Addressing Racial Inequities to Improve Care and Productivity

1. Addressing Racial Inequities to Improve Care and Productivity David R. Williams, PhD, MPH Florence & Laura Norman Professor of Public Health Professor of African & African American Studies and of Sociology Harvard University

2. A Global Phenomenon There are Large Racial Inequities in Health

3. Life Expectancy, Indigenous Men Maori, Aboriginal, First Nation, Am Indian & Alaskan Native; Bramley et al. 2004

4. InfantMortalityintheU.S.,2012 HealthUnitedStates,NCHS, 2014,

5. Infant Mortality by EthnicityEngland and Wales, 2011BirthCohort Deaths per 1,000 live births, known gestational age, Office for National Statistics, 2013

6. Ethnicity and Risk of Dying in Pregnancy2014 -2016, UK and Ireland 15 8 Deaths per 100,000 people Marian Knight et al, MBRRACE-UK, 2019

7. Race Still Matters for Health after Social class/Socieconomic Status is taken into Account

8. Life Expectancy at Age 25Based on Level of Education 6.4-year gap White 70 75 80 85 Age 5-year gap overall Black 5.3-year gap 0-12 years College graduate Overall Murphy, NVSS 2000; Braveman et al. AJPH; 2010, NLMS 1988-1998

9. Life Expectancy at Age 25Race Still Matters White 70 75 80 85 3.1-year gap between HS dropouts 4.2-year gap between college grads Age Black Blacks with a college degree have a lower life expectancy than Whites with only a high school degree 0-12 years 12 years Some college College graduate Murphy, NVSS 2000; Braveman et al. AJPH; 2010, NLMS 1988-1998

10. Why Does Race Still Matter? Could racism be a critical missing piece of the puzzle to understand the patterning of racial disparities in health?

11. 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 institutions Bonilla-Silva, 1996; Williams 2004

12. Individual vs Institutional Racism

13. Individual Bias: Waiting at Crosswalks • 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: Tara Goddard, et al., Psychology Faculty Publications, Portland State University, 2014

14. Multiple Cars Twice as likely to Pass Blacks Tara Goddard, et al., Psychology Faculty Publications, Portland State University, 2014,( * : p ≤ .05)

15. Blacks Wait 32% Longer to Cross the Street Tara Goddard, et al., Psychology Faculty Publications, Portland State University, 2014,( * : p ≤ .05)

16. Institutional Discrimination: Waiting to Vote Average number of minutes, 2012 Presidential Election African Americans Latinos Asian Americans Native Americans Whites 23 min 19 min 15 min 13 min 12 min Cooperative Congressional Election Study, 2012

17. 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

18. Institutional or Structural Discrimination

19. Institutional Racism: Segregation 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 adverselyaffected life chances in multiple ways

20. Why Place Matters Where 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 

21. Racial Differences in Residential Environment Inthe 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

22. Segregation Contributes to Large Racial/Ethnic Differences in SES

23. Residential Segregation and SES A study of the effects of segregation on young African American adults found that the elimination of segregationwould 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

24. Where Racial Inequities in SES are Born Large Racial/Ethnic Differences in SES are consequential for life: -- They are not acts of God-- They are not random events -- They reflect successful implementation of social policies Racism has produced a truly “rigged system”

25. Residential Segregation in Western Europe • Levels of segregation in Europe • are rising compared to the steady • or falling levels in North America • Patterns of Segregation in Europe: • Religion: Segregation greater for Muslims than for other religious groups • Skin Color: After religion, segregation is greater for darker skinned nationalities Douglas Massey, Oxford Handbook of Social Science, 2016

26. Segregation in Britain 56 43 35 Douglas Massey, Oxford Handbook of Social Science, 2016

27. School Segregation • Ethnic minority children in England (26% of all students) more likely than White British to attend schools in which ethnic minorities are the majority • 61% of ethnic minority kids in England (90% in London) begin year one in schools where they are the majority • 94% of White British are in schools with White British majority • Bangladeshi, Pakistani and Black Caribbean kids particularly likely to be in segregated schools • Schools are more segregated than the communities they serve Demes Integration Hub, 2015

28. Racial Inequalities in SES are Large

29. Median Household Income and Race, 2015 72 cents 1.23 dollar 1 dollar 59 cents 62 cents* Racial Differences in Income are Substantial: Asian Hispanic AI/AN White Black U.S. Census Bureau: Proctor,Semega,Kollar, 2016; *2013, Native Her. Month, 2014

