Anya and Radha host a terrific conversation about public health, racism, and health equity with Dr. David R. Williams from the Harvard T.H. Chan School of Public Health. Dr. Williams visited the University of Iowa College of Public Health to receive the Richard and Barbara Hansen Leadership Award and deliver a lecture, entitled “Understanding and Effectively Addressing Inequities in Health.” You can view the lecture online.

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Anya Morozov:

Hello everyone, and welcome back to From the Front Row. Today we have a very special guest on the show, Dr. David R. Williams. Dr. Williams is currently a Professor of Public Health, African and African American Studies and Sociology, and he is chair of the Department of Social and Behavioral Sciences at this Harvard T.H Chan School of Public Health. He has done research here in the United States and globally, which has been published in leading sociology, psychology, medicine, public health, and epidemiology journals. He just presented a talk to a full house here at the University of Iowa College of Public Health, titled Understanding and Effectively Addressing Inequities and Health.

And now, he’s here to talk with us even further about his work and we are so honored to have him on the show. My name is Anya Morozov, joined by Radha Velamuri, and if this is your first time with us, welcome. We’re a student-run podcast that talks about major issues in public health and how they’re relevant to anyone, both in and outside the field of public health. Thank you for coming all the way to Iowa City and welcome to the show, Dr. Williams.

David Williams:

Thank you. It’s good to be here with you. I’ve had a great day.

Anya Morozov:

Yeah. So our intro didn’t even really scratch the surface of your biography, so how did you get on the path you’re on today and what’s your underlying why?

David Williams:

Okay, so let me briefly talk about how I got on the path. I grew up on a small Caribbean island of St. Lucia, went to college in Trinidad. The college I went to was a Christian college. It offered majors in multiple areas, but most of the majors were associate degrees. The only major that led to a bachelor’s degree was in Theology of Religion. I did that and then, I went on and did a master’s degree in religion in the United States when I came to United States. And in studying my master’s degree in religion, I took a course in health and I really thought that public health was a way in which I was committed. I was a child of the ’60s, a child of the Civil Rights Movement, even though I was outside of the US.

But we followed closely what was happening in the United States and I was very committed to making a difference for people. That was what motivated me, how do we improve the lives of others? And taking a course in health really convinced me that that is the area I should do. So I went from a master’s degree, graduated with a master’s degree in religion. And the next semester, I was in the Master of Public Health program and finished my Master of Public Health program at Loma Linda University in Southern California and got a job in Battle Creek, Michigan, where I was working a for hospital, but doing community health education. Developing programs on how to stop smoking, how to manage stress, how to reduce the risk of cardiovascular disease, a weight management program. My first published paper was about the weight management program I developed to reduce obesity. People in the community would sign up, come to this program, I would teach it with a dietician and exercise physiologists to improve health.

And while working as a public health educator, I was somewhat dissatisfied. I felt that my training in public health had given me the facts about public health, the data, but it had not really trained me to address the underlying problems and challenges people face individually, how you could take a broader perspective and thinking of how to improve community health. And from that, I decided that sociology was the right major to understand the social context so that I could make a difference in the lives of others. And so, I moved from that to do a PhD in sociology at University of Michigan, where I specialize in health and really was specializing in understanding the social and psychological factors that affect health. So that in brief, captures my academic training.

And then, from that, I started my career at Yale with a joint appointment in the sociology department and public health. After I got promoted at Yale, went back to University of Michigan, was there for 14 years as a faculty, primarily in sociology and the Institute for Social Research, which is a Social Science Research Institute. And from that, went to Harvard University where I am again, in both the social sciences and in public health. So that’s in brief, it gives you a sense of my intellectual journey.

Radha Velamuri:

Yeah, a lot of your work talks about, or at least based on what I’ve understood, is about underlying factors to health. And one of those things is discrimination, really important factor, especially from your talk earlier today. Could you define discrimination to our audience?

