CENTER ON SOCIAL DISPARITIES IN HEALTH
University of California, San Francisco
Racial disparities in clinical outcomes:
Is racism a missing piece of the puzzle?
GME Grand Rounds
UCSF March 17, 2015
Paula Braveman, MD, MPH
Professor of Family & Community Medicine
Director, Center on Social Disparities in Health
University of California, San Francisco
More health care spending but less health: Life expectancy
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
Japan (82.3 years)
Australia
Canada
Spain
Sweden/Switzerland
Israel
Iceland
New Zealand
Italy
Norway
Ireland
United Kingdom
Greece
Austria
Netherlands
Luxembourg
Germany
Belgium
Finland
Korea
Denmark
Portugal
United States (78.2 years)
Chile
Slovenia
Czech Republic
Source: CIA: The World Factbook online, January 2011 (2010 estimate).
Higher income (or education), longer life
Life expectancy at age 25
60
55
Family Income:
58.2
Percent of Federal
Poverty Level
≤100% FPL
56.5
53.5
101-200% FPL
201-400% FPL
401%+ FPL
54.5
51.1
51.5
50
47.7
45.5
45
40
Men
Women
Analyses by Braveman et al. of
National Longitudinal Mortality Study, 1988-98.
Parents’ income (& education) shapes child health:
Poor/fair child health reported by parent
% of children age 0-17 years
with poor/fair health
6
Family Income
(Percent of Federal
Poverty Level)
5
<100% FPL
100%-199% FPL
200-299% FPL
300-399% FPL
≥400% FPL
4.3
4
3
2.4
2
1.4
1
1.0
0.6
0
Family Income (% of Federal Poverty Level)
Analyses by Braveman et al. of
National Health Interview Survey (NHIS) 2001-2005, Age-adjusted
Higher income (or education),
better adult health (self-reported)
% of adults aged ≥25 years
with self-reported poor/fair health
35
Family Income
30.9
(Percent of Federal
Poverty Level)
30
<100% FPL
100%-199% FPL
200-299% FPL
300-399% FPL
≥400% FPL
25
21.2
20
15
10
14.0
10.1
6.6
5
0
Family Income (% of Federal Poverty Level)
Age-adjusted analyses by Braveman et al., of
National Health Interview Survey (NHIS) 2001-2005.
Racial/ethnic differences do not explain
differences in adult health by income
Family Income:
% of adults age ≥25 years
with self-reported poor/fair health
40
Percent of Federal
Poverty Level
<100% FPL
100%-199% FPL
200-299% FPL
300-399% FPL
≥400% FPL
35
30
25
20
15
10
5
0
Black, Non-Hispanic
Hispanic
White, Non-Hispanic
Racial or Ethnic Group
Age-adjusted analyses by Braveman et al.
NHIS 2001-2005
Racial/ethnic differences do not explain adult
health differences by education
Educational attainment
%of adults age ≥25 years
with self-reported poor/fair health
40
Less than high school
High school graduate
Some college
College graduate
35
30
25
20
15
10
5
0
Black, NonHispanic
Hispanic
Asian Pacific
Islander
American Indian,
Alaska Native
White, NonHispanic
Age-adjusted analyses by Braveman, Egerter et al. of BRFSS 2009,
Both race and socioeconomic factors matter:
Self-reported adult health
% of adults age ≥25 years
with self-reported poor/fair health
40
35
Black, Non-Hispanic
30
White, Non-Hispanic
Hispanic
25
20
15
10
5
0
<100%
100%-199%
200-299%
300-399%
≥400%
Family Income (% of Federal Poverty Level)
Braveman et al. analyses of NHIS 2001-2005.
Age-Adjusted.
How could income (or wealth) affect health?
Income can shape:
• Medical care
• Nutrition & physical activity
options
• Housing & neighborhood
conditions
• Services
Which can affect:
• Stress
• Family stability
Parents’ income shapes
offspring’s:
• Education
• Occupation
• Income
• Work conditions
CENTER ON SOCIAL DISPARITIES IN HEALTH
University of Calif ornia, San Francisco
The stress-health link: Biologically plausible?
 Advances in neuro-science & psycho-neuro-immunology help
elucidate how social factors like income and education “get
into the body” & lead to chronic disease
 HPA axis, sympathetic nervous system, and
immune/inflammatory mechanisms have been demonstrated
as responses to stress
— Relative importance of specific mediators (e.g., cortisol,
ANS, cytokines, telomerase) not established
 Chronic stress is a plausible and likely major contributor to
both the socioeconomic gradient and racial/ethnic
inequalities in health
How could stress affect health?