30. Median Wealth and Race, 2011 For every dollar of wealth that Whites have, Blacks have only 6 cents Asians have 81 cents Latinos have only 7 cents U.S. Census Bureau, 2014

31. UK: MedianHouseholdIncome, 2009/10-2012/13 Fisher & Nandi,JosephRowntreeFoundation,2015 AHC: Net equalized household income after housing cost

32. MedianHouseholdIncome, 2009/10-2012/13 Forevery£ofweekly incomethatWhitemajorityearns OtherWhitesearn 79p Indiansearn 86p Pakistanisearn57p Bangladeshisearn52p Fisher & Nandi,JosephRowntreeFoundation,2015

33. MediumHouseholdIncome, 2009/10-2012/13 Forevery£ofweekly incomethattheWhitemajorityearns Chineseearn76p BlackCaribbeansearn 77p BlackAfricansearn60p Fisher & Nandi,JosephRowntreeFoundation,2015

34. Race and Wealth, U.K. 2009 Source: The Runnymede Trust

35. Race and Wealth, UK, 2009 Forevery£ofwealththatWhiteshave Caribbean Blackshave 34p Bangladeshishave10p Black Africanshave7p Source: The Runnymede Trust

36. Individual Discrimination

37. DiscriminationPersists • Two black and two white, young, well-groomed, well-spoken college-educated men with identical resumes apply for 350 advertised entry-level jobs in Milwaukee, Wisconsin. • In each team, one said that he was on parole: he had served an 18-month prison sentence for cocaine possession. Devah Pager; Am J Sociology, 2004

38. Percent of Job Applicants Receiving a Callback Devah Pager; Am J Sociology, 2004

39. Incredulously…. • The study found that it was easier for a white male with a felony conviction to get a job than a black male whose record was clean! shutterstock_311917349 Devah Pager; Am J Sociology, 2004

40. The Pervasiveness of Discrimination Discrimination Getting insurance Buying a home Renting an apartment Hailing a taxi Receiving a promotion Obtaining bank loans Quality of medical care Suspended from preschool Purchasing a car Getting a job Pulled over by police Cost of bail Arrested for drug–related crimes

41. Discrimination in UK

42. Work Discrimination • Racial discrimination in employment • is large and unchanged in the last 50 years • Study of 3,200 applicants to both manual and non-manual jobs – advertised between November 2016 and December 2017 • All minority applicants said they were either born in Britain or had entered the country by the age of 6 and had received all education and training in Britain • Applicants used identical resumes and cover letters Valentina Di Stasio & Anthony Heath, University of Oxford, 2019

43. Additional Applications to Receive Callback(Whites receive callback – one in every 4 applications) 90 80 60 50 20 Valentina Di Stasio & Anthony Heeth, University of Oxford, 2019

44. Recent Studies of Discrimination in the NHS

45. Discrimination in Promotion • Survey of 487 doctors who became consultants in NHS across the UK in 2017 • White doctors applied for fewer posts • (1.29 vs. 1.66) • White applicants more likely to be shortlisted (80% vs. 66%) • Whites more likely than BME colleagues to be offered a job (77% vs. 57%) • Female BME doctors fared worse than male BME doctors Royal College of Physicians, 2018

46. Discrimination in Pay • Study of 750,000 staff salaries in NHS England • Black staff, from porters to doctors, are paid less than white staff • On average, Black doctors in NHS earn £10,000 less a year • Black nurses earn £2,700 less annually than white colleagues • White consultants earn £4,664 more per year than BME counterparts NHS Digital, 2018; John Appleby, BMJ, 2019

47. Experiences of discrimination are a source of Toxic Stress

48. 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?

49. Everyday Discrimination Associated With: -- coronary artery calcification -- C-reactive protein -- blood pressure -- lower birth weight -- cognitive impairment -- poor sleep -- mortality -- visceral fat Tene Lewis 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, HlthPsy, 2012; Barnes et al., J Gerontology: Bio Sci & Med Sci, 2008; Lewis et al., Am J Epidemiology, 2011

50. Millennium Cohort Study (MCS), UK • National longitudinal study of infants born in the UK, Sept 2000 to Jan 2002 • Over 18, 500 families recruited • Disadvantaged and high proportion BME residential areas over-sampled • How does maternal discrimination affect 4 domains of social & emotional behaviour(conduct & peer problems, emotional symptoms and hyperactivity) Becares, Nazroo & Kelly, SocSci & Med, 2015