David Williams:

Sure. Discrimination occurs when people are treated differently and people are treated differently based on typically some social characteristic. You could be treated differently based on race, but you could also be treated differently based on your nationality, based on your sexual orientation, based on your weight, based on your age, and based on your sex. So it’s a range of potential social bases on which people could be treated differently. And so, if you think of the everyday discrimination scale, it asks people, not were you treated differently because of your race, but in your day-to-day life, how often are you treated with less courtesy and respect than others? How often do you receive poorer service than others in restaurants or stores? How often do people act as if they’re afraid of you? It’s just in little domains of life.

We are trying to get the sense that, that person perceives that they were treated differently. And what we find is that people who report that, regardless of the reason at the end of the scale, I ask people, what do you think was the main reason? And people could say it was my sexual orientation, was my age, was my religion. What we have found so far is that attribution does not matter much. So whether you treat it differently because of your age or because of your race doesn’t make a difference in terms of its relationship to poor health. It’s if you report high levels of being treated badly, your health is worse. So it’s the stress of that unfair treatment, the stress of being treated as if you are unwelcome, as if you don’t belong, as if something is wrong with you is consequential for health.

Radha Velamuri:

Yeah. I kind of want to backtrack a little bit. You mentioned the everyday discrimination scale, and that’s one of the scales that you have come up with in your career. And I was wondering if you could tell us a little bit more about exactly what that scale is. You mentioned some of the questions on it, I just want to know a little bit more about the scale itself and how you developed it.

David Williams:

Sure. So I was interested, out of my own experiences as a Black person in America, I had experiences where I have been treated unfairly by the police. I have had experiences when my wife and I lived in Battle Creek, we were newly married and rent in an upstairs apartment from a nurse that worked at the same hospital I did, who happened to be white. And it was a predominantly white area. And a week after we moved in late one evening, we heard something like a gunshot and looked outside the window and there was a cross burning on the lawn. And the person had fired a gunshot to let the whole community know that, that was it. So I knew that the discrimination existed because of race, but I didn’t want to base a scale to capture discrimination based on my own experiences.

I wanted to embed more broadly in the experiences that could be more generalizable than my idiosyncratic experiences, for example. And so, what I did, I immersed myself in reading are qualitative published papers or books that described the discrimination that Black people experience in the United States. The work of Joe Fagan, a sociologist in the US and Felomino [inaudible 00:08:32] was a Dutch scholar who studied Black immigrants in the Netherlands and African-American women in California. So my scales, I developed three scales. And what the scales were trying to do was to try to put in words that could be administered to the general public, the kinds of experiences that people had described in that qualitative research that I had read. And basically what was I trying to do, these experiences are stressful and I wanted to capture the stress of discrimination.

Anya Morozov:

So I guess, as a master of public health student who hopes to go into practice after graduation, one major focus of mine is trying to translate that research into evidence-based practice. So how do you hope that the research involving the discrimination scales that you’ve created gets used?

David Williams:

Well, first, the evidence is quite striking that people who report high levels of discrimination across a broad range of outcomes have worse physical and mental health. Research indicates that high levels of discrimination, like other types of stressful life experiences, are linked to biological dysregulation, not just in the person’s head. It’s not just even mental health and emotional symptoms, but we see fundamental changes in biological processes. So it says to all of us in society, in our communities that we can be agents promoting life, or we can be agents promoting illness and death, just by how we relate to each other on a day-to-day basis. So how we treat each other matters profoundly. That is one of the messages.

I think it’s also important, the fact that discrimination has these negative consequences to affirm the experiences of clients who might come to us and tell us they were being treated badly. And you say, “Just get over it, forget it.” And to document that, no, these are really powerful risk factors that have consequences for health. And of course, importantly, raising awareness levels that all of us understand that we should treat each person we encounter with the dignity and respect that they deserve. And in so doing, we are not just being nice to them, but we are really promoting their health and that we can be an agent of change in a sense by how we interact with others and affirm them. So I think there are really important lessons for us. It’s not a risk factor we normally think about of discrimination as a risk factor we need to address.

