Cafferty Lecture 2010 Transcript

OPENING REMARKS by: Neil Guterman, Dean of the School of Social Service Administration, Mose & Sylvia Firestone Professor

I'm pleased to welcome you all to the annual Pastora San Juan Cafferty lecture on race and ethnicity in American life. I'm Neil Guterman, the Dean of SSA. This is my first opportunity as Dean introducing this annual civic forum that recognizes and honors, Professor Emeritus Pastora Cafferty, and her many contributions as an educator and a scholar at the University of Chicago School of Social Service Administration. I first want to thank the Cafferty Civic Lecture Committee comprised of William Brodsky, who will join us later this evening; Frank Clark; Jeanne Marsh; Al McNally; Linda Johnson Rice; as well as the corporations that helped to make this presentation this evening possible: Exelon Corporation; Waste Management, Incorporated; Kimberly Clark; CBOE; and Harris Bank.

As many of you may know, my appointment as Dean just began a few short months ago. And one of the very first events that occurred, even before I assumed the responsibilities of the role of Dean, was a surface mail that appeared on my desk from Pastora inviting me to join her for lunch. And as a relative newcomer to Chicago, while I was aware that Pastora was an esteemed faculty emeritus at SSA, I was frankly unaware of what an enormously good friend Pastora is to SSA as an institution, even in her emerita status.

Pastora has very quickly moved to connect me for SSA's benefit with many key civic and business leaders. And this is so important because so many of us are dedicated to addressing concerns of those most vulnerable or facing social exclusion, and we don't often or naturally reach out to engage leaders in the business or civic community to let them know the important work that we do, and in particular, about the critical intellectual and educational leadership that SSA provides in addressing some of the most challenging social problems of our day.

So I'm especially appreciative to Pastora, her service as an action-oriented ambassador for SSA and through this, to help us forage real, meaningful social advances. So thank you, Pastora.

For those of you that don't know Pastora, Pastora served on the faculty of SSA for 33 years. As a scholar, Pastora has been one of the prominent intellectual leaders on the subjects of diversity, race and ethnicity, immigration, and social institutions in the context of American politics in both classrooms and in corporate boardrooms. Pastora has authored numerous books and articles on these topics. Her first book, A Diverse Society, Implications for Social Policy edited with Leon Chestang as her co-editor, was a product of a working group convened by Pastora and SSA in the mid-1970s to examine the implications of race and ethnicity on the teaching and practice of social work. That book is still in use in schools of social work and now has a companion volume entitled, Our Diverse Society, Race and Ethnicity Implications for the 21st Century American Society, edited by David Engstrom and Lissette Piedra, published in 2006 as a culmination of the symposium honoring Pastora upon her retirement from the faculty.This most recent volume raises new questions about the development and implementation of social policies in today's diverse society.

Now, before I introduce tonight's speaker, I would just like to ask you to please join me in thanking Pastora for her lasting and ongoing contributions to the study of race and ethnicity and for providing inspiration for this annual lecture this evening. So thank you, Pastora.

Now it's my pleasure and sincere honor to introduce Barry Zuckerman, Joel and Barbara Alpert Professor of Pediatrics at Boston University and Chief of Pediatrics at Boston Medical Center. Dr. Zuckerman has dedicated his professional life to working at the intersection of pediatric clinical care, research, and public health, concentrating on transforming health care to better meet the needs of young low-income children and families of color. He is the author of more than 200 influential scientific publications—by the way, many of which have importance in my own scholarship—on early child risk and maltreatment prevention research. So I'm especially interested to hear his discussion tonight. And he's founded several notable programs that aim to counteract social conditions affecting better health outcomes for children and youth. He pioneered a partnership between Boston Medical Center and the legal profession that provides assistance to parents and custodians when children become ill from living in substandard housing. Dr. Zuckerman co-founded Project Health, a national organization that mobilizes college undergraduate volunteers to work directly with low-income parents to promote access to community-based services and resources. Project Health has won numerous awards and was recently recognized by First Lady Michelle Obama as an important service effort.

He's also pioneered Reach Out and Read, a program promoting child development and early literacy that has been widely studied and implemented around the nation.

Among his many affiliations, Dr. Zuckerman is a board member of Zero to Three and a member of the Carnegie Task Force on meeting the needs of young children. He's received numerous honors—I could no way name them all—but several notable honors include the Confucius Award from UNESCO, a Nova Award, and the Robert F. Kennedy Legacy Award for the Media Legal Partnership. For tonight's 2010 Cafferty Lecture on race ethnicity, Dr. Zuckerman will speak with us this evening on health disparities, origins, and opportunities. Please join me in welcoming Dr. Zuckerman.

Note: Readers may follow along with Dr. Zuckerman's Power Point presentation, "Health Disparities: Origins and Opportunities" that can be accessed at
Thank you. It's an honor and privilege to give this Cafferty Lecture, it's always nice to have visiting lecturers in universities—but to have this open to the public and to make it available to people, I think is really a special gift to this community. These are issues that we talk about, and it's always helpful to have someone come in and help us to further understand it. Because once we stop talking about it, we're going to stop working on it. And I think hopefully as we go along, we can provide new perspectives that will lend itself to better solutions.

I'm delighted to be here in Chicago with old colleagues like Dodie Norton from the School and Sydney Hans who I've known and worked with for years—at least 20, if not more. I'm going to tell you what I'm going to talk about and then summarize it at the end.

