Harvard Public Health Review, January 1, 2007
EXPOSING THE ROOTS OF HEALTH DISPARITIES
[Rachel's introduction: "What intrigues Williams are not just extreme forms of racism, but their subtler, more insidious, day-to-day manifestations. A huge body of research on health disparities has led him to conclude that stress resulting from institutionalized racism and discrimination, be it real or perceived, blatant or muted, is an 'added pathogenic factor' that contributes to well-above-average levels of hypertension, respiratory illness, anxiety, depression, and other ills in minority populations."]
By Richard Saltus
In his latest bid to unearth the dark, tangled roots of disparities in health between blacks and whites, Harvard School of Public Health (HSPH) newcomer David R. Williams has gone to South Africa....
Williams looks at social policies and historical patterns of discrimination through a sociologist's lens. By sifting and sorting data in fresh ways, he has cast new light on the causes of blacks' poorer health and rates of survival, observe his new colleagues at HSPH. In August, Williams joined the faculty as the Florence Sprague Norman and Laura Smart Norman Professor of Public Health in the Department of Society, Human Development, and Health.
What intrigues Williams are not just extreme forms of racism, but their subtler, more insidious, day-to-day manifestations. A huge body of research on health disparities has led him to conclude that stress resulting from institutionalized racism and discrimination, be it real or perceived, blatant or muted, is an "added pathogenic factor" that contributes to well-above-average levels of hypertension, respiratory illness, anxiety, depression, and other ills in minority populations. Socioeconomic status is just part of the problem. While lower-income people generally tend to be less healthy, Williams says, "blacks do more poorly than whites at every level of socioeconomic status."
The roots of health disparities run so deep that they're invisible to most of society, he has found. "A lot of what I struggle with is understanding the larger social, political, and economic context in which health is embedded and the broader forces, many of them hidden, that shape mobility and access to health care," Williams says. "I have argued, for example, that residential segregation, resulting from historical racist policies, is a fundamental cause of excess levels of ill health in the African-American population."
Segregation by neighborhood is so high at every income bracket in the United States that, in many cities, it comes close to levels once legally mandated by apartheid in South Africa, Williams says. Sixty- six percent of blacks would have to move in order to distribute blacks and whites evenly.
Truth in numbers
Over the past decade, Williams has been among the top 10 most-cited researchers in the social sciences. His more than 100 papers have yielded insights such as these:
Blacks die at twice the rate of whites in the age groups 1-4 and 25-54--a grim fact often missed in comparisons of overall mortality rates, which yield a 30 percent mortality disadvantage for blacks.
In Pitt County, North Carolina, the odds of having hypertension were seven times higher for black men who as children and adults had low socioeconomic status (SES) than for black men whose SES was high.
In Mississippi, home to the highest heart disease death rates in America, the healthiest black women die from heart disease at a greater rate than the sickest white women.
According to Joseph Betancourt, MD, MPH, director of the Disparities Solutions Center at Massachusetts General Hospital and a senior scientist in MGH's Institute for Health Policy, Williams "understands the issue of disparities in its entire breadth and depth-- discrimination and socioeconomic status, community and societal factors. Few people have that expertise."
Betancourt and Williams served together on the National Academy of Science's Institute of Medicine committee that issued the landmark 2003 report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. The authors found that, even when they had overcome barriers to getting health care, African-Americans and other minority populations were still less likely to receive certain high- tech, expensive, yet common procedures such as coronary bypass operations, kidney dialysis, and kidney transplants. They were more likely, however, to undergo certain other procedures, including lower- limb amputations for diabetes. Why this is so continues to be a subject of research. Possible explanations include health care providers' biases, miscommunication, and blacks' lack of trust in the largely white health care system.
If death rates for blacks and whites were equal, the authors wrote, about 100,000 fewer black Americans would die every year. In fact, blacks are still dying at rates whites did 30 years ago. "And this is not an act of God," Williams points out dryly.
Reversing entrenched policies
Williams is frenetically busy, always on the move. Yet, sitting in his box-filled office, he is expansive, his conversation accented with the lilt and softness of St. Lucia, an island nation in the Caribbean where he grew up.
His college studies, in nearby Trinidad, were in theology, not as a road to the ministry but because of his view of the church as "a foundation for meaningful engagement and service to community." After college, Williams came to the United States, braving the bitter Michigan winters, to study at Andrews University, the flagship educational institution of the Seventh-day Adventist Church, which promotes preventive health practices such as exercise, vegetarianism, and abstinence from smoking and alcohol. Williams earned an MPH from the Adventist Loma Linda University in California, his field work bringing him back to Michigan as a health educator at an Adventist facility in Battle Creek.
There Williams worked in fitness, stress management, and heart-disease risk-reduction programs, where he says he was impressed by "the extent to which health practices and behaviors of individuals were shaped by larger social forces. The nature of the family environment was a strong predictor of the long-term success of a stop-smoking program, for example." This insight led to a PhD in sociology from the University of Michigan where, after a six-year stint at Yale, he returned in 1992 as professor of sociology and senior research scientist at the Institute for Social Research.
Along the way, personal experience fed into Williams' views of the corrosive effects of racist attitudes upon psychological health and well being. Not long after emigrating to the United States, for example, Williams and four other black university students were pulled over by Indiana police at about 1 a.m. on their way back to Andrews University from a weekend trip. The driver was allegedly speeding, but when the officer insisted on seeing the licenses of everyone in the car, the young men felt the sting of racism. "It made us all angry--we were nearly home, we were tired, we felt we shouldn't have to do this," remembers Williams.
A more menacing act shook him and his wife in the predominantly white neighborhood of Battle Creek, Michigan, where they were renting an apartment. "As I was going to sleep there was an explosion, and a flash of light," Williams recounts. "Someone had fired shots in the air, and on the lawn of a black family who had just moved in next door, a cross was burning." Although the police sent a hate crimes unit to investigate, "there was nothing reported in the local media." That seeming indifference rankles Williams to this day.
If entrenched social policies have contributed to the insidious health disadvantages that persist among today's minorities, it should be possible, if daunting, to reverse these, Williams believes. As part of a group that is collaborating with the Robert Wood Johnson Foundation, he is working to establish a national commission that will "look systematically at disparities in race, health, and socioeconomic status, and see what policies can be used to improve health."
"It's primarily about improving the circumstances in which people live and work," Williams says. That means job training and initiatives that improve their ability to take advantage of the opportunities that society offers." If there are no easy answers, Williams is nevertheless generating new information he hopes will help societies narrow health and economic divides along racial lines.
"What's phenomenal about David," says Lisa Berkman, who chairs Williams' department and helped lure him to HSPH, "is that he takes data that have long been in the public domain, such as decades of life expectancy data, and uses them to point out underlying causes of racial disparities in health that lay hidden or silent. He's making the roots of disparities transparent."
Richard Saltus has been a reporter for the Associated Press, the San Francisco Examiner, and the Boston Globe. He writes about science, medicine, and public health.
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