On this episode of the podcast we talk about the social determinants of health with UW Tacoma Assistant Professor Sharon Laing and UW Associate Professor Wendy Barrington. Laing and Barrington research how different factors, including racism, impact a person's health. We'll talk about how racist policies and practicies negatively impact health outcomes for people of color. These outcomes include higher instances of certain diseases and a lower average life expectancy.
Listen to Part II: https://www.buzzsprout.com/265902/5067431-racism-is-a-public-health-crisis-part-ii
Grown up thinking that if you try hard enough, you'll be able to succeed. And that's not the case. There are those who are more able to succeed than others, regardless of how much you try and that needs to change. If we truly are going to be an equitable society, those opportunities need to be equally available to individuals and populations.
From UW Tacoma, this is Paw'd Defiance.
Welcome to Paw'd Defiance, where we don't lecture, but we do educate. I'm your host, Eric Wilson-Edge. Today on the Paw'd, the social determinants of health with UW Tacoma Assistant Professor Sharon Laing and UW Associate Professor Wendy Barrington. The pair research how different factors, including racism, negatively impacted the health outcomes for people of color. We'll discuss the correlation between poverty and racist policies and practices. We'll also talk about how racism impacts quality of life for communities of color, including average life expectancy.
Dr. Wendy Barrington, Dr. Sharon Laing, Thank you for joining us today on Paw'd Defiance. I thought we would start with introductions. Dr. Laing, can you go first?
Certainly. And thank you, Eric, for having us here. My name is Sharon Laing and I'm an Assistant Professor in the School of Nursing and Healthcare Leadership at the University of Washington in Tacoma. My training is in psychology actually, specifically health related psychology. And I like to, just a little bit, talk about the lens through which I will be having this discussion today. I've conducted research in community based settings, and I have a strong interest in looking at health disparities, particularly looking at health outcomes around breast cancer for African American women, as well as low income communities. And so this is research that I've done as a doctoral level student and continued on and post-doctoral work.
I do want to talk a little bit about what brought me here and why I wanted to do this today. Certainly, the nationwide tensions that we're going through now addressing inequity and injustice has really kind of moved me to do this work today. As a researcher, you're in your enclave, working directly with your communities to address specific issues at the individual level. You hope that your work reach a pocket in the community level and the population level, so your dissemination of your research for instance. But this is an opportunity, I think, for me to use my expertise, my research experience, my personal experience as an African American woman. Certainly, I have my privilege as an African American professor to really hopefully reach a broader audience and hopefully, infuse some of the research that I'm doing addressing disparities and social determinants of health to understand where we're at in this country and where we're going, particularly in light of the COVID-19 crisis. Thank you so much for having me here today.
It's a pleasure to be in conversation with you all today. Thank you. I'm an Associate Professor at the UW School of Nursing Seattle Campus and an epidemiologist by training. My research has centered on understanding and addressing disparities and obesogenic behaviors and cancer outcomes in partnership with communities and health systems, much like Sharon. I teach graduate level courses on social determinants of health and fostering health equity, as well as epidemiologic methods.
As a mixed black woman, I strive to name power and privilege and all facets of my research and teaching as it informs how I, actually how everyone, asks questions, interprets and communicates information, as well as take action. The current Black Lives Matter moment has further pushed me to make my positionality explicit, in not only embracing my blackness, but also acknowledging that my blackness is often less visible to society because of my light skin, and this, along with my position in academia and other socially normative identities, has extended me substantial privilege and many blind spots when it comes to understanding complex social dynamics. I really do like to kind of set the stage and be very clear about who I am and my experiences and how that really informs my perspective. Thank you.
Thank you both for that. Today we are talking about the social determinants of health. Now for folks listening, who maybe haven't heard this term, let's talk about what that means, and also how to things like colonialism and racism impact social determinants of health.
Great. I'm happy to kind of jump in and just get the conversation started. Social determinants of health as a concept has been defined by many. It's really gaining traction in not only kind of academia and research, but also kind of conversations at the policy level. The World Health Organization describes social determinants of health as the conditions in which people are born, grow, live, work, and age. And examples of social determinants of health are social and built environments, economic and educational opportunities and access to healthcare.
Now, the World Health Organization and others also describe how social determinants of health are shaped by the distribution of money, power, and resources at the global, national and local levels. Dr. Camara Jones, former President of the American Public Health Association, calls the mechanisms that shape this distribution the social determinants of equity.
