social inequalities in health and how we can reduce them · life expectancy at birth, 2007-2009...

Social Inequalities in Health

and How We can Reduce Them

David R. Williams, PhD, MPH

Florence & Laura Norman Professor of Public Health

Professor of African & African American Studies

and of Sociology

Harvard University

A Global Phenomenon

There are Large Racial Inequities

in Health

Life Expectancy, Indigenous Men

76 77 7674

69

56

6967

7

21

7 70

10

20

30

40

50

60

70

80

90

New Zealand Australia Canada United States

Yea

rs

All Indigenous Gap

Maori, Aboriginal, First Nation, Am Indian & Alaskan Native; Bramley et al. 2004

Life Expectancy at Birth, 2007-2009

76.080,7

78,083,3

70,5

77,0

68,0

74,3

0

10

20

30

40

50

60

70

80

90

Males Females

White Hispanic Black Am Ind/Alaska Native

Arias, Xu & Jim, AJPH, 2014

Yea

rs

Infant Mortality by Ethnicity

England and Wales, 2011 Birth Cohort

Deaths per 1,000 live births, known gestational age, Office for National Statistics, 2013

Infant Mortality by Race in

South Africa, 1998

1

0,786

0,605

0,206

0

0,2

0,4

0,6

0,8

1

1,2

Black Coloured Asian White

OR

fo

r In

fan

t M

ort

alit

y *

* Estimates adjusted for demographic variables, SES, children born to the same mother

Source: Burgard, S. A., & Treiman, D. J, Social science & Medicine, 2006.

Infant Mortality Rate, Race, Latin America, 2010(Number of Deaths per 1,000 Live Births)

0

10

20

30

10,1

13,8

16,918,4

24,225,0

26,3

12,5

9,010,4

11,8

14,3

18,720,5

16,0

14,0

Afrodescendent Non-Afrodescendent

Social Panorama of Latin America, 2016, ECLAC, United Nations, 2017

Missing Slide

Variation by Subgroups

The Example of Data for Native

Hawaiians and Other Pacific

Islanders (NHPI)

Percent Obese by Race, 2014(Adults, Age Adjusted)

Galinsky et al., NCHS, Vital Health Statistics, 3 (40), 2017

29,3 28,8

40,443,4

11,2

42,6

0

10

20

30

40

50

60

70

Total U.S.

population

White Black AIAN Asian All NHPI

Percent Obese, NHPI Subgroups, 2014(Adults, Age Adjusted)

Galinsky et al., NCHS, Vital Health Statistics, 3 (40), 2017

29,3

42,637,9

47,8

62,2

40,8 43,0

0

10

20

30

40

50

60

70

Total U.S.

population

All NHPI Native

Hawaiian

All Pacific

Islander

Samoan Guamanian

or

Chamorro

Other

Pacific

Islander

Racial Inequities are persistent over

time

40

50

60

70

80

90

1950 1960 1970 1980 1990 2000 2010 2015

Lif

e E

xp

ecta

ncy

White Black

Life Expectancy, 1950-2015

NCHS, Health United States, 2016

63.6

70.6

60.8

69.1

74.476.1

69.1

68.1

71.7

64.1

71.8

77.3

78.778.8

75.174.7

Ominous Storm Clouds

Pixabay

Childhood Obesity

•At age 2, Black and Hispanic children more likely

to be obese than White ones

• 57% of all American children and youth currently

age 2 to 19 will be obese by the age of 35

• For Blacks and Latinos, it will be close to 70%

•Big predictor of adult obesity is childhood obesity

Ward, Long, Resch, Giles, Cradock, Gortmaker, NEJM, 2017

High and increasing levels of mental

health problems

Suicide, Black & White Boys, 1993-2012

1.7

3,6

2,0

1,4

0,0

0,5

1,0

1,5

2,0

2,5

3,0

3,5

4,0

1993 to 1997 2008 to 2012

Black Boys White Boys

Jeffrey Bridge et al., JAMA Pediatrics, 2015

Rat

es p

er o

ne

mil

lion

Making Sense of Racial Inequities

Socioeconomic Status (SES) is a

central determinant of the

distribution of valuable

resources in society

P. McDonough, Duncan, Williams, & House, AJPH, 1997

3,03

2,49

2

1,451,36

1

0

0,5

1

1,5

2

2,5

3

3,5

< 25,000 33,000 50,000 82,000 115,000 >115000

Rel

ati

ve R

isk

Household Income ( Converted to 2013$)

