Chapter 3: Social Determinants of Health
Katie Baker
racism is the belief that one group of people is superior or inferior to another based upon perceived physical and cultural characteristics. It is a social issue built upon a non-existent biological difference that has very real repercussions for its victims. Even though there is no such thing as race from a biological perspective, many people suffer from its effects. Indeed, genetic variance within a geographic population is greater than that between populations and there are no genetic variables which can be identified and labeled as markers of various races. Yet, race is used to justify treating people differently all over the world.
While racism has existed for as long as there have been societies, the racism against Black, Indigenous, and People of Color (BIPOC) in the United States was intentionally woven into its founding with the forced removal of native nations, the establishment of slavery and the lack of representation for anyone other than white male landowners. While slaves were a part of colonial society from the time Europeans landed on the U.S. east coast, the U.S. Constitution’s Thirteenth Amendment abolishing slavery did not get ratified until 1865, almost 100 years after the country’s founding. Racism against Asian immigrants was reflected in laws preventing immigration from certain Asian countries such as the Page Act of 1875 and the Chinese Exclusion Act of 1882. Mob violence and forced deportations against Latinx individuals has also been a part of our country since its founding.
Today, legal racism is much less obvious but still prevalent in laws that frequently have different effects on people from different backgrounds. While individual racism can have profound effects upon its targets, the societal effects of institutional racism rely upon its integration into institutions such as the justice system, healthcare, the education system and all levels of government itself. It is this systemic and institutional racism which primarily affects the determinants of health that we are discussing in this chapter.
Structural and Institutional Racism in Healthcare
Racism within the healthcare system can be both overt, through practitioner prejudices in patient interactions, or hidden and well-intentioned, as in how treatment protocols for bipoc patients vary from that of than white patients. When we look at healthcare education, there is, unfortunately, still much to be changed about disparities in diagnosis and treatment that are taught at our institutions. Racism can affect both mortality and morbidity rates in BIPOC populations.
A recent study (Hoffman, et al, 2016) indicates that over half of the 418 students sampled from the UVA medical school system believed in myths about black and white patient biological differences. Specifically, they believed that black people had thicker skin and a higher pain threshold than white counterparts although this is demonstrably untrue (Hoffman et al., 2016). Even considering this is just a sample of students at one institution, it isn’t any stretch of the imagination to see what harm these beliefs could cause our patients if not addressed in early medical education. Indeed there can be unintentional outcomes due to our unaddressed biases.
The process of tackling bias in medicine is an ongoing process. Studies that compare current treatment protocols, which have variations depending upon the race of the patient, to those without racial coefficients, show that if patients have the same treatment, regardless of racial identity, outcomes for BIPOC individuals improve dramatically. For example, removing racial coefficients from the calculation of kidney function tests resulted in 35% more African-American patients receiving a diagnosis of eligibility for a kidney transplant (Zelnick et al., 2021). Further studies showed variations in pulse oximetry (which relies on skin color) affecting COVID-19 treatments (Valbuena et al., 2022) and pulmonary function tests that rely on racial coefficients underdiagnosing severe lung disease (American Thoracic Society, 2021), indicating how serious the issue becomes.
Statistically speaking, we can see disparities in outcomes that are not solely the result of racialized treatment algorithms. We must also factor in social determinants of health that vary because of historical inequities that are continuing to this day. For example, while men continue to have a 40% higher mortality rate than women, Black men have the highest mortality rates of all groups, followed closely by Native American men, both groups surpassing that of white men (CDC, 2014). Outcomes are similar regarding breast cancer diagnosis. Mortality is 40% higher for Black women than for non-Hispanic white women (Jatoi et al., 2022), indicating that issues such as access to healthcare and preventive screenings take a toll.
In addition to medical care, social determinants of health such as environmental pollutants, poor workplace safety and career opportunities, food deserts and limited access to safe outdoor recreation and nature spaces all negatively affect BIPOC individuals at higher rates then white individuals. Systemic racism that affects housing and incarceration rates have been repeatedly shown to have disproportionate impacts on Black and Brown individuals and their families.
One example of housing disparities is red-lining, an illegal practice of discrimination with regard to real estate and home buying that began in the 1930s, affecting mortgage, student loan, and car buying interest rates and approval (Hayes, 2019). All of these had effects on the ability of Black and Latinx families to buy homes whose taxes would pay for funding of education, infrastructure repair and other social supports that dramatically affect our environmental determinants of health today.