We're going to look at racial disparities in health. It's probably not a whole lot except for some minute details that aren't that much of interest that you don't know. But as I've thought about this talk, it really blended together with how I see the life course of children. We want to understand how to affect and how to have an impact in preventing these health disparities among adults, blacks and Hispanics, from having more disease and dying. We have to start in early childhood, just like we've talked about other things. And I'm going to make the case about what that life course looks like. Thinking about life course has been something that the NIH and other federal policy agencies are thinking about as everyone's finally getting the importance of prevention, which we've always talked about, but you've got to start early.

I have to mention a very old special friend of mine, Irving Harris, who was a big friend, a supporter, someone intellectually who pushed us a lot to think about these kinds of things. At that point Irving thought about children doing better in school and, therefore, being more productive in society. I think we hadn't yet pulled together the data that really linked all of that to health.

And then my other friend, Harriet Meyer, who is—was, just stepped down, the president of The Ounce of Prevention and the work of Educare, which—again, is an outcome of her's and Irving's dream to really put together something special in early childhood to change the trajectory. I'm going to be talking about trajectories tonight. You start somewhere, and you either end up in a good place or a not-so-good place, and you have to understand the factors that contribute to that to get there.

I work in an inner-city hospital, I take poor children, and they come in all different skin colors and sizes and shapes from all different countries. And even the notion of race is not helpful because now we have blacks from all over Africa and other places around the world. We have Hispanics from all over South America, the Caribbean, and from Europe, and it—race just doesn't help. Culture doesn't help either. It's sort of whether you're from the rural part of any of these countries or the urban part. And it really becomes a final common denominator, which I'm going to talk about, whether you have the resources to support your family, your children and yourself, or you don't have those resources.

(see PPT slide 2)

Racism contributes to poverty. We're all aware about that, how it impacts on educational opportunity. Some statistics that are important to know—that about two thirds of all black children are at high poverty schools in the country. So they're poor schools because they're in poverty areas. On the other hand, and this is not taking a shot at Chicago, but it just came along with this article, that the number is 90 percent in grammar schools in Chicago. 90 percent of black children in Chicago are in poor schools. So there's still a racial segregation but to poor schools. Whether they're minorities or not is one issue, but whether they're in a concentrated poverty neighborhood is another area. And we know all about that, and I don't need to go into that. But racism impairs those educational opportunities.

Also employment opportunities; whether it's promotion, whether it's wages, and whether it's harassment. Though things are commonly—unfortunately, you read in the paper about suits that have been provided during the last 20, 30 years. And this interferes with income and the discrepancy in poverty. So you have increased poverty because of racism. And if you follow that with the increased poverty and where there can be a strong focus of my talk with that comes a variety of factors which are called social determinants that contribute to poor health.

And stress and violence, I'm going to really talk about that. A colleague of mine said recently that violence is to mental health as tobacco is to cancer. I mean, this is something that we're going to have to come to terms with. Race—it's not clear whether violence is more common with any particular race, but it's pervasive throughout society. And certainly poor people, it tends to be disaggregated more there.

Poor diet. When you're poor—without getting fancy—you're talking about more salt and more fats and that speaks for itself.

A poor learning environment, and whether that's child care or the schools that we spoke about. And even in terms of poverty, then you—there seems to be an article at least weekly about now with this recession, people don't have the money for their co-pays to pay for medication.

We did a recent study in our emergency room. A third of the prescriptions we gave to families, they couldn't—they didn't fill because they didn't have the co-pay. So they come to us with a health problem, we diagnose it. Their insurance—because this is Massachusetts, we have everyone covered. Their insurance covers that $200, $300 bill. We give them the solution to it, the prescription, and they can't fill it. What's wrong with this system?

And then you also have more disaggregated socio-poverty, cigarettes and alcohol. And all of those factors are going to contribute to poor health.

Taking other view—we're talking about structural racism. We're not talking about the individual attitudes of people, per se, although, that's still pervasive. We're talking about norms are developed where groups of people are considered inferior and, therefore, they're treated differently, called discrimination. And there's a long history of this. Stephen Jay Gould, who wrote a book the Mismeasure of Man, sort of a history of more than just IQ testing. If you go back 2,300 years, they drew pictures of the physiognomy of adults and that was the correlation to intelligence. So as you might imagine, the physiognomy, particularly facial physiognomy, of white males were the most intelligent. And the physiognomy of blacks were the least. And women were in between, because they were not the same as males. So this was the IQ test, and people figured out if you looked like this, based on the way they looked at society, this is the way people's IQ and chances of being leaders and being productive members of society.

So there's a long tradition, subtle and not so subtle, that certain races are considered inferior. And when they're considered inferior, society treats them differently.

The case of structural racism is interesting around medical care. Interesting isn't the exact word because I like to think most of my colleagues who are physicians are not racist; they're not doing anything purposefully harmful. But they're in a system and they have unconscious attitudes and their transaction with patients actually result in disparate care.

So we know, no matter how you cut it, minorities get less procedures, operations, preventative screening than nonminorities. Those numbers—again, you can almost read in the paper. You don't even have to read academic articles. But I want to at least cite a few. A very well-done study with 30 million people. They looked at nine surgical procedures, and they compared them by blacks against whites over the time course of 1992 to 2001. Now, over that time, there was no change in two of those surgical procedures. In one case, there was some improvement. So there's a difference between black and white.

For cases of two of the surgical procedures, one different one for women, one different one for men. The women were angioplasty and the men's were abdominal aneurysm; the disparity actually got less over that period of time.

