Abstract
In a commencement address at Emory University in Atlanta, Georgia, the White House Chief Medical Advisor, Dr. Anthony Fauci, said that COVID-19 “has uncovered a stark reality and failing of our own society,” bringing attention to the health inequities in the USA and how the pandemic has disproportionately affected minorities (Fauci, 2021). This is a much-needed acknowledgment of the social determinants of health (SDH), not just in the USA, but globally. The World Health Organization (WHO) defines the SDH as the combination of socioeconomic, social, and environmental factors that affect individual and community health (2017). These factors have a tremendous impact on the equitable accessibility and quality of healthcare. This is not a new phenomenon, but the COVID-19 pandemic has brought these social inequities within the healthcare system to the surface for all of us to see.
The Social Determinants of Health
The social determinants of health (SDH) are “factors apart from medical care that can be influenced by social policies and shape health in powerful ways” (Bravemann, 2014). The SDH disproportionally affect minority communities within the USA and globally.
Healthy People (2020) released a list of five major components of social determinants of health; these factors are significant contributors that may overlap to put individuals and communities at a disproportionate risk for poor health outcomes. The components are: neighbourhood and built environment; health and health care access; social and community context; education; and economic stability.
Up to 70% of all health outcomes are attributed to health care access, socioeconomic factors, and environmental conditions (Millett, 2020). Settler-colonial states, such as Canada and the U.S., have racism and discrimination built into their institutions, policies, and laws, which often goes unnoticed by those who do not experience it first-hand (Trudeau, 2021).
In April of 2020, 22% of U.S. counties with Black populations greater than the national average (13%) made up 52% of COVID-19 diagnoses and 57% of deaths (Millett, 2020). Moreover, the CDC has reported that Indigenous Americans had a 3.5 times greater risk of contracting COVID-19 than their white American counterparts. The patterns show clear signs of the social determinants of health being at play as BIPOC (Black, Indigenous, and people of colour) are the most impacted by COVID-19. The reason for such disparity, according to the CDC (Health, 2021), can be evaluated using Healthy People’s SDH list (2020):
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- Neighbourhood and built environment: A higher percentage of people from racial and ethnic minority groups live in crowded housing conditions.
- Health and healthcare access: barriers to BIPOC in the USA include lack of insurance, the inability to take time off work, and less access to transportation and childcare.
- Social and community context: BIPOC people often work in jobs considered to be essential, including factories, healthcare facilities, grocery stores, and transportation services, meaning they are more exposed to the virus.
- Education: some racial and ethnic minority groups have poor access to high-quality education.
- Economic stability: BIPOC people may have limited job options, and few benefits, such as paid sick leave.
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Rural living in the USA is its own SDH (Paul et al., 2021), due to rural clinics struggling to maintain a workforce, population maturation, low education rates, low income, and less of a tendency to seek preventative care than their urban neighbours. This places rural residents at higher risk for virus contraction. The disparities facing rural populations are most prevalent with Black communities within the Southern USA. The overlapping disadvantages of a lack of access due to rural living and the systemic and social oppression of being a person of colour in North America create a situation where the SDH remove opportunities for accessible and quality healthcare.
the disparities facing rural populations are most prevalent in Black communities within the Southern U.S.
Race is a major SDH globally; long-existing and ongoing racial discrimination positions communities of colour at a greater risk of contracting viruses such as COVID-19 (Millett, 2020). BIPOC populations are impacted by the lasting effects of historical, more overt forms of racism, and systemic discrimination in the modern day. Systemic racism is oppression that functions at the institutional level, embedding whiteness into national and global policies and procedures (University, 2021). In this way, healthcare systems inherently disadvantage BIPOC, while simultaneously putting white populations at an advantage. Thus, within global healthcare systems there are issues of accessibility to indiscriminatory medical practice for BIPOC.
One way that systemic racism impacts the lives of millions is through residential segregation. Residential segregation defines the physical, spatial separation of social groups in a community or nation (Driedger, 2006). Residential segregation separates the rich from the poor, and the white Americans from the Black Americans, creating spatial gaps in access to work, education, and healthcare. Segregation is both a factor of and contributor to systemic forms of racism, working in a cycle to oppress BIPOC. Racial residential segregation continues to be a function of systemic racism within Canada the USA, impacting the health of millions daily through a lack of access to equitable resources (Paul et al., 2021).
