How do our life experiences shape our health? What can we do to tackle social inequalities? Helen McKenna spoke with Professor David Williams from Harvard University about his research into the social influences on health and the interventions that could make a difference.
- Inequalities and inclusion in NHS providers
- 'We’re here and you’re there’: lived experiences of ethnic minority staff in the NHS
- Creating healthy places: perspectives from NHS England’s Healthy New Towns programme
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HM: Helen McKenna
DW: Professor David Williams
HM: Hello, and welcome to The King’s Fund podcast where we talk about the big issues and ideas in health and care. I'm Helen McKenna, a senior fellow here at The King’s Fund, and I'm going to be your host for this episode. Today I'm honoured to be sat with a guest who has been described as one of the world's most influential scientific minds and who has flown in this morning all the way from the United States to be with us here today and that guest is Professor David Williams, who is the Florence and Laura Norman Professor of Public Health and Chair of the Department of Social and Behaviour Sciences at Harvard University and who is internationally recognised for his research looking at the impact of social influences on health. David, welcome to the podcast.
DW: Thank you. It's good to be here with you.
HM: So, can you tell our listeners a little bit about who you are and what you do?
DW: I am a sociologist with training in public health and I have worked for the last 30 years as a researcher at three of America's best universities. I began my career as a faculty at Yale University and after I got promoted there after six years I then went back to University of Michigan, I say back to University of Michigan that's where I did my doctorial work, and then was a faculty there for fourteen years and I've been a faculty at Harvard since 2006. So I have conducted research, most of it in the United States but I've also led a major research project in South Africa and so I've been to South Africa about 18 times and I have collaborated with researchers especially in recent years looking at racial inequalities in health in Brazil and in Australia and other countries. Chile I'm currently collaborating with the research, looking at indigenous mental health in Chile.
HM: Okay, so hugely international and a long and illustrious academic career and we're fascinated by your work on the impact of racial discrimination on health -
HM: - and health outcomes and I want to just start by understanding how you began with this work. Can you talk us through what led you to start in this space? DW: I began to do work documenting, as many others had before, that there were large racial ethnic differences in health and most people thought that they were largely a function of socioeconomic inequality. There were racial differences in income and education and those drove the racial inequalities in health. So that if you looked at for example blacks and whites at the same level of income and education race wouldn't matter. When we began to look at that we found the patterns were more complex. No, there was still racial ethnic differences at every level of income and education and although in general the socioeconomic gaps in health were larger than the racial ones, but at every level of income and education race still matters. So there was something else -
HM: Going on.
DW: - about race that mattered and many researchers who studied racial inequalities in health talked about racism and that racism was a factor that played a role, but I was somewhat dissatisfied with simply the assertion that racism mattered without clear even articulating what the mechanisms might be and what the pathways might be and how it mattered and in the absence of any empirical evidence that racism was actually making a contribution. I remember in 1993 or thereabouts speaking at a conference and I was on the final panel and we were supposed to reflect on the last two days of presentations and think of where the field should go and I articulated that one of the priorities was to document a role for racism in health and really make that a priority and I recall one gentleman in the audience said, he agreed with me that racism was important but that what I was asking to do was impossible because racism could not be measured and I recall saying to him, "If we measure self-esteem why couldn't we measure racism if we put our minds to it?" and I think I put my mind to it and have been part of a team of researchers who do a lot of work on racism and health and I think it's a global phenomenon now.
HM: So you started by knowing that there was a disparity and saying, "Let's actually get the evidence - DW: Yes. HM: - and measure it," - DW: Exactly. HM: - and you pursued that and it's now widely recognised -
DW: Sure. HM: - and acknowledged, yes.
HM: Fantastic, thank you. So you've done a lot of research looking at the health effects of different types of discrimination and how they can impact on people's health, can you explain the different types of discrimination you've looked at and the impact that they can have?
DW: So I have developed measures that capture three aspects of interpersonal discrimination and then I've also done work, empirical work, on one dimension of institutional discrimination, so let me just talk quickly.