And two procedures—this was heart bypass and valve replacements, there was no change. So there was still a disparity.

And literally during this time, five procedures increased disparity; back surgery, stroke, prevention surgery, hip and knee replacement, and appendix surgery. So here in a common era, in the '90s, over this period of time, whites had more of this surgery than less. So this is not even a static difference. This is even getting worse in some ways.

Although, I have to qualify it a little bit because when you say there's a disparity, sometimes we're not sure if some groups are getting too much or some groups are getting too little, quite honestly. So everything I know about back surgery—I'm not a surgeon—it's not that effective. So maybe the fact that blacks are getting less of it may be good because, you know, a lot of the surgeries people are getting do not seem to be effective.

So, you know, even when we're talking about disparities, it's important to acknowledge that just because you're not getting something, it may actually be beneficial to you.

And speaking of that, when we're talking about disparities, I want to make the case that because of our bourgeoning biotechnology and scientific advances over the last 30 years, that unequal access to healthcare, and particularly the medication and procedures, has the potential to increase disparities. Why do I say that? Forty years ago there was more unequal access. The minorities and poor people had less access to healthcare. But honestly, back then, we didn't have that many effective treatments. We had antibiotics and a couple of surgical procedures and not a whole lot else that was effective. I'm making a generalization. So if you don't have access to it, you're not going to suffer much because there wasn't that much to offer.

But in the last 30 or 40 years, the effectiveness of our medications, our treatments, have just gone sky high. So now with unequal access—there's a potential increase in disparities. And part of my own work is I've been talking to the pharmaceutical industry because in some ways, I can align my interest in reducing disparities with their interests in a full market. They want to see everyone have access to their medications because that's profit for them. So I'm hoping there's a way to sort of bring together, in this case, a market solution with a way of reducing disparities, but it's just something to keep in mind.

And along with the racism, there's stress. And that's pretty clear, too, that even when incomes are controlled, the stress of racism has an impact on certain aspects of healthcare.
So keep this in mind. What I'm going to be doing is focusing a tad more from the poverty to the poor adult's health, but I'm going to take that early childhood perspective, and you'll see how I'm going to play that out because that has implications, I think, where we should start.

(see PPT slides 3 & 4))

This is a very important study that looked at what's called allostatic load. Allostatic load is aspects of the environment that get embedded in physiology. Nine—eight factors of physiology that are the precursors of disease. And that may include hypertension, it may include markers of inflammation, it may include markers of glucose, metabolism. So you don't have a disease, per se. But you can see the black/white difference. And blacks at every age have a greater allostatic load, which is probably consistent with the fact that they have more disease later on in life.

But what I want—and what I'm going to keep emphasizing in this talk is look at the trajectory. Starting the first 20 years, they're pretty close together. But blacks are on a different trajectory. And you see where it starts taking off in the early twenties through age forty and beyond. So the difference between trying to get back on track here is a lot less than trying to get back on track here.

It makes the case that maybe we can move that trajectory a little bit early on to get people back on. So we're not talking—we're talking about a factor, once you're tracked, you're heading in the wrong direction, how best can you influence that tracking?

This is the same thing aggregated by gender. Basically, the important thing to take away from this is that black women have the worst allostatic load, more so than black men. And you see very little difference between white men and white women.

And again, look where the chart's coming from. So the end result is not a surprise because any outcome you look at is different. It's the trajectory that I want you to keep in mind.
I was trying to figure out how to put this into the talk, and I really couldn't figure out a good way to do it. This is a quick tangent. It's about sickle cell anemia, because it's an interesting health story about race, and part of my challenge for this talk is, how can I tell this audience something that they don't know about? How many things can I bring to their attention? I thought this would be a good one and very consistent with the spirit of this talk.

So when was the last time any of you either gave money or raised money for any event for sickle cell anemia? Probably not at all because they're aren't too many of them. And I should say now, for those of you who don't know, sickle cell anemia is a disease approximately—primarily of blacks, 1 in 400, 1 in 12,000 of Hispanics, and maybe 1 in 100,000-plus for whites. It's a single gene disease, and people die earlier. We've increased their lifespan and that's been good, but somewhere in people's 30s, 40s, or 50s—and it's gotten much better—the kids will die. So it's a serious disease, and about 80,000 people in the U.S. have sickle cell anemia.

When was the last time you went to an affair? When was the last time you saw an announcement or a media person come out wearing a ribbon that said sickle cell anemia? Probably not at all. And then I want you to ask yourself why, why is that? It's pretty easy when you think about it because this is a disease of blacks and it's not clear that anybody knows about it or cares.

Why is it important that the public knows about this and cares? Because parent groups and groups for every disease provide resources and education for people with those diseases, it reduces stigma, they work legislatively to get money from the Feds, and they also give money themselves and that moves the field.

I first was sensitized to something about sickle cell—the macro context. Two things happened about six, eight months apart. The first thing was when I was taking care of sick children on the Inpatient Ward, I had this young male adolescent with sickle cell anemia and just one late afternoon I was just sitting there talking to him about school and his life and things like that. I asked him 'do his teachers accommodate him' or 'what was it like with his friends.' And basically he said that his teachers don't know and his friends don't know.

And I talked to him a little more, and it was very clear that this disease still has a stigma. All diseases have stigma. But the nice thing in the last thirty years, probably starting with HIV, most diseases have been de-stigmatized; HIV, breast cancer, cancer, prostate cancer, cystic fibrosis, you name the disease. Everyone, unlike forty years ago, people know someone, they're aware of it, and there's groups of—you know, family groups and there's legislative activity and there's fundraising.

