Social and Behavioral Determinants of Toxic Stress

Social and Behavioral Determinants of Toxic Stress


Thank you so very much. It’s really good
to be here with you and to talk about an
important area of work that we need to think about
as we move forward, in terms of addressing toxic stress. And I will talk about social
and behavioral factors that play an important role
in triggering toxic stress. And that we have to
address if we will be successful in the long-term. And I will focus,
particularly in the time we have, on the question of race
and racial-ethnic differences in toxic stress. So, in the U.S. context… Before I talk about
racial-ethnic differences in toxic stress, I want us
to realize that as a nation we face a challenge. The US invests a lot in
the health care domain. Spends more money per
person and more money, absolutely than
any other country in the world on medical care. But on any health
outcome we look at, we tend to rank near the bottom
of the industrialized world. I picked the example
of infant mortality, where we ranked 11th in the
world in infant mortality in 1960. But in 2009, we ranked 31st. So over time, we
are losing ground, ranked behind other
countries that we don’t think of as our peer countries. And it’s not just the
minorities that are doing badly. I’ll talk a lot about the
minorities doing badly. But if white America
were a country in 2009, it would rank 29th in the
world on infant mortality. And black America
would rank 49th. An example of the magnitude
of the difference we have. And the differences that
exist in infant mortality death in the first
year of life, persists throughout the life course. So there are very large
racial differences in health. In fact, if you could… One way of thinking of the
size of the racial differences in health– Scholars
have come up with this concept
called excess deaths. And excess deaths for
a particular population describes the number
of individuals within that population
who die each year, that wouldn’t die if there were
no disparaging health. And in the United States,
96,800 black people die prematurely every
year, who wouldn’t die if the health of blacks
was identical to the health of whites. That’s 265 black people
dying prematurely every day. Imagine a fully-loaded
jumbo jet taking off from Boston Logan Airport,
or any of America’s largest airports. It took off and it crashed–
265 passengers and crew– and everyone died. And that happened today. And happened tomorrow. And happened every
day next week. And happened every
day next month, and every day for a year. That’s what we’re
talking about when we say there are racial
disparities in health in the United States. And think of what
Congress would do to move heaven and earth,
to find out why there was such a massive loss of life. Well, we have a
massive loss of life on such an unprecedented
scale that we need to address. And that we really
understand the importance of the foundation for
good health in adulthood is laid in childhood. And that there is
much that we can do to improve the health of all. One of the striking things
about racial disparities in health in the US, is
that they still exist today. They have existed
for a long time. So I’m showing you data on
infant mortality in the US, from 1950 to 2013. There’s good news and
bad news in the data. The good news is that
the racial gap in health absolutely is narrower
today than it was in 1950. The good news is that infant
mortality rates have declined for both groups over time. Those are the only two
racial groups in the US where we have data
going back that far. However, the bad news is that
in 2013, a black child born in the US is still
2.2 times more likely to die before his
or her first birthday than a white child. And that’s still a
huge disparity that is unacceptable in our country. We know that socioeconomic
status is a central determinant of variations in health. And it determines
the distribution of all desirable
resources in society. With health being one of them. And when I say
socioeconomic status, I’m talking about variations
by income, education, occupational status, or wealth. And just to illustrate, it’s
not only true for health, but every desirable resource. Here is SAT scores. And for those who
are not from the US, SATs an important exam taken
at the end of high school that determines where students
can go to college– the quality of college they go to. And here’s a relationship
between SAT scores and household income in the
2014 national data of students who took the SAT score. And you see this trait
graded relationship. Every higher level
of household income is associated with
a higher SAT score. Just illustrating the power
of socioeconomic status, shaping the resources
that households have to provide a secure
future for their children. Given this strong relationship
between socioeconomic status and everything,
including health, there’s not a
surprise that we have racial disparities in health. Because there are large
racial ethnic differences in socioeconomic status. This is a census report in 2014. Looking at median household
income in the United States. And I just have put it in a
form that you just can’t miss. For every dollar of
income whites have, Asian households have $1.15. Asian households
is a group heavily made up of immigrants, who
come to the United States with twice the level of college
completion than whites do. So they have higher levels of
income is not surprising given their high levels of education. However, that data
is misleading. If I look at just
household income, because Asian households have
more persons contributing to income, on average, than any
other racial-ethnic category, here. So if we did a per capita
household income measure, white households would
have the highest levels of per person income in the US. But the two disadvantaged
groups that we want to focus on– Latinos have $0.70
in income for every dollar of income whites have. And blacks have $0.59. What’s intriguing about
a $0.59 is exactly the racial gap between
blacks and whites in 1978. It’s identical to
what it is in 2013. Most American thinks we
have made much more progress than that. But even the data on
