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3
Minority/White Ratio
2.5
2 B/W ratio
AmI/W ratio
1.5
API/W ratio
1 Hisp/W ratio
0.5
0
<1 1-4 5-14 15-24
Age
There Is a Racial Gap in Health in Mid Life:
Minority/White Mortality Ratios, 2000
2.5
Minority/White Ratio
2
B/W ratio
1.5
AmI/W ratio
1 API/W ratio
Hisp/W ratio
0.5
0
25-34 35-44 45-54 55-64
Age
There Is a Racial Gap in Health in Late Life:
Minority/White Mortality Ratios, 2000
1.6
1.4
Minority/White Ratio
1.2
1.0 B/W ratio
AmI/W ratio
0.8
API/W ratio
0.6
Hisp/W ratio
0.4
0.2
0.0
65-74 75-84 85+
Age
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
Lifetime Prevalence of Psychiatric Disorder,
60
by Race and Generational Status (%)
54.6
First
50
Second
43.4
Third or later
40
35.3
30.1
30
25.6
23.8 24.0
19.4
20
15.2
10
0
Caribbean Black Latino Asian
White
Death Rates per 100,000 Population
600
Black
500
400
300
200
100
1950 1960 1970 1980 1990 2000
YEAR
Age-Adjusted Cancer Death Rates for
Blacks and Whites, 1950-2000
300
White
Death Rates per 100,000 Population
Black
250
200
150
100
1950 1960 1970 1980 1990 2000
YEAR
Diabetes Death Rates 1955-1998
60.0 White 5.0
Am Ind 4.5
Deaths per 100,000 Population
Am Ind/W Ratio
40.0
3.0
30.0 2.5
2.0
24.3 24.4
20.0
1.5
17.0
1.0
10.0 12.6 11.7 11.9
10.4
8.6 0.5
0.0 0.0
1955 1975 1985 1995 1996-98
Year
50 White
40 Black
33.0
30
20
10
0
1900 1950 1970 1990 2000
Year
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
-- Major advances in medical research & technology
We have made little progress in reducing the elevated
death rates of blacks and American Indians relative to
whites.
Understanding Elevated Health Risks
Krieger, 1994
SAT Scores by Income
25 26.6
25.3
20 21.5
Poverty Rate
15
16.1 16.8
10
10.7
9.3
5
0
White Black AmI/AN NH/PI Asian Hisp. 2+ races
Any
Race
U.S. Census 2006
Racial/Ethnic Composition of People in
Poverty in the U.S.
2+ races, 2.6%
Hisp. Any
23.9%
White
Asian, 3.6% 46.1%
NH/PI, 0.17%
Black
23.1%
AmI/AN, 1.6%
2.0
1.5
1.0
0.5
0.0
<10K 10-19K 20-29K 30-39K 40-49K 50-99K 100+K
Black 17.3
Hispanic 15.1
Poor=Below poverty; Near poor+<2x poverty; Middle Income = >2x poverty but
<$50,000+
Source: Parmuk et al. 1998
Percent of Women with
Fair or Poor Health by Race and Income,
1995
Household
White Black Hispanic
Income
Poor 30.2 38.2 30.4
Near Poor 17.9 26.1 24.3
Middle Income 9.2 14.6 13.5
High Income 5.8 9.2 7.0
18
16 2.5
14 2
B/W Ratio
12 White
10 1.5 Black
8 B/W Ratio
6 1
4 0.5
2
0 0
<High High School Some College
School College grad. +
Education
Infant Mortality by Mother’s Education,
1995
20
NH White Black Hispanic API AmI/AN
18
17.3
16
14 14.8
Infant Mortality
12 12.7 12.3
11.4
10
9.9
8
7.9
6 6.5
6 5.7 5.9 5.5
4 5.1 5.4 5.1 5.7
4.2 4.4 4
2
0
<12 12 13-15 16+
Years of Education
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.
Race/Ethnicity and Wealth, 2000
Median Net Worth
Income White Black Hispanic
All $79,400 $7,500 $9,750
Excl. Hm. Eq. 22,566 1,166 1,850
Poorest 20% 24,000 57 500
2nd Quintile 48,500 5,275 5,670
3rd Quintile 59,500 11,500 11,200
4th Quintile 92,842
32,600 36,225
Richest 20% 208,023 65,141 73,032
Orzechowski & Sepielli 2003, U.S. Census
Wealth of Whites and of Minorities
per $1 of Whites, 2000
White B/W Hisp/W
Household Income Ratio Ratio
Experiences of discrimination
may be a neglected psychosocial
stressor
MLK Quote
Yes 17% 5%
Lauderdale, 2006
Discrimination and Disparities in Health
Discrimination accounts for some of the racial
differences in:
-- self-reported physical and/or mental health in the
U.S. (Williams et al, 1997; Ren et al, 1999; Pole et
al, 2005), Australia (Larson et al, 2007), South
Africa (Williams et al. 2008) & New Zealand
(Harris et al. 2006)
-- birth outcomes (Mustillo et al. 2004)
-- health care trust (Adegmembo et al, 2006)
-- sleep quality and physical fatigue (Thomas et al.