And then about eight months later I needed to hire another head of pediatric hematology, and because sickle cell is our primary disease of blood cells, I wanted to get an academic who would take care of the kids and do research and do things academics would do.

I looked around the country and I had advertisements and I spoke to people, and I identified three pediatric hematologists who were academic leaders in sickle cell. And then I had to ask myself, jeez, this is a major disease of kids. Why aren't there academics doing research and why aren't people making their careers of it? That's pretty clear: People make their careers where the money is. If there's money there, they're going to do the work and they're going to be successful. But if there's no money there, they're going to go somewhere else to do the work where the money is.

So that sort of got me looking at this, and I went back and looked a little bit at the history of this. About in the '50s and well before that, it was a disease that was characterized, again, among blacks. It was called "bad blood." Now, it was a stigma. So if you're black, you have bad blood. I mean, it's bad enough you have black skin in our society, but then you get an image of black, you know, throughout you. And part—one of the important symptoms of this disease is you have these painful crises because your blood cells sludge together, and it's like a stroke and it causes pain distal to wherever they sludge together. So here you have a disease among blacks that's caused by bad blood where your whole body turns on you to cause pain. I mean, you can imagine the images that that can invoke in the people experiencing the pain. Forget what anyone else does. My body's turning against me because I'm black and my blood is bad, and you generalize to who you are.

And with the oncoming civil rights in the late '60s and '70s, there was two very important articles in the medical literature pointing out the potential racial implications of sickle cell anemia, and these articles, they compared federal spending on sickle cell anemia—this is, again, in the late '60s, early '70s—compared to it diseases of whites. And the white diseases were primarily cystic fibrosis and maybe three or four other—I'm trying to remember—diseases primarily of whites. And lo and behold, they found more funding for the disease of whites than disease of blacks. And again, this being the civil rights era, and Ted Kennedy played a big role in this. They had the hearings; this data was presented. And there was a piece of legislation that came about called "The Comprehensive Sickle Cell Centers," and it created 11 research centers around the country to move this ahead, which was wonderful.

That was 1975. The hearings were in '73. I think the legislation was passed in '75. Let me just go through and tell you where we are now and how we got here.

(see PPT slide 6)

This is basically the prevalence of this disease. Sickle cell disease and cystic fibrosis, 80,000 versus 30,000 people. Both diseases, people die approximately the same time, in their forties. It used to be much less, but let's just use forties. So the federal support, as you can see, millions of dollars is—this is from about forty years ago. It is about 25 percent more for cystic fibrosis. And then when you look at the per-person funding of disease, which may or may not be an important number, you can see what that looks like. It's about four to one. So you have more federal funding.

Then when you look at philanthropic support, you see for the Cystic Fibrosis Foundation, 152 million a year and 500,000 for sickle cell anemia.

And then you look at the total NIH of private support, and basically for cystic fibrosis, for every $9 spent on cystic fibrosis, public and private money, there's $1 spent in sickle cell. So here a disease of blacks compared to a disease of whites, this is what it looks like. And I'll throw the challenge out here. I've been looking for leadership for this disease, whether it's media stars or athletes, and I've been unable to find someone. I contacted a friend that was on the board of the Urban League, and I was told that HIV/AIDS is what we're doing.

I don't understand where the lack of interest and focus for this is, assuming there's interest and focus on almost every disease. And it's necessary. It's necessary for the adults and children who have the disease to de-stigmatize, it's necessary for the families to have the resources. And the cystic fibrosis group have—by the way, one reason they have a lot of money, there was a star quarterback from the Cincinnati Bengals whose child had cystic fibrosis. A producer in Hollywood's son had cystic fibrosis, made a made-for-TV movie. Those things just resulted in huge amounts of money coming in. And that's important and that's needed. And so that's—I wanted to just present that example to you.

(see PPT slide 7)

But moving on, I also want to show you this from 1975 with the funding when it was initiated, I think what you can see here is there was actually more funding at that time because prior to that, there was more funding for cystic fibrosis. If you go here, you see more funding for sickle cell. 1980 a little more funding. And then look as the waning, if you will, of civil rights in this country, at least my perception, look at the funding differentials. Sickle cell sort of went down while cystic fibrosis sort of stayed the same, and look at 2000-2004. Fortunately, sickle cell went up, but not even keeping the same pace with cystic fibrosis. So it's a new example of an old problem and just something for all of us to think about it. And my contribution is I want to make people aware of this with the hope that I'll get somebody's attention somewhere because the kids I take care of need the kind of input that a societal focus would provide. Just like any person with any chronic disease, no different than anyone else.

(see PPT slide 9)

Okay. So I want to go back to this scheme, and move it. Instead of going across to look at where we're starting. And again, here's another slide. And again, I'm taking the income to the health aspect of it. And not surprising—you see at every income quartile—high blood pressure, poor glucose regulation, inflammation. Inflammation is now thought to be really associated with heart attacks and a number of other diseases, and it's a very early marker.

And also, if you look at the graph, it's incremental. The potential for any time you have this kind of graph is if you can move the income quartiles, you can move people down one notch in the risk level. So you're not talking about a threshold. You have to go down below something and everyone's okay. If you just move a quartile, you can go from 30 percent prevalence of blood pressure to 25 percent. That's the way on a population basis we think about this kind of graph of moving people through a public health population control.

