can adversely affect health. Racism can lead to increased exposure to traditional stressors (e.g. unemployment). Experiences of discrimination may be a neglected psychosocial stressor.

Perceived Discrimination: Experiences of discrimination may be a neglected psychosocial stressor

..Discrimination is a hellhound that gnaws at Negroes in every waking moment of their lives declaring that the lie of their inferiority is accepted as the truth in the society dominating them. Martin Luther King, Jr. [1967] MLK Quote

Discrimination Persists Pairs of young, well-groomed, well-spoken college men with identical resumes apply for 350 advertised entry-level jobs in Milwaukee, Wisconsin. Two teams were black and two were white. In each team, one said that he had served an 18-month prison sentence for cocaine possession. The study found that it was easier for a white male with a felony conviction to get a job than a black male whose record was clean. Source: Devan Pager; NYT March 20, 2004

Percent of Job Applicants Receiving a Callback Criminal Record WhiteBlack No34%14% Yes17%5% Source: Devan Pager; NYT March 20, 2004

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 theyre better than you are. You are called names or insulted. You are threatened or harassed.

Everyday Discrimination and Subclinical Disease In the study of Womens 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

U.S. Surgeon General, 1979 Determinants of Health in the U.S.

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?

Centrality of the Social Environment An individuals chances of getting sick are largely unrelated to the receipt of medical care Where we live, learn, work and play 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.

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

American Apartheid: South Africa (de jure) in 1991 & U.S. (de facto) in 2000 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

Neighborhood Renewal and Health - I A 10-year follow-up study of residents in 5 neighborhood types in Norway found that changes in neighborhood quality were associated with improved health. The neighborhood improvements: a new public school, playground extensions, a new shopping center with restaurants and a cinema, a subway line extension into the neighborhood, a new sports arena & park, and organized sports activities for adolescents. Residents of the area that had experienced these dramatic improvements in its social environment reported improved mental health 10 years later This effect was not explained by selective migration Dalgard and Tambs 1997

Neighborhood Renewal and Health - II Neighborhood improvement in a poorly functioning area in England was linked to improved health and social interaction. Improvements: housing was refurbished (made safe & sheltered from strangers), traffic regulations improved, improved lighting & strengthening of windows, enclosed gardens for apartments, closed alleyways, and landscaping. Residents involved in planning process. One year later: –Levels of optimism, belief in the future, identification with their neighborhood, trust in other neighbors, and contact between the neighbors had all increased. –Symptoms of anxiety and depression had declined. Halpern, 1995

Neighborhood Change and Health The Moving to Opportunity Program randomized families with children in high poverty neighborhoods to move to less poor neighborhoods. It found, three years later, that there were improvements in the mental health of both parents and sons who moved to the low- poverty neighborhoods. Leventhal and Brooks-Gunn, 2003

Reducing Inequalities 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

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 19682,119.72, ,738.22,331.8 Change % Change Cooper et al., 1981b

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

Median Family Income of Blacks per $1 of Whites Source: Economic Report of the President, 1998

Health Status Changes, Indicator Excess Deaths (Blacks) 59,000 66,000 2.Infant Mortality Black/White Ratio, Males Black/White Ratio, Females Life Expectancy Black/White Gap, Males Black/White Gap, Females Source: NCHS, 1994.

U.S. Life Expectancy at Birth, NCHS, 1995

Policy Area Reducing Childhood Poverty Challenges and Opportunities

Childhood Poverty, U.S., 1996 Percent of Children Under Age 18 Income PoorNear PoorEconomically Vulnerable All White, non-Hispanic Asian or Pacific Islander Black, non-Hispanic Hispanic Source: U.S. Census Bureau (Pamuk et al. 1998)

Family Structure and SES Compared to children raised by 2 parents those raised by a single parent are more likely to: grow up poor drop out of high school be unemployed in young adulthood not enroll in college have an elevated risk of juvenile delinquency and participation in violent crime. McLanahan & Sandefur 1994; Sampson 1987