2006)
Discrimination and Health Behaviors
Recent studies indicate that experiences of
discrimination are associated with:
• Delays in seeking treatment
• Lower adherence to treatment regimes
• Lower rates of follow-up
• Poorer perceived quality of care
• Alcohol, tobacco and other drug use
Van Houteven et al. 2005, Banks & Dracup, 2006; Wagner & Abbott 2007; Wamala et al. 2007
Policy Area: Stress & Resources
Environment
20%
Behavior
50%
Genetics
20%
Medical Care
10%
• Reducing Smoking
• Improving Nutrition and Reducing Obesity
• Increasing Exercise
• Reducing Alcohol Misuse
• Improving Sexual Health
• Improving Mental Health
Reducing Inequalities I
Reducing Negative Health Behaviors?
*Changing health behaviors requires more than just more
health information. “Just say No” is not enough.
House & Williams 2000; Lantz et al. 1998; Lantz et al. 2000
Changes in Smoking Over Time -I
Successful interventions require a coordinated and
comprehensive approach:
Warner 2000
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
Moving Upstream
WHY?
WHY?
Centrality of the Social Environment
An individual’s chances of getting sick are largely
unrelated to the receipt of medical care
Place Matters!
Geographic location determines
exposure to risk factors and resources
that affect health.
Racial Segregation Is …
1. …"basic" to understanding racial inequality in
America (Myrdal 1944) .
2. …key to understanding racial inequality (Kenneth
Clark, 1965) .
3. …the "linchpin" of U.S. race relations and the source
of the large and growing racial inequality in SES
(Kerner Commission, 1968) .
4. …"one of the most successful political ideologies" of the
last century and "the dominant system of racial
regulation and control" in the U.S (John Cell, 1982).
5. …"the key structural factor for the perpetuation of
Black poverty in the U.S." and the "missing link" in
efforts to understand urban poverty (Massey and
Denton, 1993).
How Segregation Can Affect Health
100
90
80 86% Black
70
Percentage
70 66
60
50
40
30
20
10
0
a
nd
.
k
e
go
it
S
ic
ke
or
ar
ro
U.
ica
la
fr
w
au
Y
t
ve
A
De
Ne
Ch
w
ilw
le
th
Ne
C
u
M
So
Source: Massey 2004; Iceland et al. 2002; Glaeser & Vigitor 2001
Reducing Inequalities II
Address Underlying Determinants of Health
Year
65
60
1984 1985 1986 1987 1988 1989 1990 1991 1992
Year
NCHS, 1995
Policy Area
• grow up poor
• drop out of high school
• be unemployed in young adulthood
• not enroll in college
• have an elevated risk of juvenile delinquency and
participation in violent crime.
Spain 2 32 12
Italy 3 22 20
Mexico 4 28 26
France 8 26 6
Ireland 8 48 14
Germany 10 51 6
United States 19 55 16
United Kingdom 20 46 13
Sweden 21 7 2
Source: UNICEF (United Nations Children’s Fund), 2000
Child Poverty Rates
Country Before Taxes After Taxes
Netherlands 16.0 7.7
Spain 21.1 12.3
Sweden 23.4 2.6
Canada 24.6 15.5
Italy 24.6 20.5
United States 26.7 22.4
Australia 28.1 12.6
France 28.7 7.9
United Kingdom 36.1 19.8
Poland 44.4 15.4
Source: UNICEF (United Nations’ Children’s Fund), 2000
Policy Matters
40
White
Black
30
20
10
0
Never <1 week 1/week > 1/week
Sheila P. Burke
Faculty Research Fellow and Adjunct Lecturer in Public Policy, Kennedy School of
Government, Harvard University
Linda M. Dillman
Executive Vice President of Benefits and Risk Management, Wal-Mart Stores, Inc.
Allan Golston
U.S. Program President, The Bill & Melinda Gates Foundation
Commissioners
Kati Haycock
President, The Education Trust
Hugh Panero
Co-Founder and Former President and Chief Executive Officer, XM Satellite Radio
Dennis Rivera
Chair, SEIU Healthcare
Carole Simpson
Leader-in-Residence, Emerson College School of Communication and Former Anchor,
ABC News
Jim Towey
President, Saint Vincent College
Gail L. Warden
Professor, University of Michigan School of Public Health and President Emeritus,
Henry Ford Health System
Commission will Focus on Non-Medical
Pathways to Improve Health
Medical Personal
Care Behavior
HEALTH
HEALTH
Commission Activities will Garner National Attention
• Commission Launch
– February 28, 2008, Washington, DC
• Final Report
www.commissiononhealth.org