Radha Velamuri:

The lessons you’re sharing are very important. And I’m really glad that you came here today to talk to us about it. But I just kind of want to know how you get your message and all of your research and the change you want to see out into the real world. Do you know what I mean? How you get those interventions planned and how it happens? Because we can talk about in academia, but I want to know more about how it happens in the real world.

David Williams:

It’s a good question. So I am primarily an academic, so I teach-

Radha Velamuri:

Just your thoughts.

David Williams:

No, but I teach courses at a university. I think that by training the next generation, that is having an impact that my students are learning about what are the factors that affect health. And they’re going out to be leaders in public health and in other domains of life, that’s one. Secondly, we published these findings, so they are being placed in the scientific literature. So the scientific community around the world is following this. My everyday discrimination scale has been used in more than 30 countries of the world. We just published a paper two weeks ago, looking at the impact of everyday discrimination on the health of the aboriginal population in Australia. And I collaborated with scholars studying aboriginal health to do this. So first of all, it’s having a global impact at that level.

Some of our work, not all of our work gets public media attention, even 60 Minutes in the United States was interested in the everyday discrimination scale and had an interview with me about discrimination and its impact as an example of media pickup of these and which reaches a larger, broader audience. And certainly there have been multiple newspaper articles about the role of discrimination and the stress that it does. And importantly, in the early days, I could have counted on one hand the scholars in the world who were doing discrimination when I started out. Today there are hundreds of people studying discrimination around the world. So I think there is greater awareness in the field. There’s greater awareness in the public. And what we are trying to do is to create a kinder, gentler society and world where we treat each other with dignity.

Radha Velamuri:

I mean, that’s all we need.

David Williams:

Yes. That’s all we need.

Anya Morozov:

And I do think what the scale has done is it’s very easy to, I guess, refute claims, but when you have the huge amount of data backing them, it’s a lot harder to refute that this is an issue that we need to do something about. And so, then you can move that conversation towards solutions.

David Williams:

Yes, absolutely. We ultimately always want to do solutions.

Radha Velamuri:

Yeas. Thanks for sharing your opinion. I didn’t mean to spring that on you, but I don’t know. I was curious, because you always hear about all these, I learned so much in the classroom, but I’m fortunate that I’m in a master’s program and I can learn about these things. But I keep thinking about what if I wasn’t in this setting? How would I learn about these interventions, or how would I learn about public health practices? How would I learn about these things? But you bring up the media, you bring up all the interventions that are happening. I thought the thing you mentioned where you’re just recently getting published on a study in Australia, that’s amazing. So I don’t know, it gives me a little bit of faith about how all this stuff is getting disseminated out there.

David Williams:

Yes. I’ve done work on African discrimination on health in South Africa. I have collaborated with colleagues in Brazil, and in Chile.

Radha Velamuri:

Have you done anything in your hometown?

David Williams:

No.

Radha Velamuri:

Oh, sorry. Okay.

David Williams:

I’ve done talks in my hometown, but I haven’t done a study in my hometown.

Radha Velamuri:

Okay. Well, I don’t know. I just thought we’re throwing out places. I thought I’d bring that up. Okay. I’m going to change the topic a little bit. How about we talk more about the future? You mentioned that public health professionals are the future, or you are educating the future public health professionals. So a lot of us, we’re going to be future professors, we’re going to be future healthcare administrators, we’re going to be future practitioners, etc. So I was wondering if you had any advice, just in general to give to the up-and-coming scholars on racism, socioeconomic status, discrimination, anything you would like to share about?

David Williams:

That is a really difficult question for me because…

Radha Velamuri:

I’m really throwing out the hard hitters.

David Williams:

No, but it’s a good question for us to think about. Clearly, public health is more than just issues of race and racism and discrimination. And these are important issues that have historically been neglected, so we want to pay attention to them. I think my message that I would want to say to public health students in general is that we can make a big difference. We can make a big difference for the health of communities. When the average American thinks about health, they think about access to medical care, or they think about health behavior. And both of those are important, but we need to understand them in the broader context of social and economic opportunities and of opportunities to be healthy in the places where we spend most of our time, our homes, our neighborhoods, our schools, our workplaces, our houses of worship. All the opportunities to be healthy in all of those places shape our health.