STRESSOR
Hypothalamus
CRH
Pituitary Gland
ACTH
Adrenal Glands
CORTISOL
DAMAGE TO MULTIPLE
ORGANS & SYSTEMS 
chronic disease, immune
suppression, inflammation
Source: Center on Social Disparities in Health, UCSF.
Less income, more stressors.
Separation or divorce during pregnancy
(similar patterns for 11 major stressors)
% of women separated or divorced
during pregnancy
15
Family Income:
Percent of Federal
Poverty Level
≤100%
12.7
12
101-200%
201-300%
9
301-400%
7.0
>400%
6
3.6
3
3.0
1.2
0
Family Income (% of Federal Povery Level)
Braveman et al., analyses of CA Maternal & Infant Health Assessment 2003-2006.
13
Education can shape health behaviors by
determining knowledge and skills
Educational
attainment
•Health
knowledge
•Literacy
•Problemsolving
•Coping skills
•Diet
•Exercise
•Smoking
•Health/disease
management
Other plausible pathways from education to health,
e.g., via work & income
Income
Educational
attainment
Work
Neighborhood
environment
Diet & exercise
options
Stress
Workrelated
resources
 Health insurance
Sick leave
Wellness programs
Stress
Working
conditions
 Control / demand
imbalance
Stress
HEALTH
Psychosocial pathways
from education to health
Social
standing
Educational
attainment
Social
networks
Control beliefs
(powerlessness,
sense/locus of
control, fatalism,
mastery)
Social & economic
resources
Perceived status
Stress
Social & economic
resources
Norms
Social support
Stress
Coping
Response to
stressors
HEALTH
CENTER ON SOCIAL DISPARITIES IN HEALTH
University of Calif ornia, San Francisco
Childhood socioeconomic conditions
shape adult health
 Adult health is shaped by early experiences
 Lasting effects of in utero/early childhood deprivation, e.g.,
–  low SES in adulthood (by limiting education)
– May  neuro-endocrine or immune dysregulation
– Early childhood socioeconomic conditions could have
crucial effects not erased by later circumstances
 Chronic stress/deprivation in childhood

 chronic disease in childhood and adulthood
Cumulative effects of disadvantage
CENTER ON SOCIAL DISPARITIES IN HEALTH
University of Calif ornia, San Francisco
Structural racial bias transmits socioeconomic
disadvantage across generations
 The legacy of (once-legal) discrimination:
 Lower incomes, wealth, education, occupations
 And, at a given income or educational level, African
Americans and Latinos on average:
Have far less wealth
Live in under-resourced, often unhealthier neighborhoods
Were worse off in childhood
More hardship with fewer resources to cope
Rarely measured but studies often conclude a racial difference
is genetic if it persists after “control for SES”
– Race often captures unmeasured socioeconomic factors
–
–
–
–
–
Unmeasured socioeconomic differences
could increase African Americans’ risk of ill health
Racial segregation 
 Pollution, toxins, crime
 No safe places to exercise
 Pervasive unhealthy food
 Ads for harmful substances
 Social networks & support
 Norms, role models, peers
 Poor access to jobs 
lower income, less wealth 
financial hardship  stress,
hopelessness
 Poor quality schools
 Blacks tracked into poorer
neighborhoods than Whites
of similar income
Image: Dan Loh/AP
And direct psychological effects
of racism-related stress?
 Overt or subtle incidents
 Constant vigilance, fears about
loved ones
 Chronic stress increases risk for
chronic disease through HPA axis
activation  inflammation,
immune dysregulation (e.g., via
cortisol, CRH, ANS, cytokines,
prostaglandins…)
 Both race & SES matter:
Image: http://www.empowermagazine.com/how-racism-affects-your-health/
 Racism  low SES
 Race -- or racism?
Improving health & reducing disparities by
addressing the role of social factors
like racism and poverty
Policies to promote economic
development, reduce poverty,
and reduce racial segregation
Economic & Social
Opportunities and Resources
Policies to promote child
and youth development
and education, infancy
through college
Living & Working Conditions
in Homes and Communities
Policies to promote healthier
homes, neighborhoods,
schools and workplaces
Behaviors
Medical Care
Biology & Interactions between biology and experiences
HEALTH
Adapted from Braveman et al., Robert Wood Johnson Foundation Commission to Build a Healthier America |
www.commissiononhealth.org