Now, how does this relate to settler colonialism, white supremacy, whiteness, and racism. And I'm saying a bunch of words here that are really uncomfortable for all of us to hear and say, but let's do it. We're at this point where we really have to be explicit and intentional and engage in these kinds of conversations and come to these understandings in order to move forward constructively.
First, we're taught in our national primary and secondary educations, how this nation was formed by the immigration of the English who were first fleeing religious persecution and then tyranny. And now that is a narrative that makes us feel that the formation of this nation was right and good. And yet we must also reconcile that upon arrival to what is now the US, indigenous peoples were annihilated through warfare or assimilated through missionaries and Indian schools in order to seize land and resources.
Dr. Anne Bond, Associate Professor at the University of Wisconsin and former UW grad, describes this process as settler colonialism, and explains how it is perpetual and enduring. And it's not historic. It hasn't ended, it continues. And it continues in order for the incoming populations to maintain control. It's really an ongoing phenomenon. And white supremacy, or the idea of white racial superiority, was used to justify that process, that colonization, that seizing of control. And really as we needed as a nation to build capital in order to support the continued control of land and resources, white supremacy was also used to justify the kidnapping and enslavement of blacks to serve as a free workforce in this nation. And quite frankly, efforts to undo the impact of those historical insults and traumas are nonexistent. And if anything, we have new mechanisms that are ingrained in our society that maintain the impact of those results.
Why am I talking about this? I mean, we are at the height of protest in this country about Black Lives Matter, and many people don't really understand, and please chime in here, don't understand why people are calling for focus and celebration and care and time and safety for black lives. And that's quite frankly, because of these perpetual systemic mechanisms that are excluding and harming black, indigenous and other communities of color.
Racism is one of those mechanisms through which that is achieved. And it really is a byproduct of white supremacy and other mechanisms to maintain white privilege and control. Dr. Camara Jones elegantly describes racism as functioning at three levels. Three levels. We usually think of racism as really kind of at the interpersonal level, somebody calling me a derogatory name or doing something such that I might be changing my behavior and acting one way towards this person and acting another way towards another person. But it's really more than that. It's really at the systemic or structural level that we have policies and practices and norms that are not affecting people equally.
When you think about white supremacy, it is the heart of what you see happening in black communities or communities of color that lack the advantages of the majority community.
Let's start with communities of color and the preponderance of these detrimental social determinants of health. We have these upstream factors like racism, as Wendy has mentioned. You have socioeconomic status, which speak to education and social status and income. And then you have social isolation, disenfranchisement. And these are the upstream factors that really are a result of racism.
When you think about practices that have led to segregation, residential segregation, this is an outcome of racism and was residential segregation. You have communities of color that are more, at a higher level located in more or less affluent communities, whereby you may have houses in areas where there's toxic dump items, you may have houses that are afflicted with things like mold and rot and pesticides and all these other types of environmental toxicants. You may have communities that lack green space, that may lack parks and recreation, so you do not have easy movements within that community. And so you do have the system, this so called racist, and it's not really so-called, it's racist system that has really segmented individuals and literally put people in their place so to speak.
I'll speak a little bit more about this later on, but you even see this in our education system, whereby we see differences in terms of income within groups who are kind of graduated from the same level. From high school graduates to university graduates to post graduates between black and white male, there's a difference in the income achieved according to race. That should not be the case. Research has shown that in terms of income attained by white males who are only high school grads, that income is substantially higher than the counterpart to the white male, which is a black male, who is a university grad. That also is inexplicable... so that your education in some ways do not seem to be enough of an equalizer because race is a factor that seems to be disarming and creating that imbalance.
But I don't want to speak to the preponderance of social determinants of health factors for African-Americans. When we look at morbidity and mortality for a number of different causes, blacks seem to fare the worst. We're talking about morbidity and mortality from breast cancer or prostate cancer, colorectal cancer, African-American seem to fare worst. Hypertension, again, another condition where we feel where we fare worse. Asthma, diabetes, and obesity, that is our issue as well.
One item that caught my attention as I reviewed the research was the issue of life expectancy. Life expectancy reflects overall mortality, that is how long will you live from a certain age. When we look at life expectancy from birth for Americans, the average life expectancy is 78 years. However, we see disparities between black Americans and white Americans in overall life expectancy, and we can even go granular by looking at life expectancy based on gender. The life expectancy for whites is 78.8 years. And for blacks, it's 75.3 years, which is about a three and a half year difference. The life expectancy for white American man is 76.4 years. However, the life expectancy for black American man is 72 years. Now, this is well below the national average and four years below that of his white counterpart. Now for women, it's a similar issue. The life expectancy for the average white woman is 81 years, but for black women in America, life expectancy is 79 years. That's a two year difference.