And so, I would encourage young persons going into the public health field, to keep this broader perspective, we need to work at every level. We need to work at a level of the individual, but at a level of small groups and institutions, but also, at a level of the community. There is a lot that we can do to improve health. And for those who are in the United States, while I talk about racial disparities in health, what the data from public health tells us that even the best of Americans could be doing better in terms of health. Let me give you a concrete example. When we talk about racial inequities in health, we typically look at the health of Blacks or Native Americans compared to the health of whites. If we look at the rankings of life expectancy in the world, if white America were a country, it would rank 32nd in the world on life expectancy, behind Costa Rica, behind Cuba.

So there’s a report from the National Academy of Medicine that shows even the best of Americans in terms of health–college educated Americans who do not smoke and exercise regularly–have worse health than their counterparts in Western Europe. So all of us need to be doing better in terms of health. So we need to think of strategies that seek to improve the health of all, even as we give an extra help in hand to those of low income and low education and racial ethnic minorities who are even further behind and have a longer way to go. But there is an effort that we have to focus on all of us in terms of a commitment to better health.

Radha Velamuri:

That stat was staggering.

Anya Morozov:

Yeah. 32nd, wow.

David Williams:

Yes. And I think the important point that public health needs to remember is that the solution is not just medical care. According to the World Bank, half of the money spent on medical care in the world annually is spent in the United States. We are 4% of the world’s population, consume one half of the medical resources in the world, but ranked near the bottom of the industrialized world on health. So it highlights the importance of just, yes, medical care is important, but we also need to think of the factors outside the healthcare system, managing stress, taking those steps that promote health, getting regular exercise, for example, getting adequate sleep. All of these drivers of good health and all of these need to be engaged. And of course, given everyone the opportunity to feel valued and feeling that they have the resources to capitalize on the opportunities of the society in which they live.

Anya Morozov:

Just kind of taking a much more holistic view of health.

David Williams:

Yes, absolutely.

Anya Morozov:

Beyond the hospital setting itself.

Radha Velamuri:

Sorry. It’s not a competition globally to see which country is healthier. But if you just putting that into perspective, that the amount of money we spend on healthcare versus how we stand again, everyone deserves the right to be healthy, it shouldn’t be a competition. But just thinking about that staggering difference is concerning.

David Williams:

But the point is that there are many countries spending a lot less money than we do and have better health outcomes than we do. And we know the reason why, most of our expenditure, according to the CDC, only about 2% to 3% of the money spent on medical care in the United States is spent on prevention. So our healthcare system largely functions as a repair shop that does a good job of taking care of us once we get sick. But it’s not a driver of whether or not we get sick in the first place. And it’s the factors outside the healthcare system that determine that. And so, we need to have that balance.

Radha Velamuri:

That’s where public health comes in.

David Williams:

Exactly.

Radha Velamuri:

At least that’s what we’re learning about.

David Williams:

Exactly. That’s the essential role of public health. That’s what we are trying to do.

Anya Morozov:

And that actually kind of leads into another question, kind of based on the vast amount of research you’ve done or people have done based on your work. If you could change a few things about our public health system, or our healthcare system, what would they be? Maybe you could talk about a few of the examples you mentioned earlier today.

David Williams:

Sure. If I could change a few things about a healthcare system, number one, I would ensure that every person in this country has access to high quality medical care. And importantly, there was a study done in the state of Delaware where the state of Delaware had large racial disparities in colorectal cancer screening, cases of colorectal cancer and deaths from colorectal cancer. And they made a commitment to make colorectal cancer screening and treatment available to everyone in the state. And they did outreach to those communities, poor communities, minority communities who let make sure everybody’s aware this is available. And what they were able to do in about six years to eliminate the racial gap that had existed in colorectal cancer screening, so that everyone was getting screening at the same rate, one. Two, to eliminate the racial gap that existed in the incidents on new cases of colorectal cancer in the first place.

