David R. Williams, PhD, MPH, is a leading social scientist whose work has consistently broken new ground in research about the complex ways that race, discrimination and socioeconomic status shape physical and mental health. He is a professor of public health at the Harvard School of Public Health.
Williams, who lectured on race, ethnicity and health at the June 2013 Robert Wood Johnson Foundation (RWJF) Center for Health Policy at Meharry Summer Institute, is also a former RWJF Investigator in Health Policy Research (1994).
A few days after the reconvening of the RWJF Commission to Build a Healthier America, of which Williams is staff director, he sat down with RWJF for a Q&A. He discusses why the nation has failed to stop health disparities and how the problem can be solved.
Q: Has the United States made significant progress toward eliminating health disparities linked to race or socioeconomic status?
A: We have made a little progress, but the overall evidence clearly indicates that health disparities are still large and widening for many populations in America. If you look at overall racial gaps in health, the differences in death rates from diabetes, for example, between Blacks and Whites is larger now than in the 1950s. The same is true of the diabetes mortality gap between Whites and Native Americans.
Q: Do you think that the implementation of the Affordable Care Act (ACA) will help to reduce disparities?
A: Many people are worried about the impact the ACA will have in those states that will not be expanding Medicaid. In those areas, the ACA may make it even harder for many of the poorer members of society to get health care.
But in general, the legislation holds the promise of helping many people by expanding opportunities for them to access preventive and primary health care.
The question is: What will really happen on the ground as the time comes for the law to fully take effect? Will Congress de-fund part of the program? We just do not know.
Q: America has invested billions in stopping health disparities. Why have we failed?
A: Because we are not doing what needs to be done. First, as a nation, we have not made the level of commitment necessary to make a real difference in disparities in health.
In 1899, W.E.B. Dubois wrote in his book The Philadelphia Negro that the most difficult problem in improving Negro health in America was the attitude of the nation. He said: “There have … been few other cases in the history of civilized peoples where human suffering has been viewed with such peculiar indifference.”
To a great extent, this is still true today. In addition, many Americans do not know the magnitude of ongoing disparities or the impact that they have on all of us as a society. The literature on all-cause mortality shows that when you look at declines in mortality [measured between 1991 and 2000], for every life saved, we could have saved five lives if we had eliminated Black vs. White disparities in health.
But it’s not just a moral issue; there is also great value in eradicating disparities from an economic standpoint. We know that health disparities among adults begin in early childhood. It is clear that we must invest in a healthy childhood for every child in the United States as that would lay the foundation for them to have good health for the rest of their lives.
We also know that as a society, we can save $17 for every $1 invested in the health of our children. Yet many of the policies that would make a real impact in this area are not being implemented on a large scale.
Q: What advice do you have for health care providers? How can they reduce the disparities they see among their patients?
A: Well, in all cases, the solutions we choose must be commensurate to the magnitude and complexity of the problem. Frequently, when someone becomes ill, we just address the disease, but people’s lives are not compartmentalized in that way.
Health is affected by where you live, learn, work and play. Medical care is only responsible for approximately 10 to 15 percent of what determines health. What’s the point in giving people the best possible medical care and then sending them to live in the same conditions that made them sick in the first place?
There are Robert Wood Johnson Foundation programs that recognize and address this situation, such as Health Leads. The program assists families with the resources that they need to create healthier lives.
If a mother has a child with asthma and the asthma is caused by poor housing conditions, medicine cannot help that child if the mother returns the child to the same housing after the child receives treatment. In cases like these, programs such as the RWJF National Center for Medical-Legal Partnership link clinicians and social workers with vulnerable families to help those families get the legal assistance needed to get out of unhealthy public housing. Another example of a program that helps people address a range of problems that lead to poor health would be the RWJF Nurse-Family Partnership.
The point is physicians cannot do it all by themselves. They need to work collaboratively with other professionals to address the root causes of disease. We must take a global approach, a community approach to solving the health disparities problem.
Q: Are you working on any new research related to disparities?
A: I currently have a paper in press that examines evidence about what kinds of interventions it will take, at multiple levels of society, to eradicate the impact of racism so that we can create a healthier society for all.
I am also directing a center [The Lung Cancer Disparities Center at Harvard] that addresses the persistent problem of tobacco use in the United States. This year, lung cancer will kill more Americans than breast, prostate, colon and pancreatic cancer combined! However, smoking is more concentrated among people in lower socioeconomic groups now than in the 1960s and 1970s, so the strategies that have worked to reduce smoking in general have been much less successful for our most vulnerable populations.
So we need to develop new strategies to reduce tobacco use in these groups. Our research shows, for example, that levels of psychosocial stress are much higher among smokers. Effective efforts to reduce smoking must include creative ways to reduce the stressors that are part of the underlying reason why many people still smoke.
Q: What is the most important thing we can do to eliminate health disparities?
A: We need to address disparities in the larger context of improving the health of all Americans. We need to develop strategies that help all of us to do better but that also improve the health of the disadvantaged more rapidly than the rest of the population. This will require that we bring more experts into the tent—not just academics, nurses, physicians and public health experts. We desperately need political scientists, communications experts, community activists and organizational leaders from across all sectors of society to work together to meet this challenge.
Learn more about the RWJF Center for Health Policy at Meharry Medical College.
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