Again, this goes back to when I showed you before, and the key of this talk is, you know, where do you start? If someone is sick or they have—you know, any other reason—and again, I'm taking poverty and income as the final common pathway to racism and other factors for the sake of this discussion. And you can even ask yourself, if you had $3,000—let me say $5,000— to spend on a child, can you get more bang for the buck here, when you just have to move this trajectory a little bit; or do you get more bang for the buck here when they're an adolescent and you give them job training and retraining and a number of other things? I think you can see the potential opportunity that earlier is better. And that's going to be my case.

(see PPT slides 10 & 11)

But to also show—the effect of early life social adversity, poverty and all the things associated with it, because it's not just poverty, and future health, this slide was taken from all the longitudinal studies. Most of them are in the U.K. and some in Australia and others, because the U.S. does not have longitudinal studies. You can see what happened. If you're poor in early childhood, the first five to ten years; the second decade of life, you know, you experience school failure, you may or may not be pregnant, criminality, poor health behaviors, unprotected sex, cigarette smoking. It's all there when you're poor. And then you see the third or fourth decade, you have some of these precursors to disease. Fifth or sixth decade, you have coronary heart disease, you have diabetes. And then if you will, at old age, which starts at the seventh decade, which is the seventies, premature aging, memory loss.

If you have social adversity early in life, you're having all of these problems a decade or so early, meaning that it's being laid down, imprinted—and I'm going to talk a little bit about that—earlier in life. So everything is early. I want to say something about when we look at mortality figures for either by race or poor people; and obviously, blacks and Hispanics die at an earlier age, it may be a few years. But as we're thinking about wellness, the outcome now is less that you're going to live to be a hundred, which seems to be happening anyhow; but literally, your quality of life, your lack of disease before you die is compacted to weeks or months, not years. This is very important. So you still may die at 76. But the goal is if you've kept yourself healthy, so to speak, you'll die on the golf course. You'll be well, and you'll just sort of fall over. And, you know, people can make a case from a quality of life, that's a lot better than the kind of restrictions and the kind of in and out of hospital that, you know, some people suffer for one year, two years, three years before they die.

So all this wellness stuff may or may not make you live to be a hundred because there's probably some genetic component to it. You're compacting the morbidity, the chronic disease, in a much smaller amount. And I think that's what we're going to find out. So looking at mortality statistics only is the beginning of really what's going to happen to you.

(see PPT slide 12)

When we think about racism, we think about poverty, it's from a epidemiologic study point of view, it's something we know is associated with it. And in reality, we talk about racism. Poverty is frequently a factor that's controlled statistically. Because you see whether race itself contributes to poor outcome. And in many studies it does for certain problems. But that's missing the point. If poverty is part of the sequence, it's the end result of race that gets you there. You should be looking, I think, at both.

And when we talk about social factors, sometimes we talk about, well, disease and biology and social factors. The reality is these social factors get embedded in biology. So whether it's social, whether it's—I use stress. Whether it's physical or nutritional. Nutritional—I'll use anemia, lack of iron. Any of these physical factors—could be allergens during pregnancy or not—they then move over to interact with genes. So anybody is potentially more or less vulnerable genetically for any of these factors. And so there's a gene environment interaction. You then get a change of physiology and an adaptation or a disruption. And I'm going to talk a little about that. It could disrupt the glucose metabolism, it could disrupt brain development, it could disrupt immunologic function around allergies and asthma. But I'm not going to talk much about these other organs. I'm going to really focus on the brain because with the brain, there are two pathways. One is impact on the brain, inability to learn, school failure, which leads to all of those things. But also, the biology gets embedded into the brain that causes its own set of problems, particularly around mental health and even physical health. And I'm going to just try and draw that out for each of you.

(see PPT slide 13)

So from a very simple point of view, what the brain needs, it needs good stuff to positive stuff. So it needs the positive stuff: There's nurturing and stimulation. It needs to be protected against the adverse problems, which—stressful, harmful interactions; neurotoxic exposure; you know, lead, air pollution; inadequate nutrition; all of those things directly affect the brain. I want to sort of just walk you through this just to help you understand. When children reach 18—for me as a pediatrician, and you can see on those charts—they're healthy. I don't see any physical disease. You know, two, three decades later, they have a lot of problems. But what you do see, the organ I think is most sensitive to that environment is the brain and, therefore, learning. That's the first thing that goes. That's the first organ that goes. And I'm putting this in medical speak. Because then you look at these 18 year olds and you say, they're physically fine. You know, they went through this rough time; and okay, they got Cs and Ds in school or maybe they dropped out or maybe they're smoking cigarettes. But not only are they on this trajectory to poor health, but—you can't see it in other organs, but their liver, their immunologic system, their lungs, and everything else has laid the groundwork, but it hasn't caused disease yet although the precursors that I tried to tell you are still there.

(see PPT slides 14 & 15)

And I'm just going to give you a little bit on brain development. At the time of birth, it would be like having telephones in Boston and telephones in Chicago. If they're not connected, they can't do much in terms of communicating. And you see when there's input, stimulation, they get connected except brain cells that don't get connected, and you see up there the second or third from the left didn't get any input, and they go away. That's called pruning. That's a natural process, that you start with more connections than you need. And the ones that are sustained are the ones that are stimulated.

So if you grow up in a language-rich society, those connections that involve language and communication are readily supported. On the other hand, things that have to do with fine motor and the kind of things that certain people in villages in South America, if you ever watch them weave, the way they can move their hands quickly and precisely is beyond probably what anybody in this room can do because that's the part of the brain that gets stimulated.

