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Race, Racism and Health: Patterns, Paradoxes and Needed Research

Race, Racism and Health: Patterns, Paradoxes and Needed Research. David R. Williams, PhD, MPH Florence & Laura Norman Professor of Public Health Professor of African & African American Studies and of Sociology Harvard University. African American Mortality.

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Race, Racism and Health: Patterns, Paradoxes and Needed Research

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  1. Race, Racism and Health: Patterns, Paradoxes and Needed Research David R. Williams, PhD, MPH Florence & Laura Norman Professor of Public Health Professor of African & African American Studies and of Sociology Harvard University

  2. African American Mortality • For the 15 leading causes of death in the United States in 2005, Blacks had higher death rates than whites for: 1. Heart Disease 2. Cancer 3. Stroke 6. Diabetes 8. Flu and Pneumonia 9. Kidney Diseases 13. Hypertension 10. Septicemia 15. Homicide • Blacks had equivalent rates of accidents and lower death rates than whites for: 4. Respiratory Diseases 7. Alzheimer’s Disease 11. Suicide 12. Cirrhosis of the liver 14. Parkinson’s Disease Source: NCHS 2007

  3. Hispanic Mortality • For the 15 leading causes of death in the United States in 2005, Hispanics had higher death rates than whites for: 6. Diabetes 12. Cirrhosis of the liver 13. Homicide • Hispanics had equivalent rates of hypertensionkidney disease and lower death rates than whites for: 1. Heart Disease 2. Cancer 3. Stroke 5. Accidents 4. Respiratory Diseases 7. Alzheimer’s Disease 9. Kidney Disease 8. Flu and Pneumonia 10. Septicemia 11. Suicide 14. Parkinson’s Disease Source: NCHS 2007

  4. Age-Adjusted Mortality rates for 2003-2005 Rates per 10,000 population Source: National Center for Health Statistics, 2007

  5. There Is a Racial Gap in Health in Early Life:Minority/White Mortality Ratios, 2005

  6. There Is a Racial Gap in Health in Mid Life:Minority/White Mortality Ratios, 2005

  7. There Is a Racial Gap in Health in Late Life:Minority/White Mortality Ratios, 2005

  8. 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

  9. 12-Month Prevalence of Psychiatric Disorder, by Race and Nativity Status (%) Source: NCS-R, NSAL, NLASS

  10. Lifetime Prevalence of Psychiatric Disorder, by Race and Generational Status (%) Source: Williams et al. 2007; Alegria et al 2007; Takeuchi et al. 2007

  11. 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.?

  12. 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

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

  14. Heart Disease Death Rates Mississippi 1996-2000 White Women, Ages 35+ CDC, Heart Disease and Stroke maps

  15. Heart Disease Death Rates Mississippi 1996-2000 Black Women, Ages 35+ CDC, Heart Disease and Stroke maps

  16. Heart Disease Death Rates Mississippi 1996-2000 Women WHITE BLACK CDC, Heart Disease and Stroke maps

  17. Race and the Burden of Breast Cancer Compared to white women, black women are less likely to get breast cancer, BUT they are more likely to: -- get breast cancer when young -- be diagnosed at an advanced stage -- have aggressive forms of breast cancer that are resistant to treatment -- have triple negative tumors: grow quickly, recur more often, kill more frequently (Hispanic women also) -- die from breast cancer Chlebowski et al. 2005, JNCI; CA Study

  18. Race and Major Depression Blacks have lower current and lifetime rates of major depression than Whites, BUT depressed Blacks are more likely than their White counterparts to: -- be chronically or persistently depressed -- have higher levels of impairment -- have more severe symptoms -- not receive treatment Williams et al. 2007; Archives of Gen. Psychiatry

  19. Neonatal Mortality Rates (1st Births), U.S. Geronimus & Bound, 1991; National Linked Birth/Death Files, 1983

  20. Racial/Ethnic Disparities in Health:More than just Socioeconomic Status

  21. Black-White Mortality Hazard Ratios Franks et al., 2006; 1990-1992 NHIS linked to NDI through 1995

  22. Race and Prostate CancerHealth Professionals Study • 51,529 U.S. male health professionals, aged 40-75, followed from 1986 to 2002: • Compared to whites, blacks had elevated multivariate risk of - incident cancer 1.49 (1.13-1.96) - high grade cancer 1.75 (1.11-2.77) Non-significant risk for - fatal cancer 2.04 (0.90-4.62) Giovannucci et al., 2007 Int. J. Cancer