Relative Risks of All-Cause Mortality by Household

Income Level: U.S. Panel Study of Income Dynamics

Added Burden of Race

807570 85

White

Black

Age

Overal

l

0-12 years College graduate

Life Expectancy at Age 25Based on Level of Education

5-year gap

overall

6.4-year gap

5.3-year

gap

Murphy, NVSS 2000; Braveman, Cubbin, Egerter, Williams, Pamuk, AJPH, 2010; NLMS 1988-1998

807570 85

White

Black

Age

0-12 years 12 years Some college College graduate

3.1-year gap between

HS dropouts

4.2-year gap between

college grads

Blacks with a college degree have a

lower life expectancy than Whites with

only a high school degree

Murphy, NVSS 2000; Braveman, Cubbin, Egerter, Williams, Pamuk, AJPH, 2010; NLMS 1988-1998

Life Expectancy at Age 25Race Still Matters

Why Does Race Still Matter?

Could racism be a critical missing piece

of the puzzle to understand the

patterning of racial disparities in

health?

Racism Defined

• Racism: an organized system that,

-- categorizes and ranks

-- devalues, disempowers, and

-- differentially allocates opportunities/resources

• The development of racism is typically undergirded

by an ideology of inferiority in which some population

groups are regarded as being inferior to others

• This leads to the development of

-- negative attitudes/beliefs (prejudice and stereotypes) to

out-groups, and

-- differential treatment (discrimination) by individuals

and social institutionsBonilla-Silva, 1996; Williams 2004

The House that Racism Built

Racism

• Ideology of

inferiority

• Institutional

• Cultural

Social Forces

• Political

• Legal

• Economic

• Religious

• Cultural

• Historical Events

Individual vs Institutional Racism

Individual Bias: Waiting at Crosswalks

Tara Goddard, et al., Psychology Faculty Publications, Portland State University, 2014

• 3 Black and 3 White males, in Portland, OR

• Males in their 20s, wearing identical clothing

• Male indicates intention to cross

dhttps://www.google.com/search?hl=en&biw=1242&bih=711&tbm=isch&sa=1&ei=G1uRWqT6BorsjwOjpq6wDA&q=men+at+crosswalk&oq=men+at+crosswalk

&gs_l=psy-ab.3...2233594.2244297.0.2246358.30.25.0.0.0.0.167.2273.10j11.21.0....0...1c.1.64.psy-

ab..13.13.1345...0j0i67k1j0i30k1j0i8i30k1j0i24k1j0i5i30k1.0.GnPxcQj7MR4#imgrc=arzq1gjH2EhR5M:

Multiple Cars Twice as likely to Pass Blacks


, ( * : p ≤ .05 )

Blacks Wait 32% Longer to Cross the Street


, ( * : p ≤ .05 )

Institutional Discrimination: Waiting to Vote Average number of minutes, 2012 Presidential Election

Cooperative Congressional Election Study, 2012

African Americans

Latinos

Asian Americans

Native Americans

Whites

23 min

19 min

15 min

13 min

12 min

Institutional Processes

• Length of time waiting to vote linked to the

residence of the voter and the policies and

procedures (budgeting and space constraints

and local administrative procedures) linked to

place:

• How many voters being served by a polling

site?

• How many precincts in a given area?

• Staffing of a precinct affects how long it takes

to vote

Place Matters

Residential Segregation is

a striking legacy of racism

• As is the forced removal and relocation of

indigenous peoples

• The institutionalized isolation and

marginalization of racial populations has

adversely affected life chances in multiple

ways

Racial Segregation Is …

• One of the most successful domestic policies of the 20th

century

• "the dominant system of racial regulation and control" in the U.S

John Cell, 1982

Why Place MattersWhere you live determines access to:

• High-quality schools

• Job opportunities

• Safe, affordable & healthy housing

• Fresh produce & nutritious food

• Safe to exercise, walk or play outside http://pittsburghpa.gov/finance/

• Nearby Nature

• Toxins (from highways, factories & other)

• Quality primary care and good hospitals

• Affordable, reliable, public transit

• Social cohesion and social capital

Racial Differences in Residential Environment

In the 171 largest cities in the U.S., there is not even one city where whites live in equal conditions to those of blacks

“The worst urban context in which whites reside is considerably better than the average context of black communities.”

