There has never been a more salient time for physicians and other health care professionals to understand the structural and social determinants of health. Recent events, including the hugely inequitable impacts of the COVID-19 pandemic and the killings of George Floyd and Breonna Taylor by law enforcement, have starkly highlighted health disparities and should renew our attention on why these disparities occur.

The COVID-19 pandemic has disproportionately infected and killed communities of color on a historic scale. Black, Native American, Asian American, and Latinx communities are experiencing infections, hospitalizations, and deaths at far higher rates than white communities.^{[i],[ii],[iii]} The COVID Racial Data Tracker, for instance, shows that majority-Black counties have infection rates three times the rate of majority-white counties, and Black people have died at 2.5 times the rate of white people.[iv] The Navajo Nation — which has long faced health disparities, racism, and economic exclusion — has seen COVID infection rates surpass that of New York City, and they likewise have suffered disproportionate fatality rates.^[v] In cities and states with larger Asian American populations, the fatality rates among Asian Americans are 2.5 to 3 times the overall population rates.^[vi] The Centers for Disease Control and Prevention has reported that Latinos make up 34 percent of COVID cases nationwide, a much higher proportion than the group’s 18 percent share of the population.^[vii]Many of the nation’s largest outbreaks have occurred in prisons and jails — which disproportionately incarcerate people of color — and in low-wage, high-risk workplaces such as meat processing plants — which disproportionately employ immigrants and people of color.^[viii],[ix] Meanwhile, remarkably, Immigration and Customs Enforcement (ICE) immigration raids continue to be a priority of the federal government, with deadly COVID outbreaks occurring in crowded ICE detention facilities across the country.[x]

The killings of Breonna Taylor in March 2020 and George Floyd in May 2020 triggered widespread protests against police brutality across the globe and renewed attention to the disproportionate number of people of color killed by law enforcement.^[xi] Police shootings are one of the leading causes of death for young Black men in America.^[xii] African Americans comprise 13.2% of the US population, but account for 26.5% of all civilians killed by law enforcement in 2015. In 2016, 2.9 per million people killed by police were white, but 3.23 per million were Hispanic.^[xiii] This ethnic group comprises only 17.6% of the US population but is 30% of arrests and 23% of all searches. The American Medical Association has named police brutality as a public health issue.[xiv]

What can a clinician do to understand the structural and social determinants of health impacting their patients?

Health systems science is defined as the understanding of how care is delivered, how health care professionals work together to deliver that care, and how the health system can improve patient care and health care delivery.^[xv] Social determinants of health is a critical domain within health systems science. Elsevier released the 2nd edition of the Health Systems Science textbook at the end of May 2020, with a significantly revised chapter dedicated to the structural and social determinants of health, supporting the development of structural competency, including a case study outlining the health impacts of police brutality on an older Black man concerned about the safety of his grandson.

Following the World Health Organization framework[xvi] presented in the chapter, we can unpack the complexity of the statistics provided above. The disparities in health outcomes related to COVID-19 (with marked differences in infection rates and severity of illness) are most immediately related to intermediary social determinants of health, including:

Differences in living and working conditions are most visible.

• Social distancing, the most effective strategy to reduce the risk of infection, is less accessible to people of color because of economic disparities.[xvii]
• People of color are less likely to work in jobs that can be performed at home, more likely to work essential jobs that can only be done on location, less likely to have access to the technology to work at home, and more likely to have lost jobs or experienced other financial hardship in this pandemic.^7,[xviii]

And there are important behavioral and psychosocial factors at play.

• Some racial and ethnic groups have historically experienced negative interactions with the health system, and this impairs trust.¹⁸ Public health messages may not be appropriately delivered or received by people of color because of this history.¹⁸
• The chronic stress of experiencing racism can alter immune function, lead to hypothalamic-pituitary axis (HPA) dysfunction, and accelerate metabolic changes contributing to medical co-morbidities that increase the risk of infection with and death from COVID-19.³

The model goes on to identify more upstream concerns: the structural determinants of health inequities — including economic inequality, disparities in education, and racism — which in turn are driven by longstanding public policies and societal and cultural norms.

How can a clinician intervene on behalf of their patients and communities?

The text offers several levels of intervention.

• At the level of individual patients, physicians and other health care professionals play an important role in screening for and identifying structural and social determinants and helping to connect patients with appropriate local resources.
• At the community level, equitable practice design refers to the need for clinicians to create inclusive settings and processes in the care environment (clinic or hospital).
• Improved signage, wording on intake forms, and staff training about bias are simple steps all practices can take.
• Using data to recognize community needs and improve practice is essential.
• On a policy level, providers can serve as powerful advocates, helping legislators understand health issues and promoting the role of science and data in policymaking at all levels of governance, from local to state to federal. [xix]

The structural, social, and economic factors that contribute to health inequities are not new, but our current reality highlights the acute need—and indeed responsibility—to address them.^18,19,[xx],

The first edition of the Health Systems Science textbook, published in December 2016, provided a groundbreaking framework for this nascent discipline. The second edition builds on the first with updated material, additional exercises, insightful sidebars from experts on the ground, and new chapters on systems thinking, health care structure and processes, and ethics and legal issues.

