- Welcome everyone to Wednesday Nite @ the Lab.
I'm Tom Zinnen.
I work at the UW-Madison Biotechnology Center.
I also work for the Division of Extension, Wisconsin 4-H.
And on behalf of those folks
and our other co-organizers, PBS Wisconsin,
the Wisconsin Alumni Association,
and the UW-Madison Science Alliance,
thanks again for coming Wednesday Nite @ the Lab.
We do this every Wednesday night, 50 times a year.
Tonight, it's my pleasure to introduce to you Eva Vivian.
She's a professor in the School of Pharmacy here.
She was born in Chicago
and went to Aquinas Dominican High School there.
Then she went to Benedictine University
to get her bachelor's degree in biology
and got her doctorate of pharmacy degree
at the University of Illinois.
She came here to get a master's in public health,
at the School of Medicine and Public Health,
and stayed to get a PhD from the School of Human Ecology
in civil society and community research.
Tonight, she's gonna speak with us about social
and ecological factors that influence health.
Would you please join me in welcoming Eva Vivian
to Wednesday Nite @ the Lab.
- Thank you, Tom, for that wonderful introduction.
Today, I have the distinct pleasure of speaking to you
about the social and ecological factors
that influence health.
Today, I will identify factors that influence the health
and well-being of all persons,
and identify needs and barriers that persons face
that may inhibit their ability to lead a healthy lifestyle.
And I'll also describe how social and ecological
and environmental conditions can negatively impact
the health and well-being of those individuals
that reside in under-resourced communities.
I'd like to start off today by providing a slide
that provides a picture of a conceptual model
of the social determinants of health.
And at the very core of this conceptual model
are non-modifiable factors that influence our health,
such as our age, sex, and genetic makeup.
These are factors that clearly have an impact on our health,
but they are things that we cannot change.
Right above those factors are lifestyle,
individual lifestyle factors.
And these are factors that we can actually modify.
Things such as physical activity, healthy nutrition,
alcohol consumption, and cigarette smoking.
These factors are usually addressed at our annual visit
with our healthcare provider.
Unfortunately, all too often, the social
and community networks that a person engages in
are often overlooked.
But we know that those individuals
who have strong relationship with family, friends,
and interact and work with their community
on a regular basis are healthier than those individuals
who are socially isolated.
Living and working conditions clearly affect our health,
and they are included in this conceptual model.
Education, work environment, water and sanitation,
housing, are all factors that play a role in our health.
We know that if an individual is fortunate
to obtain a good education, that they will go on
and obtain a good job that affords them health insurance
and allows them to obtain housing
in a well-resourced community.
While things such as physical activity
and nutrition clearly impact health,
how does poverty and education and employment influence health?
I'd like to share a story about a boy named Jimmy.
Jimmy was recently hospitalized
because he had a bad infection in his leg.
And he obtained this infection while he was playing
in a junkyard in his neighborhood.
There was some sharp, jagged steel in the junkyard
that he fell on.
And as a result, he cut his leg and his leg became infected.
You may wonder, well, why was Jimmy playing in a junkyard?
It's because Jimmy lives in a rather run-down neighborhood
and the junkyard is the only place for children to play.
And they often play in this junkyard
and they're unsupervised.
Why would Jimmy's family have to live
in that type of neighborhood?
Well, it's because his father is unemployed
and his mother is ill.
Why is this father unemployed?
And that is because his father does not have a good education
and cannot obtain a job.
But why?
Unfortunately in our country,
everyone does not have the same opportunities.
And on this slide, we see examples
of equality versus equity.
And these terms are frequently used interchangeably,
but they actually have different meanings.
Equality means sameness.
And it means that everyone essentially
gets the same thing.
However, this only works if everyone
has the same opportunities.
In the cartoon, you see that
there's three boys of different heights.
And they are all attempting to view a baseball game.
Each boy has been provided with a box.
So the tallest boy is able to view
the baseball game with ease.
The boy in the middle can now see the baseball game
because he can stand on the box
and it allows him to view the game.
However, the shortest boy is unable to see the game
in spite of having a box to stand on.
Equity means fairness.
And it means that we afford
the same opportunities to everyone.
We have to have equity before we can really enjoy equality.
And in this cartoon, we see the same three boys.
However, the tallest boy does not receive a box
because he's tall enough to view the baseball game without a box.
