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Barnes and... A Conversation with Dr. David Williams

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Diabetes, hypertension and other cardio-pulmonary ailments, tobacco and alcohol abuse -- a huge problem for the country and Arkansas in particular; and the toll among minority groups is especially serious. To make matters worse, high mortality in the African-American community is a road block to racial reconciliation. Say that again? Dr. David Williams can, and will. A professor at Harvard University's School of Public Health, Williams offers persuassive evidence that Arkansas and the nation is shooting itself not in the one but both feet by failing to address public health issues among all our people.

TRANSCRIPT

HELLO AGAIN, EVERYONE, AND THANKS VERY MUCH FOR JOINING US. DR. DAVID WILLIAMS WAS EDUCATED IN THE UNITED STATES AND HOLDS AN ENDOWED SHARE IN PUBLIC HEALTH AT HARVARD UNIVERSITY WHERE HE STUDIES THE PUBLIC HEALTH CONSEQUENCES OF PUBLIC POLICY, AND ONE SUSPECTS PRIVATE SUSPICION. AT THE CLINTON PRESIDENTIAL LIBRARY, THE CLINTON SCHOOL OF PUBLIC SERVICE, RACIAL HEALING IN THE AMERICAN SOUTH HIS SUBJECT. DR. WILLIAMS, THANK YOU VERY MUCH FOR BEING WITH US.

GOOD TO BE HERE.

PROGRESS NOT PERFECTION, NO ONE WOULD ARGUE WE'RE EVEN CLOSE TO PERFECTION. BUT HOW MUCH PROGRESS IN TERMS OF HEALING, RECONCILIATION?

WELL, I THINK WE HAVE TAUNTED THE JOURNEY, AND WE HAVE TO ACKNOWLEDGE THE PROGRESS WE'VE MADE AND GIVE CREDIT FOR WHAT WE'VE DONE. BUT ALSO RECOGNIZE THERE IS A LONG WAY STILL TO GO. SO, AN EXAMPLE OF THE PROGRESS WE'VE MADE IS THERE'S BEEN DRAMATIC CHANGES, SHIFTS ON THE ORDER OF 40, 50 PERCENTAGE POINTS IN TERMS OF RACIAL ATTITUDES IN THE UNITED STATES. AND DIRECTION OF THOSE ATTITUDES ARE MUCH MORE POSITIVE, MUCH MORE EGALITARIAN, SUPPORT FOR ALL. I'LL GIVE YOU AN EXAMPLE. EARLY 1940s, MORE THAN HALF OF WHITES SAID THAT WHITES SHOULD HAVE THE FIRST CHANCE AT ANY JOB IN THE UNITED STATES. AND BY 1973 LESS THAN 5% OF WHITES WANTED THAT. THAT'S A BIG SHIFT. AND THAT KIND OF COMMITMENT TO EQUALITY IS EVIDENT IN EVERY DOMAIN, HOUSING AND EDUCATION AND HEALTH CARE, YOU SEE THOSE POSITIVE TRENDS SUPPORTIVE OF EQUALITY.

AND YET, BIG GAPS IN PUBLIC HEALTH, IN EDUCATION, ENTERTAINMENT LEVELS, IN HOUSING , IN ALMOST EVERY FIELD OF HUMAN ENDEAVOR.

AND EVEN THE ATTITUDINAL DATA GIVES US A HINT AS TO WHAT THE PROCESS IS. RESEARCHERS WHO STUDY THIS AREA TALK ABOUT THE PRINCIPAL IMPLEMENTATION GAP, AND THAT IS THERE ARE MORE PEOPLE -- THE MANY PEOPLE WHO SUPPORT THE PRINCIPLE OF EQUALITY WHO WILL NOT SUPPORT POLICIES TO ACHIEVE EQUALITY. YOU CANNOT EXPECT INDIVIDUALS WHO HAVE BEEN SHACKLED BY CHAINS AND PUT THEM AT THE START OF A LINE TO RUN A MARATHON OR EVEN A 100-METER DASH, AND EXPECT THEM IF THEY HAVEN'T HAD ANY TRAINING, ANY PREPARATION, TO BE SUCCESSFUL COMPARED TO THOSE WHO HAVE HAD IT. SO, WE REALLY NEED TO HAVE A COMMITMENT TO POLICIES THAT WOULD ADDRESS THE DEFICITS THAT HAVE EXISTED HISTORICALLY, AND PROVIDE EVERYONE AN OPPORTUNITY TO ACHIEVE THE BENEFIT THAT THE AMERICAN SOCIETY OFFERS.

PRIVATE INITIATIVE OR PUBLIC POLICY, BOTH, WHAT'S THE RATIO?