We do see racial disparities in life expectancy in the United States. What we do know is that life expectancy and other health outcomes are affected by a broad array of social and economic risk factors that occur during very critical times in a person's life course. These social economic and other risk factors do shape the course of blacks and other economically disadvantaged communities and these factors do lead to premature disease and death.
Now, I would really like to reference a study that was done about nine years ago. This is a Seminole study by Paula Braverman and David Williams. There were assessing the extent to which income and education predicted overall health outcome and also life expectancy. Now, this was a national survey that followed the respondents over a certain period of time. The predictors in the study were multiple income levels, as well as various educational levels, and this was across various racial and ethnic groups. The outcomes were activity limitations that the respondents experienced as a result of some chronic disease that they had at the time, heart disease occurrence, diabetes, as well as obesity. Okay, so a number of different health conditions, as well as life expectancy will be predicted here.
Now, what these investigators found were that lower income, individuals who had lower income, the lower income status associated with lower life expectancy, right. Looking at the data in more detail, the results show that lower income was not only linked to life expectancy, but it was linked specifically to limitations in the respondent's daily life activities that was really good due to the presence of chronic diseases. Lower income was also linked to coronary heart disease and lower income was associated with the onset of diabetes.
Now, all of this makes sense because with insufficient income, lacking sufficient income, the individual is unable to access the resources that they need to keep healthy, right. He or she might not hold a job that affords proper healthcare coverage or the needed benefits that is required to take care of their existing healthcare needs.
We know that with many African Americans, the problem when addressing health outcome is not that we are getting diseases more frequently than other groups. Rather, what this is all about is that when we do get the disease, that disease tend to progress to a more severe form because of not having the resources to take care of this condition when it first occurs.
To give you a sense of what I'm talking about here, a black woman might detect a small knot in one of her breasts, right? She might not have a resources to get a mammogram to diagnose the condition. Now, a delay in this diagnosis means delay in treatment, if it is cancer, and this may lead to the development of late stage breast cancer, consequently the probability of her lower likelihood of survival. Here we see very clearly how low income will lead to poor health outcomes and minimize survival for communities without adequate resources. And so these communities we know are more often than not African American communities. What this means is that race really do matter.
In addition to showing the impact, when we look at the Braverman and Williams study, in addition to showing the impact of income and health outcome, this study also revealed that lower education, another social determinant of health factor, is associated with reduced life expectancy, increased rates of diabetes, increased rates of obesity. And interestingly enough, for African Americans in particularly, lower education was associated with individuals having a poor perception of their general health and wellbeing. That is individuals have a lower educational standing, they were likely to not perceive themselves to be in good health.
Now, this piece is an important observation because perceived health status is strongly related to morbidity and mortality. That means that a lower perceived health status predicts poor current health status, how the person's doing at this moment, as well as predicting on favorable health outcomes for the future. When some individuals with the lowest income and the lowest education were found to be least healthy and were likely to experience higher mortality levels. Social determinants of health factors, such as income and education, they do predict poor health outcome and social determines of health factors are linked to race and systemic bias in our society.
And I'd love to just piggyback off of what you were saying, Sharon, because I think we also, as a society, have a tendency to have the mindset that individuals are really in control of being able to marshal economic resources or take advantage of opportunities. And I just really want to emphasize how there are resources and opportunities that are structured and are allocated by policies, practices, and norms. I'm talking about structural, sometimes it's called systemic racism. How there are differences in the way that laws, that policies that opportunities are afforded to people and that that has serious health consequences that Sharon is talking about.
Racism dictates where black indigenous and other people of color live because of historic access segregation that have never been undone. We still have defacto segregation. In Seattle, a primarily white city, we have segregation. City zonings resulted in communities of color being situated in very specific places and for that land to be undervalued, and therefore, more likely to have those toxic exposures, because it's cheaper to be able to go to those areas and be able to have those harmful practices concentrated in those areas.
