PH201x: Health and Society Racial/Ethnic Disparities...Ichiro Kawachi, MD, PhD Monica Wang, ScD, MS...

Ichiro Kawachi, MD, PhD

Monica Wang, ScD, MS

Harvard School of Public Health

PH201x: Health and Society

Racial/Ethnic Disparities

Lesson objectives

1.  Analyze the different ways in which “race” has been used in the medical/public health literature as a marker of biological difference vs. social construct

2.  Evaluate the genetic contribution to racial disparities in health

3.  Analyze examples of racial discrimination at different levels of action (institutional, interpersonal, internalized)

http://www.cdc.gov/nchs/data/databriefs/db125.pdf


] 3.8 years

]7.6 years

Nature Genetics, November 2004, volume 36 (11s)

The biologic basis for “race” •  Existence of major genetic clusters based on

continental origin, using - multi-allelic microsatellite loci

- single nucleotide polymorphisms •  Clusters correspond roughly to major “racial”

groups – African-Americans, white Americans, Asian-Americans.

Relevance of genetic variations across “racial” groups for public health? •  Not proven (yet) •  Most population-specific microsatellite alleles are

unlikely to be functional •  Some well-characterized diseases such as sickle

cell can be traced to continental origin •  But there is no evidence (as yet) that the 3.8-year

average life expectancy gap between black & white Americans is primarily attributable to genetic differences

International comparisons of hypertension prevalence in European vs. African-descent populations

0 5

10 15 20 25 30 35 40 45 50

Nigeria

Jamaica

US black

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Sweden

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African-Origin Populations European-Origin Populations Cooper et al. BMC Med January 5, 2005


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10 15 20 25 30 35 40 45 50

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US black

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Cooper et al. BMC Med January 5, 2005

African-Origin Populations European-Origin Populations


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Jamaica

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US w

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Cooper et al. BMC Med January 5, 2005

African-Origin Populations European-Origin Populations

Overlap between whites and blacks in response to antihypertensive drugs •  Meta-analysis of 15 randomized trials of

black/white differences in response to antihypertensive agents

•  9,307 whites, 2,902 blacks •  Mean difference in response to treatment

between races ≈ 0.6-3.0 mmHg •  But standard deviations of response to

treatment within each race ≈ 5.0-10.1 mmHg

The majority of blacks and whites have similar responses to antihypertensive treatment

Sehgal, AR (2004). Overlap Between Whites and Blacks in Response to Antihypertensive Drugs. Hypertension, 43: 566-572. doi: 10.1161/01.HYP.0000118019.28487.9c

Conclusion

“Clinical decisions to use a specific drug should be based not on race, but rather in efficacy on individual patients, compelling indications, and cost.”

Sehgal, 2004

Sehgal, AR (2004). Overlap Between Whites and Blacks in Response to Antihypertensive Drugs. Hypertension, 43: 566-572. doi: 10.1161/01.HYP.0000118019.28487.9c

Race = biology? State of the evidence •  Growing reports of race-based differences in genetic

predisposition to disease (e.g. non-muscle myosin heavy chain 9 gene (MYH9) polymorphisms & end-stage renal disease in African Americans)

•  However there insufficient evidence (so far) that the 3.8-year average life expectancy gap between black & white Americans is primarily attributable to genetic differences

•  Meantime, there is plenty of evidence that unequal socioeconomic circumstances of blacks vs. whites can account for much of racial health disparities (Occam’s razor)

Class poll

Are racial disparities in health primarily due to: a)  Genetic differences between racial groups?

Not proven b)  Socioeconomic differences between racial

groups?

Two observations about relationship between race and SES

1)  Race is strongly correlated with SES in the United States (sometimes revealed after a natural disaster)

Hurricane Katrina, August 2005

L to r: Jocelyn Augustino, FEMA, http://commons.wikimedia.org/wiki/File:FEMA_-_14951_-_Photograph_by_Jocelyn_Augustino_taken_on_08-30-2005_in_Louisiana.jpg, PD; Jocelyn Augustino, FEMA, http://commons.wikimedia.org/wiki/File:Katrina-14890.jpg, PD; Marty Bahamonde, FEMA,http://commons.wikimedia.org/wiki/File:FEMA_-_15508_-_Photograph_by_Marty_Bahamonde_taken_on_08-31-2005_in_Louisiana.jpg, PD

Households living in poverty in New Orleans, 2000 Census

35

11

12.7

0

5

10

15

20

25

30

35

40

Black White National

% poverty

Poor households in New Orleans with no access to cars, 2000 Census

58.5

34.1

0

10

20

30

40

50

60

70

Black White

% n

ot o

wn

car

Two observations about the relationship between race and SES 1)  Race is strongly correlated with SES in

the United States

2) Race is strongly correlated with health status in the United States

Male average life expectancies

69.3 69.6 70.4 71.575.2

40

50

60

70

80

Black male,New

Orleans

Jamaica Algeria Tunisia USA male

Sources: American Human Development Project, Louisiana Human Development Report 2009; UNDP Human Development Report, 2008.