I CERTAINLY THINK IT'S BOTH. I CERTAINLY AM A BIG FAN OF PUBLIC-PRIVATE INITIATIVE, GET EVERYONE ON BOARD BY BOTH PUBLIC INVESTMENTS AND PRIVATE INVESTMENTS WORKING TOGETHER. WE HAVE WONDERFUL EXAMPLES OF WHERE THAT KIND OF ACCOMPLISHES GOOD IN SOCIETY. BUT THE CHALLENGE OF RACE AND RACISM AND RACIAL PREJUDICE AND NEGATIVE STEREOTYPES, IT DEEPLY IS EMBEDDED IN AMERICAN CULTURE, AND IT WILL TAKE ALL SECTORS OF SOCIETY WORKING TOGETHER TO UNDO THE DEEPLY EMBEDDED CULTURAL PATTERNS THAT ALREADY EXIST. SO, ALL OF US NEED TO BE ON BOARD.

WE CONTINUE TO PAY A PRICE AS A NATION FOR THAT IMBALANCE.

WE DEFINITELY DO. ONE OF MY AREAS OF EXPERTISE AS YOU MENTIONED IS HEALTH. AND ONE OF THE THINGS I STUDY, RACIAL DIFFERENCES IN HEALTH. A RECENT STUDY DOCUMENTS THAT BECAUSE OF THE RACIAL GAP IN HEALTH AS CAPTURED BY DIFFERENCES IN MORTALITY RATES, 96,000 AFRICAN AMERICANS DIE EVERY YEAR PREMATURELY. 96,000 A YEAR. IF YOU DIVIDE THAT BY 365, THAT'S 265 BLACK PEOPLE DYING EVERY DAY WHO WOULDN'T DIE IF THERE WEREN'T RACIAL DISPARITIES IN HEALTH. THAT'S EQUIVALENT TO A FULLY LOADED JUMBO JET TAKING OFF FROM THE LOCAL AIRPORT WITH 265 PASSENGERS AND CREW AND CRASHING AND DYING. THAT HAPPENS EVERY SINGLE DAY. IT'S A HUGE PROBLEM BECAUSE WE'RE LOOKING AT THE LOSS OF LIFE IN THE MOST PRODUCTIVE YEARS OF LIFE, WHEN THOSE PERSONS SHOULD BE CONTRIBUTING TO OUR OVERALL PRODUCTIVITY AND ECONOMIC COMPETITIVENESS. AND FOR ME AS I GET OLDER, CONTRIBUTING TO THE SOCIAL SECURITY SYSTEM SO THERE WILL BE MONEY THERE WHEN I'M READY TO RETIRE.

THESE DISPARITIES, THEY PRESENT AS HOW?

THE DISPARITIES IN HEALTH, FOR EXAMPLE --

YES, WITH SPECIFIC REFERENCE TO HEALTH.

SURE. DISPARITIES IN HEALTH ARE EVIDENT FROM BIRTH THROUGH THE RETIREMENT YEARS. WHAT I MEAN BY THAT IS THERE'S A RACIAL GAP IN INFANT MORTALITY. INFANT MORTALITY REFERS TO THE CHANCES THAT A BABY DIES BEFORE HIS OR HER FIRST BIRTHDAY. A BLACK INFANT IN THE U.S. TODAY IS 2.5 TIMES MORE LIKELY TO DIE BEFORE HIS OR HER FIRST BIRTHDAY THAN A WHITE INFANT AND THOSE DISPARITIES EXIST IN CHILDHOOD, GET EVEN LARGER IN THE MIDDLE YEARS AND CONTINUE THROUGH AGE 85. OLD AGE 85 WE CALL IT THE MORTALITY CROSS OVER WHERE BLACKS WHO MAKE IT TO THAT POINT, VERY SELECTIVE SUBGROUP, ACTUALLY OUT LIVE WHITES WHO MAKE IT TO THAT POINT.

WHAT ARE THE FACTORS THAT ARE INVOLVED HERE? THE ONES YOU START OFF WITH, CERTAINLY NOT INFANT MORTALITY. MAYBE TO A DEGREE, OBESITY. POOR NUTRITION, INADEQUATE DIET, SMOKING, DRUG AND ALCOHOL ABUSE. I DON'T KNOW IF YOU CITE IT HAD IN YOUR RESEARCH, BUT OTHER PUBLIC HEALTH OFFICIALS SAID WE SHOULD TREAT GANG VIOLENCE AS A PUBLIC HEALTH AFFRONT JUST AS CERTAINLY AS DIABETES, HYPERTENSION.

