Racial disparities in health persist despite advances in medicine and technology. Minorities experience higher rates of illness and death than whites across many health conditions. Socioeconomic status, which is strongly linked to race, is a major determinant of health. Improving living conditions, education levels, income, and neighborhoods could help reduce health inequalities by making healthy choices easier and alleviating stress. Comprehensive social and economic policies are needed across all sectors to address fundamental causes of poor health and disparities.

1. Building Healthier Communities: where People Live, Learn, Work, Play and Worship David R. Williams, PhD, MPH Florence & Laura Norman Professor of Public Health Professor of African & African American Studies and of Sociology Harvard University

2. Racial Disparities in Health Persist There are large gaps in health. In the last 50 years, we have had little success in narrowing them

3. Racial Disparities in Health African Americans have higher death rates than Whites for 12 of the 15 leading causes of death. Blacks and American Indians have higher age-specific death rates than Whites from birth through the retirement years. Hispanics have higher death rates than whites for diabetes, hypertension, liver c irrhosis & homicide Minorities get sick younger, have more severe illness and die sooner than Whites

4. Source: NCHS Data, Table 29, 2007

5. Source: NCHS Data, Table 29, 2007

6. Source: NCHS data, Table 29, 2007

7. Source: NCHS data, Table 29, 2007

8. Diabetes Death Rates 1955-1998 Source: Indian Health Service; Trends in Indian Health 2000-2001

9. Life Expectancy Lags, 1950-2006 Murphy, NVSS 2000; Braveman et al. in Press, NLMS 1988-1998 63.6 70.6 60.8 69.1 74.4 76.1 69.1 68.2 71.7 64.1 71.4 73.2 78.2 77.6

10. 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.

11. Understanding Elevated Health Risks “ Has anyone seen the SPIDER that is spinning this complex web of causation?” Krieger, 1994

12. SAT Scores by Income Source: (ETS) Mantsios; N=898,596 873 Less than $10,000 920 $10,000 to $20,000 964 $20,000 to $30,000 992 $30,000 to $40,000 1016 $40,000 to $50,000 1034 $50,000 to $60,000 1049 $60,000 to $70,000 1064 $70,000 to $80,000 1085 $80,000 to $100,000 1129 More than $100,000 Median Score Family Income

13. SES: A Key Determinant of Heath - I 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.

14. SES: A Key Determinant of Heath - II 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.

15. Percentage of College Grad+ by Race Percentage U.S. Census 2000

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. SES: Multiple Disadvantages Poor education in childhood and adolescence Insecure employment Stuck in hazardous or dead-end jobs Living in poor housing Trying to raise a family in difficult circumstances Living on an inadequate pension WHO: The Solid Facts

20. 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.

21. Life Expectancy At Age 25, 1998 Murphy, NVSS 2000; Braveman et al. in Press, NLMS 1988-1998 5.0 48.4 53.4 All Difference Black White Group

22. Life Expectancy At Age 25, 1998 Murphy, NVSS 2000; Braveman et al. in Press, NLMS 1988-1998 6.4 Difference 56.5 d. College Grad 55.2 c. Some College 54.1 b. 12 Years 50.1 a. 0-12 Years 5.0 48.4 53.4 All Education Difference Black White Group

23. Life Expectancy At Age 25, 1998 Murphy, NVSS 2000; Braveman et al. in press, NLMS 1988-1998 5.3 6.4 Difference 52.3 56.5 d. College Grad 50.9 55.2 c. Some College 49.9 54.1 b. 12 Years 47.0 50.1 a. 0-12 Years 5.0 48.4 53.4 All Education Difference Black White Group

24. Life Expectancy At Age 25, 1998 Murphy, NVSS 2000; Braveman et al. in Press, NLMS 1988-1998 5.3 6.4 Difference 4.2 52.3 56.5 d. College Grad 4.3 50.9 55.2 c. Some College 4.2 49.9 54.1 b. 12 Years 3.1 47.0 50.1 a. 0-12 Years 5.0 48.4 53.4 All Education Difference Black White Group

25. Infant Death Rates by Mother’s Education NCHS, 1998

26. Infant Mortality by Mother’s Education NCHS, 1998

27. 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.