DW: In terms of interpersonal discrimination I've developed a scale that captures what I would call major experiences of discrimination. It's being unfairly fired, unfairly not hired for a job or being unfairly physically stopped, threatened or abused by the police. So it captures big events of discrimination. Probably my most famous scale is the everyday discrimination scale. It doesn't capture the big things it captures little indignities, being treated with less courtesy or respect than others, receiving poorer service than others at restaurants or stores, people acting as if they think you are not smart or if they are afraid of you. It's just little day to day things and…
HM: But they add up.
DW: They add up because the findings for that scale in general are even stronger than the findings the major experiences of discrimination. Both matter but everyday discrimination scale has been powerfully predictive of biological function across a broad range of indicators in multiple countries and it documents that just how we relate and treat each other on a day to day basis may not just matter for how they make the person feel or how their mental health responds, but it's literally leading to pathogenic processes within the body and people were adapting and were making changes in their life based on the reality that they thought they could be a victim. So I developed a scale called the Heightened Vigilance Scale. We ask people in dealing with these experiences how often you try to prepare for them before you leave home? How often are you careful about what you say and how you say it? How often are you careful about where you go? Basically it was trying to capture the steps that people were taking to minimise the occurrence of incidents of discrimination. What the research has found is that exposure to discrimination is linked to worse health but the threat of discrimination, vigilance about discrimination predicts health independent of the actual exposures. So it's both the actual exposure that matters but the threat of exposure also matters.
HM: Can you talk a bit about the disparity and the differences in health outcomes that we're talking about?
DW: So I'll give an example of one researcher, Dr Tanya Lewis, and she's done a lot of research in multiple studies looking at everyday discrimination and its effects on health. In one study she finds that greater exposure to everyday discrimination is associated with more rapid development of heart disease as measured sub clinically in the arteries as the development of heart disease over a five year window. Another study finds persons who report higher levels of everyday discrimination have higher levels of inflammation as measured by C-reactive protein. High levels of inflammation puts you at increased risk for most chronic diseases. Another study of pregnant women who report everyday discrimination they give birth to lower birth weight infants. A study of adults followed over time high levels of everyday discrimination is an independent predictor of premature mortality. Literally it raises the risk of death. Another study of elderly followed over time higher levels of everyday discrimination predicts more rapid declines in cognitive function over time. A study of black and white women high levels of everyday discrimination manifest what we call a dose response relationship between the exposure to discrimination and visceral fat. Visceral fat is the abdominal fat, the deep abdominal fat in between the internal organs that predicts elevated risks of cardiovascular disease and other chronic diseases. So just an example of the broad range of outcomes that we find everyday discrimination matters for.
HM: I know that while you're based in the US obviously you said you've done a lot of work internationally, you've also done a bit of work looking at these issues in a UK context, so I wanted to ask you about some of it as it applies here and in 2018, it's called the Embrace UK Report on the UK and Ireland confidential enquiries into maternal deaths and morbidities, sorry long name, found that compared to their white peers a black mother is five times more likely to die as a direct result of pregnancy or childbirth and I just wanted to ask, does that surprise you or is it simply in line with what you've seen in your research?
DW: It is completely in line. I have a slide in the talk that I give that shows a slide for the US and a slide for the UK, we see the same pattern. We see the same pattern with racial ethnic differences and infant mortality for the UK and the US. So yes, there's more similarity across context than differences and so, no, it is not surprising and we know that there are multiple factors that contribute to the pattern. One of them is racial ethnic differences in the quality and intensity of care, but it's not just about care there are racial ethnic differences in what I would call all of the opportunities to be healthy. So from the living and working conditions and exposure to at first influences in those contexts and then there are also differences in treatment and equality of intensity of care. In the UK context there is less evidence of racial ethnic differences in the treatment in quality and intensity of care but primarily because racial ethnic status is not routinely available in the medical records. So the studies that we could easily do in the US that documented this pattern in a very overwhelming fashion it's not readily possible to do them in the UK - HM: So actually … DW: - but there's no reason to think that the pattern is different.
HM: So the data is limited here.
DW: Exactly. HM: There's no reason to assume -
HM: - it would be any different.