The Times-‐Picayune

Obituary Page

October 26, 2002

v

The Times-Picayune, Obituary Page, October 26, 2002

Quiz 1)  Race is strongly correlated with SES in the United States

2)  Race is strongly correlated with health status in the United States

Therefore, is the association between race and health confounded by SES? a)  Yes b)  No

Is the association between race and health confounded by SES?

Race Health

SES


Race Health

SES

No! SES is not a prior cause of Race (i.e., does not meet formal definition of a confounder).


Rather, SES partly mediates the association between Race and Health.

Race Health

SES

Up to two-thirds of racial disparities can be explained by SES differences between blacks and whites BUT there is also a residual “direct” effect of race on health.

Race Health

SES

“Direct” effect

Infant mortality by mother’s education

9.9

6.5

5.14.2

17.3

14.8

12.311.4

0

2

4

6

8

10

12

14

16

18

20

<12 12 13-15 16+Years of Education

Infa

nt M

orta

lity

NH White Black

“RACE”

Is it a proxy for-

•  SES? No! •  Biology? Not yet proven. •  Social construct?

U.S. policy for assigning racial status on birth certificates, prior to 1989

Source: LaVeist, Minority Populations and Health, Jossey-Bass, 2005

Father Mother Child White White White White Black ? White Japanese ? Black White ? Black Black Black Black Japanese ? Japanese White ? Japanese Black ? Japanese Japanese Japanese

U.S. policy for assigning racial status on birth certificates, prior to 1989

Father Mother Child White White White White Black Black White Japanese Japanese Black White Black Black Black Black Black Japanese Black Japanese White Japanese Japanese Black Japanese Japanese Japanese Japanese

Source: LaVeist, Minority Populations and Health, Jossey-Bass, 2005

2010 U.S. Census

Japanese policy for assigning racial status on birth certificates, prior to 1985

Father Mother Child

White Japanese ?

Black Japanese ?

Japanese White ?

Japanese Black ?

Japanese policy for assigning racial status on birth certificates, prior to 1985

Father Mother Child

White Japanese White

Black Japanese Black

Japanese White Japanese

Japanese Black Japanese

Brazilian policy for assigning racial status on birth certificates

Father Mother Child

White White White

White Black ?

Black White ?

Black Black Black

Brazilian policy for assigning racial status on birth certificates

Father Mother Child

White White White

White Black Mulatto

Black White Mulatto

Black Black Black

“Race” in Brazil •  Pretos (black) •  Preto Retinto (dark black) •  Cabra (slightly less black) •  Cabo Verde (even less black) •  Escuro (lighter still) •  Mulato Escuro (dark mulatto) •  Mulato Claro (light mulatto) •  Sararas •  Moreno •  Branco de terra •  Branco

Outdoor thermometer in Salvador, Bahia

Blond & ginger

Light morenos

Mulato & black

Dark morenos

Photo courtesy of Dr. Alexandre Chiavegatto Filho

Infant mortality by mother’s education and skin color, Brazil

Years of maternal educa:on

Infant mortality

rate

Victora et al. (1992), Maternal educa:on in rela:on to early and late child health outcomes: findings from a Brazilian cohort study. Soc Sci Med, 34(8):899-‐905.

Infant mortality by mother’s education and skin color, Brazil

Years of maternal educa:on

Infant mortality

rate

•  Innate biological difference? •  Residual difference in SES? •  Impact of discrimination? }

Victora et al. (1992), Maternal educa:on in rela:on to early and late child health outcomes: findings from a Brazilian cohort study. Soc Sci Med, 34(8):899-‐905.

Definition of racial discrimination

“The process by which a member of a socially defined group is treated differently (especially unfairly) because of his/her membership of that group*.” *group membership defined by race/ethnicity, gender, age, sexual orientation,

immigrant status, etc. -Krieger, Social Epidemiology chapter 3, p. 41.

[ ]

Levels of discrimination

•  Institutional •  Personally-mediated •  Internalized

Jones, CP (2000) "Levels of racism: a theoretic framework and a gardener's tale." Am J Public Health. 2000 Aug;90(8):1212-5.