Sampson & Wilson 1995

Segregation Contributes to Large

Racial/Ethnic Differences in SES

Residential Segregation and SES

A study of the effects of segregation on young African American adultsfound that the eliminationof segregation would eraseblack-white differences in:

▪ Earnings

▪ High School Graduation Rate

▪ Unemployment

And reduce racial differences in single

motherhood by two-thirdsCutler, Glaeser & Vigdor, 1997

There are Large Racial Differences in

SES

Median Household Income and Race, 2015

Racial Differences in Income are Substantial:

U.S. Census Bureau: Proctor, Semega, Kollar, 2016; *2013, Native Her. Month, 2014

1 dollar 1.23 dollar 72 cents 59 cents

White Asian Hispanic Black

62 cents*

AI/AN

Median Wealth and Race, 2011

For every dollar of wealth that Whites have,

Blacks have only 6 cents

U.S. Census Bureau, 2014

Latinos have only 7 cents

Asians have 81 cents

Where Racial Inequities in SES are Born

Large Racial/Ethnic Differences in SES that

are consequential for life:

-- They are not acts of God

-- They are not random events

-- They reflect the successful

implementation of social policies

Racism has produced a truly “rigged system”


Individual

DiscriminationRacism

• Ideology of

inferiority

• Institutional

• Cultural

Social Forces

• Political

• Legal

• Economic

• Religious

• Cultural


SegregationA

B

The Pervasiveness of Discrimination

Gett

ing

a j

ob

Rece

ivin

g a

pro

mo

tio

n

Hailing a taxi

Ob

tain

ing

ba

nk lo

an

s

Buying a home

Pulled over by police

Renting an

apartment

Getting insurance

Arrested for drug–related crimes Qu

ality

of

me

dic

al

ca

re

Purchasinga car

Suspended from preschool

Cost of bail

“… 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

Every Day Discrimination

In your day-to-day life how often do these happen to you?

• You are treated with less courtesy than other people.

• You are treated with less respect than other people.

• You receive poorer service than other people at restaurants or stores.

• People act as if they think you are not smart.

• People act as if they are afraid of you.

• People act as if they think you are dishonest.

• People act as if they’re better than you are.

• You are called names or insulted.

• You are threatened or harassed.

What do you think was the main reason for these experiences?

-- coronary artery calcification

-- C-reactive protein

-- blood pressure

-- lower birth weight

-- cognitive impairment

-- poor sleep

-- mortality

-- visceral fat

Everyday Discrimination Associated With:

Sources: Lewis et al., Psy Med, 2006; Lewis et al., Brain Beh Immunity, 2010; Lewis et al., J Gerontology:

Bio Sci & Med Sci 2009; Earnshaw et al., Ann Beh Med, 2013; Barnes et al., 2012; Lewis et al, Hlth Psy,

2012; Barnes et al., J Gerontology: Bio Sci & Med Sci, 2008; Lewis et al., Am J Epidemiology, 2011

Tene Lewis

Discrimination and Allostatic Load

• 331 Blacks (20 year olds), 9 rural counties in Georgia

• Discrimination assessed at age 16, 17, and 18

• Allostatic load assessed at age 20; overnight cortisol,

epinephrine, norepinephrine, SBP, DBP, CRP, BMI

• 79% of sample had low and increasing levels of

discrimination; 22% had stably high levels

• Stably high levels of discrimination as a teen

linked to higher allostatic load at age 20

• Association increased when adjusted for CES-D, life

stress, socioeconomic risk and unhealthy behavior.

Gene Brody et al., 2014., Child Development

Buffering Effect: Social Support

• Social support: 11 item caregiver emotional & instrumental

support and 4 item measure of peer support

• High social support erased the negative effect of

high discrimination on allostatic load

• That is, for youth high on social ties, support reduced

the allostatic load of those high on discrimination to

the levels of those low on discrimination

Gene Brody et al., 2014., Child Development


Individual


• Ideology of

inferiority

• Institutional

• Cultural

Social Forces

• Political

• Legal

• Economic

• Religious

• Cultural


Segregation

• Stereotypes

• Implicit

and explicit

bias

• Stigma

A

B

C

Negative stereotypes about race remain

deeply embedded in our culture

Negative Stereotypes Trigger Racial

Discrimination

Where do these Negative Stereotypes

come from?

