When Good Intentions Fail: Why Health Disparities Persist and what you can do about them. David R. Williams, PhD, MPH Florence & Laura Norman Professor of Public Health Professor of African & African American Studies and of Sociology Harvard University.
David R. Williams, PhD, MPH
Florence & Laura Norman Professor of Public Health
Professor of African & African American Studies and of Sociology
Source: Indian Health Service; Trends in Indian Health 1998-99
“Has anyone seen the SPIDER that is spinning this complex web of causation?”
Source: (ETS) Mantsios; N=898,596
U.S. Census 2006
U.S. Census 2006
Family Income in 1980 (adjusted to 1999 dollars)
9-year mortality data from the National Longitudinal Mortality Survey
Poor=Below poverty; Near poor+<2x poverty; Middle Income = >2x poverty but <$50,000+
Source: Parmuk et al. 1998
Percent of Women with Fair or Poor Health by Race and Income, 1995
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.
Orzechowski & Sepielli 2003, U.S. Census
Source: Orzechowski & Sepielli 2003, U.S. Census
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
Perceived Discrimination:Experiences of discrimination may be a neglected psychosocial stressor
“..Discrimination is a hellhound that gnaws at Negroes in every waking moment of their lives declaring that the lie of their inferiority is accepted as the truth in the society dominating them.”
Martin Luther King, Jr. 
Source: Devan Pager; NYT March 20, 2004
Source: Devan Pager; NYT March 20, 2004
In the study of Women’s 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
U.S. Surgeon General, 1979
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
Effective Policies to reduce inequalities in health must address fundamental non-medical determinants.
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
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
Factors that facilitate opportunities for health:
Health Policies include policies in all sectors of society that affect opportunities to choose health, including, for example,
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
Geographic location determines exposure to risk factors and resources that affect health.
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).
Source: Williams & Collins , 2001
Source: Massey 2004
A study of the effects of segregation on young African American adults found that the elimination of segregation would erase black-white differences in
And reduce racial differences in single motherhood by two-thirds
Cutler, Glaeser & Vigdor, 1997
Source: Sampson & Wilson 1995
American Apartheid: Neighborhoods Than Worst Off White ChildrenSouth Africa (de jure) in 1991 & U.S. (de facto) in 2000
Source: Massey 2004; Iceland et al. 2002; Glaeser & Vigitor 2001
Dalgard and Tambs 1997
Leventhal and Brooks-Gunn, 2003
Kehrer and Wolin, 1979
Costello et al. 2003
In the last 50 years, black-white differences in health have narrowed and widened with black-white differences in income
Cooper et al., 1981b
Cooper et al., 1981b
Source: Economic Report of the President, 1998
Health Status Changes, 1980-1991 (Women)
Indicator 1980 1991
Black/White Ratio, Males 1.9 2.1
Black/White Ratio, Females 2.0 2.3
Black/White Gap, Males 6.9 8.3
Black/White Gap, Females 5.6 5.8
Source: NCHS, 1994.
Reducing Childhood Poverty
Challenges and Opportunities
Source: U.S. Census Bureau (Pamuk et al. 1998)
Compared to children raised by 2 parents those raised by a single parent are more likely to:
McLanahan & Sandefur 1994; Sampson 1987
Bishop 1980; Testa et al. 1993; Wilson & Neckerman 1986
Investments in early childhood programs in the U.S. have been shown to have decisive beneficial effects
High/Scope Educational Research Foundation
Schweinhart & Montie, 2005
We Need to Better Understand How Resilience Factors and Processes Can Affect Health and how to Build on the Strengths and Capacities of Communities
Wallace and Forman 1998; Monitoring the Future Study
Hummer et al. 1999
Griffith et al. (1980); Gilkes (1980): Pargament et al. (1983)
The RWJF Commission to Build a Healthier America is a national, comprehensive effort to raise awareness about the large socio-economic status (SES) differences in health among Americans and then seek practical, common-ground solutions to improve the health of all.
Raise awareness and identify areas for action by
A serious commitment on the part of the RWJ Foundation to:
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
…to help reframe the nation’s debate over health and what we as a society can—and should—do to tackle our health inequities.
(check local listings)
(temporary site now up: www.unnaturalcauses.org)
organized by LPHDs
H - Housing
E – Education & Environment
A - Access
L - Labor
T – Transportation
H – Hope and Happiness
“The only thing necessary for the triumph [of evil] is for good men to do nothing.”
Edmund Burke, British Philosopher