Social Inequalities in Health: Patterns, Causes, Interventions

1
Social Inequalities in Health Patterns, Causes,
Interventions

• David R. Williams, Ph.D., MPH
• Harold W. Cruse Collegiate Professor of
  Sociology, Professor of Epidemiology,
• Research Professor
• Institute for Social Research
• University of Michigan

2
Racial Disparities in Health

• In 2001, African Americans had higher death rates
  than Whites for 12 of the 15 leading causes of
  death.
• Blacks and American Indians have higher
  age-specific mortality rates than Whites from
  birth through the retirement years.
• The death rate for Blacks today is equivalent to
  that of Whites some 30 years ago.
• Hispanics have higher death rates than whites for
  diabetes, hypertension, liver cirrhosis homicide

3
There Is a Racial Gap in Health in Mid
LifeMinority/White Mortality Ratios, 2000
4
Immigration and Health

• Immigrants of all racial/ethnic groups enjoy
  better health (adult infant mortality) than
  their native-born counterparts.
• As length of residence in the U.S. increases, the
  health of immigrants declines.
• For example, infant and adult mortality, low
  birth weight, poor health practices, multiple
  indicators of morbidity increase for Latinos with
  length of stay in the U.S.

Vega Amaro 1994 Finch et al. 2002
5
Major Challenge

• What interventions, if any, can reverse the
  downward health trajectory of immigrants with
  length of stay in the U.S.?

6
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7
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8
Diabetes Death Rates 1955-1995
Source Indian Health Service Trends in Indian
Health 1998-99
9
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
10
Infant Mortality Rates, 1950-2000
11
Infant Mortality
Health, United States, 2005
12
Excess Deaths for Black Population
Levine et al. 2001
13
The Persistence of Racial Disparities

• We have FAILED!
• In spite of a War on Poverty, a Civil Rights
  revolution, Medicare, Medicaid, the Hill-Burton
  Act, dramatic advances in medical research and
  technology, we have made little progress in
  reducing the elevated death rates of blacks
  relative to whites.

Source NCHS 2000 Deaths per 1,000 population
14
Why Disparities Exist?

• Racial differences in health are not primarily
  caused by genetic factors

15
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
16
Why Disparities Exist?

• Socioeconomic Status (SES) is a central but
  incomplete explanation of racial differences in
  health.

17
SAT Scores by Income
Source (ETS) Mantsios N898,596
18
SES and Race

• African Americans and multiple other minorities
  have lower levels of education, income,
  professional status, and wealth than whites.
  These racial differences in SES are the major
  reason for racial differences in health.
• Education and income are generally more strongly
  associated with health status than race.
• Racial differences in health status decrease
  substantially when racial groups are compared at
  similar levels of SES.

19
Determinants of Health of the Population
Source Candian Institute for Advanced Research,
AB/NWT 2002.
20
Determinants of Health in the U.S.
U.S. Surgeon General, 1979
21
Determinants of Health in the U.S.
McGinnis et al. 2002
22
SES and Health Risks
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
23
Percent of persons with Fair or Poor Health by
Race, 1995
PoorBelow poverty Near poorlt2x poverty Middle
Income gt2x poverty but lt50,000 Source Parmuk
et al. 1998
24
Percent of Men with Fair or Poor Health by Race
and Income, 1995
25
Percent of Women with Fair or Poor Health by
Race and Income, 1995
26
Race/Ethnicity and SES

• Race and SES reflect two related but not
  interchangeable systems of inequality
• In national data, the highest SES group of
  African American women have equivalent or higher
  rates of infant mortality, low birth-weight,
  hypertension and overweight than the lowest SES
  group of white women

27
Infant Death Rates by Mothers Education, 1995
28
Infant Mortality by Mothers Education, 1995
29
Why Race Still Matters

• 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.
• Health is affected not only by current SES but by
  exposure to social and economic adversity over
  the life course.
• Personal experiences of discrimination and
  institutional racism are added pathogenic factors
  that can affect the health of minority group
  members in multiple ways.

30
Why Disparities Exist?

• All indicators of SES are not the same across
  racial/ethnic groups.

31
Race/Ethnicity and Wealth, 2000Median Net Worth
Source Orzechowski Sepielli 2003, U.S. Census
32
Wealth of Whites and of Minorities per 1 of
Whites, 2000
Source Orzechowski Sepielli 2003, U.S. Census
33
Why Disparities Exist?

• In addition to SES, racism is an added burden.