And three, they eliminated over 90% of the gap in colorectal cancer mortality. And this is all done in a very short window of time based on what they were able to do in the state of Delaware. So it shows that it can be done. And you know what the best part about this, they eliminated these gaps and you said, “Well, they were spending more money, they were bringing more money in to provide a screening and provided treatment.” Yes, it costs more money, but the savings from the treatment of colorectal cancer, they had a net gain of $1 million per year in that, it’s a relatively small state. In other words, the program costs eight $8 million a year and they were saving $9 million a year. So the net gain was a million dollars a year. So the state actually saved money by implementing the program guaranteeing access to this treatment.

Now, I’m not naive, I don’t think that will be true of every single medical procedure and every single outcome, but it’s an example of we can accomplish a lot. So ensuring everyone has access to care is important. Two, a greater emphasis on preventive care of, we don’t want to wait until people get sick. We want to enable people to take the steps that they need so they can prevent illness before it occurs, that’s number two. Number three, we want to create an environment where everyone has the opportunity to live a full and productive life. That means they get the skills and strategies they need so they can work, get a good job that with a decent pay to take care of themselves, to take care of their families, their children, and so on. That is a good job, it’s a health enhancing strategy. We need to recognize that.

And certainly, we need to help everyone manage all of the stressful conditions of life. Now, we’ve talked about discrimination, and importantly, discrimination is one type of stressful life experiences that we have not historically assessed, but it’s not the only type of stress. People have financial stress, people have relationship stresses, people have stresses at work. So we need to create those supportive environments in which people can thrive. And those would be the places I would start in terms of thinking, what’s the big tool?

Anya Morozov:

Step one. Just three steps now, the health system can improve.

Radha Velamuri:

Three steps to world peace. So you just mentioned overwhelming stress and how that can cause people pain. And you know mentioned poverty, discrimination. How it’s all overwhelming, and I’m overwhelmed just thinking about it. But how do you stay hopeful despite all of these things? And your work is in very informative, but it really makes you reflect a lot. You know what I mean? How do you stay hopeful despite all of this or in light of all of this?

David Williams:

I am an optimist, I see the glasses half full. In spite of all the challenges that we face, I see greater awareness, greater knowledge, greater engagement around the world on many of these issues. So the glass is half full and not half empty. And to be honest with you, my greatest signs of hope are my students. I have students who want to make a difference, who are motivated, who are vast patient than I am with the status quo and want to transform the world and make it a better place. So as I look at the students I teach, and I don’t think it’s just my students, I teach at Harvard.

Radha Velamuri:

I was like, “We’re not directly your students, but I’m going to take the compliment anyway.”

David Williams:

Yes. We have a generation of young people who want to build a better world, who want to see things better. And honestly, they are a source of inspiration for me and a source that what I’ve done is not in vain. There are people taking the heat of what I’ve done, they’re people who are going to take this torch-

Radha Velamuri:

People are listening.

David Williams:

… and run with it. Exactly. So that for me, is certainly a source of optimism and hope.

Radha Velamuri:

It makes us feel good about what we’re doing. We took the decision to come here and spend a couple years in our life just entrenched in this field and trying to… Entrench sounds morbid, but we’re deep inside, we’re trying to learn. And every now and then, it can get kind of sad seeing some of the hardships people face that maybe we might not have been aware of before. Or hardships that we faced on our own that we see are much bigger problems that than just our own personal issues. So really, it’s rewarding to us to know that someone who’s as experienced as you looks at us or your students, I guess.

David Williams:

Students that I encountered along the way.

Radha Velamuri:

And sees that we have potential.

David Williams:

I just spoke to some of the American Public Health Association meeting. I spoke at a session there and there were lots of students there. So yes, it’s the students in general. Yes.

Radha Velamuri:

Thank you. No, I’m just fishing out.

David Williams:

I know.

Radha Velamuri:

But yeah. Well, we have one last question for you. Do you want to ask it?

Anya Morozov:

Yeah. So this is a question we ask to all of our guests on the show. What was one thing you thought you knew, but were later wrong about?

Radha Velamuri:

We like to know this one. It’s really funny.