DW: Correct. HM: You mentioned about differences in opportunities to be healthy there -
HM: - you've spoken previously about the impact the environment where someone lives has upon their health -
HM: - and that something we're interested in in our work her at the Fund. What's the relationship between people's health and where they live?
DW: In the US public health researchers today like to say that your postal code is a stronger predictor of how well and how long you will live than your genetic code and it's just one way of trying to highlight the fact that health varies dramatically by place. I have been part of a research project, I haven't been the driver of the maps, but part of a project that drew maps for different cities in the United States and showed how the life expectancy varied by which part of the city you lived in, which neighbourhood you lived in and one of the first maps was for Washington DC and we looked at the train system, the subway system, and looked at how life expectancy varied by which station you boarded a train and there have been maps for London that have been done like that.
HM: Yes, I think I've seen one for the Jubilee line -
DW: That's … exactly. HM: - and it shows, yes -
DW: Exactly, that's right. HM: - by each stop you're losing a year.
DW: Your stop matters for health. So there's a lot of evidence that the opportunities to be healthy, the access to high quality education, to jobs, the quality of neighbourhood and housing environments, the levels of stress exposure are all varied by place. So that place is a driver of just the opportunities for individuals to be healthy, all of these things shape health in profound ways and the evidence is that our bodies keep a record of all that we've been exposed to over our lifetime and so that what we have for many people in disadvantaged contexts is the accumulation of negative exposures over the life course that adds up in powerful ways to shape health.
HM: And in a physical way that just can't be forgotten.
DW: In a physical way that cannot be forgotten. In the United States there's a term that's being used called accelerated aging or premature aging or biological weathering. It's capturing evidence that suggests that disadvantaged racial ethnic populations like blacks in the US are literally biologically aging more rapidly than whites and we have good scientific evidence looking at a measure of telomere length for example which is capturing biological aging at a level of every cell of your body and we find if you look at blacks and whites at the same chronological age but the blacks biologically are seven and a half years older -
DW: - and it's other evidence documenting this pattern. So right, so it's again the cumulative, it's not one thing -
HM: No. DW: - but it's the accumulation and the clustering of social groups.
HM: And, as you say, with the accrual, so the stuff starts right from the off -
HM: - and then it's a lifetime.
DW: That's right, it's a lifetime.
HM: Here in the UK we've got organisations like Public Health England and the Department of Health, Health and Wellbeing Alliance who are undertaking work to try and tackle health inequalities by race. In terms of what you've seen from your experience in the US, what are the main actions that we in the UK need to be looking at?
DW: I think the first and most important thing I would emphasise is to start early. These effects become evident very early in life. We have overwhelming scientific evidence that the exposures and stressors that children experience in the first few months and years of life can have lifelong negative consequences. We also have good examples of effective interventions that can be implemented early in life that leads not only to better academic performance for their lifetime and better job skills for their lifetime, but better health and we have high quality scientific evidence that shows that these work and not only that they work but they literally save society money; that investment in early childhood interventions has a large return to society in terms of the greater productivity of the individuals who benefit from it and less dependent on the social service system and less involvement with the criminal justice system. So it's a win win that helps the next generation. What do we do for the current generation? We have high quality scientific evidence as well that interventions that improve economic wellbeing, that provide additional income to struggling families that improves neighbourhood and housing conditions lead to improvement in health even in the absence of any health intervention. Those interventions are more challenging in that it takes a commitment of economic resources, but there's evidence that it can be done and they will work and they do have positive effects. When I think of the challenge of inequalities, I think the biggest challenge we face in our world today is the political will - HM: Yes. DW: - to make the changes.
HM: And you talk about the political will, why is it not there yet?