YEAH, I AGREE. I THINK THE FACTORS ARE MULTIPLE. I THINK ONE OF THE IMPORTANT DISTINCTIONS THAT HAS BEEN MADE IN RECENT PUBLIC HEALTH RESEARCH IS THE IMPORTANCE OF DISTINGUISHING -- BETWEEN WHAT WE CALL BASIC AND FUNDAMENTAL CAUSES VERSUS SURFACE AND SUPERFICIAL CAUSES. AND THEY SAID A REALLY IMPORTANT POINT, AND THE POINT IS THE BASIC CAUSES ARE THE REAL DRIVERS OF THE OUTCOME. IF YOU ALTER THEM, YOU CHANGE THE OUTCOME. THE SURFACE SUPERFICIAL CAUSES ARE RELATED TO THE OUTCOME. BUT IF YOU CHANGE THEM, THE BASIC CAUSES WILL FIND ALTERNATIVE PATHWAYS TO ACHIEVE THE SAME OUTCOME. JUST TO GIVE YOU AN EXAMPLE, IF WE LOOK AT 1900, THE THREE LEADING CAUSES OF DEATH IN THE UNITED STATES IN 1900 WERE THE FLU AND PNEUMONIA, TB, TUBERCULOSIS, AND NUMBER THREE GASTROINTRITESS. RISK FACTORS AND UNDERLYING CAUSES ARE VERY DIFFERENT THAN HEART DISEASE, CANCER AND STROKE WHICH ARE THE THREE LEADING CAUSES TODAY. BUT WE HAD A BIG RACIAL GAP IN HEALTH IN 1900 AND WE STILL HAVE A BIG GAP TODAY. THE INTERVENING CAUSES, PRIMARY RISK FACTORS HAVE CHANGED, BUT THE BASIC OUTCOMES HAVE NOT CHANGED DRAMATICALLY. SO, I WOULD ARGUE THAT A KEY, THE FIRST BIG FUNDAMENTAL CAUSE WE NEED TO THINK ABOUT IS SOMETHING SOCIOLOGISTS CALL SOCIOECONOMIC STATUS. THAT REFERS TO INCOME, EDUCATION, OCCUPATIONAL STATUS, AND WEALTH. SOCIOECONOMIC STATUS IS ONE OF THE STRONGEST, MOST CONSISTENT DETERMINANTS OR VARIATIONS OF HEALTH IN THE UNITED STATES AND IN VIRTUALLY EVERY COUNTRY OF THE WORLD WHERE WE HAVE DATA. EVEN IN COUNTRIES WITH WONDERFUL HEALTH SYSTEMS THAT PROVIDE ACCESS TO HEALTH CARE FOR EVERYONE, THERE ARE LARGE SOCIOECONOMIC VARIATIONS IN HEALTH. AND ONE OF THE BIG REASONS WHY THERE IS A RACIAL GAP IN HEALTH IS THAT BLACKS AND OTHER MINORITIES IN THE UNITED STATES HAVE LOWER LEVELS OF INCOME, LOWER LEVELS OF EDUCATION, LESS WEALTH, LESS HIGH QUALITY JOBS THAN WHITES DO. AND VIRTUALLY EVERY RISK FACTOR FOR HEALTH IS PATTERNED BY SOCIOECONOMIC STATUS.

THIS INVOLVES POOR WHITES AS WELL --

THIS INVOLVES POOR WHITES. IN FACT, THIS IS NOT SOMETHING THAT IS WIDELY RECOGNIZED, AND THAT IS THE GAP IN HEALTH BY EDUCATION OR INCOME FOR MOST HEALTH OUTCOMES IS LARGER THAN THE GAP IN HEALTH BY RACE. SO, IF YOU LOOK AT A DIFFERENCE IN HEALTH BETWEEN POOR WHITES AND MIDDLE CLASS WHITES, IT'S BIGGER THAN THE BLACK-WHITE GAP. IF YOU LOOK AT THE DIFFERENCE IN HEALTH BETWEEN POOR AFRICAN AMERICANS AND MIDDLE CLASS AFRICAN AMERICANS, THAT'S ALSO BIGGER THAN THE WHOREV ALL -- OVERALL BLACK-WHITE GAP.

YOU NOTED IN YOUR RESEARCH, THE LAST HALF CENTURY, WE HAVE -- THE UNITED STATES HAS DEVOTED ENORMOUS SUMS OF TREASURY DOLLARS TO ADDRESSING THE VERY ISSUES THAT SO TORMENT THE HEALTH OF BLACK AMERICANS AND POOR WHITE. AND YET THE GAP IS THERE. WHAT ARE WE DOING WRONG?