Given that our public education system is funded by proxy property taxes, having these areas undervalued means that the schools that serve those areas are under resourced and that they continue to be under resource. It's a vicious cycle and it's intrinsically... this idea about economic and educational opportunities are conflated and intricately tied to racist processes, such that the reason why communities of color tend to be more low income is because of those racist processes. I just want to kind of emphasize that, because we are all kind of... we've grown up thinking that if you try hard enough, you'll be able to succeed. And that's not the case. There are those who are more able to succeed than others, regardless of how much you try and that needs to change. If we truly are going to be an equitable society, those opportunities need to be equally available to individuals and populations. And quite frankly, given that we have this historic marginalization, what we need to do to kind of rectify that unfairness, that injustice is that we have to focus resources on the communities that have been historically marginalized.
If I may, and I think, I really believe Wendy did a very good job in speaking about how we need to move forward, quite frankly. And we need to consider that. I want to just bring one more illustration about what we're talking about in terms of disparities, because sometimes we can speak just in terms of pros, right. But it's important to kind of bring some concrete information to this to really demonstrate what we're talking about here.
There's this concept of deep poverty, deep poverty. And deep poverty is really abject poverty. And abject poverty... I really loved the WHO, the World Health Organization, definition of this, which defines deep poverty as living on $2 a day or less per person. Imagine that, living on $2 day or less per person. In the US, a recent report from 2016 indicated that a single individual under the age of 65 years old for their experience of deep poverty, their income per year is just over $6,000 a year. $6,000 a year for a single person who's under 65. For a family of four, a family like mine, two children, a mother, and a father, deep poverty for that family is income of $12,000 a year. That's four times the single person. 18 million people in 2016, 18 million Americans lived in deep poverty in 2016. That's about 6% of the total population. Of that children, under 18 years of age, we had 8% of these children lived in deep poverty.
The research shows that deep poverty has a very chronic impact on health outcome, okay, in terms of developmental disabilities, developmental issues, as well as chronic diseases. When we look at communities of color, particularly African American and Hispanic communities, African-Americans make up 10% of individuals who are living in deep poverty, 10.8%. That's about 11%. Hispanic-Americans made up about 7.6%, 8% of individuals living in deep poverty in this United States. Now, for other groups say whites who are not Hispanic and Asians, they're less than half of African-American and Hispanics. Whites, only 4% are living in deep poverty and Asians about 5%.
And so researchers at the Urban Institute who study the effects of deep poverty, tells us that deep poverty is a chronic condition that percents from generation to generation. This is the problem that we're talking about, how difficult it is to lift yourself up from the situation when it is a chronic and persistent situation that you find a certain group or segment of the American community who are infected with. Research also showed that poverty during childhood, and we see that a large proportion of youth under the age of 18 are living in deep poverty, that poverty during childhood has very lasting consequences, right, on the health of the child, on the developmental level of the child, on educational outcome.
I only brought up this to really support what Wendy's saying, that we have some real structural issues that exist here, and it will take some time to work and it takes really the galvanization of multiple sectors of our society to really address an entrenched problem that is a result of the systemic racism that Dr. Barrington has just spoken to us about.
One thing I wanted... this is not a question, it's more just an observation about my own lived experience. I am a white heterosexual, middle-class male. In so many ways this nation was made for me. Well, now that's a different question, whether or not that's something I would have wanted had I known anything about that when I was younger, and people who look like me, but who probably had a lot more money than I do. When I'm in conversation with folks, when I'm doing reading about structural racism and sort of the history of this country, I always appreciate when people can point us to specifics, right, because when I was growing up, I grew up in a house, and this is just my own lived experience, I grew up in a house that's like and I went to school and you were told kind of these things like, "Oh, racism was bad, but it doesn't exist anymore on a large scale. It ended somewhere in the late 1960s." That was the education I received in school and what I heard at home, right.
And so as you grow up and I'm fortunate, my wife is the one who really got me to be less clueless in terms of this world. She works with marginalized populations and has done for some time. I'm grateful for her, for this notion that I've been learning more for the last several years. Still have some things that I'm... I think everyone has things need to work on, but I'm less clueless.
But I do appreciate from my perspective, because those things and it's... I mean, to me, it says something to the nature of how things were built in this country is that the things that I were told were probably told to the people who taught me because it was taught to them. And at some point it went from being a very overt, we are going to force history to look like this, to being sort of the accepted norm and most people, unless you were a scholar, didn't know this other part, so they were just regurgitating the same information over centuries or decades, centuries, so many people, myself included, were told a very specific version of events that turns out if you just even Google it, you're going to find a much more robust understanding of American history.
I appreciate the two of you giving some very... racism is a big word and it's hard to get your head around, so I appreciate when we can directly relate it to very specific things. Thank you for that.