28. Economic Policy is Health Policy But the minority poor are poorer than the white poor

29. Wealth of Whites and of Minorities per $1 of Whites, 2000 Source: Orzechowski & Sepielli 2003, U.S. Census 35 ¢ 31 ¢ $ 208,023 Richest 20% 39 ¢ 35 ¢ $ 92,842 4 th Quintile 19 ¢ 19 ¢ $ 59,500 3 rd Quintile 12 ¢ 11 ¢ $ 48,500 2 nd Quintile 2 ¢ 1 ¢ $ 24,000 Poorest 20% 12 ¢ 9 ¢ $ 79,400 Total Hisp/W Ratio B/W Ratio White Household Income

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

32. Reducing Inequalities 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

33. Moving Upstream Effective Policies to reduce inequalities in health must address fundamental non-medical determinants.

34. WHY? WHY? WHY?

35. Centrality of the Social Environment An individual’s chances of getting sick are largely unrelated to the receipt of medical care Where we live, learn, work, play and worship determine our opportunities and chances for being healthy Social Policies can make it easier or harder to make healthy choices

36. Our Neighborhood Affects Our Health Unhealthy Community Healthy Community vs Exposure to toxic air, hazardous waste Clean air and environment Unsafe even in daylight Safe neighborhoods, safe schools, safe walking routes No parks/areas for physical activity Well-equipped parks and open/spaces/organized community recreation Limited affordable housing is run-down; linked to crime ridden neighborhoods High-quality mixed income housing, both owned and rental Convenience/liquor stores, cigarettes and liquor billboards, no grocery store Well-stocked grocery stores offering nutritious foods

37. Our Neighborhood Affects Our Health Burned-out homes, littered streets Well-kept homes and tree-lined streets Streets and sidewalks in disrepair Clean streets that are easy to navigate No culturally sensitive community centers, social services or opportunities to engage with neighbors in community life Organized multicultural community programs, social services, neighborhood councils or other opportunities for participation in community life No local health care services Primary care through physicians’ offices or health center; school-based health programs Lack of public transportation, walking or biking paths Accessible, safe public transportation, walking and bike paths Unhealthy Community Healthy Community vs

38. 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

39. 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

40. 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

41. 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

42. Yonkers Housing Intervention City-wide de-concentration of public housing Half of public housing residents selected via a lottery to move to better housing 2 years later, movers reported better overall health, less substance abuse, neighborhood disorder and violence than those who stayed Movers also reported greater satisfaction with public transportation, recreation facilities and medical care Movers had higher rates of employment and lower welfare use Fauth et al. Social Science and Medicine , 2004

43. 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

44. 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

45. Conditional Cash Transfer Programs Mexico’s PROGRESA (now Oportunidades) established in 1997 Low income families, randomized at the community, level to receive additional cash conditional on children’s school attendance, preventive care visits and participation in health information sessions Compared to controls, the intervention group had decreased illness rates, child stunting, BMI and improvements in endurance, language development, memory, and height for age Additional cash is key determinant of program success Rawlings & Rubin, 2005; Paxson & Shady, 2007; Fernand et al. 2008

46. New Hope Random Experiment Families in poverty in Milwaukee, WI receive intervention that provides work support and earnings supplements to raise total income above poverty Five year evaluation showed multiple positive effects on children aged 6-16, especially boys: Better study skills , school-related measures and positive social behaviors Higher school engagement, future expectations and lower aggression Huston, et al. Developmental Psychology , 2005

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

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

49. 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.

50. 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

51. 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

52. 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

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

54. U.S. Life Expectancy at Birth, 1984-1992 NCHS, 1995

55. Resources

56. RWJF Commission to Build a Healthier America David R. Williams, Ph.D. Executive Staff Director

57. A twin philosophy: Good health requires personal responsibility and a societal commitment to remove the obstacles preventing too many Americans from making healthy decisions The Commission’s Recommendations Building a healthier America is feasible in years, not decades, if we collaborate and act on what is making a difference The recommendations focus on people and the places where we spend the bulk of our time: Homes and Communities Schools Workplaces

58. Resources: www.commissiononhealth.org Overcoming Obstacles to Health Charts Leadership blog Multimedia personal stories Commission information and activities Commission news coverage Relevant news articles Interactive education and health tool State-level child health data Issue briefs Beyond Health Care: New Directions to a Healthier America State-level adult health data

60. WHO Commission’s Recommendations Improve Daily Living Conditions Tackle the Inequitable Distribution of Power, Money, and Resources Measure and understand the Problem and Assess the Impact of Action WHO 2008, Closing the Gap in a Generation

61. www.macses.ucsf.edu

62. 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

63. Take Home Message -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

64. Take Home Messages -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

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