Racial Stereotypes in Our Culture

Verhaeghen et al. British J Psychology, 2011

• BEAGLE Project

• 10 million words

• Sample of books, newspapers, magazine

articles, etc. that average college-level student

would read in lifetime

• Allows us to assess how often Americans have

seen or heard words paired together over their

lifetime

Stereotypes in Our Culture


BLACK poor .64

BLACK violent .43

BLACK religious .42

BLACK lazy .40

BLACK cheerful .40

BLACK dangerous .33

FEMALE distant .37

FEMALE warm .35

FEMALE gentle .34

FEMALE passive .34

WHITE wealthy .48

WHITE progressive .41

WHITE conventional .37

WHITE stubborn .32

WHITE successful .30

WHITE educated .30

MALE dominant .46

MALE leader .31

MALE logical .31

MALE strong .31

Stereotypes in Our Culture


BLACK poor .64

BLACK violent .43

BLACK religious .42

BLACK lazy .40

BLACK cheerful .40

BLACK dangerous .33

BLACK charming .28

BLACK merry .28

BLACK ignorant .27

BLACK musical .26

WHITE wealthy .48

WHITE progressive .41

WHITE conventional .37

WHITE stubborn .32

WHITE successful .30

WHITE educated .30

WHITE ethical .28

WHITE greedy .22

WHITE sheltered .21

WHITE selfish .20

Internalized Racism:

Acceptance of society’s negative characterization

can adversely affect health


Individual


• Ideology of

inferiority

• Institutional

• Cultural

Social Forces

• Political

• Legal

• Economic

• Religious

• Cultural


Segregation

• Stereotypes

• Implicit

and explicit

bias

• Stigma

Income

Education

Employment

Under-

employment

Wealth

Health

Incarceration

Stress

Individual and

Collective

Resources,

Social

Resources

A

B

C

D

D

E


Individual


• Ideology of

inferiority

• Institutional

• Cultural

Social Forces

• Political

• Legal

• Economic

• Religious

• Cultural


Segregation

• Stereotypes

• Implicit

and explicit

bias

• Stigma

Income

Education

Employment

Under-

employment

Wealth

Health

Incarceration

Stress

Individual and

Collective

Resources,

Social

Resources

Stereotypes

Implicit and

Explicit

Bias

Stigma

A

B

C

D

D

EF


Individual


• Ideology of

inferiority

• Institutional

• Cultural

Social Forces

• Political

• Legal

• Economic

• Religious

• Cultural


Segregation

• Stereotypes

• Implicit

and explicit

bias

• Stigma

Income

Education

Employment

Under-

employment

Wealth

Health

Incarceration

Stress

Individual and

Collective

Resources,

Social

Resources

Stereotypes

Implicit and

Explicit

Bias

Stigma

A

B

C

D

D G

EF

H

H

What Can We Do?

Strategy Number 1

Create Communities of Opportunity to minimize,

neutralize and dismantle the systems of racism

that create inequities in health

Communities of Opportunity

Invest in early Childhood

Carolina Abecedarian Project (ABC) • 1972-77, economically disadvantaged children,

birth to age 5, randomized to early childhood

program

• Program offered a safe and nurturing

environment, good nutrition and pediatric care

• At age 21, fewer symptoms of depression, lower

smoking & marijuana use, more active lifestyle, &

educational & vocationl assets benefits

• In mid-30’s, lower levels of multiple risk factors

for CVD and metabolic disease. Effects stronger

for males

•Campbell et al. App Dev Science, 2002; Campbell et al, Science, 2014

Carolina Abecedarian Project (ABC)