  23. Meharry vs Johns Hopkins A 1958 – 65, all Black, cohort of Meharry Medical College MDs was compared with a 1957- 64, all White, cohort of Johns Hopkins MDs. 23-25 years later, the Black MDs were more likely to have: • higher risk of CVD (RR=1.65) • earlier onset of disease • incidence rates of diabetes & hypertension that were twice as high • higher incidence of coronary artery disease (1.4 times) • higher case fatality (52% vs 9%) Thomas et al., 1997 J. Health Care for Poor and Underserved

  24. Percent of persons with Fair or Poor Health by Race, 1995 Poor=Below poverty; Near poor+<2x poverty; Middle Income = >2x poverty but <$50,000+ Source: Parmuk et al. 1998

  25. Percent of Women with Fair or Poor Health by Race and Income, 1995

  26. Infant Death Rates by Mother’s Education, 1995

  27. Infant Mortality by Mother’s Education, 1995

  28. Racial/Ethnic Disparities in Health:More than simplistic genetic hypotheses

  29. What is Race? “Pure races in the sense of genetically homogenous populations do not exist in the human species today, nor is there any evidence that they have ever existed in the past… Biological differences between human beings reflect both hereditary factors and the influence of natural and social environments. In most cases, these differences are due to the interaction of both.” American Association of Physical Anthropology, 1996

  30. Source: International Collaborative Study of Hypertension in Blacks, 1995 Hypertension, 7 West African Origin Groups (%)

  31. Prevalence of Diabetes, 6 West African Origin Groups Source: Cooper et al., 1997; International Collaboration Study of Hypertension in Blacks

  32. Research Opportunity As research on the human genome moves forward, there will be increasing need for comprehensive, detailed, and rigorous characterization of the risk factors/resources in the psychological, social, and physical environment that may interact with biological predispositions to affect health risks.

  33. 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.

  34. Wealth of Whites and of Minorities per $1 of Whites, 2000 Source: Orzechowski & Sepielli 2003, U.S. Census

  35. 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

  36. 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

  37. Child and Adult SES and HypertensionPitt County, NC Men Odds Ratios James et al. 2006; AJPH

  38. Racism and Health: Mechanisms • Institutional discrimination (segregation) can restrict SES attainment and group differences in SES and health. • Segregation can create pathogenic residential conditions. • Discrimination can lead to reduced access to desirable goods and services. • Internalized racism (acceptance of society’s negative characterization) can adversely affect health. • Racism can create conditions that increase exposure to traditional stressors (e.g. unemployment). • Experiences of discrimination may be a neglected psychosocial stressor.

  39. Residential Segregation is an example of Institutional Discrimination that has pervasive adverse effects on health

  40. Racial Segregation Is … 1. Myrdal (1944): …"basic" to understanding racial inequality in America. 2. Kenneth Clark (1965): …key to understanding racial inequality. 3. Kerner Commission (1968): …the "linchpin" of U.S. race relations and the source of the large and growing racial inequality in SES. 4. John Cell (1982): …"one of the most successful political ideologies" of the last century and "the dominant system of racial regulation and control" in the U.S. 5. Massey and Denton (1993): …"the key structural factor for the perpetuation of Black poverty in the U.S." and the"missing link" in efforts to understand urban poverty.

  41. How Segregation Can Affect Health • Segregation determines SES by affecting 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 medical care and to high-quality care. Source: Williams & Collins , 2001

  42. Segregation and Employment • Exodus of low-skilled, high-pay jobs from segregated areas: "spatial mismatch" and "skills mismatch" • Facilitates individual discrimination based on race and residence • Facilitates institutional discrimination based on race and residence

  43. Race and Job LossEconomic Downturn of 1990-1991 Source : Wall Street Journal analysis of EEOC reports of 35,242 companies

  44. Race and Job Loss Source: Sharpe, 1993: Wall Street Journal

  45. 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

  46. Segregation and Neighborhood Quality Municipal services (transportation, police, fire, garbage) Purchasing power of income (poorer quality, higher prices). Access to Medical Care (primary care, hospitals, pharmacies) Personal and property crime Environmental toxins Abandoned buildings, commercial and industrial facilities

  47. Segregation and Housing Quality Crowding Sub-standard housing Noise levels Environmental hazards (lead, pollutants, allergens) Ability to regulate temperature

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