The boy in the middle receives one box.
However, the shortest boy is given two boxes
so that he can now view the game.
So now we see how equity ensures equality.
Now this can apply to health equity.
Health equity means that every person
has the same opportunities, resources,
and supports needed to stay safe and healthy.
Socioeconomic status clearly is a central determinant
of the distribution of resources within our society.
An example is the Scholastic Aptitude Test, known as the SAT.
And this is an exam that most high schools students take
prior to applying to college.
This test has recently been nicknamed
the Student Affluence Test.
And this slide provides an explanation
of why this test has been given that nickname.
On the x-axis, we have the annual household income
of families.
And on the y-axis, we have SAT score.
And what we see is a comparison of SAT score
based on family income.
And it's clear from this graph that
as the annual household income increases,
there's a corresponding increase in student SAT scores.
So students that are from families with high incomes
tend to have higher SAT scores when compared to students
from lower income families.
And this could probably be because students
from higher income families are able to attend schools
that prepare them for college.
And they also have the resources to help them prepare
for this important examination.
There is clearly large racial and ethnic differences
in socioeconomic status.
For example, for every dollar of wealth
that whites have, Asians have about 81 cents.
Blacks have only 6 cents, and Latinos have only 7 cents.
So it's important to keep these things in mind
when we attempt to make sense of racial disparities in health.
Over the last year, we've all been socially isolated
and dealing with the impact of the COVID-19 pandemic.
And I'm sure that most of us have heard that this pandemic
has dramatically impacted people of color.
For example, on this slide,
we see that Hispanic or Latinx individuals
actually only make up 7% of the population
in the state of Wisconsin,
but accounted for over 11% of all COVID-19 cases.
This slide provides a percent of the total population
that received at least one vaccine dose based on race
and ethnicity between the months of March and May.
And this accounts, this data is from 40 states.
And what we see is that overall, Asians are leading
in the percent of individuals who have actually received
at least one dose of the COVID-19 vaccine.
However, you'll notice that Black Americans
and Hispanic Americans have the lowest percentage
of individuals that have been vaccinated,
with Blacks still below 30%.
So why are Blacks hesitant to be vaccinated?
There are multiple reasons.
And over the last few months, I've been involved
in mobile vaccine clinics and I've had an opportunity
to speak to many African Americans
about their concerns about the vaccine.
And one common concern that I hear from people is
that there's a concern about how quickly
the vaccine was developed.
And the fact that the previous administration seemed
to be involved in getting the vaccine
on the market as quickly as possible.
Another very common concern is
the long-term effects of this vaccine.
Many people told me that they just wanted to wait and see
what the outcome would be of receiving this vaccine.
And there are some people that
just mistrust the healthcare system.
Because of bad experiences in the past
with the healthcare system,
they really don't trust healthcare providers' messages.
Then of course, there are historical reasons
that can lead to mistrust.
There are African Americans that still remember
the Tuskegee experiment that was conducted
in the mid 20th century, where Black men
were denied treatment for syphilis so that researchers
could actually study the long-term effects
of syphilis on their neurological system.
Then of course, Hispanics are also hesitant to be vaccinated.
And often, many people express concern about sharing
their personal information with the government.
And there is some historical mistrust as well.
In the 1940s, the United States Public Health Service
used sex workers to expose prisoners
in the Guatemalan jails
with sexually transmitted diseases.
And this hasn't been forgotten,
and many Latinx individuals remember this.
In the 1950s, Puerto Rican women from low income communities
were given experimental birth control pills
without being told that they were enrolled
in a clinical study.
So these things break down the trust within a community
and can contribute to vaccine hesitancy.
So I believe that the key to unlocking vaccine hesitancy
is trusted messengers.
I think it's important as people
from various communities become vaccinated,
that they share with their families and friends
their experience of being vaccinated.
And I believe that as people who are hesitant
see that their family and friends actually benefit
from being vaccinated and do not endure
any long-term side effects, that more
and more people are likely to become vaccinated.
However, healthcare providers should still make efforts
to go into the community
and deliver accurate information about the vaccine.
There's a significant amount of misinformation
about the vaccine.
And it's our responsibility as healthcare providers
to ensure that people in the community
have accurate information so that they can make
an informed decision about whether or not
they should become vaccinated.