• Example: systolic BP

143 mm Hg in male

controls vs. 126mm Hg

in the treatment group

• One in 4 males in

control group met

criteria for metabolic

syndrome compared to

none in the treatment

group

• Lower BMI at zero to 5

yrs equals a lower BMI

in their 30s

115

120

125

130

135

140

145

Control Treatment

Systolic BP

Campbell et al. AJPH, 2008; Campbell et al, Science, 2014


Reduce Childhood Poverty

Child Poverty Rate

UNICEF, Measuring Child Poverty, 2012

AV

=

$53

.480

0 5 10 15 20 25 30

35. Romania

34. USA

33. Latvia

32. Bulgaria

31. Spain

30. Greece

29. Italy

28. Lithuania

25. Poland

24. Canada

22. United Kingdom

20. New Zealand

15. Malta

10. Czech Republic

5.Norway

4.Netherlands

3. Cyprus

2. Finland

1. Iceland

Childhood Poverty and Race, 2016

American Community Survey, 2015-2016; Economic Policy Institute, 2017

10,8%

26,6%

11,1%

33,8%

30,8%

0% 5% 10% 15% 20% 25% 30% 35% 40%

White

Hispanic

Asian American

Native American

Black

Poverty and Race in 2016(in Millions)

Senegal et al., U.S. Census Bureau, 2017

17,3

11,1

1,9

9,2

0 5 10 15 20

White

Hispanic

Asian

Black

Child Poverty Rate

UNICEF, Measuring Child Poverty, 2012

AV

=

$53

.480

42

3128

30

25 24

810

12 13 13

23

0

5

10

15

20

25

30

35

40

45

Ireland Hungary Australia New Zealand Canada USA

Before Taxes and Transfers After Taxes and Transfers


Enhance Income and Employment

Opportunities for Youth and Adults

Increased Income Leads to Improved Health • Civil Right Policies

• Earned Income Tax Credits

(EITC)

• Social Security

implementation and cost of

living Adjustments

• Conditional Cash Transfer

Programs

• Additional Income to

Native American

CommunitiesDavid R Williams & Lisa Cooper, Int J Env Res & Pub Hlth, 2019

K. Komro et al., American Journal of Public Health, 2016

Minimum Wage and Infant Mortality

• Study of the effects of state-level minimum wage for each of the

50 states by month from 1980-2011

• Using quasi-experimental difference-in-differences research

design

• The study found that a dollar increase in the

minimum wage above the federal minimum was

associated with a 1% to 2% decrease in low birth

weight and a 4% decrease in postneonatal mortality

• If all states in 2014 had increased their minimum

wage by 1 dollar, there would have been 2,790

fewer low birth weight births and 518 fewer

postneonatal deaths for the year


Improve Neighborhood and Housing

Conditions

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

Purpose Built Communities

• Based on efforts in Atlanta’s East Lake district

• Purpose Built Communities uses integrative strategies including cradle-to-college educational opportunities, mixed-income housing, early child development programs, employment support and recreational opportunities

• Community engagement and philanthropy

• Key: addressing all of the challenges faced by disadvantaged communities simultaneously

• Purpose Built Communities in Atlanta, New Orleans, Indianapolis, Charlotte, among others

Implementing the Purpose Built Model

Strong local leadership. A proven national model. Best in class partners.

77

East Lake Meadows - 1995Safety

• 18x national crime rate

• 90% of families victims of a

felony each year

• $35 million a year drug trade

Housing

• 100% public housing

• 1400 residents in 650 apartments

• 40% of units unlivable

Employment

• 13% employment

• 59% of adults on welfare

• Median income of ~$4,500

Education

• One of lowest performing

schools in Georgia

• 5% of 5th graders meet state

math standards

• 30% graduation rate

78

Villages of East Lake - Present

Housing

• High-quality, privately managed

housing

• Mixed-income (50% public

housing, 50% market rate)

• 1400 residents in 542 apartments

Safety

• 73% reduction in crime

• 90% lower violent crime

Employment

• 75% employment in public

housing, remainder in job

training, elderly or disabled

• Median income of ~ $15k in

public housing households

Education

• ~1500 in Pre-K through 10th

• 98% meet or exceed state

standards

• A top performing school in

Atlanta and the state

Strategy Number 2

Building More Health into the

Delivery of Medical Care



Ensuring Access to Care for All

Colorectal Cancer (CRC) Intervention

• State of Delaware fully funds a CRC screening

program promoting colonoscopy in 2002

• Provides reimbursement for uninsured residents up to

250% of Federal poverty level (FPL)

