|
Reprint - The
Epidemiology Monitor - June 2008
David Williams Gives John Cassel
Memorial Lecture Detailing The Dramatic Impact Of Race/Social
Environment On Health
We Know Enough To
Take Action, Says Speaker
Many could not recall
any previous speaker at SER receiving a standing ovation for his or
her lecture. But a standing ovation is indeed what David Williams,
the Norman Professor of Public Health at Harvard received for his John
Cassel Memorial lecture at the annual SER meeting in Chicago. In an
impressive, flawless presentation style in which he never missed a
beat, Williams presented finding after finding and statistic after
statistic detailing the dramatic impact that the social environment
operating through race can have on health.
Specific findings
Among the specific
findings presented were that African-Americans ( AA) have higher death
rates for many outcomes, these higher rates operate from cradle to
grave with higher age specific mortality in African-Americans at each
age group, immigrants to the US from minority populations fare better
in the US than native born minorities, rates of mental health illness
increase from 1st to 3rd generation immigrants to the US indicating
declining health with increasing length of stay in the US, and life
expectancy has been lower in African-Americans from 1900 to the
present.
The power of the
social environment to impact health was illustrated with data from
Mississippi where heart disease mortality rates are among the highest
in the US. In that area, rates for whites still do not overlap with
rates for African-Americans which are lower still. And for diseases
where the incidence is lower for African-Americans, such as breast
cancer, persons from that ethnic minority experience a worse
prognosis, according to Williams.
“Weathering”
Also, in a phenomenon
called "weathering", Williams described how African-Americans can be
more compromised than can be accounted for by their chronological age
because they have been exposed longer to adverse conditions. And he
noted that this effect is due to more than SES variables because
adjusting for these still leaves disparities. He used the example from
a health professions study which showed higher rates of cardiovascular
disease, hypertension, diabetes, and coronary heart disease with
higher case fatality rates for African-American doctors compared to
doctors with equivalent SES categories. For well educated women,
Williams described data showing that infant mortality rates among the
best educated African-American women we're still higher than those
among white women with significantly lower education.
Impact of
environment
In trying to make
sense of these health disparities by race, Williams made clear that
the differences are not due to some West African gene, and cited the
example of hypertension which is higher in US born than in African
born residents of the same race. Likewise, diabetes is worse among
blacks in the UK and in the US than it is in African populations.
Williams pointed to the "social genome" or risks in the social
environment as the culprits for the disparities he documented.
Mechanisms of
action
In seeking to
explicate what the mechanisms of action might be for allowing race to
operate on health even after SES factors are accounted for, Williams
had three possibilities. The first one he called the "non-equivalence
of SES" wherein he noted that the African Americans are more likely to
have experienced six indicators of economic hardship, and he reminded
the audience that income does not equate to wealth and that wealth
does matter for health.
Second, Williams
pointed to experiences in early life to account for racial disparities
in health. He said there are multiple pathways to disadvantage in
childhood, and that low SES in childhood can create a disadvantaged
foundation for adult health.
Thirdly, Williams
pointed to the historic legacy of racism in the US and said that
institutional mechanisms of racism are hard to measure. He cited
residential segregation as the most successful form of institutional
racism and said that it was very pervasive in the US.
Residential
segregation
Williams believes that
residential segregation operates so successfully on health, that the
US could completely erase health disparities if it could eliminate
residential segregation. He stated that such segregation in the US is
now only slightly lower than what was legal under apartheid in South
Africa.
Williams brought his
talked to a close by stating that 3/4 of African-American children and
2/3 of Latino children are now doing worse than white children. He
said that the social environment has a dramatic effect on health, and
that minorities in the US are living under distinctively different
environmental conditions. In such a situation, Williams said we should
expect differences by race as people adapt biologically to their
environments. He mentioned Arab American women who experienced more
low birth weight babies and more preterm delivery after 911 compared
to before then.
Challenges
Dr. Williams noted
several challenges facing those who wish to study the influence of
discrimination on health and better understand the pathways to bad
health, but he said the most pernicious of all myths is the one which
believes that the problem of disparities is so overwhelming and so
complex that we cannot do anything about it. "We know enough to take
action," said Williams. He stated that health could be impacted by all
policy sectors. He called medical care the "repair shop", and said
that social policy on the other hand can make it easier or harder for
people to achieve appropriate health behaviors.
He cited the Perry
Preschool Program as an example of an effective intervention. This
program provides high-quality early childhood education to
disadvantaged children in order to improve their later school and life
performances. "There is more to learn but a lot we can do", said
Williams, "and giving more active support to families is one promising
area or intervention." Williams closed by quoting Edmund Burke
that "the only thing necessary for the triumph of evil is for good men
to do nothing".
■
|