Addressing Social Determinants of Health

Addressing Social Determinants of Health

The effects of structural racism on medicine and health care continue to cause inequalities in treatment as well as in educational/professional opportunities. To examine and begin to address this complex, multifaceted issue, Dr Michele Evans, deputy scientific director at the National Institute on Aging, moderated a September 2021 roundtable with key stakeholders from a range of clinical and biomedical backgrounds. The goal of the roundtable discussion was to take a critical first step in recognizing the impact of structural racism and informing the dismantling of healthcare inequities.

The panel identified system-level, provider-level, and patient-level barriers to health equality, starting with the limitations of using the social construct of race as a proxy for social determinants of health. They feel that most differences in outcomes and inequities in healthcare are largely driven by the idea of race, not because of biologic or genetic differences between populations, but because of associated oppression and hierarchy that have been built around race. However, there is also agreement that there is relatively low genetic diversity between populations compared to within populations that exists due to demographic history, population history, and adaptation to different environments. This suggests that ancestry may be more relevant than race as a genetic risk factor. The panel agreed that genetic ancestral markers can sometimes inform disease expression in particular ethnic minority groups, and this is an area that should be explored further.

From the patients’ perspective, those in minority ethnic groups have a large measure of distrust in the structured system of healthcare on the basis of historical legacies of mistreatment. Particularly in the United States, society fosters racial discrimination through multiple systems, including housing, education, employment, earnings, benefits, access to banking and credit, media access, healthcare, and the criminal justice system. Demographic challenges of poverty and segregation contribute to disparate outcomes in terms of the quality of care. The example was given of an analysis of patients initiating dialysis within the US Renal Data System registry, which showed that Black Americans who lived in highly racially segregated areas had an increased rate of mortality. There are also misconceptions about differences in estimated glomerular filtration rate (GFR) and in pain sensitivity. The panel discussed the issue of race correction for estimating GFR, which can cause Black individuals to be improperly categorized with higher levels of renal function. This leads to disparities for Black patients with regard to renal replacement services, including renal replacement therapy, referral to nephrology, timely placement of dialysis access, and timely referral for transplant evaluation. The panel emphasized the need for more precision medicine to better understand individual genetic risk factors.

Structural racism also affects workforce diversity. The panel discussed the importance of creating a more diverse workforce that will question what is taught, acknowledging that scientific conclusions can be impacted by the timing of when research is done. Fortunately, there has been an increase in diversity among those in medical education, and new students are questioning what drives the presumed differences, rather than simply accepting them.

Behavioral patterns, environmental exposure, healthcare, and social circumstances are all considered social determinants of health. According to Dr Ruth Shim from the University of California, Davis, 70% of early deaths are related to social determinants of health, while 30% are due to genetics, ancestry, or a family history that predisposes someone to disease. To move toward greater health equity, healthcare providers must learn how to identify and combat the social determinants and the effects of structural racism on outcomes in health.

High level
There are multiple factors that must be addressed to reduce the influence of race in medicine. First, investors and researchers have a responsibility to ensure more diversity in their research. One way to do this is to include targeted populations and minorities in randomized clinical trials. Protocols should be designed to dissect and assess hypotheses about genetic and environmental influences on health. Employers should strive for a more diverse workforce, not only for equal representation but also to ease some of the historical distrust that often exists. Finally, industry must invest funding into research of therapeutic treatments in a broader range of patients with diverse ancestries. Given the lower costs of gene sequencing today vs 10 years ago, the panel suggested that the use of proxies is no longer appropriate.

From an education standpoint, it was also suggested that evolutionary medicine be incorporated into medical and premedical curricula. Students should be trained to understand population genetics and conceptualize how to evaluate patients in their future careers.

Ground level
All medical students should gain a basic understanding of population genetics to establish that there are not discrete differences that correspond with biologic concepts of race. At the same time, young doctors need to learn the genetic risk factors that do exist for certain diseases at the individual level and how to distinguish the interaction of genetic, environmental, and social factors that influence disease risk. Clinicians can establish cultural competence by rethinking how they deliver messages to vulnerable populations.