SO, YOU ARE ABSOLUTELY RIGHT. THE U.S. SPENDS MORE MONEY ON MEDICAL CARE THAN ANY OTHER COUNTRY IN THE WORLD, MORE MONEY PER PERSON. AND ACCORDING TO THE WORLD BANK, HALF OF THE MONEY SPENT ON MEDICAL CARE WORLDWIDE ANNUALLY IS SPENT IN THE U.S. WE'RE LESS THAN 6% OF THE WORLD'S POPULATION, CONSUME ONE HALF OF ITS MEDICAL RESOURCES. IF YOU LOOK EVEN FOR THE WHITE POPULATION AT MAJOR INDUSTRIALIZED COUNTRIES, WE RANK NEAR THE BOTTOM OF THE LIST ON MOST OF THE STANDARD INDICATORS OF HEALTH STATUS. WHAT WE ARE DOING ISN'T WORKING AND IT'S NOT A SURPRISE. THE CENTERS FOR DISEASE CONTROL ESTIMATES THAT ONLY 2% OF OUR MEDICAL CARE EXPENDITURES IN THE U.S. IS ON PREVENTION. SO, WHAT WE DO A WONDERFUL JOB OF IS TAKING CARE OF INDIVIDUALS ONCE THEY GET SICK. OUR HEALTH CARE SYSTEM IS A REPAIR SHOP. BUT WHAT MAKES US A HEALTHY IN THE FIRST PLACE HAS MORE TO DO WITH THE OPPORTUNITIES AND CHANCES TO BE HEALTHY IN THE PLACES WHERE WE SPEND MOST OF OUR TIME. OUR HOMES, OUR WORKPLACES, OUR SCHOOLS, OUR NEIGHBORHOODS. AND WE NEED TO FIND WAYS TO PROMOTE HEALTH AND DEVELOP A CULTURE OF HEALTH WHERE WE LIVE, LEARN, WORK, PLAY, AND WORSHIP. THOSE ARE THE DRIVERS OF HEALTH. THAT'S WHERE GOOD HEALTH BEHAVIORS ARE SHAPED, ENCOURAGED, SUPPORTED, INCENTIVIZED.

THERE REMAINS SOME, AND MAYBE EVEN SIGNIFICANT POLITICAL RESISTANCE, CULTURAL RESISTANCE TO WHAT MANY WOULD ARGUE HAS BEEN -- GOVERNMENT SHOULDN'T BE TELLING US HOW WE SHOULD HAVE OUR HAMBURGER COOKED, HOW MUCH MERCURY SHOULD BE IN OUR FISH. HOW TO ADDRESS THAT?

I THINK IT'S A VERY GOOD POINT. AND IT HIGHLIGHTS THE IMPORTANCE OF WHAT I WOULD SAY IS BALANCE. THERE IS AN INDIVIDUAL RESPONSIBILITY, AND THERE IS A SOCIAL RESPONSIBILITY. EACH OF US -- ALL AMERICANS COULD BE HEALTHIER THAN WE CURRENTLY ARE. AND EACH OF US NEEDS TO BE INFORMED AND ENCOURAGED TO MAKE HEALTHY CHOICES. BUT THERE ARE MANY AMERICANS WHO LIVE IN PLACES AND WORK IN ENVIRONMENTS AND ARE IN CONTEXT WHERE IT'S DIFFICULT TO MAKE THE HEALTHY CHOICE, WHERE, IN FACT, THERE ISN'T A HEALTHY CHOICE TO MAKE. FOR EXAMPLE, RESEARCH REVEALS THAT IF SOMEONE LIVES IN THE NEIGHBORHOOD WHERE THERE AREN'T SUPERMARKETS THAT SELL FRESH FRUITS AND VEGETABLES, THEIR DIET IS POOR AND THEIR OBESITY RATES ARE HIGHER. WHEN SOMEONE LIVES IN A NEIGHBORHOOD WHEN THERE ISN'T ACCESS TO SAFE PLACES TO WALK OR PARKS WHERE IT'S SAFE TO TAKE THEIR KIDS, THEY DON'T GET EXERCISE, AND THEIR OBESITY RATES ARE HIGHER. SO, ON THE ONE HAND, WE HAVE TO ENCOURAGE EVERYONE -- INFORM THEM AND ENCOURAGE EVERYONE TO MAKE HEALTHY CHOICES, BUT THERE IS A SOCIETIAL OBLIGATION TO REDUCE THE BARRIERS AND TO CREATE THE INCENTIVES SO THAT ALL ARE IN A POSITION TO MAKE THE HEALTHY CHOICE, THE RIGHT CHOICE.

YOU HAVE NOTED THAT IT IS OFTEN EASIER IN PREDOMINANTLY BLACK NEIGHBORHOODS OR LOW-INCOME NEIGHBORHOODS --

YES.

IT IS EASIER TO BUY BEER --

THAT'S RIGHT.

-- THAN FRESH APPLES.

THAT IS ABSOLUTELY CORRECT.

EASIER TO BUY CIGARETTES THAN PEACHES.