Economic marginalization of males (high unemployment & low wage rates) is the central determinant of high rates of female-headed households. Marriage rates are positively related to average male earnings. Marriage rates are inversely related to male unemployment. Determinants of Family Structure Bishop 1980; Testa et al. 1993; Wilson & Neckerman 1986

Source: UNICEF (United Nations Childrens Fund), 2000 % ChildrenChild Poverty (%) Country1 Parent HH 1 ParentOther Spain23212 Italy32220 Mexico42826 France8266 Ireland84814 Germany10516 United States United Kingdom Sweden2172

Source: UNICEF (United Nations Childrens Fund), 2000 Child Poverty Rates CountryBefore TaxesAfter Taxes Netherlands Spain Sweden Canada Italy United States Australia France United Kingdom Poland

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

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 three- and four-year-olds and made weekly home visits. Children participated in their own education by planning, doing, and reviewing their own activities.

Results at Age 40 Those who received the program had better academic performance (more likely to graduate from high school) Program recipients did better economically (higher employment, annual income, savings & home ownership) The group who received high-quality early education had fewer arrests for violent, property and drug crimes The program was cost effective: A return to society of $17 for every dollar invested in early education _____________________________________________________________________ Schweinhart & Montie, 2005

Building on Resources We Need to Better Understand How Resilience Factors and Processes Can Affect Health and how to Build on the Strengths and Capacities of Communities

Religion & Health: Potential Mechanisms 1.Religious institutions can provide support, intimacy, a sense of connectedness and belonging 2.Religious beliefs and values can provide systems of meaning to interpret and re-interpret stress 3.Religious beliefs can provide feelings of strength to cope with adversity 4.By encouraging moderation in all things and reducing risk taking behavior, religious involvement can reduce exposure to stress. 5.Religious participation can discourage negative health behaviors (tobacco, alcohol, drugs, risky sexual practices) 6.Religious institutions can generate stress: time demands, role conflicts, social conflicts, criticism

Religion and Adolescent Risk Behavior Religious high school seniors are less likely than their non-religious peers to –Carry a weapon (gun, knife, club) to school –Get into fights or hurt someone –Drive after drinking –Ride with driver who had been drinking –Smoke cigarettes –Engage in binge drinking (5 or more drinks in a row) –Use marijuana Religious seniors were more likely to –Wear seat belts –Eat breakfast, green vegetables and fruit –Get regular exercise –Sleep at least 7 hours per night Wallace and Forman 1998; Monitoring the Future Study

U.S. Life Expectancy at Age 20 by Religious Attendance Age Hummer et al. 1999

Religious Services as Therapy? Several aspects of some religious services are distinctive in the provision of opportunities to articulate and manage personal and collective suffering. he expression of emotion and active congregational participation can promote collective catharsis in ways that facilitate the reduction of tension and the release of emotional distress. There are parallels between all the key elements of formal psychotherapy and the rituals of some religious services. Griffith et al. (1980); Gilkes (1980): Pargament et al. (1983)

RWJF Commission to Build a Healthier America

Overall Goal The RWJF Commission to Build a Healthier America is a national, comprehensive effort to raise awareness about the large socio- economic status (SES) differences in health among Americans and then seek practical, common-ground solutions to improve the health of all.

Key Objectives Increase awareness about the relationships between social factors and health, and how these relationships have produced large inequalities in health among Americans Generate concern and motivate efforts to address the problem of health inequalities based on socioeconomic status and race/ethnicity Foster and inform constructive public discourse about ways to reduce these health inequalities Identify and prioritize the adoption of public and private policies and interventions to reduce social inequalities and thereby improve the health of Americans overall

Commission Infrastructure RWJF Foundation Board and Staff Central Office: George Washington University, Dept. of Health Policy Research Arm: Center on Social Disparities in Health, UCSF Communications Partners: –Burness Communications –Health 360 Strategies -- a service of Chandler Chicco Agency and Mehlman Vogel Castagnetti, Inc

Approach Raise awareness and identify areas for action by –Targeting decision-makers in public and private sector –Reaching beyond health care to non-traditional allies and advocates –Making academic research on social inequalities more accessible to policy makers –Conducting work in a resolutely nonpartisan fashion –Designing a plan that is sustainable, flexible and relevant