They did study with imaging studies with violinists, and the fingers of a violinist obviously move in a very precise, very coordinated, very fast fashion. And the part of the brain that's associated with the finger movement was bigger in violinists than it was—so it's really like building muscles. You know, if you work it out it stays, and if you don't, you're flabby. But this is the brain. So the input does matter.

And this gives an example: Each of these have the same number of brain cells; but you see at age 14, it's pruned out. Only those synoptic connections that are maintained remain.

(see PPT slide 16)

And to give you an idea what the environment—when I said they need the good stuff, and part of the good stuff is stimulation and nurturing—this is just a study of language development done by some researchers in the Midwest maybe twenty years ago. They took an audiotape and put it in people's homes from—I think it was eight months to three years, and they just taped the interactions and counted—basically counted the words. And you see the number of words per hour, of a group of poor children, working class, versus children of professional parents, you see a four-fold increase in the number of words that the children heard. Not only did the children of professional parents hear more words, but the words were richer. Because among the poor parents, a lot of the words were repeat commands; stop that, shut up, behave, listen, as opposed to more adjectives and descriptive language. So the quality of the language, it's responsivity to an interaction differed and the quantity really mattered.

When you add that up for the first three years of life, the poor children had a 20 million word deficit compared to the professional. This is per hour. And then it's just a simple math number. Twenty million of anything is a big number and hard to make up.

(see PPT slide 22)

And then when you test the children at age three, as you might imagine, these children have poorer language scores than the other kids at age three. And we know that's just the beginning of the trajectory of entering school not ready to learn and, therefore, continuing that trajectory on. So that's just one example of stimulation.

(see PPT slide 18)

I want to give one example of the impact of stress. I think that's made the common media, but I want to just walk you through that to understand it because the lack of the good stuff and too much of the bad stuff is really common on social adversity, which is disproportionally seen in black and Hispanic kids in part due to the structural racism that we spoke about.
During the course of the day, we all have stress responses. A stress response means you get a hit of cortisol. So to get out of bed in the morning to do a task, your body has to prepare itself. You have to get engaged and stay focused. In some ways it's like having a cup of coffee in the morning. It's that kind of a response. And during the course of the day, you know, it goes up and down like that and that's just a normal fluctuation.

(see PPT slides 19 & 20)

Then you have to ask yourself, what about children or people in the face of what people are now calling toxic stress, significant and chronic stress? What the slide looks like is this. The cortisol response goes up and stays up. It doesn't come down.

And then you have to ask yourself, what does cortisol do? Well, it has a lot of effects. Some are positive; but over the long haul, it basically poisons a lot of the body's systems; the immunologic system, the cardiovascular system, and particularly the brain. It affects certain minerals from not going into the brain. It actually kills nerve cells. And if you think I'm making more of a case of that, just to show a picture is always worth a thousand words, these are those brain architecture, those branching-in synaptic connections. You see that normal over there, and you see what it looks like under a large microscope. And then under chronic stress, you see what's there, that actually the dendroids have disappeared. This is for – not because of lack of input. This is because, if you will, the stress and, therefore, the cortisol was toxic and literally affected these brains at the level of the brain cell.

(see PPT slide 21)

And then when you do an imaging study, and that's called a hippocampus. The hippocampus in the brain is where your memory is. They did this study with women who reported stress scores over time. None of them had what—the prototype stress model is posttraumatic stress disorder. Which we see in veterans, we see in women who have been raped, we see in anyone who's suffered a traumatic experience. And the more stress, the smaller the volume of the hippocampus. And you can see the pictures there. So we're talking about information that's connecting the social environment on how it gets embedded in biology.

So with this as a background, what should we be doing? I'm going to make the case that there are—until we get a whole societal re-haul of all of our institutions, to get rid of racism and do income transfers to get rid of poverty, that's not going to happen. So what are the short fixes? And I want to just go through a few for you to think about, because sometimes small things can have a big impact, and we're the leverage points. And I'll tell you a few that are going around the country which I found more or less interesting.

One is that health facilities that want to build have to in many states apply for a certificate of need, have to go through a regulatory process to see whether these beds are needed. And, you know, the idea is to—you don't want to build too much of it because it could be a cost problem.

What we've done in Massachusetts and a few other states is part of this certificate of need is you have to demonstrate who the population this facility is serving; and if it is a population of poor and minority people, how many translators are you going to have? What kind of other adaptations and accommodations are you going to make to ensure access? So this is the only place where there's leverage in facilities to do this. Because once they have their facility, the government or states really can't intervene. But, you know, in order to get this permit, you have to show your plan to accommodate, to ensure access and particularly access for marginalized populations. I think that's a good idea.

The other is I spoke about the differential surgical rates and other medical procedures. Well, someone did a study and looked at millions—where—and it was elderly black men, and they found out that 50 percent of elderly black men were taken care of at 5 percent of the hospitals in the U.S. And 90 percent of elderly black men were taken care of at 25 percent of the hospitals. So one could say—and those hospitals, as best as they could for quality weren't necessarily as good as some of the other hospitals. Not surprising to any of us. It's like schools and high-poverty areas.

So one thing that you could do is target these hospitals for improvement efforts. So instead of giving everyone money for medical care, say the government; okay, we're going to go after the 5 percent of the hospitals where 50 percent of—in this case it was black men, but I think you can probably generalize to more minorities or 25 percent. So you can really focus your money and put your money where the problem is to make the change.

