How racism, segregation drive health disparities
When David R. Williams, PhD, MPH, started his career, most researchers focused only on racial differences in education and income. But while economic status matters for health, there is more to the story of racial differences in health care. That’s why Dr. Williams developed a scale to measure the impact of discrimination.
Dr. Williams is now a professor of public health at Harvard’s T.H. Chan School of Public Health. He recently delivered a talk about racial inequality and social determinants of health at TEDMED in Palm Springs, Calif. For the last 25 years, he has been on a mission to understand why race matters so profoundly for health.
“What else is it beyond education and income that might matter?” Dr. Williams asked. There is a five-year gap between the life expectancy of blacks and whites at age 25, he said.
“At the same time, at every level of education, whites live longer than blacks,” he said. “Whites who are high-school dropouts live 3.4 years longer than their black counterparts … Most surprising of all, whites who have graduated from high school live longer than blacks with a college degree.”
Factors beyond education and income
In the early 1990s, Dr. Williams reviewed a new book on the health of black America. “I was struck that almost every single one of its 20 chapters said that racism was a factor that was hurting the health of blacks … Researchers were stating that racism was a factor … but they provided no evidence.”
Later, during a conference in Washington, D.C., Dr. Williams said that one of the priorities for research was to document the ways in which racism affects health. A man in the audience rose to speak, arguing that that while he agreed racism was important, it was not something that could be measured. Dr. Williams replied, “We measure self-esteem … there is no reason why we can’t measure racism if we put our minds to it.”
So that is what Dr. Williams did. He developed research methods that could measure racism.
The first captured major occurrences of discrimination, such as being unfairly fired or unfairly stopped by the police. “But discrimination also occurs in more minor and subtle experiences,” Dr. Williams said. His second instrument, the Everyday Discrimination Scale, examines nine items that capture experiences like being treated discourteously, receiving poor service in restaurants or being feared by strangers.
“This scale captures ways in which the dignity and the respect of people who society does not value [are] stripped away on a daily basis,” he said. “Research has found that higher levels of discrimination are associated with the elevated risk of a broad range of diseases, from blood pressure to abdominal obesity to breast cancer and even premature mortality.”
A study of young African-Americans, he said, found those who reported higher levels of discrimination as teenagers had higher levels of stress hormones, blood pressure and weight at age 20.
“Discrimination and racism also matter in other profound ways for health,” Dr. Williams said. “For example, there’s discrimination in medical care.”
In 1999, the National Academy of Medicine—then known as the Institute of Medicine—asked Dr. Williams to serve on a committee that concluded, based on scientific evidence, that blacks and other minorities receive poorer quality health care than whites in both simple treatments and the most technologically advanced.
Culture perpetuates bias
“One explanation of this factor was a phenomenon called implicit bias or unconscious discrimination,” he said. “Research for decades by social psychologists indicates that if you hold a negative stereotype about a group in your subconscious, and you meet someone from that group, you will discriminate against that person—you will treat them differently. It is an unconscious process. It’s an automatic process. It’s a subtle process, but it’s normal and it occurs even among the most well-intentioned individuals.”
One group of researchers has created a database that contains the books, magazines and articles that the average college-educated American would read over his or her lifetime. They can look through the database and see which words are commonly paired by race.
“Negative stereotypes and images of blacks in our culture literally create and sustain both institutional and individual discrimination,” Dr. Williams said. “When the word ‘black’ appears in American culture, what co-occurs with it? Poor, violent, religious, lazy, cheerful, dangerous.
“When ‘white’ occurs, the frequent [words] are wealthy, progressive, conventional, stubborn, successful, educated.”
Meanwhile, discrimination that exists in the processes of social institutions is known as institutional discrimination, Dr. Williams said. “Residential segregation by race, which has led to blacks and whites living in very different neighborhood contexts, is a classic example … One of America’s best-kept secrets is how residential segregation is the secret source that creates racial inequality in the United States.”
Dr. Williams presented evidence that where people live determines their access to opportunities in education, employment, housing and even access to medical care. “One study of the 171 largest cities in the United States concluded that there’s not even one city where whites live under equal conditions to blacks,” he said. “Another study found that if you could eliminate statistically racial segregation, you completely erase black-white differences in income, education and unemployment, and reduce black-white differences in single-motherhood by two-thirds.”
In 1978, he noted, black households earned 59 cents for every dollar of income whites earned, he said. In 2015, black families still earned 59 cents for every dollar of income whites earned.
“The fact is, racism is producing a truly rigged system that is systematically disadvantaging some racial groups in the United States,” Dr. Williams said. “That’s why I am committed to working toward dismantling racism.”
Anthony Iton, MD, senior vice president of healthy communities at the California Endowment, in August spoke to medical students at the University of California, Davis. The session, “Death by ZIP Code,” reflected a similar explanation. “In an ideal world,” he said, “where you live shouldn’t predict how long you live … When you’re seeing health disparities, you’re only seeing the tip of the iceberg. You’re not seeing all the underlying, structural inequities that produce those disparities.”