THAT IS RIGHT. AND NOT ONLY IS IT EASIER BECAUSE THERE ARE MORE RETAIL OUTLETS FOR THE SALE OF ALCOHOL, IT'S ALSO THE FACT RESEARCH HAS SHOWN THAT 80% OF BILL BOARDS IN THE UNITED STATES ARE TARGETED TO THE BLACK AND HISPANIC COMMUNITY.

80%?

YES, THEY EXIST IN THE BLACK AND HISPANIC COMMUNITY, 80% OF BILLBOARDS. THE TWO MOST COMMONLY ADVERTISED PRODUCTS ON BILLBOARDS IN THE U.S. IS TOBACCO AND ALCOHOL. IF EVERYWHERE YOU TURN YOU SEE A GLAMOROUS PERSON SMOKING A CIGARETTE OR DRINKING ALCOHOL, AND THEN ON EVERY STREET CORNER THERE ARE MORE RETAIL OUTLETS FOR ALCOHOL THAN EVEN CHURCHES, IT CERTAINLY APPEARS TO BE NORMATIVE. IT SEEMS TO BE THE NATURAL THING TO DO BECAUSE IT'S ALL AROUND YOU. AND RESEARCH SHOWS THE GREATER THE AVAILABILITY OF ALCOHOL THE HIGHER THE RATE OF ALCOHOL ABUSE.

YOU ARGUE ALSO THAT HOUSING OFTEN EQUALS HEALTH.

YES. HOUSING CREATES AN ENVIRONMENT THAT CAN BE SUPPORTIVE OF HEALTH OR CAN BE DANGEROUS TO HEALTH. TO GIVE AN EXAMPLE THAT WE'VE PAID A LOT OF ATTENTION TO IN THE U.S. AND WE'VE CERTAINLY MADE PROGRESS ON, IT'S ONE OF OUR SUCCESS STORIES EVEN THOUGH THERE IS STILL MORE WORK TO BE DONE. THAT'S LEAD, AND CHILDREN BEING EXPOSED TO LEAD IN THE UNITED STATES AND LEAD PAINT, MANY OF THE OLDER HOMES STILL HAVE LEAD AND THAT HAS NEGATIVE EFFECTS ON THE DEVELOPMENT AND HEALTH OF CHILDREN. AS A SOCIETY, WE HAVE MADE ENORMOUS PROGRESS, ALTHOUGH POOR KIDS AND MINORITY KIDS ARE STILL MORE LIKELY TO BE EXPOSED TO LEAD. BUT THAT'S ONE EXAMPLE OF THE WAYS IN WHICH HOUSING CAN AFFECT HEALTH.

THE LARGER CONCEPT I SENSE THAT YOU'RE DRIVING AT IS THAT HOUSING EQUALS NEIGHBORHOODS EQUALS SELF-ESTEEM EQUALS HEALTH.

THAT'S RIGHT. SOMEONE HAD SAID IT RECENTLY, AND I THINK IT'S A VERY EFFECTIVE AND ACCURATE STATEMENT, IS THAT OUR ZIP CODE HAS MORE TO DO WITH OUR HEALTH THAN OUR GENETIC CODE. OF COURSE, GENETICS MATTERS. BUT THE PLACES WHERE WE LIVE CAN EITHER ENCOURAGE HEALTH AND ENCOURAGE US TO BE HEALTHY, OR CAN ENCOURAGE BEHAVIORS THAT LEAD TO POOR HEALTH. AND ONE OF OUR CHALLENGES AS LEADERS IN BOTH THE PUBLIC AND PRIVATE SECTOR -- BECAUSE THERE ARE ENORMOUS BENEFITS TO SOCIETY FOR HELPING AMERICANS TO BE HEALTHY. ONE OF THE CHALLENGES FOR US IS HOW DO WE ESTABLISH A CULTURE OF HEALTH THAT MAKES THE HEALTHY CHOICE THE EASY CHOICE SO THAT WE MAKE IT EASIER FOR INDIVIDUALS TO CHOOSE HEALTH?

EXPENSIVE, AS OTHER PEOPLE SAY. IT'S SOMETIMES CHEAPER TO BUY ALCOHOL THAN IT IS --

EXACTLY.

LESS EXPENSIVE TO BUY ALCOHOL AND TOBACCO THAN CARROTS OR BANANAS.