income, dramatically understate,
racial-ethnic differences in economic resources. Because income only tells us
about the flow of resources into the household. It doesn’t tell us anything
about the resources– the reserves– that we have to
cushion shortfalls of income. And if we look at racial-ethnic
differences in wealth– again from a 2014 census report. For every dollar of wealth that
whites have, blacks have $0.06. And Latinos have $0.07. That’s the magnitude of
the racial gap in wealth. And it’s an illustration of
why, in the United States, the minority poor are so much
poorer than the white poor. Or that there are more
poor whites than Latinos. And more poor whites than
poor African Americans. The minority poor are much
poorer because they, basically, have no economic cushion. One paycheck away from
being homeless when there is no wealth, in fact. The data also suggests that all
those socioeconomic status– these inequalities– drive
the differences in health. It’s not just
socioeconomic status. There is something else
about race that matters. And I’m illustrating that with
national data for the United States on infant mortality. This is all births, in the given
year, to mothers age 20 or over by mother’s education. And what you can see,
if you look here: At 12 years of education,
high school completion. Less than 12 years,
high school completion. Some college. And a college degree or more. We see the power of education. Every higher level
of education is associated with global
infant mortality rates. That’s exactly what
we would want to see. But we also see something
else that’s quite striking. We see the towering, excess
risk for African Americans. With African Americans
with a college degree still having rates
of infant mortality at about three times higher
than other racial groups. And the also stunning example,
that the most advantaged black women– black women
with a college degree or more education– have a higher
rate of infant mortality than white, Latino,
and Asian women who are high school dropouts. So a powerful
illustration of the fact, there’s something powerful about
socioeconomic status the drives health. But there’s something else
about race that matters a lot. So we are looking at what
might these distinctive social exposures be that drives
this poorer health for racial-ethnic populations? We know that part of it is
higher levels of stress. You think of any
psychosocial stress. Minorities have higher levels. They not only have
higher levels of stress, but they also have greater
clustering of stress. We’ve done recent work looking
at early childhood adversities. And for almost all of the
early childhood adversities, black and Hispanic kids are, in
fact, much higher than whites. And there’s also a huge gap
by income level in the United States. So this stress is not randomly
distributed in the population. And the higher levels and
the greater clustering are factors that
drive the poor health. In addition to that, there are
distinctive social exposures. The distinctive social exposures
I want to talk about is racism. Racism still persists
in American society. And in fact, it’s
deeply embedded in American culture that has a
powerful set of consequences. To illustrate that,
some scientists have created a database
of American culture. If put in one data set, books,
magazines, newspaper articles that average
college-educated Americans would read over his
or her lifetime. It allows us now, to look at
the association between pairs of words in American culture. So in this large database
of 10 million words, when black occurs
in American culture, what word tends to most
frequently concur with it? Poor. Then violent. Then religious. Then lazy. Then shareful. Then dangerous. So the ideas that blacks are
violent, lazy, and dangerous, are deeply embedded in
the American psyche. Reflecting how frequently,
these associations have occurred in your lifetime
as being a normal American. So when police
officers overreact to young, black males,
they’re not being bad cops. They’re being normal Americans–
reflecting the higher perceptions of violence
and dangerousness that instantly occurs
in the split second when they see someone
of a certain skin color. Just for comparison,
when white occurs in American culture– wealthy,
progressive, conventional, stubborn, successful, educated. When female occurs– distant,
warm, gentle, passive, male dominant, leader,
logical, strong. The size of the
coefficient is a measure of the associative strength–
how tightly clustered those particular
associations are. These stereotypes
are nontrivial. Because as a lot of
research indicates, that these negative stereotypes
leads instinctively– without conscious awareness–
to differential treatment. Another word for differential
treatment is discrimination. And there’s a growing
body of research documenting that discrimination
is one type of stressful life experience that has negative
consequences on health. I’ll illustrate that with
a measure of discrimination that I developed many
years ago, called Everyday Discrimination Scale. It is not a comprehensive
measure of discrimination. But it captures those
kinds of experiences, that are patterned into
the day-to-day experiences of individuals. Not big things, like being
stopped by the police, or losing a job, or not
getting a promotion. But being treated with
less courtesy than others and treated with less
respect than others. And people acting as
if you are not smart, or if they are afraid of you. To illustrate the
power of that work, I’m showing you the research of
one researcher, Dr. Tene Lewis, who was at Yale, now at Emory. And every line on
this slide represents a different published
scientific paper, relating everyday discrimination
to a particular health outcome. High levels of everyday
discrimination in adults predict high levels of
coronary artery calcification. That’s the development of
subclinical heart disease as measured in your artery. High levels of inflammation,
high levels of blood pressure, among pregnant women. High levels of low birth weight. High levels of
cognitive decline, in a sample of the elderly
followed over time. In a community