Not a New Problem
The existence of SDH is by no means a new problem; it has impacted the lives of millions for centuries. Pandemic after pandemic, those most affected are disproportionality within communities of colour (Millett, 2020). The HIV crisis highlights similar patterns in health disparities and outcomes across U.S. population, specifically burdening people of colour.
The primary factors of the disparities among HIV contraction rates among rural U.S. regions were poverty, unemployment, mental stress, and social exclusion. In urban areas, the SDH are race, socioeconomic status, and racial residential segregation (Paul et al., 2021).
In modern day, issues of racism and discrimination are ongoing, hiding within its systemic form. For instance, within both rural and urban counties in the U.S. today, Black populations experience substantial health inequities, including a lack of social capital, systemic racism, residential segregation, and poverty (Paul et al., 2021).
Racism is also prevalent in more overt forms of discrimination. Dr. M.E. Turpel-Lafond (Aki-Kwe) highlights the disproportionately high level of Indigenous-specific racism and discrimination that exists in the current British Columbia health care system (2020). Indigenous people who seek out health care in B.C. are often met with discrimination in the form of stereotyping, being labelled as drug-seeking, less capable, irresponsible, and less worthy of health care. The Indigenous population also face discriminatory behaviours when seeking healthcare, often receiving rough treatment, inappropriate pain management, or long wait times. This racism is disproportionately aimed towards Indigenous women and girls, targeting their matriarchal roles, and disrespecting their unique risk profile and healthcare needs.
An example of such stereotyping and discrimination is seen in the case of Joyce Echaquan, an Indigenous woman, in Quebec. During her final moments, Echaquan was insulted by the nurses who were supposed to keep her safe (Global News, 2020), who blamed her poor health on the choices she had made in life, stereotyping her as a bad parent and only good for sex. This case shows that, even when access to good healthcare is available through the government, stereotyping and discrimination with the delivery of that system still exists.
In a Global Context
Within the global context, the same trends can be observed that are prevalent at the national level within the United States and Canada; there is evidence of the SDH globally (Andermann, 2016). Overall, those who have low income and poor education experience more health issues and die earlier than their richer and better-educated peers.
As you post to Facebook or Twitter about your joy at rejoining society after months of social distancing, or declaring the pandemic to be “over,” remember to check your privilege and acknowledge that most of the world will continue to suffer with this disease for months and years after life in the richer countries returns to normal
In January 2021, The Economist published an article discussing how a full vaccine rollout for COVID-19 is not likely until 2023. The article looks at how lack of access to vaccines in 85 of the world’s poorer countries will skew the time frame of a fully-vaccinated future. From the North American point of view, the rollout of the vaccines appears to be going smoothly as of June 3, with Canada administering 65 doses per 100 population and the United States administering a whopping 89 per 100 (Ritchie et al., 2021). Now, compare that to the overall global rate of 25 per 100, or to Peru, which has the highest recorded death rate from COVID-19 and has only administered 12 doses per 100 population (Ritchie et al., 2021), and you begin to see the disparity in access to and administration of life-saving vaccines. As you post to Facebook or Twitter about your joy at rejoining society after months of social distancing, or declaring the pandemic to be “over,” remember to check your privilege and acknowledge that most of the world will continue to suffer with this disease for months and years after life in the richer countries returns to normal. The cost of immunization is significant and problematic in countries without equitable resources.
Possible Solutions
The University of British Columbia (2021) offers a list of three steps to take at the individual to social level to fight systemic racism:
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- Reflect
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Acknowledge and accept the fact that racism remains, both at the systemic and individual level, contributing to the SDH. Reflect on your experiences and imagine them in the shoes of others; notice any biases or prejudice that you hold. Look at issues of the SDH within an intersectional context – observing the effects of multiple, intersecting social identities on systemic privileges and oppressions.
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- Educate
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Educate yourself through research, reading, and self-reflection. Acknowledge past biases and mistakes and try to think of how you would approach those situations with new knowledge of the social determinants of health and the link to systemic racism.
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- Speak Up
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Share your knowledge, reflections, and education with others. Take action within your communities. Advocate for an equitable society in everything you do.
