Title: A Time For Action: the Enigma of Social Disparities in Health and How to Effectively Address Them
1A Time For Actionthe 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
2There Is a Racial Gap in Health in Early
LifeMinority/White Mortality Ratios, 2000
3There Is a Racial Gap in Health in Mid
LifeMinority/White Mortality Ratios, 2000
4There Is a Racial Gap in Health in Late
LifeMinority/White Mortality Ratios, 2000
5Immigration 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
6Lifetime Prevalence of Psychiatric Disorder, by
Race and Generational Status ()
Source Williams et al. 2007 Alegria et al
2007 Takeuchi et al. 2007
7Challenges
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.?
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10Diabetes Death Rates 1955-1998
Source Indian Health Service Trends in Indian
Health 2000-2001
11Life Expectancy at Birth, 1900-2000
76.1
77.6
71.7
71.9
69.1
69.1
64.1
60.8
47.6
Age
33.0
Year
12The 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.
13Understanding Elevated Health Risks
- Has anyone seen the SPIDER that is spinning this
complex web of causation?
Krieger, 1994
14SAT Scores by Income
Source (ETS) Mantsios N898,596
15SES 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.
16Percentage of Persons in Poverty Race/Ethnicity
Poverty Rate
U.S. Census 2006
17Racial/Ethnic Composition of People in Poverty in
the U.S.
U.S. Census 2006
18Relative 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
19Added 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.
20Percent of persons with Fair or Poor Health by
Race, 1995
PoorBelow poverty Near poorlt2x poverty Middle
Income gt2x poverty but lt50,000 Source Parmuk
et al. 1998
21Percent of Women with Fair or Poor Health by
Race and Income, 1995
22Infant Death Rates by Mothers Education, 1995
23Infant Mortality by Mothers Education, 1995
24Why 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.
25Race/Ethnicity and Wealth, 2000Median Net Worth
Orzechowski Sepielli 2003, U.S. Census
26Wealth of Whites and of Minorities per 1 of
Whites, 2000
Source Orzechowski Sepielli 2003, U.S. Census
27Race 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
28Racism 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.
29Perceived Discrimination Experiences of
discrimination may be a neglected psychosocial
stressor
30MLK 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
31Discrimination 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
32Percent of Job Applicants Receiving a Callback
Source Devan Pager NYT March 20, 2004
33Recent 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
34Every 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.
35Everyday 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
36Arab 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
37Discrimination 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)
38Discrimination 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
39Policy 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
40Stress 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
41Determinants of Health in the U.S.
U.S. Surgeon General, 1979
42Policy Area Health Care
- There are racial ethnic differences in access
to care and the quality of care
43The Effect of Race and Sex on Physicians'Recommen
dations for Cardiac Catheterization
- 720 physicians viewed
recorded
interviews - Reviewed data about
a hypothetical patient - The physicians then made
recommendations about
that
patient's care
44The Effect of Race and Sex on Physicians'Recommen
dations 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 1999340618.
45- 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.
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48Race 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
49Ethnicity 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
50Reducing Inequalities -IHealth 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
51Care that Addresses the Social context
- Effective health care delivery must take the
socio-economic context of the patients 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
clients environment and the non-medical
resources that may be mobilized to assist the
client
52Nurse 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
53Needed Interventions
- Policies to reduce inequalities in health must
also address fundamental non-medical determinants.
54Guiding 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.
55Needed Behavioral Changes
- Reducing Smoking
- Improving Nutrition and Reducing Obesity
- Increasing Exercise
- Reducing Alcohol Misuse
- Improving Sexual Health
- Improving Mental Health
56Reducing 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
57Changes 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
58Changes 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
59Moving Upstream
- Effective Policies to reduce inequalities in
health must address fundamental non-medical
determinants.
60WHY?
61Centrality of the Social Environment
An individuals 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
62SES 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
63Making 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
64Redefining 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
65Policy 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
66Policy Area
- Place Matters!
- Geographic location determines exposure to risk
factors and resources that affect health.
67Racial 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).
68How Segregation Can Affect Health
- Segregation determines quality of education and
employment opportunities. - Segregation can create pathogenic neighborhood
and housing conditions. - Conditions linked to segregation can constrain
the practice of health behaviors and encourage
unhealthy ones. - Segregation can adversely affect access to
high-quality medical care.