Institutional discrimination? Contrasting media reports during Hurricane Katrina

http://carolineheldman.wordpress.com/2010/08/25/the-truths-of-katrina/; top: http://news.yahoo.com/news?tmpl=story&u=/050830/1913/w083049ajpg 18sep2005; bottom: http://rds.yahoo.com/S=53720273/K=%22two+residents+wade%22/v=2/SID=w/l=NIR/R=1/SIG=13k92p8pr/EXP=1127172410/*-http%3A//story.news.yahoo.com/news?tmpl=story&u=/050830/photos_ts_afp/050830071810_shxwaoma_photo1 18sep2005

Flooding and residential segregation in New Orleans (9/2/2005)

Lam et al. (2009). Business Return in New Orleans: Decision Making Amid Post-Katrina Uncertainty. PLoS One, 4(8): e6765. doi:10.1371/journal.pone.0006765

Levee break

Levee break

But wait a minute…

Isn’t residential segregation the result of personal choices about where people want to live?

But wait a minute…

Isn’t residential segregation the result of personal choices about where people want to live?

Yes, partly. But history and government

policies also contributed.

Birth of the modern mortgage •  At height of Great Depression, banks were extremely reluctant

to make housing loans •  Typical home loan in 1930 required 50% down payment, and

had to be paid off within 5-7 years at 6-8% interest •  In 1934, President Roosevelt established Federal Housing

Administration, to encourage new home building and to create jobs for unemployed construction workers

•  FHA-guaranteed mortgage program made possible 10% down payment, 30-year financing, at 5.5% interest

Home Owner’s Loan Corporation (HOLC)

•  To assist banks in making housing loans, the Home Owner’s Loan Corporation was established to create an inventory of all residential areas in the nation

•  Surveyors sent out to inspect for any sign of decay or neglect, as well as presence of black residents, Jews, and foreign-born whites (Poles, Italians)

•  Several hundred secret maps of “residential security” were produced

Residential grades A – First Grade (green) Free of black and foreign-born white residents.

Lenders encouraged to offer maximum amount.

B – Second Grade (blue) Lenders advised to make loans 10-15% below maximum.

C – Third Grade (yellow) Subject to “infiltration of a lower grade population”.

D – Fourth Grade (red) Lenders often refused loans. Often closest to downtown, or next to factories or railroad tracks.

Southeast Syracuse

http://syracusethenandnow.org/Redlining/OldRedlining/HOLC_Maps/Syracuse_1937_Redline_Map_SE.pdf

“It was the assumption of the era that when minorities moved into a ‘nice’ neighborhood, property values for all would soon suffer.”

“The great irony is that prior to 1937 this supposition held only

the power of myth; after 1937 it was mandated by law.” -Syracuse Then and Now, http://syracusethenandnow.org/

Redlining/HOLC_Maps.htm

[ ] [ ]

Cumulative impact of discrimination

•  Through history •  Across generations •  Over the life-course of individuals •  Across domains (e.g., discrimination in

education can influence outcomes in labor market, even if no further discrimination occurs in latter domain)

The contribution of unequal treatment in health care to racial disparities

Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (2003), Eds: Smedley, Stith, and Nelson

http://www.iom.edu/Reports/2002/Unequal-Treatment-Confronting-Racial-and-Ethnic-Disparities-in-Health-Care.aspx

But health care is just one domain in which racial ethnic minority groups experience unequal treatment

Discrimination has been documented in multiple domains…

Source points Health Care Labor Markets Education Housing Justice system

Consumer credit

Access to institutions or procedures

While functioning

within a domain

Movement thru a domain

Key actors

Source: National Research Council 2004

Discrimination has been documented in multiple domains…

Source points Health Care Labor Markets Education Housing Justice system

Consumer credit

Access to institutions or procedures

•  Hiring •  Interviewing

While functioning

within a domain

•  Wages •  Evalua:on

Movement thru a domain

•  Promo:on •  Layoffs •  Rehiring

Key actors •  Managers •  Customers •  Coworkers

Source: National Research Council 2004

Unemployment rates by race

0 2 4 6 8

10 12 14 16

Apr-09 May-09 Jun-09 Jul-09 Aug-09

% White

Black

http://www.bls.gov/news.release/empsit.t02.htm

Are Emily and Greg more employable than Lakisha and Jamal? A field experiment on labor market discrimination

Marianne Bertran (University of Chicago) and Sendhil Mullainathan (Harvard University)

•  Selected 1,300 help-wanted ads from Boston &

Chicago newspapers and sent identical résumés, differing only with respect to names.