A starting point for change at the institutional level is that health professionals must address the SDH (Andermann, 2016); without doing so, discrimination within global healthcare environments will not be acknowledged, preventing equitable access to quality healthcare that is free of excessive risk. Moreover, in the USA specifically, past inequalities and acts of discrimination must be acknowledged when examining the financial burden of healthcare; it is in no way equitable that people of colour and low-income households continue to suffer due to intergenerational burdens of a capitalist society that was imposed upon them.
The idea of patient-centered care is a necessary plan-of-action as it will enhance empathy and understanding within the workplace (Andermann, 2016). When working with patients, physicians and other healthcare professionals should be aware of clinical flags and discuss social challenges in a supportive and empathetic way. Through sensitive and caring discussion, physicians can help patients to access all options available to them, including benefits and support systems. Moreover, in practice, physicians should offer a space with culturally-safe services, patient navigators, and accessible care. Using our privilege in the workplace to help everyone to access all opportunities available to them and their well-being is the best job many of us can do.
Whether you compare the social determinants of health between different countries, to different pandemics, or to global rates, the same pattern emerges: people of colour, especially those within low-income communities, bear the brunt of the issue. There are various complex angles to the social determinants of health, however one thing is clear: racism is ongoing within the healthcare system through both overt and systemic means in patient care, accessibility, and policy making.
References
Andermann, A. (2016). Taking action on the social determinants of health in clinical practice: a framework for health professionals. CMAJ, 188 (17-18). https://doi.org/10.1503/cmaj.160177
Braveman, P., & Gottlieb, L. (2014). The social determinants of health: it’s time to consider the causes of the causes. Public health reports (Washington, D.C. : 1974), 129 Suppl 2(Suppl 2), 19–31. https://doi.org/10.1177/00333549141291S206
Driedger, L. (2006). Residential Segregation. The Canadian Encyclopedia. https://www.thecanadianencyclopedia.ca/en/article/residential-segregation
Fauci, A. (2021). Commencement Address at Emory University, Atlanta, Georgia. https://news.emory.edu/features/2021/05/class-of-2021/index.html
Global News. (2020). Coroner investigating death of Indigenous woman at Quebec hospital. https://globalnews.ca/video/7367473/coroner-investigating-death-of-indigenous-woman-at-quebec-hospital
Health Equity Considerations and Racial and Ethnic Minority Groups. (2021). https://www.cdc.gov/coronavirus/2019-ncov/community/health-equity/race-ethnicity.html
Millett, G. A. (2020). New pathogen, same disparities: why COVID-19 and HIV remain prevalent in U.S. communities of colour and implications for ending the HIV epidemic. Journal of the International AIDS Society, 23(11). http://dx.doi.org.proxy.library.brocku.ca/10.1002/jia2.25639
Paul, R., Arif, A., Pokhrel, K., & Ghosh, S. (2021). The Association of Social Determinants of Health With COVID-19 Mortality in Rural and Urban Counties. The Journal of Rural Health, 37(2). https://doi.org/10.1111/jrh.12557
Ritchie, H., Ortiz-Ospina, E., Beltekian, D., Mathieu, E., Hasell, J., Macdonald, B., Giattino, C., Appell, C., Rodés-Guirai, L., & Roser, M. (2021). Statistics and Research: The Coronavirus (COVID-19) Vaccinations. https://ourworldindata.org/covid-vaccinations
The Economist. (2021). More than 85 poor countries will not have widespread access to coronavirus vaccines before 2023. https://www.eiu.com/n/85-poor-countries-will-not-have-access-to-coronavirus-vaccines/
Trudeau, J. (2021). Press conference, March 9, 2021. Turpel-Lafond, M.E. (2020).
In Plain Sight: Addressing Indigenous-specific Racism and Discrimination in B.C. Health Care. https://engage.gov.bc.ca/app/uploads/sites/613/2020/11/In-Plain-Sight-Full-Report.pdf
University of British Columbia. (2021). Systemic Racism: What it Looks Like in Canada and How to Fight it? https://vpfo.ubc.ca/2021/03/systemic-racism-what-it-looks-like-in-canada-and-how-to-fight-it/
World Health Organization. (2017). Determinants of health. https://www.who.int/news-room/q-a-detail/determinants-of-health