EXACTLY. WE NEED TO THINK AS A SOCIETY STRATEGICALLY, AND WE NEED TO THINK ABOUT STARTING EARLY. WHICH MEANS WE NEED TO LOOK AT THE SCHOOLS AND WHAT OUR SCHOOLS ARE DOING TO ENCOURAGE PHYSICAL FITNESS, WHAT ARE THE SCHOOLS DOING TO ENCOURAGE GOOD NUTRITION. WE NEED TO LOOK EVEN AT THE FOOD PROGRAMS IN SCHOOLS AND ARE THEY PROVIDING HEALTHY OPTIONS FOR INDIVIDUALS. ONE OF MY AREAS OF RESEARCH IS RELIGION AND THE WAYS IN WHICH RELIGION AFFECTS HEALTH, AND IN GENERAL IN THE UNITED STATES RELIGION IS A POWERFUL RESOURCE THAT PREDICTS GOOD HEALTH. FOR EXAMPLE, PEOPLE WHO ATTEND RELIGIOUS SERVICES REGULARLY ON AVERAGE LIVE 7 YEARS LONGER THAN THOSE WHO NEVER ATTEND. AND AMONG AFRICAN AMERICANS, IT'S AN EVEN BIGGER BENEFIT. BUT RECENT RESEARCH ALSO DOCUMENTS THAT PEOPLE WHO ATTEND RELIGIOUS SERVICES REGULARLY ARE MORE LIKELY TO BE OBESE. I CALL IT A CHURCH POTLUCK EFFECT. [LAUGHTER]

ONE OF THE THINGS EVEN -- WHAT I'M SAYING IS THE BENEFITS OF RELIGION AND HEALTH WILL BE EVEN GREATER IF THERE WASN'T THIS RELATIONSHIP BETWEEN FREQUENCY OF ATTENDANCE AND OBESITY. AND, SO, WE NEED TO THINK OF ALL OF OUR INSTITUTIONS -- I'M NOT PICKING ON THE CHURCH, BUT I'M THINKING OF SCHOOLS, WORKPLACES, CHURCHES NEED TO BE ENCOURAGING HEALTHY CHOICES AND ENCOURAGING INDIVIDUALS TO TAKE AS GOOD CARE OF OUR BODIES AS WE TAKE OF OUR CARS.

FUNERALS CAN BE FATENING, A JOKE IN THE SOUTH.

THAT IS ABSOLUTELY RIGHT.

OBVIOUSLY, THEN, YOU WOULD ARGUE THAT CIRCUMSTANCES OF BIRTH DO NOT GUARANTEE DESTINY.

THAT'S RIGHT.

THEY ARE NOT DEFINITIVE OF DESTINY.

ONE WAY YOU CAN THINK OF IT IS GENETIC LOADS THE GUN, BUT ENVIRONMENT PULLS THE TRIGGER. AND YOU REALLY HAVE THE COMBINATION OF GENE AND ENVIRONMENT. AND EVEN YOUR EARLY SOCIAL ENVIRONMENT, RESEARCH DOCUMENTS IT CAN HAVE LONG-TERM NEGATIVE EFFECTS ON HEALTH. BUT THOSE EFFECTS CAN BE REVERSED, ESPECIALLY IF WE CAN START EARLY. THE EARLIER WE START THE BETTER. THE EARLIER WE START, THE BETTER THE REVERSAL. SO, IF EVERYONE REGARDTIONV OF THE SITUATION THEY'RE IN RIGHT NOW CAN IN FACT TAKE STEPS TO IMPROVE THEIR HEALTH. RESEARCH SUGGESTS, GIVE A CONCRETE EXAMPLE, THAT CIGARETTE SMOKER WHO STOPS SMOKING CIGARETTES IN ABOUT 7 TO 8 YEARS HE CAN -- HE OR SHE CAN DRAMATICALLY REDUCE THE RISK THAT THEY HAD FOR ELEVATED OUTCOMES; LUNG CANCER AND OTHER -- CARDIOVASCULAR DISEASE LINKED TO CIGARETTE SMOKING. SO, YES, WE CAN ALL MAKE CHANGES. THE SOONER THE BETTER.

DO YOU SEE A LINK BETWEEN IMPROVING THE SOCIOECONOMIC STATUS, PARTICULARLY OF AMERICANS -- OF AFRICAN AMERICANS AND MAYBE LATINOS AND POOR WHITE, AND THE OTHER GOAL -- I DON'T WANT TO SAY IT'S A SECONDARY GOAL -- THE OTHER GOAL OF RECONCILIATION BETWEEN THE RACES, ARE THEY LINKED?

