Dr. David R. Williams grew up on Saint Lucia, a Caribbean island where 80 percent of the population is Black and residential segregation has not been an issue. But it remains a big one in the United States, he maintains, and in a way not obvious to most people.
“I argue that residential segregation by race is the fundamental cause of racial disparities in health in the United States,” says Williams, a professor of public health, sociology and African and African American Studies at Harvard University.
Williams has reached that sweeping conclusion with a sociologist’s reasoning. “Socioeconomic status is a stronger predictor of variations in health than cigarette smoking,” he says, adding that racially segregated neighborhoods come with underresourced schools, few job opportunities and depressed income levels, contributing to the lower socioeconomic status of African-American residents in particular.
“Unless we dismantle segregation or the concurrence of social ills, we’re not going to make progress on gaps in health or any of these other issues. It’s the driver,” he says.
“Nothing is inherently wrong about living next to people of the same race,” as was evident in his Caribbean upbringing, Williams, 56, adds. The health-related problems spring from “the clustering of poverty and social ills” that accompanies segregated Black neighborhoods in this country.
Though the Fair Housing Act swept away the legal architecture of segregated housing more than 40 years ago, where Americans of different races live has not changed much, particularly in urban areas. Williams cites statistical measures showing that New York, Chicago, Detroit and other cities with large Black populations were nearly as segregated in 2000 as South Africa was in the waning years of the apartheid regime.
Other researchers have documented the specific health deficiencies present in segregated Black neighborhoods compared to White neighborhoods of the same socioeconomic status: two to three times fewer supermarkets with fresh produce, two to three times more fast-food outlets, three times more likely to lack outdoor recreational facilities and, in hospitals serving Black neighborhoods, less technology, fewer specialists and fewer doctors with the highest medical certification.
Williams is pessimistic that the nation can eliminate segregation because he believes racism is so entrenched that Whites move out of racially mixed neighborhoods or make isolated Black families uncomfortable in White ones. He says his family experienced that discomfort while living in Michigan and Connecticut; today they live in Newton, a predominantly White suburb of Boston that last year elected its first Black mayor.
His perspective on the connection between residential segregation and health is consistent with the trend among public health specialists of pointing to “the social determinants of health,” a broader category that also includes age and disability. Those specialists have been moving to pay more attention to “treating” whole neighborhoods rather than concentrating solely on providing medical care to individuals.
In a similar vein, Williams advocates “area-based” approaches that include opening full-service grocery stores through public-private partnerships, constructing walking paths in green spaces and waging campaigns to promote healthy behaviors in Black communities.
He also supports, more controversially, zoning restrictions on the number of liquor stores and fast-food restaurants in neighborhoods, but not on small eateries that are often Black-owned. With those struggling enterprises, he says, patrons and advocates have more leverage to push for healthier menus.
The latest thrust of his research focuses on smoking. Williams directs the Center on Lung Cancer and Disparities, which has received a $9 million grant from the National Institutes of Health. African-Americans are at a greater risk of getting lung cancer even though they smoke about as much as Whites.