34
Racism Mechanisms

• Institutional discrimination can restrict
  socioeconomic attainment a group differences in
  SES a health.
• Segregation can create pathogenic residential
  conditions.
• Discrimination can lead to reduced access to
  desirable goods and services.
• Internalized racism (acceptance of societys
  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.

35
MLK Quote
...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. 1967
36
Discrimination Persists

• Pairs of young, well-groomed, well-spoken college
  men with identical resumes apply for 350
  advertised entry-level jobs in Milwaukee,
  Wisconsin. Two teams were black and two were
  white. In each team, one said that he had served
  an 18-month prison sentence for cocaine
  possession.
• 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.

Source Devan Pager NYT March 20, 2004
37
Percent of Job Applicants Receiving a Callback
Source Devan Pager NYT March 20, 2004
38
Every Day Discrimination

• In your day-to-day life how often do the
  following things 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 theyre better than you are.
• You are called names or insulted.
• You are threatened or harassed.

39
Everyday Discrimination and Subclinical Disease

• Everyday discrimination was positively related
  with subclinical carotid artery disease
  (intima-media thickness) for black but not white
  women.
• Everyday discrimination was positively related to
  coronary artery calcification in the study of
  Womens Health Across the Nation (SWAN)

Troxel et al. 2003 Lewis et al. 2005
40
Arab American Birth Outcomes

• Well-documented increase in discrimination and
  harassment of Arab Americans after 9/11/2001
• Arab American women in California had an
  increased risk of low birthweight and preterm
  birth in the 6 months after Sept. 11 compared to
  pre-Sept. 11
• Other women in California had no change in birth
  outcome risk pre-and post-September 11

Lauderdale, 2006
41
Why Disparities Really Exist?

• Has anyone seen the SPIDER that is spinning this
  complex web of causation?

Krieger, 1994
42
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.

43
How Segregation Can Affect Health

• Segregation determines 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
  high-quality medical care.

Source Williams Collins , 2001
44
Racial Differences in Residential Environment

• The sources of violent crimeare remarkably
  invariant across race and rooted instead in the
  structural differences among communities, cities,
  and states in economic and family
  organization,p. 41
• In the 171 largest cities in the U.S., there is
  not even one city where whites live in ecological
  equality to blacks in terms of poverty rates or
  rates of single-parent households.
• The worst urban context in which whites reside
  is considerably better than the average context
  of black communities. p.41
• Source Sampson Wilson 1995

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 Distinctive for Blacks

• Blacks are more segregated than any other
  racial/ethnic group.
• Segregation is inversely related to income for
  Latinos and Asians, but is high at all levels of
  income for blacks.
• The most affluent blacks (income over 50,000)
  are more highly segregated than the poorest
  Latinos and Asians (incomes under 15,000).
• Thus, middle class blacks live in poorer areas
  than whites of similar SES and poor whites live
  in much better neighborhoods than poor blacks.
• African Americans manifest a higher preference
  for residing in integrated areas than any other
  group.

Source Massey 2004
47
American ApartheidSouth Africa (de jure) in
1991 U.S. (de facto) in 2000
Source Massey 2004 Iceland et al. 2002 Glaeser
Vigdor 2001
48
Why Disparities Exist?

• There racial/ethic differences in access to care
  and the quality of care

49
Race and Medical Care

• Across virtually every therapeutic intervention,
  ranging from high technology procedures to the
  most elementary forms of diagnostic and treatment
  interventions, minorities receive fewer
  procedures and poorer quality medical care than
  whites.
• These differences persist even after differences
  in health insurance, SES, stage and severity of
  disease, co-morbidity, and the type of medical
  facility are taken into account.
• Moreover, they persist in contexts such as
  Medicare and the VA Health System, where
  differences in economic status and insurance
  coverage are minimized.
• Institute of Medicine, 2002

50
Ethnicity and Analgesia

• A chart review of 139 patients with isolated
  long-bone fracture at UCLA Emergency Department
  (ED)
• All patients aged 15 to 55 years, had the injury
  within 6 hours of ER visit, had no alcohol
  intoxication.
• 55 of Hispanics received no analgesic compared
  to 26 of non-Hispanic whites.
• With simultaneous adjustment for sex, primary
  language, insurance status, occupational injury,
  time of presentation, total time in ED, fracture
  reduction and hospital admission, Hispanic
  ethnicity was the strongest predictor of no
  analgesia.
• After adjustment for all factors, Hispanics were
  7.5 times more likely than non-Hispanic whites to
  receive no analgesia.
• Todd, et al. 1993

51
Disparities in the Clinical Encounter The Core
Paradox

• How could well-meaning and highly educated health
  professionals, working in their usual
  circumstances with diverse populations of
  patients, create a pattern of care that appears
  to be discriminatory?