THEY ARE ABSOLUTELY LINKED. IT ISN'T BY ACCIDENT THAT AFRICAN AMERICANS HAVE LOWER LEVELS OF INCOME, EDUCATION, OCCUPATIONAL STATUS. I TALKED ABOUT HOW CENTRAL SOCIOECONOMIC STATUS IS AS A DRIVER OF HEALTH. THE LOWER LEVELS OF ECONOMIC WELL-BEING IN THE BLACK POPULATION REFLECTS THE SUCCESSFUL IMPLEMENTATION OF SOCIAL POLICY. SOCIAL POLICIES HAVE CREATED THESE DISPARITIES AND WE NEED ALTERNATIVE SOCIAL POLICIES TO REVERSE THEM AND TO CREATE THE OPPORTUNITY AND TO NARROW THE GAP IN SOCIOECONOMIC STATUS. THERE IS COMPELLING EVIDENCE THAT REVEALS WHEN YOU NARROW THE GAPS IN SOCIOECONOMIC STATUS, YOU ACTUALLY NARROW THE GAPS IN HEALTH, EVEN WITH NO HEALTH INTERVENTION. ONE EXAMPLE OF THAT RESEARCH IS RESEARCH THAT HAS BEEN PUBLISHED IN THE LAST SEVERAL YEARS LOOKING AT THE IMPACT THAT THE CIVIL RIGHTS MOVEMENT HAD ON HEALTH. BETWEEN 1968 AND 1978 AS A RESULT OF THE WAR ON POVERTY AND GAINS OF THE CIVIL RIGHTS MOVEMENT, WE HAD A NARROWING OF THE BLACK-WHITE GAP IN INCOME CORRESPONDING TO THE NARROWING OF THE BLACK WHITE GAP IN INCOME, AFRICAN AMERICANS MADE LARGER IMPROVEMENTS IN HEALTH AND NARROWED THE BLACK-WHITE GAP IN HEALTH DURING THAT SAME DECADE OF '68 TO '78. AND WHAT HAPPENED DURING THE DECADE OF THE '80s, THE RACIAL GAP IN ECONOMIC STATUS REVERSED. WE LOST GROUND FROM WHERE WE WERE IN 1978 AND HEALTH WORSENED. SO, HEALTH NATIONALLY TRACKS WITH THE ECONOMIC WELL-BEING OF A POPULATION NATIONALLY.

YOU NOTED THE CULTURAL IMPACT, SOCIAL IMPACT OF THE AFRICAN-AMERICAN CHURCH.

YES.

MUCH AS THE CIVIL RIGHTS MOVEMENT OF THE 20TH CENTURY MAY HAVE BENEFITED FROM HEALTH OUTSIDE THE WHITE COMMUNITY, BUT IT HAD TO BE POWERED FROM WITHIN A BLACK COMMUNITY. THESE CHANGES YOU'RE TALKING ABOUT, TO WHAT EXTENT WILL THEY HAVE TO BE POWERED -- DRAW THEIR STRENGTH FROM WITHIN THE COMMUNITY?

I THINK WE ARE TALKING ABOUT FUNDAMENTAL CHANGES THAT WILL REQUIRE COOPERATION. YOU KNOW, SOMEONE ONCE SAID THAT  A RISE IN TIDE WILL RAISE ALL SHIPS. BUT THAT'S TRUE FOR THOSE PEOPLE WHO ARE IN A BOAT. FOR THOSE WHO ARE OUT IN THE OCEAN WITHOUT A BOAT RISING WATER CAN DROWN THEM. WHAT WE NEED IN THE UNITED STATES, I THINK, IS WHAT I CALL A MARSHAL PLAN THAT REALLY CREATES OPPORTUNITIES FOR ACADEMIC AND JOB SUCCESS IN DISADVANTAGED COMMUNITIES IRREGARDLESS OF RACE. SO, THAT'S TRUE IN ALL COMMUNITIES IN THE SOUTH AND IN APPALACHIA AS WELL AS IN POOR URBAN ENVIRONMENTS. AND THAT CANNOT BE DONE ONLY WITHIN THE COMMUNITY, YET THE COMMUNITY NEEDS TO BE MOBILIZED AND ACTIVATED AND MOTIVATED TO TAKE ADVANTAGE OF THE OPPORTUNITY. BUT THERE NEEDS TO BE COOPERATION AGAIN FROM THE PUBLIC AND PRIVATE SECTOR TO MAKE THOSE CHANGES. ONE IMPORTANT POINT THAT WE NEED TO REALIZE IS THERE ARE RECENT ECONOMIC ANALYSES THAT SHOW IF WE CAN REDUCE THE GAPS IN HEALTH, WE WILL LOWER THE COST TO SOCIETY. DIFFERENCES IN HEALTH IS COSTING THE U.S. ECONOMY $308 BILLION ANNUALLY. THE GAP IN HEALTH BY EDUCATION IS COSTING THE U.S. ECONOMY $1 TRILLION A YEAR. IT'S AN ESTIMATE FROM TWO ECONOMISTS WHO SERVED ON THE PRESIDENT'S COUNCIL OF ECONOMIC ADVISORS. SO, IT'S HURTING OUR COMPETITIVENESS AS A NATION, GLOBALLY, AND IT'S HURTING OUR PRODUCTIVITY AS A PEOPLE. SO, IT'S IN OUR INTEREST -- IN ADDITION TO THE MORAL REASONS I'M SAYING, WHICH ARE IMPORTANT, THERE ARE POWERFUL ECONOMIC REASONS FOR CHANGE.

