IHI Open School Short

Video Transcript: Why Haven’t We Made more Progress on Health Equity?: A Conversation Between Donald Berwick, MD, and David R. Williams, PhD, MPH

Donald Berwick, MD, Senior Fellow and President Emeritus of IHI
David R. Williams, PhD, MPH, Professor of Public Health, Harvard T.H. Chan School of Public Health

BERWICK: So, OK, I mean, some of the data are new, but not all of them. We’ve known about disparities and inequity for a long time. I could remember it from years of my training, decades ago. Why aren’t we there yet? What’s been in the way?

WILLIAMS: I would want to first say that we have made progress. And we certainly want to celebrate the progress that has been made. So for example, the life expectancy gap between blacks and whites was eight years in 1950. It’s four years today. So we’ve cut it in half. That is definitely progress.

BERWICK: This is for a child born today?


BERWICK: The life expectancy gap is shortened by four years.

WILLIAMS: Is shortened, right. And that is progress, and we want to celebrate the progress that we’ve made. On the other hand, a four-year gap is, in fact, considerable, and if we look at the average rate at which life expectancy increases, it will take us more than 25 years to close that gap, if we freeze the life expectancy of whites and the life expectancy of blacks increases at the average rate at which life expectancy has increased over the last decade.

So four years is in fact a considerable gap. Why? I would say there are two big reasons in my mind. One is, there is not broad-based awareness in the general population, and among some policymakers, of the magnitude and extent of disparities in health, or inequities in health. So that’s one reason, is the lack of awareness. If we don’t know that a problem exists, we’re certainly not going to mobilize to address it. So that’s one.

The second reason is maybe more troubling, and more difficult to deal with. The second reason is, there is the absence of political will, I think, to make the investments that need to be made in order to make progress. And by that I mean, that just for many people who are aware of the problem, that there isn’t an emotional connection to it. There isn’t a feeling that this is unacceptable, and that we really have to mobilize to do something about it.

I’ll give you a statement that was made by W.E.B. DuBois in 1899. This is a long time ago. He wrote a book called the Philadelphia Negro. In that book, he had a chapter on the health of blacks in Philadelphia in the late 1890s. And he said, “One of the most difficult social problems in the matter of Negro health is the peculiar attitude of the nation towards the well-being of the race.” And DuBois went on to say, “There have been few other cases in the history of civilized people where human suffering has been viewed with such peculiar indifference.” So it’s that peculiar indifference, the absence of will to address what is in some ways an unprecedented national tragedy, that I think is a part of the problem.

And so we need to think of ways in which we can tell the story, and I think narrative is important, so I used the word “story” carefully and deliberately. We need to tell the story of health equity in a way that connects with the American population, because I think we have a very compassionate and generous population. But we need to tell the story in a way that they can connect with, and then be mobilized to address it.