I had mentioned the word whiteness, and I've been really... I've been doing some deep thinking about this because it seems to me, and having conversations, I've had conversations with white friends and family about white privilege and it hasn't really gone well. People get very upset and very defensive. I'm coming from a place where that's not me, I don't want to be that, I don't know what you're talking about, but that is not me, this vehement denial. And I think it's partly because of how we've been socialized to not want to, I guess, rock the status quo. There's a reason why things are working as they are, and we've been socialized.
You mentioned earlier this idea of rugged individualism, right, being able to kind of pull yourself up by your bootstraps, and if you work really hard, if you work hard enough, then you should be successful. And if you're not successful, it's because you're not working. But we know that that's not true. I mean, I think we can all point to people in our communities who work really hard and may not necessarily be achieving the American dream. But this idea of whiteness, as not explicit individuals, it's really a structure, like a way of thinking that kind of perpetuates that narrative, that narrative of if I work hard enough and I look a certain way, then this is what needs to happen.
And then also as a part of that, this idea that when we're talking about making reparations, as another big R word, if we're talking about having somebody get something, then that means that there's less for me. And I think that that's the toxic kind of ideology that we have to get past. It's not necessarily that we have to keep doing things the same way and that we have a finite amount of resources, because if we completely transform the way that we do things and reallocate and prioritize things differently, we have the opportunity to actually advance as a society as a whole.
I mean, it's really interesting this kind of being stuck and trapped into this kind of this or that, this kind of binary thinking. And I think that's really limiting. And I think it's that idea of well, if I hear that black lives matter, then that means that my life doesn't matter, when that's not at all, at all the case. What it means is we need to focus on Black Lives Matter because black lives are being disproportionately ended at the hands of state violence, quite frankly. Does that happen to the same degree for other communities? The answer is no. That's the reason why we say, "Black lives matter." We can say, "Black lives matter," and it doesn't mean that other lives don't matter.
The one thing... thank you so much Wendy. The one thing that I do want to address is Eric's comment about, and this is not an unusual thing, where a lot of whites didn't think that racism do exist, and there's a reason for that. There's the structural factors that segregates groups. And so you are not... you have no reason to go into an urban disadvantaged community, right. You live in your community, you have your friends, you have your resources, you access those things. You're not going to drive into a community that is disadvantaged to see how people are living. That's the first thing.
The second thing is what psychologists likes to call confirmation bias, right. That is we're going to seek out information that confirms what we perceive to be the reality, right. And so, in terms of, and this is something that I do want to just put out there really for whites who've... because there's an explanation why there's a feeling that, well, of course it didn't exist, so I'm okay. But without confirmation bias, you're going to identify a black friend who's doing really well. You're going to point to things on television, where you see black athletes who are making millions of dollars and you'll say, "Look, these guys are making millions of dollars. Black people can be doing all that badly." You're going to point to billionaires, whether it's Oprah or whomever and say, "Well, look, they're black billionaires. Come on blacks can't be doing that badly." That's your confirmation bias. And it's not an indictment. It's just something that is a psychological phenomenon that happens to every single one of us.
But I think what's happening now that makes things so different is that this George Floyd situation, we're all home, we're all watching TV, so we're forced to see all these things and this George Floyd situation forced reality into our consciousness. Every single one of us, we are forced to see the injustices that have been going on forever. And a lot of people could not have imagined that. When the shooting occurred five years ago in Missouri and Black Lives Matter started, Black Lives Matter in many ways was something that you couldn't even say out loud because it was almost like this awful connotation. That's why people were saying, "White lives matter. All lives matter. Blue lives matter," so frequently because they didn't believe that police brutality was a reality. Really. They just heard about the shooting, but something had to... that person had to have done something to cause that, right. The black community, we see crimes and all that. That's what's happening.
But now you're forced. And so you get this information that confirms your understanding that blacks are doing well. It's just a subset that's engaged in, that's not doing so poorly, but for the most part they're doing well. But now we're forced to face the reality that it's more, that there are a few black people doing well, but for the most part, the community really is not doing well, not the other way around, where we would like to think that blacks as a whole, they're doing well, look at all those billionaires. There's just a few of them that are dealing with health disparities.
This confirmation bias where we get information to confirm what we'd like to think is really what's happening I feel that causes whites to really think that we have no problem, but we have a systemic problem that continues to get larger and larger.
Thank you to our guests and thank you for listening. Be sure to like, and subscribe. You can find us on Spotify, Google Podcasts, Pocket Casts, Stitcher, and Apple Podcasts.