DW: I think there is research that suggests that there are many dominant frameworks that individuals have of making sense of social inequalities in health and why some disadvantaged populations are not doing well that leads them to blame the individuals or blame the groups that maybe it's not our responsibility if we think that people are doing badly because of their own choices because they haven't bought into the right set of values and that's what's the driver of the inequalities. There's also a very sobering body of research suggesting that there's what the scientists call an empathy gap, that for most people on the planet we tend to feel greater empathy, greater identity with the suffering of what happens to someone of own group as opposed to someone of a different group. There's research from both Europe and the US that shows that how we feel about a group drives our policy preferences towards a group and so one of the things I think we need to do as advocates is how do we tell the story of the challenges the disadvantaged populations face in ways that resonate with the general public and in ways that connect with them emotionally so that they feel empathy, because when we feel empathy we respond and we take action?
HM: Yes. So relating to your other groups in an empathetic way –
HM: - and in a human way and what do you think is needed to bring about a step change so we can really make headway in tackling the level of inequality that we have?
DW: I think there are many ways in which we have made progress and there are many ways in which we take two steps forward and one step backwards. So I think that we are in an era of increasing hostility. Research that I and other have done finds that the policy and the larger hostility in the environment also directly adversely impacts health. We have a number of studies in the US context that shows the climate created by the last presidential election has led to worsening health of vulnerable populations, increases in preterm birth in the Hispanic population nationally in the US. We've looked at the impact of immigration raids on the community in which they occur and lead into worsening health for those populations, we have done work published in Lancet documenting that the police shooting of an unarmed black man leads to worsening health for the entire black population in the state in which it occurred for the next three months. So what I'm saying is all of the events, the political and social events in our communities that are so tension filled and hostility filled is literally harming health in ways that many people are unaware of or don't think about.
HM: And it's making this work harder.
DW: It's making the work harder, it's making the political context of getting values driven investments harder because other groups instead of seeing our common humanity and seeing our destinies being tied to each other because we're all part of the web of the society.
HM: Now I know that you've done some work with NHS England's workforce race equality team and the work of that team focuses on race equality and fair treatment for the black and minority ethnic staff that work in the NHS, they've developed the workforce race equality standard which seeks to better understand and measure what's going on for BME staff and encourages action to try to address those issues. However, the NHS still has a problem and the latest data from 2018 shows that 15% of black, Asian and minority ethnic staff reported experiencing discrimination at work in the last twelve months, and that's compared to 6.6% of white staff. I just wanted to ask what is your take on those findings?
DW: Not surprising (laughter). HM: Yes. DW: A 2017 survey in the US found that 60% of physicians in the United States reported discrimination at work based on their gender, their race, ethnicity, their religion, their sexual orientation. So across the board. It's a problem, it's not widely recognised by the leaders of many of our health care systems and so we are not implementing interventions that would be effective. I can give an example from Canada where they have implemented interventions to reduce incivility at work and they found that those interventions they are effective in reducing incivility and discrimination in the workplace and they lead to greater commitments of individuals to workplace, greater productivity, fewer missed days from work and we have scientific evidence of the kinds of things that could be done that would make a difference. It's the commitment, the recognition of how large and serious the problem is because if we don't take care of our employees within the NHS or any other workplace their ability to care for their patients is adversely impacted. Ensuring workers that are fulfilled and are not harassed and discriminated against in the work context is in the best interests of the NHS being successful in doing the job it wants to do of delivering high quality care to every person who comes to the NHS.
HM: Absolutely, including its staff.
DW: Exactly. HM: Presumably from the research you've done to understand the impact of this type of discrimination on health you'd expect to see this data and the level of discrimination taking its toll on the health of NHS staff and those staff - DW: Yes. HM: - impacted.
DW: The research in the UK has shown that it adversely impacts its staff but there's also very strikingly a link between the level of discrimination staff experience and the staff in a particular NHS Trust experience and the outcomes from the patients who have been treated in that facility and how satisfied they were with their care. So when staff are not well cared for it impacts the care they're able to provide to others.
HM: And it's just to me a huge obviously tragic irony that our health service is making our own staff ill. So I wanted to talk a little bit about leadership and your journey, so we've talked about your research into the relationship between racism and discrimination and health, and in the context of wider conversations around race particularly in the US, what's been the response to your research and has that response changed over time?