•  5,000 applications submitted between mid-2001 and mid-2002.

Percentage receiving interview requests Common White Names %

Kristen 13.6 Carrie 13.1 Laurie 10.8

Meredith 10.6 Sarah 9.8 Allison 9.4

Jill 9.3 Anne 9.0 Emily 8.3

Average 10.3 Bertrand, Marianne, and Sendhil Mullainathan. (2004). "Are Emily and Greg More Employable Than Lakisha and Jamal? A Field Experiment on Labor Market Discrimination" American Economic Review, 94(4): 991-1013. DOI: 10.1257/0002828042002561

Common White Names % Common Black Names % Kristen 13.6 Ebony 10.5 Carrie 13.1 Latonya 9.1 Laurie 10.8 Kenya 9.1

Meredith 10.6 Latoya 8.8 Sarah 9.8 Tanisha 6.3 Allison 9.4 Lakisha 5.5

Jill 9.3 Tamika 5.4 Anne 9.0 Keisha 3.8 Emily 8.3 Aisha 2.2

Average 10.3 Average 6.9

Percentage receiving interview requests

Bertrand, Marianne, and Sendhil Mullainathan. (2004). "Are Emily and Greg More Employable Than Lakisha and Jamal? A Field Experiment on Labor Market Discrimination" American Economic Review, 94(4): 991-1013. DOI: 10.1257/0002828042002561

•  Applicants with white-sounding names were 50% more likely to be invited to interview

•  Same results in Boston & Chicago •  Racial gap rises with credential levels of

applicants •  No evidence of gender discrimination within racial

groups – men & women equally likely to be invited (or not)

Bertrand and Mullainathan results cont.

Race

Unequal treatment by institutions

(schools, workplaces, access to consumer credit)

Unequal SES

outcomes Health disparities

Pathways between race and health disparities

Race

Unequal treatment by institutions

(schools, workplaces, access to consumer credit)

Unequal SES

outcomes Health disparities

Perceptions of unfair treatment

Stress & maladaptive

coping responses

Pathways between race and health disparities

Internalized discrimination “Stereotype Threat and the Intellectual Test Performance of

African Americans” Claude Steele & Joshua Aronson, J Pers Soc Psych 1995;69(5):797-811.

•  “Stereotype threat” refers to existence of a negative stereotype about a group. In situations where the stereotype is applicable, affected member of group is at risk of confirming it.

•  Threat can be disruptive enough to impair cognitive performance.

Stereotype threat experiment •  24 black and 23 white Stanford undergraduates

randomized to take ½ hour GRE-V test

•  Half randomized to an initial questionnaire in which they were asked to provide information on their race; other half did not

•  Test scores adjusted for SAT scores

Results Mean Items Solved (Adjusted by SAT)

Steele and Aronson. (1995). Stereotype Threat and the Intellectual Test Performance of African Americans. J Pers Soc Psych, 69(5):797-811.

Stereotype susceptibility: identity salience and shifts in quantitative performance

•  N=46 female Asian-American undergraduates •  N=14 filled a survey inquiring about their sex and

gender-identity •  N=16 filled a survey inquiring about their ethnic identity

(e.g. what languages they spoke at home) •  N=16 control subjects filled out a neutral survey about

campus life

Shih et al. (1999). Psychological Science, 10(1): 80-‐3.

•  The female-identity-salient condition mobilized stereotypes about gender & mathematical ability

•  The ethnicity-salient condition mobilized stereotypes about Asians performing well on math tests

•  No baseline difference in Quantitative SAT scores between randomized groups (X = 750.9)

•  Everyone took a standardized 12 question math test over 20 mins

-

Stereotype susceptibility study (Shih et al., 1999)

Mean accuracy on math test

Shih et al. (1999). Psychological Science, 10(1): 80-‐3.

Life expectancy gaps

US Black vs. White: 3.4 years US Native American vs. White: 6 years Maori vs. Pakeha New Zealanders: 9 years Aboriginal/Torres Islander peoples vs. rest of

Australia: 20 years

Racial/ethnic health disparities takeaway messages Race is a social construct; cannot be conflated with SES Discrimination

•  occurs and is perceived through different forms (institutional, personally-mediated, and internalized)

•  exists across multiple domains

•  contributes to negative health outcomes over the lifecourse and across generations

PH201x: Health and Society Racial/Ethnic Disparities...Ichiro Kawachi, MD, PhD Monica Wang, ScD, MS...

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