• Other state residents eligible through other insurance

• Cancer screening nurse navigator system added in

2004, at each of the 5 acute care hospital sites

• Cancer treatment program added in 2004: covers costs

of cancer care for 2 years for newly diagnosed

uninsured if income under 650% FPL

• Special outreach efforts for African Americans

S Grubbs et al. J Clin Oncology, 2013

Eliminated screening disparities


3 – year average, age adjusted

Equalized Incidence rates



Near Elimination of Mortality Difference





Eliminating Inequities in the Receipt of

High Quality Care

Racial Bias in

Medical Care

Ethnicity and Pain Medicine

55%

26%

0%

10%

20%

30%

40%

50%

60%

Hispanics NH Whites

Percent of Patients with broken bone receiving no

analgesia

Hispanics

NH Whites

Todd et al., JAMA, 1993

Unconscious Discrimination• When one holds a negative stereotype about a

group and meets someone who fits the

stereotype s/he will discriminate against that

individual

• Stereotype-linked bias is an

– Automatic process

– Unconscious process

• It occurs even among persons who are not

prejudiced

• More Implicit bias associated with:

-- more clinician verbal dominance*

-- less patient centered dialogue

-- lower patient positive affect*

-- lower perception of respect from clinician*

-- less patient liking of clinician*

-- lower trust and confidence in clinician

-- less likely to recommend clinician to others*

-- less perception of clinician as participatory*

-- longer visits and slower speech (compensation for mistrust?)

Implicit Bias & Care for Blacks

Cooper et al., AJPH, 2012; * = significant interaction with race

Jones et al., Dual Pathways to a Better America, APA, 2012

Implicit Biases are:

• Normal, natural, subtle and often subconscious

• Universal: all humans have them

• Developed naturally through routine social

interactions and exposure to culture (media, etc.)

• Guide our expectations and interactions with others

• Can become harmful when assumptions and

generalizations about a group affect our

interactions with an individual

• Even the most well-meaning individual can harbor

deep-seated biases

• Not the only type of discrimination

Faster than the Twinkling of an Eye!

• Studies find that most Americans have rapid and

unconscious emotional and neural reactions to

blacks

• A millisecond is 1/1000 of a second

• 100 milliseconds - how quickly an

individual's race is noticed and whether or

not that person is trustworthy

• 300 - 400 milliseconds: time for human eye to blink

• 800 milliseconds: human resting heart cycle time

Fiske et al, Du Bois Review, 2009

Implicit (unconscious) Bias

Can be reduced under certain conditions

Propranolol Intervention?

• Propranolol is a beta blocker that

reduces emotional conditioning and

amygdala responses to visual emotional

stimuli (e.g. facial expressions)

• Randomized double blind, parallel group, placebo

controlled design of a single oral dose of Propranolol

(40mg) of 36 whites in the U.K.

• Compared to placebo, propranolol eliminated

implicit bias and reduced heart rate, but had no effect

on explicit bias (measured by feeling thermometer: warmth to

blacks, whites, homosexuals, Muslims, Christians, drug addicts)

Terbeck et al, Psychopharmacology, 2012

94

Multiple Prejudice-reducing Strategies:

• Stereotype replacement

• Counter-stereotype imaging

• Individuation

• Perspective taking

• Increasing interracial contact

The Devine Solution

• Implicit biases viewed as deeply engrained

habits that can be replaced by learning multiple

new prejudice-reducing strategies

• Non-black adults were motivated to:

✓ Increase their awareness of bias against blacks

✓Increase their concerns about the effects of bias

✓Implement multiple strategies

✓These were effective in producing substantial

reductions in bias that remained evident three

months laterDevine, P. G., Forscher, P. S., Austin, A. J., & Cox, W. T. L. 2012 J Exp Soc Psych

Structural CompetenceBeyond Diversity Training

• Racism that is deeply embedded in our culture

operates not only at the individual level

• It has shaped our social institutions, policies, and

procedures that initiated and sustain racial

inequality

• Effectively addressing implicit bias requires

identifying and dismantling its institutional

legacies and social consequences

• Policy change across multiple domains is necessary

to reduce the negative impact of implicit bias

J Metzl & H Hansen, Soc Sci & Med, 2014



Providing Care that Addresses the

Social context

Why treat illness

and send people

back to live in the

same conditions

that made them sick

in the first place?