Learn more about Health Systems Science, second edition here.

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References:

[i] Fink-Samnick E. COVID-19 and America’s Racial Divide. RACMonitor. April 23, 2020. https://www.racmonitor.com/covid-19-and-america-s-racial-divide. Accessed September 8, 2020.

[ii] GW Milken Institute School of Public Health. Medium. April 27, 2020. https://medium.com/gwpublichealth/covid-19-whats-equity-got-to-do-with-it-7a30c701cb99. Accessed September 8, 2020.

[iii] Ajilore O, Thames AD. The Fire This Time: The Stress of Racism, Inflammation and COVID-19. Brain Behav Immun. 2020 Jun 4

[iv] The COVID Racial Data Tracker. The COVID Tracking Project at the Atlantic. https://covidtracking.com/race. Accessed September 8, 2020.

^[v]Sequist TD. The Disproportionate Impact of Covid-19 on Communities of Color. NEJM Catalyst. July 6, 2020. https://catalyst.nejm.org/doi/full/10.1056/CAT.20.0370. Accessed September 8, 2020.

^[vi]Yan BW, Ng F, Chu J, Tsoh J, Nguyen T. Asian Americans Facing High COVID-19 Case Fatality. Health Affairs Blog. July 13, 2020. https://www.healthaffairs.org/do/10.1377/hblog20200708.894552/full/. Accessed September 8, 2020.

^[vii]Hubler S, Fuller T, Singhvi A, Love J. Many Latinos Couldn’t Stay Home. Now Virus Cases Are Soaring in Their Communities. New York Times. Published June 26, 2020. Updated June 28, 2020. https://www.nytimes.com/2020/06/26/us/corona-virus-latinos.html. Accessed September 8, 2020.

^[viii]The Marshall Project. A State-by-State Look at Coronavirus in Prisons. Updated August 6, 2020. https://www.themarshallproject.org/2020/05/01/a-state-by-state-look-at-coronavirus-in-prisons. Accessed September 8, 2020.

^[ix]Waltenburg MA, Victoroff T, Rose CE, et al. Update: COVID-19 Among Workers in Meat and Poultry Processing Facilities ― United States, April–May 2020. Morbidity and Mortality Weekly Report. July 10, 2020 / 69(27);887-892.

[x] Kerwin D. Immigrant Detention and COVID-19: How a Pandemic Exploited and Spread through the US Immigrant Detention System. Center for Migration Studies of New York. Published August 12, 2020. https://cmsny.org/publications/immigrant-detention-covid/. Accessed September 8, 2020.

[xi] Dreyer BP, Trent M, Anderson AT, et al. The Death of George Floyd: Bending the Arc of History Towards Justice for Generations of Children. Pediatrics. https://pediatrics.aappublications.org/content/pediatrics/early/2020/06/23/peds.2020-009639.full.pdf. Accessed September 8, 2020.

[xii] Edwards F, Lee H, Esposito M. Risk of being killed by police use of force in the United States by age, race–ethnicity, and sex. PNAS August 20, 2019 116 (34) 16793-16798; first published August 5, 2019. https://doi.org/10.1073/pnas.1821204116. Accessed September 8, 2020.

[xiii] Brown CA, Powell W, Corbie-Smith G, Ritchie O. Evidence Brief: Health Equity Implications of Police Violence. UNC Center for Health Equity Research. Published August 2017. https://www.med.unc.edu/cher/evidence-brief-health-equity-implications-police-violence/. Accessed September 4, 2020.

[xiv] Police brutality. American Medical Association. https://www.ama-assn.org/topics/police-brutality. Accessed September 8, 2020.

[xv] Skochelak SE. Health Systems Science. 2nd edition. Philadelphia, PA. Elsevier. 2021.

[xvi] Solar O, Irwin A. Conceptual Framework for Action on the Social Determinants of Health. World Health Organization. 2010. https://www.who.int/sdhconference/resources/ConceptualframeworkforactiononSDH_eng.pdf. Accessed September 8, 2020.

[xvii] Henry-Nickie M, Hudak J. Brookings. May 19, 2020. https://www.brookings.edu/blog/fixgov/2020/05/19/social-distancing-in-black-and-white-neighborhoods-in-detroit-a-data-driven-look-at-vulnerable-communities/. Accessed September 8, 2020.

[xviii] Yancy CW. COVID-19 and African Americans. JAMA. April 15, 2020. doi:10.1001/jama.2020.6548.

[xix] Berwick DM. The Moral Determinants of Health. JAMA. Published online June 12, 2020. doi:10.1001/jama.2020.11129.

[xx] van Dorn A, Cooney RE, Sabin ML. COVID-19 exacerbating inequalities in the US. The Lancet. April 18, 2020. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30893-X/fulltext. Accessed September 8, 2020.