52
Why Disparities Exist?

• Minorities are under-represented in the health
  professions

53
Enrollment in Dental SchoolBlacks, Other Races,
Women
Source National Center for Health Statistics,
2003 1 Comparison years for women are 1971-72
with 1999-2000.
54
Representation in the Health Professions

• Reducing the under-representation of minorities
  in the health professions is one strategy to
  improve both access to care and quality of care
  for minority populations.
• Physicians from under-represented minority
  backgrounds are more likely than others to
• Care for the uninsured and those with Medicaid
• Work in primary care specialties
• Practice in urban and rural under-served areas

Komaromy et al., 1996
55
Race-concordance

• A study of black white patients in 16 urban
  primary care practices found that both black and
  white patients in race-concordant encounters had
  visits that were on average two minutes longer
  than in race-discordant medical encounters.
• Patients in race-concordant visits reported
  higher levels of satisfaction and more positive
  judgments of physicians participatory
  decision-making style
• Independent ratings of audiotapes of the
  encounters indicated that race-concordant visits
  had a more positive emotional context (as
  indicated by voice tone) and a slower pace
  (slower speech by both the physician and the
  patient).
• Thus, increasing the racial diversity of health
  care providers is likely to be an effective
  strategy in improving health care experiences of
  minority group members

Cooper et al. 2003
56
Enrollment in Medical SchoolBlacks, Other
Races, Women
Source National Center for Health Statistics,
2003 1 Comparison years for women are 1971-72
with 1999-2000.
57
Where No Disparities Exist or pattern is opposite
to the expected?

• Mental Health of African Americans is better than
  expected

58
Disparities in Mental Health

• Blacks have lower rates than whites of
• 1. Any Affective Disorder
• 2. Any Anxiety Disorder
• 3. Any Substance Abuse/Dependence
• 4. Any disorder
• Source Kessler et.al. (1994)

59
Religious Services as Therapy?

• Several aspects of some religious services are
  distinctive in the provision of opportunities to
  articulate and manage personal and collective
  suffering.  
• The expression of emotion and active
  congregational participation can promote
  collective catharsis in ways that facilitate
  the reduction of tension and the release of
  emotional distress. 
• There are parallels between all the key elements
  of formal psychotherapy and the rituals of some
  religious services.  

  Griffith et al. (1980) Gilkes (1980)
Pargament et al. (1983)
60
U.S. Life Expectancy at Age 20by Religious
Attendance
63.5
63.4
60.1
57.9
60.1
56.1
52.4
46.4
Age
Hummer et al. 1999
61
Needed Interventions

• Policies to reduce inequalities in health must
  address fundamental non-medical determinants.

62
Guiding Principles

• Health Policy must be re-defined to include
  policies in all sectors of society that have
  health consequences.
• Policies which improve average health may have no
  impact on social inequalities in health.
• We need policies that improve health overall and
  targeted interventions to address social
  inequalities.
• Major gains are possible through strategies that
  tackle health problems that occur most
  frequently.
• Families with children should be a priority.

63
Reducing Inequalities -IHealth Care

• Improve access to care and the quality of care
• Give emphasis to the prevention of illness
• Provide effective treatment
• Develop incentives to reduce inequalities in the
  quality of care

64
A meaningful interpersonal relationship

• A good interpersonal relationship is the
  cornerstone of a successful interaction between
  provider client
• Empathy, warmth, acceptance, and encouragement
  must be present in the provider-client
  relationship and communicated in a way that is
  readily evident to the client.
• Patients tend to be more dissatisfied about the
  information they receive from their physicians
  than about any other aspect of medical care

65
Common Patient complaints

• Limited consultation and communication of
  information
• The provider's manner
• Waiting too long
• No privacy
• Receiving little respect from the office staff
• Bills,
• Perception that providers are more interested in
  the disease than in the patient's health concerns

Smedley, Stith and Nelson, 2003 Stoeckle, 1987
Waitzkin Waterman, 1976
66
Simple Language

• Many healthcare providers greatly over-estimate
  the comprehension level of their patients
• Often providers speak at a level that many of
  their clients are not able to understand.
• Health care information must be communicated in
  simple, readily understood language. Specific
  inquiry should be made regarding any
  dissatisfaction with information received and any
  additional information needed.

