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A Time For Action: the Enigma of Social Disparities in Health and How to Effectively Address Them

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Title: A Time For Action: the Enigma of Social Disparities in Health and How to Effectively Address Them


1
A 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

2
There Is a Racial Gap in Health in Early
LifeMinority/White Mortality Ratios, 2000
3
There Is a Racial Gap in Health in Mid
LifeMinority/White Mortality Ratios, 2000
4
There Is a Racial Gap in Health in Late
LifeMinority/White Mortality Ratios, 2000
5
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

6
Lifetime Prevalence of Psychiatric Disorder, by
Race and Generational Status ()
Source Williams et al. 2007 Alegria et al
2007 Takeuchi et al. 2007
7
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.?
8
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9
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10
Diabetes Death Rates 1955-1998
Source Indian Health Service Trends in Indian
Health 2000-2001
11
Life 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
12
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.

13
Understanding Elevated Health Risks
  • Has anyone seen the SPIDER that is spinning this
    complex web of causation?

Krieger, 1994
14
SAT Scores by Income
Source (ETS) Mantsios N898,596
15
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.

16
Percentage of Persons in Poverty Race/Ethnicity
Poverty Rate
U.S. Census 2006
17
Racial/Ethnic Composition of People in Poverty in
the U.S.
U.S. Census 2006
18
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
19
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.

20
Percent 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
21
Percent of Women with Fair or Poor Health by
Race and Income, 1995
22
Infant Death Rates by Mothers Education, 1995
23
Infant Mortality by Mothers Education, 1995
24
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.

25
Race/Ethnicity and Wealth, 2000Median Net Worth
Orzechowski Sepielli 2003, U.S. Census
26
Wealth of Whites and of Minorities per 1 of
Whites, 2000
Source Orzechowski Sepielli 2003, U.S. Census
27
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
28
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.

29
Perceived Discrimination Experiences of
discrimination may be a neglected psychosocial
stressor
30
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
31
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
32
Percent of Job Applicants Receiving a Callback
Source Devan Pager NYT March 20, 2004
33
Recent Review
  • 115 studies in PubMed between 2005 and 2007
  • Broader outcomes (fibroids, breast cancer
    incidence, Hb A1c, CAC, stage 4 sleep, birth
    weight, sexual problems)
  • Studies of effects of bias on health care seeking
    and adherence behaviors
  • Some longitudinal data
  • Attention to the severity and course of disease
  • International studies
  • -- national New Zealand, Sweden, South Africa
  • -- Australia, Canada, Denmark, the Netherlands,
    Norway, Spain, Bosnia, Croatia, Austria, Hong
    Kong, and the U.K.
  • Discrimination accounts, in part, for
    racial/ethnic disparities in health

Williams Mohammed, in press
34
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.

35
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
36
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
37
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)

38
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
39
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

40
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

41
Determinants of Health in the U.S.
U.S. Surgeon General, 1979
42
Policy Area Health Care
  • There are racial ethnic differences in access
    to care and the quality of care

43
The 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

44
The 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.

46
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47
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48
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
49
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
50
Reducing 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

51
Care 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

52
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
53
Needed Interventions
  • Policies to reduce inequalities in health must
    also address fundamental non-medical determinants.

54
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.

55
Needed Behavioral Changes
  • Reducing Smoking
  • Improving Nutrition and Reducing Obesity
  • Increasing Exercise
  • Reducing Alcohol Misuse
  • Improving Sexual Health
  • Improving Mental Health



56
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
57
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
58
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
59
Moving Upstream
  • Effective Policies to reduce inequalities in
    health must address fundamental non-medical
    determinants.

60
WHY?
  • WHY?
  • WHY?

61
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, play and worship
determine our opportunities and chances for being
healthy Social Policies can make it easier or
harder to make healthy choices
62
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
63
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


64
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


65
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

66
Policy Area
  • Place Matters!
  • Geographic location determines exposure to risk
    factors and resources that affect health.

67
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).

68
How 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
69
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
70
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

71
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
72
Proportion of Black Latino Children in Poorer
Neighborhoods Than Worst Off White Children
73
American ApartheidSouth Africa (de jure) in
1991 U.S. (de facto) in 2000
Source Massey 2004 Iceland et al. 2002 Glaeser
Vigitor 2001
74
Reducing 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

75
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
76
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
77
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
78
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
79
Reducing 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

80
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
81
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
82
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
83
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

84
Changes in Mortality Rates per 100,000
Population, Age 35-74, Between 1968 and 1978 (Men)
Cooper et al., 1981b
85
Changes in Life Expectancy at Birth Between 1968
and 1978 (Women)
Cooper et al., 1981b
86
Median Family Income of Blacks per 1 of Whites
Source Economic Report of the President, 1998
87
Health 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.
88
U.S. Life Expectancy at Birth, 1984-1992
NCHS, 1995
89
Policy Area
  • Reducing Childhood Poverty
  • Challenges and Opportunities

90
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
91
Childhood Poverty, U.S., 1996 Percent of
Children Under Age 18
Source U.S. Census Bureau (Pamuk et al. 1998)
92
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
93
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
94
  • Source UNICEF (United Nations Childrens Fund),
    2000

95
  • Source UNICEF (United Nations Childrens Fund),
    2000

96
Policy Matters
  • Investments in early childhood programs in the
    U.S. have been shown to have decisive beneficial
    effects

97
The High/Scope Perry Preschool Study to Age 40
  • Larry Schweinhart
  • High/Scope Educational Research Foundation
  • www.highscope.org

98
High/Scope Perry Preschool
  • 123 young African-American children, living in
    poverty and at risk of school failure.
  • Randomly assigned to initially similar program
    and no-program groups.
  • 4 teachers with bachelors degrees held a daily
    class of 20-25 three- and four-year-olds and made
    weekly home visits.
  • Children participated in their own education by
    planning, doing, and reviewing their own
    activities.

99
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

100
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

101
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

102
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
103
U.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
104
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105
Commission Overview
  • David R. Williams, Ph.D.
  • Executive Staff Director, Commission to Build a
    Healthier America

106
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

107
Commission 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.
108
Commissioners
  • 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

109
Commissioners
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
110
Commission will Focus on Non-Medical Pathways to
Improve Health
111
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

112
www.commissiononhealth.org
  • Key features now available
  • Commission resources Overcoming Obstacles to
    Health report, charts
  • Leadership perspectives/Blogs
  • Multimedia personal stories
  • Commission information and activities
  • News releases
  • Commission news coverage
  • Relevant news articles
  • Coming Soon
  • Interactive tool to demonstrate how changing a
    factor such as average educational attainment at
    the county level could affect mortality rates
  • Chartbook with state-level data on health
    shortfalls
  • Issue briefs

113
commissiononhealth.org
  • A Resource for Public Health Professionals

114
Because Theres More to Health than Health Care
115
www.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

117
Conditions for HEALTH
  • H - Housing
  • E Education Environment
  • A - Access
  • L - Labor
  • T Transportation
  • H Hope and Happiness

118
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

119
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

120
A Call to Action
  • The only thing necessary for the triumph of
    evil is for good men to do nothing.

Edmund Burke, British Philosopher
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