DW: I mean in many ways there are very positive responses. I'm heartened by the number of young students I encounter today and who are interested in the topic, who would like to learn more, who are completely dissatisfied with what the evidence says and feel we can build a better future. So it's on the one hand it's great that we have more people aware, more people interested, more organisations interested, more demands to come and talk about the topic so that's good. At the same time, as I mention, there are other trends in our society that are leading to increasing hostility and leading to the public expression and celebration of views that have been rejected in all societies for a long time. It's the best of times and it’s the worst of times is the way to think of it.
HM: Just listening to you some of the stuff that you've said in our discussion around the strength of the evidence, also the strength of the evidence base for the interventions that work and some of the actions we already know we could take to sort this stuff out, it feels immensely frustrating to be where we are now despite all of that and I guess I wanted to ask you how frustrating it is from your perspective to be doing this when progress is so slow.
DW: Yes, so I think I tend to be an optimist and I tend to see the glass as half full not half empty. I'll give you one simple example, I teach a course at Harvard University and Harvard College, it's an undergraduate course, it's called poverty, race and health. It deals with social inequalities by socioeconomic status, by race, ethnicity, what we can do about it and interventions and I would say for ten years before the last presidential election my class has had 20 to 35 students every year that I teach it. I've taught it three times since the election, my enrolment jumped from 20 to 35 students to 79 students, to 105 students and I'm teaching it now 166 students.
DW: So for me that in and of itself is a sign. I haven't changed the way I taught the course it's the same course I have taught for years, but there is so much more student interest in understanding these issues with the commitment to making America a better place and my student … my class is very diverse in terms of the racial ethnic background of the students who are there. So just even that is an example of a sign of progress in a way that more people are interested, more people are concerned, more people want to dig deeper and try to understand these issues. So, yes, there are reasons to be concerned but there are reasons to be hopeful.
HM: And do you think that's symptomatic that yes while it's the debate and the environment has become so much more polarised actually previously there may have been some complacency and there's actually a fight back and a resistance?
DW: Yes, it does reflect that. I think again we have seen the efforts in both directions that there is a push back, there is a resistance that has been mobilised, at the same time there are many people who are emboldened and are more aggressively pursuing an agenda that only fosters hostility of other groups that are not valued.
HM: So final question from me, I've got in front of me a quote from a talk you gave back in 2016 where you said, "I'm standing on the shoulders of those who have sacrificed even their lives to open the doors that I've walked through. I want to ensure that those doors remain open and that everyone can walk through those doors." I just wanted to ask you if you could tell us a bit about this quote and what it means.
DW: Yes. It is in part what motivates me, America has had a very painful history, I'm an immigrant to the United States, grew up in a British colony and I have benefitted from doors of opportunity that have been opened in the United States and I think by any measure I have done better than I could have ever dreamed I would have done on the one hand, at the same time the problems still exist and in some ways while we've made some improvements in other ways some problems are getting worse and I think that to whom much is given, much is required. So I do see myself, I see my life as to be lived with a sense of responsibility, I need to treasure the memory, the commitment that others have made and I can honour them by continuing their legacy of working to provide dignity and best outcomes to every child of humanity regardless of where they're from or what their beliefs are or what their sexual orientation is or what their gender is. It's just everyone to me, that's what life is about and that's what all of us are called to do. So, yes, I do take … I do think I'm blessed but I think with it comes responsibility that I have to lead and so that means I need to be involved in training the next generation and one of the challenges we face especially in the US context is many of our institutions are trying to get the best and the brightest from disadvantaged backgrounds but not investing in what it takes to expand access to opportunities very early in life so that we can have much larger cohorts of people prepared to take advantage of the opportunities society offers.
HM: Thank you. Thank you so much for the time that you've given us today.
DW: You're very welcome.
HM: Professor David Williams.
DW: Good talking to you.
HM: Thank you. Well that's it from us, you can find the show notes for this episode and all our previous episodes at www.kingsfund.org.uk/podcast. I'm Helen Mckenna and thanks as always to our producers Ian Ford and Sarah Murphy and also a huge thanks to Professor David Williams. If you enjoyed this episode why not subscribe to The King’s Fund podcast and get the latest episode downloaded straight to your device. Thank you for listening, hope you can join us next time.