Smedley, Stith and Nelson, 2003
67
Making Care Accessible

• Especially important for vulnerable populations
• National study found that
• 55 of uninsured persons delay seeking health
  care because of inability to pay.
• 30 of uninsured did not get the medical care
  that they felt they needed,
• 24 had times when they did not fill their
  prescriptions
• Ensuring access to care requires identifying and
  eliminating both real and perceived barriers

Blendon et al., 1989 Politzer et al. 2001
Smedley, Stith and Nelson, 2003
68
More Primary Care

• Care that will improve health and reduce
  disparities must be primary care
• Access to regular primary care can improve health
  status and reduce health disparities at all
  levels of income
• Primary care is the most significant health care
  variable associated with better health status

Politzer et al. 2001
69
What is Effective Primary Care?

• Care that is regular and usual, user-friendly,
  and engenders the trust of its patients
• Services that are integrated and accessible
• Care delivered by providers who are accountable
  for addressing majority of health care needs and
  who develop and sustain effective
  provider-patient relationships
• Considers the context of family and community
• Care that emphasizes prevention

Institute of Medicine report 1996
70
Need for Primary Care

• Minority and other economically vulnerable
  populations are less likely to receive health
  counseling on nutrition, physical activity,
  smoking, drinking drug use, STDs, etc.
• Racial disparities exist even on simple
  preventive screening measures such as pap smears,
  mammograms, and clinical breast exams
• Healthy behaviors and preventive screenings can
  reduce disease risks, detect disease in its early
  stages, reduce illness premature death

Politzer et al, 2001 Smedley, Stith and Nelson,
2003.
71
Culturally Sensitive Care

• Effective health care delivery must utilize
  culturally sensitive approaches
• Ethnic-specific health programs that use
  culturally responsive techniques can be effective
  in increasing utilization among minority groups
• BUT, there are no clear standards of what
  constitutes good cultural sensitivity training
  and little rigorous evaluation of the impact that
  such programs have on improving quality of care
• Little attention is given in discussions of
  cultural sensitivity to routine processes of
  unconscious and unthinking discrimination

Takeuchi, Sue Yeh 1995 Smedley, Stith and
Nelson, 2003
72
Cautions Regarding Cultural competence

• Some forms of content-oriented culturally
  competent training that emphasize negative
  stereotypes and lead to unconscious
  discrimination.
• Such unconscious bias is a likely contributor to
  the pervasive pattern of racial and ethnic
  differences in the quality and intensity of
  medical care in the U.S.
• In contrast, process-oriented approaches
  emphasize understanding and responding to the
  unique needs of every patient
• Key aspects of culturally appropriate care
  include devoting adequate time and attention to
  the patient, providing individual or group
  support, or both, and improved quality of care.

Smedley et al. 2003 Kehoe et al. 2003.
73
Care that Addresses the Social context

• Effective health care delivery must take the
  socio-economic context of the patients life
  seriously
• The health problems of vulnerable groups must be
  understood within the larger context of their
  lives
• The delivery of health services must address the
  many challenges that they face
• Taking the special characteristics and needs of
  vulnerable populations into account is crucial to
  the effective delivery of health care services.
• This will involve consideration of
  extra-therapeutic change factors the strengths
  of the client, the support and barriers in the
  clients environment and the non-medical
  resources that may be mobilized to assist the
  client

74
Active Outreach By Nurses

• A prospective randomized trial of 1,554 high-risk
  pregnant women (72 Black) found that telephone
  calls by nurses, one or two times each week
• Were effective in reducing low birth weight
  births
• Resulted in cost saving for African American
  mothers age 19 and over

Muender et al., 2000
75
Community Workers

• A randomized controlled trial of young mothers
  (97 Black) studied the effects of home visits by
  nurses during pregnancy and the first two years
  of life.
• Women who received home visits had
• fewer subsequent pregnancies
• longer intervals between the 1st and 2nd births
• fewer months of using AFDC and food stamps
• and were more likely to live with the childs
  father

Hayward, 2000
76
Telemonitoring

• A randomized trial with African American
  hypertensive clients found that nurse-managed
  telemonitoring of the clients at home and in the
  community, was successful in reducing both
  systolic and diastolic pressure

Artinian, Washington and Templin, 2001
77
Prenatal care in Guilford County, NC -I