David Williams:

What was one thing…

Radha Velamuri:

You thought you knew?

David Williams:

I thought I knew?

Radha Velamuri:

But were later wrong about it.

David Williams:

But I was wrong about?

Radha Velamuri:

It’s a toughie.

David Williams:

That is a toughie. I am racking my brain. No, I really am. I’m racking my brain to think of what was one thing I thought I knew.

Radha Velamuri:

It doesn’t have to be insightful. It could be like I didn’t know that bubble tea had tapioca pearls inside of it. I thought it was gelatin, or you could say whatever you want.

David Williams:

Well, I learned a lot about public health here at the University of Iowa, that I didn’t know before. I didn’t know that this department came out of a medical school just a few years ago. That it’s a relatively young school of public health and that it’s making a difference in so many ways. So I have learned a lot from this journey that I didn’t know about. You think of Iowa as in the Midwest, it’s a place where there isn’t a lot happening. And I’ve learned about a lot of good things that have taken place here. So it has certainly broadened my horizons of the great opportunities you have as students here, to learn and to be prepared to make a difference in the future.

Radha Velamuri:

I remember you saying in the beginning of your talk earlier that you’ve driven through Iowa before, but you haven’t stopped.

David Williams:

That’s true.

Radha Velamuri:

What you thought you knew, you thought you knew Iowa was a drive through state, but now you know that it has a really cool public health college.

David Williams:

That’s right.

Radha Velamuri:

Sorry. Just narrow…

David Williams:

Which is absolutely true. Were there people who have being trained and making a difference? And I came because I got an invitation from your dean. I saw it and instantly I said, “I’m going to go,” because I knew her. She was a great colleague at Michigan, where we taught. So yes, it’s been great to be here and to learn more and to put Iowa on my mental map.

Radha Velamuri:

We’re happy to have you.

Anya Morozov:

Yes. Well, do you have any kind of final thoughts about anything we’ve talked about today before we wrap up?

David Williams:

Well, I would say I am very impressed with the fact that two busy MPH students have taken the time to create a program that I understand you have listeners not just in this community, but even overseas. And I just want to commend you on your vision and dedication because I know it takes hard work. It takes making this a priority in your lives to do it. But that’s the kind of innovation and that’s the kind of thinking outside a box it will take to move the field of public health forward. And so, both of you are source of personal inspiration to me because you’re blazing a path. No, I’m serious. You are blazing a path. And that’s exactly the kind of thinking and the kind of actions that we need, to not be stuck in doing things the way we’ve done them before, but to think of the opportunities that exist and to maximize them.

Anya Morozov:

Yeah. I think one of the most powerful messages that I got from your talk earlier today was when you were talking about that project in Georgia and the fact that it can be done.

David Williams:

It can be done. Exactly.

Anya Morozov:

What was the name of that?

David Williams:

Purpose Built Communities.

Anya Morozov:

Purpose Built Communities. And it was a community that had…

David Williams:

Transforming a public housing project into an oasis of people doing well of high employment, of high quality education and everything else.

Anya Morozov:

Yes.

David Williams:

So if they can do it, so can we.

Anya Morozov:

Yes, exactly. And hopefully we will. Once we get off this episode, we will go and make changes. So thank you so much for taking the time to come to the college. I hope you have enjoyed your time in Iowa, and I think we’ll just wrap up there.

David Williams:

Thank you. It’s been a pleasure.

Anya Morozov:

And that’s it for our episode this week. Big thanks to Dr. David Williams for joining us today. This episode was hosted and written by Radha Velamuri and Anya Morozov, and edited and produced by Anya Morozov. You can learn more about the University of Iowa College of Public Health on Facebook, and our podcast is available on Spotify, Apple Podcasts and SoundCloud. If you enjoyed this episode and would like to help support the podcast, please share it with your colleagues, friends, or anyone interested in public health. Have a suggestion for our team, you can always reach us at CPH-GradAmbassador@uiowa.edu. This episode was brought to you by the University of Iowa College of Public Health. Until next week, stay healthy, stay curious, and take care.