Care that Addresses the Social context

New Questions• How can we identify patients’ non-medical health needs

as part of their overall care?

• How can we connect patients to local services/resources

that help people avoid getting sick in the first place or

better manage illness, including mental health needs?

• How can we be a strong leader and champion to

collaborate with other sectors to improve health where

patients live, learn, work, and play?

• How can we connect community residents to jobs in the

health care sector – one of the largest employers?

• How can we use community health workers to provide

services or link patients to needed supports?

Medical Legal Partnership• Enables MDs to refer to unique

specialists: on-site attorneys

• Most low-income persons face

legal issues that affect their quality

of life and their management of disease

• Adding lawyers to medical team can screen and assist

families for these social problems that affect care

• Stressors addressed: unhealthy housing, immigration,

income, food, education access, disability, family law

• Child with asthma, in moldy apartment, will not get

well, regardless of meds, if conditions not improved

Zuckerman et al. Pediatrics, 2004



Diversifying the Workforce to meet the

Needs of all Patients

Strategy Number 3

We need to Raise Awareness

levels of Racial Inequities and

Build Political Will to Address

them

What Is Holding Us Back?

What are the Barriers we have to Address?

Unaware, Indifferent, Delusional?

•National public opinion

data reveal that most

Americans are unaware

that racial disparities exist

•Large subgroups of see

disparities in health as

fault of minorities

themselves

•Many are indifferent

•Some are delusional105

The Real Challenge

An Empathy Gap?

“The most difficult social

problem in the matter of Negro health is

the peculiar attitude of the nation toward

the well-being of the race. There have…

been few other cases in the history of

civilized peoples where human suffering

has been viewed with such peculiar

indifference” W.E. B. Du Bois, 1899 [1967] p.163

https://www.phila.gov/personnel/Jobs/NonCivilServiceJobOpps.html

Recent Review on Empathy Gap

Han, S. Trends Cogn. Sci. 2018

•Studies of empathic responses in brain

activity when viewing suffering of persons

of one’s own race vs. members of another

race

•Racial ingroup bias consistently

found in brain imagery studies in

Europe, Africa, Asia, and the U.S.

•Stronger empathic neural

response to the pain of same race

versus other race individuals,

using a variety of stimuli•This racial bias in neural responses more

consistent than self-reports of empathy

Lack of Empathy, Evident Early in Life• Mainly white 5-, 7- and 10-year

olds rate pain of black and white

children

• No racial bias at age 5

• Children show weak bias (blacks feel less pain) at age 7

• At age 10 children rate pain of black child less than

white one (strong, reliable racial bias)

• Unrelated to social preference (would like to be friends

with)

• We may need to start empathy training very young

108

R. Dore et al, Br J Dev Psych, 2014

http://www.huffingtonpost.com/2013/10/17/racial-empathy-gap_n_4118252.html

What Reduces Gap in Empathic Brain Activity?

Han, S. Trends Cogn. Sci. 2018

1) When individuals are instructed to focus on a person’s

suffering (individuation) instead of his/her racial

background

2) When individuals are on the same team with members

of a racial outgroup

3) Experiences of greater inter-racial interaction in one’s

socialization

•Major investments in research are needed to identify

how to best close the empathy gap in real world contexts

and to expeditiously bring to scale interventions that are

proven to be effective

--We need to raise awareness levels of the

problem of inequities in health

-- We need to build the science base that will

guide us in developing the political will to address

racial and SES inequities in health

-- We need to build empathy, that is, identify how

to tell the story of the challenges of the

disadvantaged in ways that emotionally connects

and resonates with the public

3 Communication Challenges

"True compassion is

more than flinging a

coin to a beggar; it

understands that an

edifice which

produces beggars

needs restructuring.”

A Call to Action

“Each time a man stands up

for an ideal, or acts to

improve the lot of others, or

strikes out against injustice,

he sends forth a tiny ripple

of hope, and those ripples

build a current which can

sweep down the mightiest

walls of oppression and

resistance.”- Robert F. Kennedy

Further Reading

David R Williams & Lisa A. Cooper,

“Reducing Racial Inequities in Health:

Using What We Already Know to Take

Action.” International Journal of

Environmental Research and Public

Health, 16 (4), 606, 2019.

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social inequalities in health and how we can reduce them · life expectancy at birth, 2007-2009...

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