We did a recent analysis for children and found, again, minority children are more likely to be hospitalized and not throughout a broad spectrum of hospitals but in a few which makes targeting that easier.

Other things that are happening is providing health information in some services in nonhealthcare settings because of all the barriers. So barber shops—there's a program, I think it was in Detroit, where they trained barbers to actually do blood pressures and teach them. We all know that a lot of education around sex and other things are going in salons for women. And there are a number of other churches, and there a number of other places that ensure access of information that's critically important. And I think this is important. I think increasing the number of minority physicians is important. And one of the things that I always—having dealt with this a little bit, some of you can remember in high school, who do the teachers tell you—tell rich kids they should go to medical school? The kids that are very bright in science. The reality is medicine, like social work and medicine, is all about caring for people. You've got to be smart enough, but they should also look at the nice kids who care about people and say, you're really nice. You love people, you take care of people. You should be a doctor. You should be a nurse. You should be a social worker. Somehow it's the IQ. So maybe we're not looking in the right places, you know, as we think about this earlier pipeline.

And lastly, I just want to mention two of my programs very briefly. One is Reach Out and Read, where doctors give books to children each pediatrics visit because I found out that the mothers not only weren't reading to their children, the reason they weren't reading is because there were no books in the home. These were poor mothers. You know, talk about cultural differences, in most parts of the world, mothers don't read to their children. It's just not part of the culture. You don't get read to until you go to school. And the teacher does that, not a mother. So, you know, that becomes a interesting message.

(see PPT slides 30 & 31)

There's certainly very few or none—particularly when I started this—children's book stores in inner-city places—nice books are expensive, and we give new books because I think for all of us, new books are important and send its own message. And unlike other messages that doctors can give about nutrition or safety where the mother actively has to remember to do it, if there's a book in the home, the child is going to toddle up to the parent, hands outstretched with the book, and elicit the behavior from the parent that actually we want.

I've often thought, Sydney, of all the outreach programs we did for twenty, thirty years, people going in the home and doing all kinds of nice things and maybe even having a book to read to the child. The one thing we didn't do is leave the book, you know, in the home instead of taking it back with us. I mean, just think about that.

And lastly, I have a program, you know, really I think metaphorically consistent—more than a metaphor for this audience and this group that talks about justice. I put lawyers in healthcare settings to do—if you will, to back up the social worker, the nurse, and the doctor. Because what I've learned as a clinician, I see my poor patients who would become ill and become hospitalized for reasons my children or your children wouldn't be. Things in these social determinants and the environment. And the epiphany was that not all these social determinants were equal; that actually as a society, we've put in protections and benefits. There are laws to protect and to provide benefits, whether it's if you have a disability or whether you're below a certain income. There are those—their health insurance or benefits, the predictions or housing codes of what your house conditions could or shouldn't be. It varies by states. There are all kinds of other protections, and social workers are usually pretty good at it 70, 80 percent of the time. But like any of us in an adversarial relationship, when a landlord doesn't want to do something or an administrative structure doesn't want to do something, a lawyer helps. And a lawyer—I was telling folks this afternoon, my way of advocating for twenty years before I decided to do this was to call up a landlord or an administrator of a program and be very nice to them and explain the need and them telling me, you know, basically they're not going to do anything. Then my notion of advocacy was yelling, and I did enough of that. But that just didn't get much.

(see PPT slide 38)

Lawyers are pretty good. They cite the law to the person, they tell them what the documented violation is and what the consequences were for the child. You hardly the have to go to court. And we've really—on the process of transforming the way healthcare for low income, not just children, but for people to address social determinants. We're also transforming legal aid, and we also have a lot of help, pro bono law firms, which have been a big part of this, where an emphasis on prevention.

Because what I've learned is lawyers tend to get involved, at least legal aid, you know, after the crisis, after the eviction, after the child abuse, after all of these things. But there are all of these factors that lead up to it, like eviction threats, lack of food, all kinds of things, and you can intervene earlier, prevent the legal crisis which prevents the medical crisis.

I was challenged in giving this talk that issues about race and health in America are pretty well covered in the daily news. Unfortunately, you probably see it around you. So I just wanted to hopefully bring you some different insights to it. The insight that, well, starting early won't address racism; but at least if people have a good education and have a job and have material resources, they could better fight racism. And that's really starting early. And it's programs that you have in Chicago, particularly like Educare, and I think we need a more—it's not the Educare. It's not just the early learning. It's the material stability of families, and it's a number of other factors. So I want to thank you all very much.

DEAN GUTERMAN: Questions? Comments?

AUDIENCE MEMBER: You were really talking about a concerted team approach; social work, the healthcare providers, nurse, and physician, and then the legal dimension. And obviously, that's a very concerted effort that you have very wisely and effectively put together. But the idea of developing that model at major city hospitals, Children's Memorial Hospital here for example, or major teaching hospitals is a wonderful one, and I'm wondering just how much of this is being pushed by you, I guess.

DR. ZUCKERMAN: A lot. But fortunately, I've always been kind of one of the early adapters. So you actually have one of these programs here at the children's hospital, here at the Comer Children's Hospital. There's another from a group at Loyola who are working with the Erie Health Centers to do this.

