Harvard Public Health Review Winter 2007
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Exposing the Roots of Health Disparities

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In his latest bid to unearth the dark, tangled roots of disparities in health between blacks and whites, Harvard School of Public Health (HSPH) newcomer David R. Williams has gone to South Africa. Using the country as a kind of living laboratory, Williams is leading an effort to assess the effects on blacks' mental health of psychological and physical torture during almost 50 years of apartheid, which ended in 1994.

The South African Stress and Health Study, as it is known, is a pioneering epidemiologic effort to survey the prevalence and severity of mental disorders in the population, and to explore these disorders' association with the violence and torture of the apartheid years. Through interviews with almost 4,500 subjects, Williams and colleagues hope to identify factors, ranging from mental health services to social support networks and religion, that may have cushioned the blows of violence in the short and long term.

"There's never been a study looking at an entire population shortly after exposure to torture," Williams says of the project, part of a global World Health Organization initiative. "We knew about the persecution of activists Nelson Mandela and Steven Biko, but what percentage of the population has suffered?"

Insidious racism
Williams looks at social policies and historical patterns of discrimination through a sociologist's lens. By sifting and sorting data in fresh ways, he has cast new light on the causes of blacks' poorer health and rates of survival, observe his new colleagues at HSPH. In August, Williams joined the faculty as the Florence Sprague Norman and Laura Smart Norman Professor of Public Health in the Department of Society, Human Development, and Health.

What intrigues Williams are not just extreme forms of racism, but their subtler, more insidious, day-to-day manifestations. A huge body of research on health disparities has led him to conclude that stress resulting from institutionalized racism and discrimination, be it real or perceived, blatant or muted, is an "added pathogenic factor" that contributes to well-above-average levels of hypertension, respiratory illness, anxiety, depression, and other ills in minority populations. Socioeconomic status is just part of the problem. While lower-income people generally tend to be less healthy, Williams says, "blacks do more poorly than whites at every level of socioeconomic status."

The roots of health disparities run so deep that they're invisible to most of society, he has found. "A lot of what I struggle with is understanding the larger social, political, and economic context in which health is embedded and the broader forces, many of them hidden, that shape mobility and access to health care," Williams says. "I have argued, for example, that residential segregation, resulting from historical racist policies, is a fundamental cause of excess levels of ill health in the African-American population."

Segregation by neighborhood is so high at every income bracket in the United States that, in many cities, it comes close to levels once legally mandated by apartheid in South Africa, Williams says. Sixty-six percent of blacks would have to move in order to distribute blacks and whites evenly.

Truth in numbers
Over the past decade, Williams has been among the top 10 most-cited researchers in the social sciences. His more than 100 papers have yielded insights such as these:

Blacks die at twice the rate of whites in the age groups 1–4 and 25–54--a grim fact often missed in comparisons of overall mortality rates, which yield a 30 percent mortality disadvantage for blacks.

In Pitt County, North Carolina, the odds of having hypertension were seven times higher for black men who as children and adults had low socioeconomic status (SES) than for black men whose SES was high.

In Mississippi, home to the highest heart disease death rates in America, the healthiest black women die from heart disease at a greater rate than the sickest white women.

According to Joseph Betancourt, MD, MPH, director of the Disparities Solutions Center at Massachusetts General Hospital and a senior scientist in MGH's Institute for Health Policy, Williams "understands the issue of disparities in its entire breadth and depth--discrimination and socioeconomic status, community and societal factors. Few people have that expertise."

Betancourt and Williams served together on the National Academy of Science's Institute of Medicine committee that issued the landmark 2003 report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. The authors found that, even when they had overcome barriers to getting health care, African-Americans and other minority populations were still less likely to receive certain high-tech, expensive, yet common procedures such as coronary bypass operations, kidney dialysis, and kidney transplants. They were more likely, however, to undergo certain other procedures, including lower-limb amputations for diabetes. Why this is so continues to be a subject of research. Possible explanations include health care providers' biases, miscommunication, and blacks' lack of trust in the largely white health care system.

If death rates for blacks and whites were equal, the authors wrote, about 100,000 fewer black Americans would die every year. In fact, blacks are still dying at rates whites did 30 years ago. "And this is not an act of God," Williams points out dryly.

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Richard Saltus has been a reporter for the Associated Press, the San Francisco Examiner, and the Boston Globe. He writes about science, medicine, and public health.

Photograph: Patrick Doherty/The Image Bank

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David T. Williams

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