Institutional racism is observed in the types of laws that are enforced, sentencing guidelines and mass incarceration, all of which disproportionately affect Black and Brown individuals. Something as simple as different sentencing guidelines for the possession of crack cocaine (more often used in poorer neighborhoods which were predominantly Black) and powdered cocaine (more often used by upper-middle class white people) can have a dramatic effect on the number of young people imprisoned from different populations. The Fair Sentencing Act of 2010 attempts to minimize (not eliminate) disparities in sentencing that disproportionately affect different groups, although it only addresses federal laws, not the state laws under which most drug offenses are tried. Also, it does not address the fact that approximately 80% of the people prosecuted for crack possession were black, although two-thirds of the users were white or LatinX (Bigler, 2010).
During the COVID-19 pandemic, BIPOC individuals were more likely to fulfill essential positions requiring them to continue to be in contact with patients, customers, and clients as the virus spread. According to data published by the Centers for Disease Control in September of 2022, Native American/Alaska Native individuals had a 1.6 x higher rate of COVID cases, 2.7x higher rate of hospitalizations and 2.1x higher rate of death than non-Hispanic whites. Latino cases were 1.5x higher, hospitalizations were 2.0x higher and deaths were 1.8x higher than non-Hispanic whites. Black/African-American rates were 1.1x higher, 2.3x higher and 1.7x higher, respectively. Only Asian-American/Pacific Islander rates were lower than white rates, with 0.8x the white rate for all three categories (CDC, 2022) What determinants of health, aside from employment, may have caused these disparities?
Developing Different Measures to Overcome Health Disparities Due to Racism
If racism is systemic, what can we, as healthcare professionals, do to combat it? How can we ensure that the next generation of providers looks at their patients through an anti-racist lens? And how can we make these changes sustainable and institutionalized at the same time?
In 2020, the University of Washington School of Medicine students pushed their instructors in Nephrology to look at racialized differences in diagnosis, after a study was published showing large differences in kidney care along racial lines. As a result, the UW School of Medicine eliminated the racial coefficient for the glomerular filtration rate test, which measures kidney function. This one change has increased the number of African-American patients who qualify for severe kidney disease treatment and a transplant list by over 30% (Cerdeña, 2020). Other schools and medical organizations are following suit, including major centers in Maryland and Mississippi and Cedars-Sinai hospital in Los Angeles, CA. By some estimates, using the race-blind kidney function test instead improves care and interventions for over 720,000 African American patients (Washington, 2021).
In other areas, such as variations in medication dosing, differences in outcomes guidelines for cardiovascular and diabetic health, and even bone health and fracture risk statistics, all consider race as a factor in their calculations (Cerdeña, 2020). Proponents of re-examining these racialized tests and treatment algorithms suggest that although the initial addition of race-based coefficients was intended to improve outcomes, they may be doing the opposite. A push to re-evaluate clinical and diagnostic practices that divide patients into racial categories is well underway and we can expect to see changes as more information is collected.
Laws that affect public health have been changing as well, for better or worse. The Supreme Court decision to overturn Roe v. Wade has very real public health consequences for people who can become pregnant, their partners and families. On the other hand, there has also been recent positive news, such as the creation of the Environmental Justice Index, which looks at data from the EPA, the U.S. Census Bureau, the CDC and the Mine Safety and Health Administration (MSHA) to evaluate impacts on health for various groups from environmental concerns (ATSDR, 2023).
In addition to student-led reforms in medicine and new laws, the general social changes occurring in American society, many spurred on by the pandemic, including a reimagining of work-life balance, a strengthening of local community engagement, and a renewed interest in climate change technology. Support for environmental measures and universal healthcare, as well as all these other changes can all have profound effects on the determinants of health that affect everyone and have a disparate effect on BIPOC families and individuals.
The belief that one group of people is superior or inferior to another based upon perceived physical and cultural characteristics.
Differences in a population’s genomes determining variations in traits, characteristics, or susceptibility to diseases
Acronym for Black, Indigenous, and People of Color
The state of being dead, or the rate of deaths within a specific population or group over a particular period.
The state of being ill, diseased, or injured, or the rate of illness within a specific population or group over a particular period.
A factor or constant number in an equation that changes based on race.
Decision trees or pathways used to determine the treatment of an illness.