It's also very helpful when prominent figures
such as politicians actually receive the vaccine.
And I believe that that could increase trust as well.
Now there are other conditions
that disproportionately impact people of color.
And one of those conditions is obesity.
And almost every socio-demographic group
is affected by obesity.
And on this slide, we have a graph
that provides the age-adjusted prevalence of obesity
among adults 20 years of age and older.
And what I'd like to point out
is that the green bars represent non-Hispanic Asians.
And you'll notice that for the total population
as well as for men and women,
that non-Hispanic Asians have the lowest prevalence
of obesity in our country.
But when we look at other groups in total,
we see that Hispanics have the highest prevalence of obesity,
which is represented by the olive-colored bar,
followed by African Americans.
Hispanic men have the highest prevalence of obesity
among men in our country.
However, the picture is different for women,
and we see that non-Hispanic Black women
have the highest prevalence of obesity among women,
followed by Hispanic or Latino women.
Now let's look closely at the percentage of obese adults
by race and ethnicity within our country and state.
And what you notice on this chart is that the United States
is represented by white bars
and Wisconsin is represented by red bars.
And it appears like Wisconsinites are heavier
than most people in our country.
And that's the case
for all different racial and ethnic groups.
We see, for example, that the percentage
of obese white adults in the United States is about 30%.
However, the percentage of obese whites
within the state of Wisconsin is close to 33%.
Obesity has been found to be associated
with age and education.
And what we have found is that obesity tends to decrease
by level of education.
So high school individuals are more likely to be obese
when compared to someone with a college degree.
Young adults are also less likely to be obese
compared to middle-age adults.
Which is something that we would expect,
since our metabolic rate tends to decrease as we age.
Now socioeconomic status also plays a role
in obesity in our country.
And studies have found that among men, obesity tended
to be lower among the lowest and highest income groups.
However, this pattern was only seen
among non-Hispanic white and Hispanic men.
Obesity prevalence was actually higher
among the highest income group among non-Hispanic Black men
when compared to low income Black men.
So higher income Black men tended to be heavier
than lower income Black men.
Now among women, the obesity prevalence
was less among the highest income groups,
which is something that you would expect
when compared to the middle income and low income group.
But this was the case for non-Hispanic white women,
non-Hispanic Asian women, as well as Hispanic women.
But when we looked at data for non-Hispanic Black women,
we found that there was no difference
in obesity prevalence based on income.
So a high-income Black woman is just as likely
to be obese as a low income Black woman.
And this may account for why Black women
have the highest prevalence of obesity in our country.
But why is this the case?
The number one cause of obesity among women of color,
particularly Black women, has been identified as stress.
Stress and obesity had been identified as partners in crime.
And we know that in addition to dealing with ongoing racism,
many Black women have the responsibility
of being the head of household
as well as the primary breadwinner.
And these things increase the stress in their life,
which is often compensated for
by unhealthy coping behaviors such as overeating.
Stress has a striking pattern of accelerating aging,
which results in an earlier onset of disease.
And chronological age actually captures
the duration to risk for various groups of color
that are living in adverse living conditions.
Now, Blacks actually experience greater physiological wear
and tear, and are actually aging biologically faster than whites.
Biological weathering is driven by the cumulative impact
of repeated exposures to psychosocial
and chemical stressors in the environment
and work environment, as well as other environments as well.
Now, compared to whites, Blacks experience
higher level of stressors, greater clustering of stressors,
and probably a greater duration and intensity of stressors.
There was a study that was published
in Human Nature in 2010.
And this study actually looked
at the racial differences in telomere length.
Now telomeres are sequences of DNA
at the end of a chromosome.
And the telomere length is viewed
as an overall marker of biological aging.
And this study reported that Black women
had shorter telomeres than white women.
So at the same chronological age, Black women
had accelerated aging of about seven and a half years
when compared to white women.
This slide provides the United States life expectancy
based on race and ethnicity.
And we see that Asian Americans have
the longest life expectancy in our country.
However, African Americans have the shortest life expectancy.
When we compare life expectancy for non-Hispanic Black
and non-Hispanic white males in Wisconsin
and the United States, what we find is
that Black men have a average life expectancy
of about 72 years in our country
compared to 76 years for non-Hispanic white males.
So there's about a four-year difference
in life expectancy nationally.