• Standard prenatal care from private MDs compared
  to a program developed by a group of nurse
  practitioners
• All women had incomes below the poverty level and
  65 of the health departments clients and 82 of
  the MDs clients were Nonwhite
• The nurse practitioners attempted to
  comprehensively address the medical and social
  needs of the pregnant mothers.
• At prenatal care visits nurses counseled about
  nutrition, and other aspects of personal care,
  and made referrals to WIC
• These referrals missed clinic appointments were
  aggressively followed up

Buescher et al., 1987
78
Prenatal care in Guilford County, NC -II

• Women who received care from the community-based
  physicians were twice as likely to have a low
  birth weight baby, compared to those visiting the
  nurse practitioners at the health department
• The interpersonal quality of care and the
  positive cultural features of the care provided
  by the nurse practitioners may have been the key
  to the observed differences in outcome
• The nurse practitioners offered these low-income
  women an extended network of social support,
  capable of meeting their needs in the same way
  that older, more knowledgeable women have
  traditionally guided and supported young
  inexperienced mothers

Buescher et al., 1987 James 1993
79
Health Centers of Excellence

• Multiple strategies can be combined and
  integrated into a package of care offered by
  health centers
• Health care centers have been shown to be very
  successful in improving access to appropriate
  healthcare and reducing disparities in health
  status
• These community centers work to reduce
  eliminate access barriers in order to ensure that
  clients have a usual and regular source of health
  care
• These centers provide
• comprehensive preventive and primary health care
  services at low or no cost
• a broad spectrum of assistance and enabling
  services health education, nutritional
  counseling, transportation, translation,
  childcare, parenting classes, case management

Politzer et al., 2001
80
The Center for Health and Wellness, Wichita, KS

• A state-of-the-art primary health care facility
• Illustrates how barriers to health care for
  African Americans can be reduced
• Started in 1998 and is directed by nurse
  practitioner, Arneatha Martin
• Almost 8,000 sq. ft. 6 exam rooms, the center
  sees about 15,000 patients annually
• Less than 30 percent of patients are insured and
  the center uses a sliding fee scale for persons
  without insurance provides uncompensated care
  to the very poor

Center for Health and Wellness, 2002 MPH
Newsletter 2001
81
The Center for Health and Wellness, Wichita, KS -
II

• A heavy emphasis on prevention and wellness
  education and on decreasing high-risk behaviors.
  
• Attempts to deliver a seamless continuum of
  comprehensive healthcare services
• Has partnered with a broad range of service
  providers to offer a coordinated network of
  community support

82
The Center for Health and Wellness Innovation

• All clients of the center know that their
  insurance coverage and economic status are
  unrelated to the care and quantity of services
  that they will receive
• This is dramatically communicated to every client
  in that questions about insurance coverage or
  payment for care are not raised at the end of the
  health care visit, when the individual has
  already received all their needed medical care
• Clients can pay for services by volunteering at
  the clinic 10 deducted from bill for every
  hour volunteered at the center
• Clients also deduct from bill for each hour spent
  in health education classes.
• Points earned by expectant mothers for each
  prenatal appointment kept can be used to shop in
  the centers Storks Nest a room full of baby
  supplies

83
Reducing Inequalities IIReducing Negative Health
Behaviors?
Behavioral risk factors account for only 10-20
of SES differences in mortality and morbidity
Interventions addressing health behaviors
alone are unlikely to eliminate
disparities. 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
84
Changes in Smoking Over Time -I

• Successful interventions require a coordinated
  and comprehensive approach
• The active involvement of professionals and
  volunteers from many organizations (government,
  health professional organizations, community
  agencies and businesses)
• The use of multiple intervention channels
  (media, workplaces, schools, churches, medical
  and health societies)

Warner 2000
85
Changes in Smoking Over Time -2

• The use of multiple interventions
• Efforts to inform the public about the dangers
  of cigarette smoking (smoking cessation programs,
  warning labels on cigarette packs)
• Economic inducements to avoid tobacco use
  (excise taxes, differential life insurance rates)
• Laws and regulations restricting tobacco use
  (clean indoor air laws, restricting smoking in
  public places and restricting sales to minors)
• Even with all of these initiatives, success has
  been only partial

Warner 2000
86
Reducing Inequalities IIIAddress Underlying
Determinants of Health

• Improve conditions of work, re-design workplaces
  to reduce injuries and job stress
• Enrich the quality of neighborhood environments
  and increase economic development in poor areas
• Improve housing quality and the safety of
  neighborhood environments