study, high levels of everyday discrimination,
poorer sleep. High levels of
discrimination in a sample of the elderly
followed over time, is an independent
predictor of death. Elevated risk of mortality
linked simply to the exposure to everyday discrimination. And finally, a study of
black and white women, high levels of discrimination
is literally making you fat. Not making you fat, but giving
you the bad kind of fat. Predicted high levels
of visceral fat, unrelated to subcutaneous
abdominal fat– which is the fat that it
is right under your skin. But a visceral fat is a deep fat
between your internal organs. The type of abdominal
fat that predicts higher rates of
cardiovascular disease, diabetes, and so on among
both black and white women. There was this association
between everyday discrimination and health. And by the way,
I should mention, that although when I
developed this scale, I was thinking about trying
to understand minority health. We now know that all persons–
This scale has been used in multiple countries. All persons report these
types of experiences. And the attribution of why they
experience it doesn’t matter. So that although the levels
of everyday discrimination are higher for whites
than for blacks. Whites who report
everyday discrimination, the effects on health
are in fact, the same. Discrimination also predicts
poorer outcomes for kids. It’s a recent review
by Naomi Priest. There are more than 100
published peer review papers looking at the effects
of discrimination on kids and including on parents that
have consequences for kids. In one study, racial
discrimination reduced the black-white gap in
preterm delivery and low birth weight. When you statistically
adjusted for it, the black-white gap in preterm
delivery and low birth weight was reduced to nonsignificant. So it’s not only a significant
predictor of outcomes, but it helps to explain
the residual effect of race that we often find. Another study in Detroit that
I did with some researchers. We found multiple
factors contributing to maternal depression. Like low education,
and food insecurity, and financial stress, and poor
housing, and lack of childcare. All of these are factors that
linked to maternal depression. But when everyday discrimination
was added to the model, none of the other risk
factors remained significant. Again, talking about
disadvantaged minority women, the central role that these
stressors play in their life. Another way in which racism
still matters for health, is the extent to which
the historical legacy of racist policies still persist
in residential segregation. The fact that individuals are
clustered in particular places. There’s nothing inherently
negative about living next to someone of your own race. But in the history
of the United States, segregation has not only
produced living next to someone of your
own race, but has produced the clustering
of social ills in particular places. And research reveals
that segregation affects health in multiple ways. Where you live,
determines your access to opportunities for education,
the quality of education, your access to
job opportunities, the quality of stressors
in your housing, and neighborhood environment,
and violence exposure, and so on. This is a study from David
Cutler and colleagues, showing how powerful segregation
is in the US context. Following a national sample
of black and whites, Cutler– an economist at
Harvard University– showed that if you
could statistically eliminate segregation,
you would completely erase black-white
differences in America in income, education,
and unemployment, and reduce black-white
differences in single motherhoods by 2/3. What this means is
that anything we do, if we will be
effective in addressing the social determinants
of health that drive the racial
inequalities in health have to address the
question of place. We need some
place-based strategies that seeks to improve the
conditions in which people live, learn, work, and
play to effectively address inequalities. How powerful is place? Two of America’s most
eminent sociologists said that in the 171
cities in the US, there’s not even one
city where whites live on this equal
conditions to blacks. And they’re the
worst urban context in which whites reside,
is considerably better than the average context
of black communities. That’s William Julius Wilson
and Robert Sampson, two Harvard sociologists. So neighborhood, place,
in multiple dimensions, determines whether a community
is healthy or unhealthy. And one of the
things we want to do is shift communities from
being unhealthy places to being healthy places. Because we can think of all
the dimensions by which place shapes opportunities
to be healthy. So what can we do? What are we learning from the
social and behavioral sciences? That effective solutions
to reduce toxic stress and improve health need
to be comprehensive. They need to start early. They need to be place-based. They need to address
the life course exposure to toxic stressors because
all of these things accumulate to produce
the outcomes that we see in early childhood. But we also see in later life. I think there’s much that we are
learning in this area and much that we want to apply in the
Center for Developing Child. As we move forward to develop
more effective strategies to address health
and the inequalities that persist in health. Thank you.

4 thoughts on “Social and Behavioral Determinants of Toxic Stress

  1. Well presented Dr Williams – your findings clearly demonstrate how deeply imbedded racism is in society. They also reiterate how inhumane the socioeconomic system is! Would you agree with the idea that without such a system in place, racism would be obliterated?

  2. Don't get it, so a pure black city does worse than a pure white city because whites are discriminating the blacks ? How come segregation of race make difference ? Segregation is caused by wealth. Wealth and resource is the cause not race. Blacks are poor and the education of black women doesn't help infant morality rate because educated black women are still poorer than other races. Why ? Labor market racial discriminate black women.

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