However, Black men in the state of Wisconsin
have a life expectancy of about 70 years of age
compared to 78 years of age for white men
within the state of Wisconsin.
So there's a significantly wider Black/white gap
for males within our state.
When we compare the life expectancy
for non-Hispanic Black
and non Hispanic white females in Wisconsin
and our country, what we find is that Black women
in our country have a life expectancy of about 79 years
and white women have a life expectancy of about 81 years.
So that's not a significant gap, only two years.
However, within the state of Wisconsin,
we find that Black women's life expectancy
is about 76 and a half years
compared to 82 years for white women.
So once again, the Black/white gap
among females in the state of Wisconsin
is significantly wider than the Black/white gap
among U.S. females.
So why does race still matter?
And could racism be a critical missing piece of the puzzle
to understand how racism impacts health?
Now, there are several mechanisms
that can explain how racism influences health.
One is institutional discrimination.
That can actually restrict socioeconomic attainment
and group differences in socioeconomic status and health.
Segregation can also create
pathogenic residential conditions.
We know that residential segregation
is associated with poverty.
And poverty is usually associated
with poor housing conditions.
And discrimination results in an inability
to obtain desirable goods and services.
Now, racism has also been associated
with internalized racism.
And that internalized racism is when
a marginalized group accepts society's stereotypes
or negative characterization of that particular group.
And that can really adversely affect health.
Racism can also create exposure
to traditional discrimination such as unemployment.
Often, these experiences of discrimination
are overlooked by healthcare providers.
And it's very rare that a healthcare provider
will ask a person of color,
particularly of African-American,
if they feel that they experience discrimination,
and if so, do they feel that these acts
actually impact their health?
Now, once again, I would like to present
the conceptual model of the social determinants of health.
But you'll notice that I included structural racism,
which actually influences laws and policies that result in
an uneven distribution of the social determinants of health.
For example, residential segregation,
which came into existence in the mid 1800s
and lasted for over a hundred years,
still impacts our nation.
And residential segregation resulted
in poor housing for many people.
So unfair laws and policies have actually impacted
many of the determinants of health.
The pervasiveness of discrimination
cannot be ignored in our country.
There are things that some people endure
that others can't understand because of something
that is not part of their lived experience.
For example, several Black mothers have shared
with me that their young two and three-year old children
had been suspended from preschool.
We know that Black men are more likely to be targeted
and pulled over by the police.
The cost of bail is very restrictive
and results in incarceration.
We know that Blacks are more likely
to be arrested for drug-related crimes.
Something as simple as hailing a taxi
can be a challenge in a major city,
particularly if the taxi driver thinks
that the passenger is going to ask him
to take him to a very dangerous neighborhood.
Buying a home is a challenge for many people of color,
particularly African-Americans where they feel
that they may not be able to purchase a home
in a nice neighborhood because of segregation.
Purchasing a car can be a challenge.
We know that African-Americans who may
have the same down payment as their white counterpart
will still be charged a higher interest rate.
Renting an apartment is a challenge.
Getting a job, receiving a promotion, obtaining insurance
because insurance companies think that you're high risk.
Obtaining bank loans, seeking medical care.
All of these things are affected by discrimination
and impact the health of many Americans in our country.
I'd like to share a study that was conducted here
in the state of Wisconsin.
Where pairs of young, well-groomed,
well-spoken college men
with identical resumes applied for 350 advertised
entry-level jobs in Milwaukee, Wisconsin.
Two teams were Black and two teams were white.
And in each team, one of the men
was asked to state that he had served
a 18-month prison sentence for cocaine possession.
This study found that a white male with a felony record
was more likely to receive a job
than a Black male with no felony record.
And this slide provides the results.
And you can see that 17% of white males that reported
that they had a felony record received a call back,
compared to only 14 Black men with no criminal record.
Place clearly matters.
Segregation remains a legacy of racism.
And segregation affects health in many ways.
In the 171 largest cities in our nation,
there's that one city where whites live
in equal conditions to those of Blacks.
So the worst urban contexts in which whites reside
is considerably better than the condition
in which Black communities live.
Wisconsin was recently identified
as the most segregated state in our country.
Which is very surprising, because I actually expected
a southern state to come in first place.
But actually, it's our state.
And I believe that this could partly explain
the health disparities that we see within our state.