SKEPTICS AND CYNICS WOULD ARGUE THE POLICIES YOU'RE TALKING ABOUT ARE PRECISELY THOSE, WHETHER IT'S THE APPALACHIAN PROJECT -- HEAD START, ALL THE AGENCIES OF THE '60s FORWARD THAT HAVE STILL LEFT US WITH A SCAB. THE MODEL THAT YOU ENVISION, HOW WOULD IT DIFFER FROM THE SOCIAL SERVICES PROGRAMS OF THE LAST CENTURY?

THAT'S A REALLY, REALLY IMPORTANT QUESTION. I WOULD SAY TWO THINGS ARE IMPORTANT. NOT ALL OF THE PROGRAMS, TO BE HONEST, HAVE BEEN IMPLEMENTED WELL. AND I WOULD SAY ONE OF THE THINGS WE NEED TO HAVE IS GREATER ACCOUNTABILITY AND GREATER COMMITMENT TO EVALUATION, TO ENSURING THAT THE PROGRAMS ARE IMPLEMENTED WELL AND DO WHAT THEY ARE SUPPOSED TO DO. AND IF YOU LOOK ACROSS HEAD START PROGRAMS, THERE ARE EXCELLENT HEAD START PROGRAMS IN THE UNITED STATES AND THERE ARE SOME THAT LEAVE MUCH TO BE DESIRED. AND I THINK WE NEED A SYSTEM OF ACCOUNTABILITY AT EVERY LEVEL OF SOCIETY WHERE WE DO THAT. SECONDLY, EVEN THE PROGRAMS THAT WE HAVE IMPLEMENTED, WE HAVE NOT IMPLEMENTED THEM ON A SUFFICIENTLY BROAD SCALE WHERE WE CAN HAVE THE MASSIVE IMPACT THAT WE NEED TO HAVE. AND THE AREA OF EARLY CHILDHOOD DEVELOPMENT IS A GOOD EXAMPLE WHERE THERE WAS A STUDY VERY CAREFULLY DONE THAT SHOWED INVESTMENTS IN EARLY CHILDHOOD PROVIDING EDUCATIONAL ENRICHMENT, PRESCHOOL, CALLED THE PERRY PRESCHOOL STUDY DONE IN MICHIGAN, A PLACE I LIVED CLOSE TO IN MICHIGAN FOR MANY YEARS. WHAT THEY HAVE SHOWN IS THAT THE KIDS WHO GOT THAT BENEFIT HAVE AS ADULTS, HIGH LEVELS OF EDUCATION, LESS INVOLVEMENT WITH THE CRIMINAL JUSTICE SYSTEM, HIGH LEDXV OF INCOME, MORE LIKELY TO OWN THEIR HOMES, MORE LIKELY TO BE MARRIED, LESS INVOLVEMENT WITH THE WELFARE SYSTEM, AND IMPORTANTLY THERE IS A $17 RETURN TO SOCIETY FOR EVERY DOLLAR INVESTED. IT IS, AGAIN, IN OUR ECONOMIC INTEREST. IT IS TRUE DEVELOPMENT AND TRUE INVESTMENT IN THE HUMAN CAPITAL OF OUR POPULATION THAT HAS ENORMOUS PAYOFFS TO SOCIETY. I MEAN, IF YOU KNOW AFTER THIS INTERVIEW A PLACE I CAN INVEST THE DOLLAR AND GET $17 RETURN, I AM VERY INTERESTED IN GETTING THAT KIND OF RETURN. AND THAT'S THE BENEFIT FROM A VERY WELL DOCUMENTED EARLY CHILDHOOD INVESTMENT PROGRAM.

JUST A FEW SECONDS REMAINING ALLOTTED TO US, SIR. IT'S IMPOSSIBLE TO MISS YOUR OPTIMISM. YOU'RE OPTIMISTIC ABOUT THE PROCESS.

I AM AN AMERICAN. THE CLINTON PRESIDENTIAL LIBRARY, AND BILL CLINTON IS CERTAINLY ONE OF MY HEROES, AND HIS OPTIMISM IS INFECTIOUS. THE GOOD NEWS IS OUR HISTORY AS A PEOPLE SAY WE CAN DO BETTER. I THINK WE NEED TO IDENTIFY THE CHALLENGES AND WORK TOGETHER TO ADDRESS THEM.

DR. DAVID WILLIAMS, THANK YOU VERY MUCH FOR THIS TIME.

THANK YOU.

THANK YOU FOR JOINING US. AND WE'LL SEE YOU NEXT TIME.

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