Source Williams Collins , 2001
69Segregation 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
70Residential 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
71Racial 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
72Proportion of Black Latino Children in Poorer
Neighborhoods Than Worst Off White Children
73American ApartheidSouth Africa (de jure) in
1991 U.S. (de facto) in 2000
Source Massey 2004 Iceland et al. 2002 Glaeser
Vigitor 2001
74Reducing Inequalities IIAddress 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
75Improving 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
76Neighborhood 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
77Neighborhood 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
78Neighborhood 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
79Reducing Inequalities IIIAddress 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
80Increased 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
81Income 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
82Health 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
83Economic Policy is Health Policy
- In the last 50 years, black-white differences in
health have narrowed and widened with black-white
differences in income
84Changes in Mortality Rates per 100,000
Population, Age 35-74, Between 1968 and 1978 (Men)
Cooper et al., 1981b
85Changes in Life Expectancy at Birth Between 1968
and 1978 (Women)
Cooper et al., 1981b
86Median Family Income of Blacks per 1 of Whites
Source Economic Report of the President, 1998
87Health Status Changes, 1980-1991
- Indicator 1980 1991
- Excess Deaths (Blacks) 59,000
66,000 - Infant Mortality
- Black/White Ratio, Males 1.9 2.1
- Black/White Ratio, Females 2.0 2.3
- Life Expectancy
- Black/White Gap, Males 6.9 8.3
- Black/White Gap, Females 5.6 5.8
-
Source NCHS, 1994.
88U.S. Life Expectancy at Birth, 1984-1992
NCHS, 1995
89Policy Area
- Reducing Childhood Poverty
- Challenges and Opportunities
90Early 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
91Childhood Poverty, U.S., 1996 Percent of
Children Under Age 18
Source U.S. Census Bureau (Pamuk et al. 1998)
92Family 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
93Determinants 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
94- Source UNICEF (United Nations Childrens Fund),
2000
95- Source UNICEF (United Nations Childrens Fund),
2000
96Policy Matters
- Investments in early childhood programs in the
U.S. have been shown to have decisive beneficial
effects
97The High/Scope Perry Preschool Study to Age 40
- Larry Schweinhart
- High/Scope Educational Research Foundation
- www.highscope.org
98High/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.
99Results 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
100Building 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
101Religion 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
102Religion 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
103U.S. Life Expectancy at Age 20by Religious
Attendance
63.5
63.4
60.1
57.9
60.1
56.1
52.4
46.4
Age
Hummer et al. 1999
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105Commission Overview
- David R. Williams, Ph.D.
- Executive Staff Director, Commission to Build a
Healthier America
106Commission 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
107Commission Leadership
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.
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.
108Commissioners
- Katherine BaickerProfessor of Health Economics,
Department of Health Policy and Management,
Harvard University - Angela Glover BlackwellFounder 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. DillmanExecutive Vice President of
Benefits and Risk Management, Wal-Mart Stores,
Inc. - Sen. Bill FristSchultz Visiting Professor of
International Economic Policy, Princeton
University - Allan GolstonU.S. Program President, The Bill
Melinda Gates Foundation
109Commissioners
Kati HaycockPresident, The Education Trust Hugh
PaneroCo-Founder and Former President and Chief
Executive Officer, XM Satellite Radio Dennis
RiveraChair, SEIU Healthcare Carole
SimpsonLeader-in-Residence, Emerson College
School of Communication and Former Anchor, ABC
News Jim ToweyPresident, Saint Vincent
College Gail L. WardenProfessor, University of
Michigan School of Public Health and President
Emeritus, Henry Ford Health System
110Commission will Focus on Non-Medical Pathways to
Improve Health
111Commission 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
112www.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
113commissiononhealth.org
- A Resource for Public Health Professionals
114Because Theres More to Health than Health Care
115www.macses.ucsf.edu
116- 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
117Conditions for HEALTH
- H - Housing
- E Education Environment
- A - Access
- L - Labor
- T Transportation
- H Hope and Happiness
118Conclusions -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
119Conclusions -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
120A Call to Action
- The only thing necessary for the triumph of
evil is for good men to do nothing.
Edmund Burke, British Philosopher