So how does segregation affect health?
Segregation can actually determine socioeconomic status
by affecting the quality of education
and employment opportunities.
As we saw in the case of Jimmy, Jimmy's father was unemployed.
And more than likely, Jimmy's father grew up
in a low income community with under-resourced schools
that were unable to provide him with the education
that he needed to be successful.
Segregation also creates pathogenic neighborhood
and housing conditions.
Most residentially segregated communities
are poverty-stricken.
And those communities often lack grocery stores
that carry fresh produce.
But they probably have an abundance of fast food stores.
These neighborhoods are often crime-ridden,
so people feel uncomfortable to walk in their neighborhood,
for fear that they will be a victim of crime.
So what happens is that the conditions linked
to residential segregation result
in unhealthy health practices,
where people may consume fast food frequently
because it's readily available
and they are unable to be physically active
in their community.
One study that was reported over 20 years ago
found that if we eliminated segregation,
we could completely erase Black/white differences
in income, education, and unemployment.
That's incredible.
And I also believe that if segregation could be eliminated,
it would allow us as Americans to learn more
about each other and recognize that
we have more in common than our differences.
Unequal treatment in the medical profession is a reality.
Virtually across every therapeutic intervention,
ranging from high technology procedures
to the most elementary forms of diagnostic
and treatment interventions, Black Indigenous People of Color
receive fewer procedures
and poorer quality medical care than whites.
And this persists, even after differences
in health insurance, social economic status,
stage and severity of disease, and co-morbidities
are taken into account.
These situations exist even for Medicare patients
and patients within the health-- within the VA health system,
where insurance coverage is not really an issue.
This study published in JAMA
actually looked at the percent of patients with a broken arm
that received no anesthesia or pain medication.
And Hispanics are represented by the green bar.
And we can see that 55% of Hispanic patients reported
receiving no anesthesia for the pain associated
with a broken arm or leg,
compared to less than 30% of non-Hispanic whites,
which is represented by the white bar.
Now, 43% of Blacks reported receiving no pain medication,
compared to only 26% of whites.
So race does matter.
Cultural racism does matter
and it's deeply embedded in our culture.
And it's important that each and every one of us
is really reflective and really attempt
to identify unconscious discrimination or bias.
Because when someone holds a negative stereotype
about a group and they meet someone
who fits that stereotype,
he or she will discriminate against that individual.
So stereotype-linked bias results
in automatic discrimination.
And it's usually unconscious.
I'd like to share a story about a patient
who was referred to me for diabetes self-care management.
She was a older woman, about 60 years of age.
And when she presented to my clinic,
she appeared to be in great pain.
She explained that she had severe back pain.
Of course, I felt uncomfortable trying to talk to her
about diabetes self-care management
while she was in such extreme pain.
I asked her if she had received any pain medication
from her primary care doctor.
And she indicated that her doctor refused
to give her another prescription.
Her doctor happened to be at the clinic at the time,
so I went to her doctor's office and explained
that the patient was in extreme pain.
And the doctor informed me that at the patient's last visit,
that the patient was given a urine test,
which came back negative.
So the provider assumed that the patient
was selling her drugs because she was not--
Based on the negative urine test,
she assumed that the patient was not taking her medication.
I went back to my office and sat down with the patient
and I asked the patient about the urine test.
I explained that her urine test came back negative,
and I asked the patient if she could explain
to me why that test came back negative.
And the patient informed me that she was caring
for her grandchildren on the day that she took the urine test.
And when she cares for her grandchildren,
she does not take her pain medication
because she needs to be alert.
Of course, I informed her doctor of that
and that patient was provided
with a prescription for her pain that day.
So it's very important that we not make assumptions
about people and that we give everyone
the benefit of the doubt by asking questions.
Many African-Americans as well as other groups of color
have a perceived threat of discrimination
that can really impact their health as well.
Discrimination, like other stressors,
can impact health through both actual exposure
as well as the threat of being exposed to discrimination.
Experiences of discrimination are often
a neglected psychosocial factor.
All too often, when patients are monitored
for blood pressure, they're rarely asked
if there's something in their environment
that can actually increase their stress
and raise their blood pressure.
Perceived discrimination can result in
an elevated risk of diabetes, substance use,
breast cancer, uterine fibroids,
as well as coronary artery disease.