87
Neighborhood Renewal and Health - I

• A ten-year follow-up study of residents in five
  neighborhood types in Norway found that changes
  in neighborhood quality was associated with
  improved health.
• Neighborhood improvements in a poorly functioning
  neighborhood included a new public school,
  playground extensions, a new shopping center with
  restaurants and a cinema, a subway line extension
  into the neighborhood, establishment of a sports
  arena and park, and organization of activities
  for adolescents by the municipal sports
  association.
• Residents of the area that had experienced these
  dramatic improvements in its social environment
  reported improved mental health 10 years later
• This effect was not explained by selective
  migration

Dalgard and Tambs 1997
88
Neighborhood Renewal and Health - II

• An intervention in a poorly functioning
  neighborhood in England was linked to improved
  social interaction/cohesion and health.
• This project refurbished housing (made it safe
  sheltered from strangers), improved traffic
  regulations, improved lighting strengthening of
  windows, enclosed gardens for apartments, closed
  alleyways, and landscaping. Residents involved in
  planning process.
• One year after the intervention had been in
  place
• Level of optimism, belief in the future,
  identification with their neighborhood, trust in
  other neighbors, and contact between the
  neighbors had all increased.
• Symptoms of anxiety and depression had declined.

Halpern, 1995
89
Neighborhood Change and Health

• The Moving to Opportunity Program randomized
  families with children in high poverty
  neighborhoods to move to less poor neighborhoods.
• It found, three years later, that there were
  improvements in the mental health of both the
  parents and the sons who moved to the low-poverty
  neighborhoods.

Leventhal and Brooks-Gunn, 2003
90
Reducing Inequalities IVAddress Underlying
Determinants of Health

• Improve living standards for poor persons and
  households
• Increase access to employment opportunities
• Increase education and training that provide
  basic skills for the unskilled and better job
  ladders for the least skilled
• Invest in improved educational quality in the
  early years and reduce educational failure

91
Increased Income and Health

• A study conducted in the early 1970s found that
  mothers in the experimental income group who
  received expanded income support had infants with
  higher birth weight than that of mothers in the
  control group.
• Neither group experienced any experimental
  manipulation of health services.
• Improved nutrition, probably a result of the
  income manipulation, appeared to have been the
  key intervening factor.

Kehrer and Wolin, 1979
92
Income Change and Health

• A natural experiment assessed the impact of an
  income supplement on the mental health of
  American Indian children.
• It found that increased family income (because of
  the opening of a casino) was associated with
  declining rates of deviant and aggressive
  behavior.

Costello et al. 2003
93
Economic Policy Health Policy!

• In the last 50 years, black-white differences in
  health have narrowed and widened with black-white
  differences in income

94
Changes in Mortality Rates per 100,000
Population, Age 35-74, Between 1968 and 1978 (Men)
Cooper et al., 1981b
95
Changes in Mortality Rates per 100,000
Population, Age 35-74, Between 1968 and 1978
(Women)
Cooper et al., 1981b
96
Changes in Life Expectancy at Birth Between 1968
and 1978 (Men)
Cooper et al., 1981b
97
Changes in Life Expectancy at Birth Between 1968
and 1978 (Women)
Cooper et al., 1981b
98
Median Family Income of Blacks per 1 of Whites
Source Economic Report of the President, 1998
99
Health Status Changes, 1980-1991

• Indicator 1980 1991
• Excess Deaths (Blacks) 59,000
  66,000
• Infant Mortality
• Black/White Ratio, Males 1.9 2.1
• Black/White Ratio, Females 2.0 2.3
• Life Expectancy
• Black/White Gap, Males 6.9 8.3
• Black/White Gap, Females 5.6 5.8

Source NCHS, 1994.
100
U.S. Life Expectancy at Birth, 1984-1992
NCHS, 1995
101
Reducing Inequalities VEngage Multiple
Communities

• Knowledge of the extent of disparities and their
  causes is a prerequisite for effective action
• In the U.S., over 50 of whites and over 50 of
  blacks are unaware that racial disparities in
  health exist.
• Partnerships needed with government, industry,
  and other private organizations
• Important role for community involvement in the
  identification and management of interventions
• Strengthen the capacity of community
  organizations to take action

102
A Call to Action

• The only thing necessary for the triumph of
  evil is for good men to do nothing.

Edmund Burke, British Philosopher