And you're right about the team, but let me comment on that. First is the money aspect of it. So in reality, once we start moving in our terms of healthcare policy, where hospitals and doctors are going to be rewarded by outcomes, financially and not the inputs, how many tests you do, then they may be more willing to put these inputs, social workers and lawyers because, these social determinants matter, then it's going to prevent. Now if a patient gets re-hospitalized after discharge, within 30 days or something like that, and the number's pretty big, the hospital's not going to pay them again for that other hospitalization. Get paid once in a month. If they come back in a hospital three times, you still get paid once. There's going to be a big motivation to, if you will, to keep people out of the hospital. But that gets translated to really support them in the home so they get what they want. So I believe it's going to take that kind of team and that kind of work to do that, but it will become an investment. Right now it's not an investment; it's just a cost.

The other thing—so that's for people with chronic diseases, and it works there. Then if you're reading the paper around health policy, people are talking about the "medical home." And as I'm in the process of writing a paper—all homes need heat, food, utilities, and a safe environment, meaning that this fits into a medical home. You know, where are the boundaries?

And also we're talking about patient-centered care. That means the patient tells you what they need to stay healthy. So the cost issue's going to be a little trickier there. But as long as the rhetoric—this remains the rhetoric, what we're doing is going beyond the strict biology of health and disease to an understanding that sooner or later these social determinants are going to affect health and disease. And the idea is that hopefully that will add value, additional value, incremental value to healthcare. That remains to be seen, but we've interested HHS in this. We've interested one Medicaid funder in all of southern Ohio and Georgia who wants to try this for their patients with asthma, because they believe they can save money. At least I talked them into the thing. We'll find out. We'll find out.

AUDIENCE MEMBER: Would you just comment on Massachusetts healthcare? It's been described as a model program often and alternatively, as a financial disaster. And it's been used as the model for the Obama healthcare program—

DR. ZUCKERMAN: Well, when you make an insurance accessible to 25 percent more people, it's going to cost money. But it's not all good. Here are the two biggest problems from my point of view:

One is that there's not enough primary care doctors. Because all of a sudden you have 25 percent of your population who can now have access to this, and you can't get an appointment for four to six to eight months. And this is going to become a national problem which people are going to be facing. And pretty soon there won't be—you know, we talk about England, that you can't get an appointment. Well, we're not going to be able to do it here. There's no way the present healthcare system can meet the needs of everyone having insurance. And remember that people always went to our emergency rooms because that always gets paid for. But you didn't have insurance, you couldn't pay out of pocket for primary care. So that's problem No. 1.

Problem No. 2, in Massachusetts it's a little unique. We have payments problems. So hospitals and facilities taking care of poor people are taking a beating because some of that money that's going for insurance was money—if you will, block grants from the states to health centers and hospitals to make up for—it's called for uncompensated care, for people who didn't have insurance. These places would have folded. So at the end of the year, a hospital like ours might get $120 million and that covered the cost. That obviously makes sense—the money should follow the patient instead of just giving a block grant.

The trouble is the reimbursement to the patient is only 70 cents to the dollar. So the hospitals who are taking care of primarily poor are really suffering now, and it's not compounded but in part caused by a recession, because Massachusetts used to pay better rates. But Massachusetts also has a problem. We have Partners Healthcare, which is the Mass General and the Brigham, and their reimbursement is three to four times higher than anyone else because it really is antitrust because they can control the marketplace. Because everyone who has health insurance wants to have access to one of those two hospitals. And so the money is flowing to one system, let alone a recession. People will say, of course, who do you think has been paying the emergency room bills and acute care bills for people without insurance? State governments have been paying for it. I mean, somebody was or these places, health centers and hospitals, would have been down the tubes. So there's a good chunk of that. So it's not as if we're starting from scratch.

AUDIENCE MEMBER: A question occurred to me in your presentation about sickle cell anemia and cystic fibrosis, the disparity in resources. So my question is, with treatment, is her life extended if you have sickle cell anemia? Not ended in your fourth or fifth decade? And secondly, if this is true, it seems to me that you could focus on an individual like this who has great influence and get some attention to this disease, particularly if you—

DR. ZUCKERMAN: That's one reason I brought it up here. I'm hoping somebody will know someone. You know, people who have the resources are in reality looking for causes. It's a good thing to have a good cause. You know, the other the diseases are pretty crowded. This is an opportunity for someone to really make a big difference.

But in answer to your question, kids are still going to die—it's good treatment—because we don't have a cure. The cure right now is bone marrow transplants, which we don't use much because the mortality of them in sickle cell is about 15 to 20 percent. And most of the time we think that's too much of a risk unless you're going to die really soon from the sickle cell disease. And then, of course, it makes the mortality a little harder.

But it's no different than cystic fibrosis. We can do better. But that's the reason for the research. So what the Cystic Fibrosis Foundation does, there are these research centers around the country, and they fund a lot of research. But they wouldn't give these centers research money unless they'll do quality improvement on the clinical side. So they're leveraging the research dollars, which better or worse, drives the system to make clinical care better. And it's unfortunate that needs to be combined, but that is the answer. Research—you could have a great research unit in this town and all your hospitals; the quality of the care may or may not be related to that. The quality of doctors is probably very good, but the quality of care goes beyond that.

There was a wonderful New Yorker article two years ago by Atul Gawande about cystic fibrosis and how they started looking at outcomes. And some of the most pernicious hospitals around the country found themselves number eleven in lifespan, and it was pretty embarrassing to them. I'm talking about the top names in the country. But the message was until you start counting and looking at it, you don't know.

So that's really what the quality movement is going to be. We're going to look at outcomes of people with certain diseases and there's going to be a rank order. And if somebody can do it up here, then it's incumbent upon all the ones below it to figure out what they're doing and do the same thing.