Social determinants of health are generally recognized as conditions in the environments where people live, work, study and play. They include variables like socioeconomic status, employment, access to safe and affordable housing, health care, and access to affordable nutritious food. These variables directly impact and influence health outcomes, disease rates, and illness.
Social determinants of health have disproportionately affected communities of color, particularly Black communities, for a long time. Research shows that systemic racism ensures that Black people in particular are more likely to live in poorer neighborhoods with fewer social services, less access to healthy food, and a higher risk of exposure to environmental contaminants. Those factors have a huge impact on health and access to health care—data from the Centers for Disease Control and Prevention (CDC) and other research has shown that Black communities experience more disease burden as well as complications that subsequently result in higher rates of morbidity and mortality in comparison to white communities. Additionally, The CDC Health Disparities and Equities Report consistently points to Black and communities of color as disproportionately experiencing health disparities in all areas in comparison to whites.
The COVID-19 pandemic has shone a huge spotlight on these preexisting issues. New data shows that the COVID-19 mortality rate is 2.4 times higher for Black Americans than it is for white Americans, and 2.2 times as high as the mortality rate of Asians and Latinx groups. In New York, one of the areas hardest hit by the pandemic, 251 African-Americans died from COVID-19 per 100,000 people, compared to 81 white American deaths per 100,000 people. In Maine, Black people make up just 1.6 percent of the state’s population yet in mid-May (most recent data available), made up more than 16 percent of the state’s total COVID-19 cases.
"Just as the definition of health is becoming increasingly expansive, so too should the definition of violence. Violence includes racism in housing policy, health care policy, infrastructure funding, economic policy and racial bias in hiring and education.” —Michaela Leslie-Rule, MPH
Again, these health disparities did not arise with the pandemic. They have been present for centuries and are defined by the World Health Organization (WHO) as "systematic, unfair and avoidable differences in the health status of different population groups," notes Juliette G. Blount, NP, a New York based nurse practitioner and health equity speaker. This unjust imbalance has long put Black communities in particular at a disproportionate risk of death—CDC data has and continues to report higher all-cause mortality in Black communities than in white ones.
It’s time that the health-care world finally recognizes these health disparities—and the societal factors that drive them—for what they are: violence imposed on Black and brown bodies. “Just as the definition of health is becoming increasingly expansive, so too should the definition of violence,” says Michaela Leslie-Rule, MPH, researcher and communication strategist. “Violence includes racism in housing policy, health care policy, infrastructure funding, economic policy and racial bias in hiring and education.”
As a society, we should be as enraged and saddened about these acts of violence as we rightfully are about police brutality and gun violence, Leslie-Rule says. “The opportunity of this moment is for Americans to draw an explicit connection between the higher rates of disease and death experienced by Black and brown communities and the ongoing systemic violence that is being carried out against these communities,” she says.
"By blaming the racially and economically marginalized for their own poor health outcomes, we continue to absolve society from acknowledging, and taking responsibility for correcting, the social and environmental injustices that are the real cause of illness and death." —Juliette G. Blount, NP
As part of the hard work ahead to ensure racial justice in America, Leslie-Rule says that all professions must work to address how they (and the system) perpetrate violence against Black people. Part of that includes openly acknowledging that structural racism is a major driver of the health outcomes of people of color, she says. “Black and brown people are dying from the coronavirus at higher rates than whites because they are made to be more vulnerable by health, social, and economic systems that are not designed to ensure our wellness or our longevity,” she says. “Conversations about social determinants of health must acknowledge that the social system in this country is intentionally designed to create disparities of health. Our system was designed to make Black and brown people more vulnerable.”
The health-care system must also address and work to heal the deep distrust that many Black people rightfully feel towards it. “As a pediatrician, I have witnessed an increase in Black individuals that want no intervention,” says New York pediatrician Régine Brioché, MD. “They are choosing to give birth at home and declining intervention. When I ask about their reasoning, they often say they don’t trust the medical community.” It’s no wonder, considering the long history of the white medical establishment experimenting on Black people and then denying them health care, from the Tuskegee experiment to the forced sterilization of incarcerated women targeting women of color. While Dr. Brioché says that patients often come to her because she looks like them, she recognizes that “I’m part of a larger [health-care] community that they feel hasn’t served them.”
As we think about these variables and outcomes, I urge us to stop blaming Black people for their health. “By blaming the racially and economically marginalized for their own poor health outcomes, we continue to absolve society from acknowledging, and taking responsibility for correcting, the social and environmental injustices that are the real cause of illness and death,” says Blount. Where we live, how we work, and what we have access to impacts every aspect of our lives. For Black people this is not simply a matter of urgency, it’s a matter of survival.
We as a nation have arrived at a pivotal moment where we have an opportunity to demand and spur systemic long-lasting change. We have the opportunity to learn from the data, learn from the stories, redistribute funding, re-invest in Black communities, and live with the statement that racism is a public health issue.
Maya Feller, MS, RD, CDN, of Brooklyn-based Maya Feller Nutrition, is a registered dietitian nutritionist who works with patients looking for nutritional management of diet related chronic illnesses with medical nutrition therapy. Maya shares her approachable, real food based solutions to millions of people through regular speaking engagements, writing in local and national publications, via her social media account on Instagram, and as a national nutrition expert on Good Morning America, Strahan Sara & Keke, and more.
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