And often, perceived discrimination
within the healthcare system can result
in delays in a patient seeking help.
Often, patients begin to mistrust the healthcare system,
therefore they won't adhere to treatment regimens.
And discrimination actually is a significant contributor
to the disparities that we see in health
in the state of Wisconsin, as well as nationally.
Macro-stressors also impact health.
For example, large-scale societal events
such as natural disasters can be stressful for individuals.
I recall Hurricane Katrina.
Just watching on television the number
of African-Americans that were stranded
and were unable to evacuate was very stressful,
not just for the residents of New Orleans,
but for those of us who had to watch this on television.
Major negative race-related events
can also be macro-stressors.
For example, the video of George Floyd's death
was very stressful for many people across our country.
Also, research has found that historical trauma
and traumatic events that actually occurred
over a hundred years ago can cross over generations
and impact the physical and mental health
of many individuals.
And we found this particularly among Native Americans,
where incidents that occurred over a hundred years ago
can still impact current generations.
Now September 11th terrorist attacks
were a clear example of how non-race related stressors
can actually be racialized in ways that
can generate racial, ethnic discrimination.
It's well-documented that there was an increase
in discrimination and harassment
of Arab Americans after 9/11/2001.
And Arab-American women in the state of California
actually had an increase in low birth weights
six months following 9/11,
particularly when compared with birth weights
prior to September 11th.
And what was interesting is other women
in the state of California had no changes
in birth weight outcomes, before or after September 11th.
So this is an example of how discrimination
can impact the health of people immediately after an incident.
Anxiety and depression spiked for Black
as well as Asian Americans
after the police killing of George Floyd.
We know that after the pandemic hit,
that many Asian Americans were discriminated against.
And what we see on this slide is that at the time
of the release of the video of George Floyd's killing
that anxiety and depression spiked among African Americans.
And actually, there was a spike found
among Asian Americans as well.
So what do we do to dismantle institutional racism?
What's very important is that we have
to acknowledge that racism exists.
And that disparities in one societal domain
are not independent of those in other domains.
And that racism is a set of dynamically
related components of subsystems.
And it is impossible to come up with remedies for disparities
if we fail to acknowledge and address
the interdependence across domains.
For example, when we look at racism as a system,
we know that all of these systems are impacted by racism:
school segregation, residential segregation,
the criminal justice system are all impacted by racism.
But then there is an interdependence.
For example, residential segregation
will influence school segregation.
Both schools and racially segregated communities
are in fact segregated.
This impacts the education
that students receive at that school.
And as a result, can impact their ability
to obtain a job later in life.
So how do we reduce disparities?
It's important that we raise public and provider awareness
of racial and ethnic disparities in care.
Expanding insurance coverage is also vital.
Improving the capacity and number of providers
in underserved communities is important.
And increasing the awareness of interventions
that will actually work to decrease disparities
is also vital.
So one way to reduce disparities
is to support disparity reducing policies.
Many policies actually promote disparities.
So supporting disparity reducing policy interventions
that are targeted at education
in early childhood are also important.
We should support urban planning and community development.
Support housing; many low income housing apartment buildings
are placed in undesirable areas of major cities.
We should ban those policies and ensure
that those individuals can live in safe communities,
where they have access to resources
that will help them be successful.
Also, support policies that will enable people
to seek good education and employment.
The cost effectiveness of these interventions
will actually result in long-term outcomes
that are very favorable for our country.
So in conclusion, racism in its multiple forms
is a major risk factor for health.
And there is a need to increase research attention
to understand its potential effects.
There's an urgent need to have effective efforts
to mitigate the pathogenic effects of racism
and develop optimal strategies to create a political will
and support to dismantle societal structures
and things that actually promote racism
and hate and incivility.
It has been a pleasure to talk to you today
about these issues.
I am very hopeful for our country.
And I'm sure that each and every one of you
will take into consideration the things
that I presented today.
And I know that going forward, we can make our state
and our country a better place to live.
And with that, I would like to close
with a quote from the late Robert F. Kennedy,
who stated that, "Each time a man stands for an idea,
"or acts to improve the lot of others,
"or strikes out against injustice,
"he sends forth a tiny ripple of hope.
"And those ripples build a current
"that can knock down the mightiest walls
of oppression and resistance."
Thank you.