Background Activities: Setting the Stage Message testing –Qualitative research to identify how to approach topic in ways that resonate with the public and key stakeholders Polling –Public opinion data collection to gauge the publics knowledge of health disparities and to monitor change over time Interviews with key stakeholders –Interviews with key policymakers, stakeholders, and influentials for their impressions and input

Setting the Stage - II Scanning the environment –Tracking what is being done on poverty/disparity issues and assessing opportunities Recruiting Commissioners –Nationally recognized persons –Diverse backgrounds –Networks to broad constituencies –Non-partisan and bi-partisan –Demonstrated leadership and commitment to improving life for all Americans

Commission Activities Commission meetings & Special Events Field Hearings Reports Storybank Development Outreach Website

Commission Meetings & Field Hearings Raising awareness across the country Taking the message beyond Capitol Hill to real communities Listening to and learning from real people and communities who face the problem of social inequalities every day Highlighting promising potential solutions

Commission Timeline Two Year life December 2007 launch Ongoing activities in 2008 and 2009 Culminating in actionable recommendations that policy makers can embrace

Multidisciplinary Research Team At the Center on Social Disparities in Health, UCSF –Paula Braveman, Susan Egerter –Tabashir Sadegh-Nobari, Veronica Pedregon, Mercedes Dekker, Kristen Marchi Catherine Cubbin (UCSF & UT), Mah-j Soobader (MA) Demographer Elsie Pamuk (WA) Economists Bob Schoeni (U Michigan) & Will Dow (UC Berkeley) Steven Woolf (Virginia Commonwealth U) Sociologist David Williams (Harvard) GWU Dept. Health Policy: Wilhelmine Miller, Marsha Lillie- Blanton Epidemiology, demography, economics, sociology, public policy, health policy

Research Activities So Far Background literature searches for discussions and briefings; scientific support for planned communications efforts Analyses of recent national population-based data sources to measure differences in health by income, education, and race or ethnic group This information has not been available since Health US 1998 Used as basis for estimates of monetary costs of inequalities Will be presented at public launch in DC

Social (Socioeconomic and Racial and Ethnic) Differences in Health Analyses of health inequalities: By income and/or education By racial or ethnic group And: Socioeconomic differences within racial/ethnic groups and Racial/ethnic differences within each socioeconomic group Show that both SES and racial/ethnic group must be considered, separately and together –Linked but also distinct

Report from RWJF to the Commission Presents new evidence of health inequalities across income, education, and racial/ethnic groups Estimates economic costs of health inequalities Reviews literature documenting lasting impact of physical and social environments on a childs health and chances of becoming a healthy adult Examines roles of personal and societal responsibilities for health Offers a framework for seeking solutions

Research Efforts Guided by a Framework for Seeking Solutions

Save the Date When: December 5, 2007 Where: Union Station (Columbus Room) Washington, DC What: Formal announcement of the Commission. Release of the Commissions First Report

Summary A serious commitment on the part of the RWJ Foundation to: Explore the factors that influence health Raise public awareness of social inequalities in health Provide meaningful recommendations to spur action so that millions of people will have a chance to lead healthier lives

Conclusions -I 1.Health officials and organizations cannot improve health by themselves 2.Improving health and reducing inequalities in health is not just about more health programs, it is about a new path to health 3.All policy that affects health is health policy 4.Health officials need to work collaboratively with other sectors of society to initiate and support social policies that promote health and reduce inequalities and health

Conclusions -II 1.Inequalities in health are created by larger inequalities in society. 2.SES and racial/ethnic disparities in health reflect the successful implementation of social policies. 3.Eliminating them requires political will for and a commitment to new strategies to improve living and working conditions. 4.Our great need is to begin in a systematic and comprehensive manner, to use all of the current knowledge that we have. 5.Now is the time

A Call to Action The only thing necessary for the triumph [of evil] is for good men to do nothing. Edmund Burke, British Philosopher