There is something about education and socioeconomic status that matters for human health. But even after that, there is something about race that matters profoundly for health as well.
With this simple framing, Harvard sociologist David R. Williams, Ph.D., M.P.H., an internationally renowned scholar in the social determinants of health, spent Wednesday, Feb. 28, in Portland constructing, as he said, “the house that racism built” and suggesting ways to rebuild, reversing sky-rocketing health care costs, and making America healthier for all.
“Americans are not the healthiest people in the world. But we should be,” Williams said, given that the U.S. spends more per person on health care than any other developed nation. “You can’t access the promise of American society if you don’t have good health.”
Williams gave the first community-facing installment of a new lecture series in health equity that is the brainchild of Brian Gibbs, Ph.D., OHSU vice president for equity and inclusion, whose decades-long collegial relationship with Williams then made it possible to get him to Portland to speak, and John Hunter, M.D., FACS, executive vice president and CEO, OHSU health system.
Their original idea was amplified by the vision of anchor donors Drs. Nathalie and William Johnson. Medical director of the Legacy Breast Cancer Institute and president of Moda Health, respectively, the Johnsons, along with their organizations, endowed the lecture through the OHSU Foundation and named it for Dr. DeNorval Unthank, a pioneering, African American physician in Portland (1899-1977).
"We have felt an urgency to bring the community together to understand the human and the financial costs of health disparities and the forces, including implicit bias in our health care system, which fuel them,” said Nathalie Johnson, M.D. “Because it is only as a community that we will solve them.”
Evening lecture drew 750 people
Williams’ free evening lecture, “Getting to Health Equity,” drew an estimated 750 community members, health care providers, public health advocates, students and public officials to Maranatha Church, a traditionally African American church in Northeast Portland.
At the lunch, hosted by OHSU’s Department of Family Medicine, Brian Frank, M.D., assistant professor of family medicine, laid out the costs of race-based health disparities – such as in emergency room visits and hospital readmissions; lost workforce productivity and higher insurance costs; depressed high school graduation rates and reduced workforce competitiveness.
John McConnell, Ph.D., M.S., M.A., associate professor of emergency medicine, OHSU School of Medicine, and director of the OHSU Center for Health Systems Effectiveness, discussed the Oregon Community Care Organization (CCO) Medicaid model as a tool for reducing these disparities. He was joined by research colleague Leann Johnson, director of the Oregon Health Authority Office of Equity and Inclusion.
During the lunch, President Joe Robertson. M.D., reflected an important role, among many, of academic health centers in this work.
“Academic institutions must remain a refuge of free, independent and respectful discourse," said Robertson. "It is our job to model how to engage in sensitive conversations in a thoughtful way.”
Williams is the Florence Sprague Norman and Laura Smart Norman Professor of Public Health at the Harvard T.H. Chan School of Public Health and professor of African and African American Studies and Sociology at Harvard University.
The author of more than 400 scientific papers, his research has enhanced our understanding of the complex ways in which race, racism, socioeconomic status, stress, health behaviors and religious involvement can affect physical and mental health. He has been invited to keynote scientific conferences around the world, has been ranked as the Most Cited Black Scholar in the Social Sciences and, in 2014, was ranked by Thomson Reuters as one of the World’s Most Influential Scientific Minds.
Discrimination wears away at health
Drawing from myriad national research spanning years, locality and demographics, Williams unfurled a narrative that went like this:
Income is inextricably linked to health, the more you have, the healthier you are. Education is inextricably linked to health. Again, the more you have, the healthier you are. Yet, even within these, race is a powerful predictor of health.
As one of many examples, at age 25, blacks with a college degree have a lower life expectancy than whites with only a high school degree.
Historic explanations blamed lifestyle choices of individuals or groups and/or since-debunked beliefs in the intrinsic inferiority of certain groups. In more recent years, national research documents that the key drivers of health disparities are such external and systemic forces as race-based residential segregation (impacting access to quality education, health care, food, exercise opportunities, etc.) and the effects on human beings of everyday discrimination, a measurement Williams developed and is used in health studies globally.
Williams likened the impact of discrimination over time to the continuous dripping of water on concrete. A few drops today or next week mean nothing. But, over time, the constant drip, drip, drip wears away at even the hardest of surfaces. The health analogy for African-Americans is the documented disparate levels of cardiovascular disease, cancer and, ultimately, premature death.
“Discrimination,” Williams said, “literally is killing people.”
And, said Williams, it starts early.
Research shows that African-American youth scoring high on the everyday discrimination scale at ages 16 and 17 already show higher levels of stress hormones, blood pressure, weight and inflammation by age 20.
Moving to solutions
Students across OHSU schools who dialogued with Williams Wednesday afternoon shared the role they intend to play in addressing these challenges.
“As future leaders in the field, we have to think beyond patients as diagnoses and begin to realize these issues as generational, structural factors and begin to build a dialogue,” said Adam White, a third-year student in the School of Nursing who helped plan Health Equity Week activities last fall.
Williams shared a number of solution-oriented steps, including learning about implicit bias, a natural aspect of the human condition in which each one of us forms snap judgments about every person we meet based on beliefs and perceptions deeply embedded in our subconscious beginning in childhood.
Understanding this natural, neurological phenomenon allows for learning to mitigate its negative effects. This is the goal of the Unconscious Bias Initiative (O2 link) that the OHSU Center for Diversity and Inclusion is now rolling out across OHSU to support a welcoming and inclusive institutional culture.
“I tell my students that I am a prejudiced person because I think of myself as a human being,” Williams said. “It’s a normal human process.”
Additional approaches include:
- Teaching health professions students the social determinants of health, such as the structural competency course now required in the OHSU School of Medicine M.D. program and projects like the Bridges Collaborative Care Clinic run by students across OHSU schools.
- Social and economic policies that support families and provide safe and nurturing environments for all children and families to thrive.
- Multidisciplinary approaches such as schools that offer social and health services, and clinics and hospitals that prescribe not only medicine but access to attorneys and other professionals who help patients address living conditions, such as a moldy, asthma-inducing apartment that renter protection laws require be addressed.
- Preparing not only public health professionals but lay community health workers to educate and empower communities on healthy practices.
The catalyst for change, said Williams, lies in developing the empathy and sympathy that comes from recognizing the avoidable human suffering that the status quo affords.
He ended his remarks at Maranatha Church with a call to action.
We must reach a point where we say, “This will not happen on our watch. Not in our country will we keep groups subjugated based on the color of their skin,” he said. “We need to look at the challenges we face with new eyes and say, ‘This is unacceptable in our country,’ and work together to eliminate it. It is in our national interest to do this.”