Social Determinants of Health and Health Equity

What are Social Determinants of Health?

The CDC defines social determinants of health as “conditions in the environments which people live, learn, work and play, worship and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.” Examples of these conditions include housing, education, income level, access to resources, and transportation. Often, marginalized groups have less access to conditions that promote healthy living, contributing to greater health disparities among different groups.

2015 data from the CDC reveals a 3.4-year gap in life expectancy between whites and blacks, illustrating a disparity in health outcomes. To further break this down, one educational resource from the CDC (“Promoting Health Equity: A Resource to Help Communities Address Social Determinants of Health“) highlights the differences by racial/ethnic groups and socioeconomic status:

Table of Health Disparities by Racial/Ethnic Group and Socioeconomic Status

Infant Mortality1.5 times higher for children of mothers of 12 or fewer years of education compared to 13+ years. (2004)
Cancer Deaths1.2 times higher for African Americans than Whites. (2004)
DiabetesDiabetes diagnosis: Native Hawaiians or Pacific Islanders (15.4%), American Indians/Alaskan natives (13.6%), African Americans (11.3%), Hispanics/Latinos (9.8%), Whites (7%) (2005)
HIV/AIDSAfrican Americans comprised half of all diagnosed HIV/AIDS cases between 2001-2004, while only being 12% of the population. African Americans were almost 9 times more likely to die of AIDS than Whites. (2004)
Tooth decayGreater untreated dental cavities among the poor. (2004)
InjuryAmerican Indian and Alaskan Native males between 15-24 were 1.2 times more likely to die from a car vehicle-related injury and 1.6 times more likely to die of suicide than Whites.
Table on Page 7

Alongside these health disparities, more data reveals a lack of access to affordable housing, increased exposure to pollutants, greater distance from grocery stores with fresh produce, and a lack of proximity to health care sites for marginalized groups. These societal factors negatively affect the health of individuals and communities.

Adverse Childhood Experiences, Trauma, and Social Determinants of Health

Adverse childhood experiences (ACEs) include abuse, neglect, and family dysfunction that children under the age of 18 experience. Many of these experiences are traumatic. When a child is constantly stressed and on guard, it actually alters pathways in the brain and affects gene expression. This survival response leads to a reduced ability to handle daily stressors and to emotionally regulate. ACEs are linked to health problems, unemployment, mental illness, risky decision making, and substance abuse. According to the American Academy of Pediatrics, “many of the most common adult life-threatening health conditions, including obesity, heart disease, alcoholism, and drug use, are directly related to childhood adversity.” With a greater prevalence of ACEs among marginalized groups, they are also at a greater risk for these harmful health conditions.

Racism, homophobia, and the accumulation of microaggressions can manifest as trauma, heightening stress levels and hypervigilance. Chronic stress is linked to immune and cardiovascular problems. Studies in epigenetics (the study of the expression of genes) have suggested that trauma can even be inherited across generations. Considering historical and societal trauma, it is necessary to address the systems that perpetuate the cycles of poverty and instability in order to provide equitable opportunities for health.

Health Equity

What is health equity? The Robert Wood Johnson Foundation, a major philanthropy dedicated to health, defines health equity in this way:

“Health equity means that everyone has a fair and just opportunity to be as healthy as possible. This requires removing obstacles to health such as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care.”

The CDC, national, and local organizations are working to change policies and provide education and resources to communities with health disparities. Health professionals also need to educate themselves on systemic problems and listen to community members to learn how they can practice helping not just individual patients, but communities as a whole.

A Conversation with Dr. Negeri Clarke

Last week, the Center for Excellence in Collaborative Education offered an event on the social determinants of health for black communities and LGBTQA+ communities. This event featured panelists from across the nation as well as pharmacy’s very own, Dr. Negeri Clarke. You can watch a recording of the event here.

We caught up with Dr. Clarke to hear a little about her life experiences and how she views the role of pharmacists in promoting health equity for all.

Dr. Negeri Clarke.

Tell us a little bit about what you’ve been doing since graduation?

Since graduation I have been preparing for my boards, realigning/reconciling who I am and want to be with my experiences of the last four years, and making a solid transition into this next chapter of my life. 

What is your background with CECE?

CECE at UNE was a major factor in why I chose to come to UNE and attend pharmacy school. After going on several interviews at other universities, I had decided that, maybe, pharmacy as a profession based on those interactions wasn’t a very good fit for me. During the interview with UNE and reading up on the university’s background, I saw that interprofessionalism as a part of an interdisciplinary culture across the university is a major bedrock of the curricula. I hold a Master’s Degree in Interdisciplinary Arts and Leadership, so it felt like a natural fit to me. During my second year, I was invited to become a staff assistant to the, then dubbed, IPEC (now CECE) office. Through the CECE, I have had an opportunity to work with, be supported by, and offer support to every health professional discipline, and have connected with some really amazing people as well. 

How did you get involved with this particular CECE presentation?

I am lucky enough to be respected by Kris Hall. She invited me to be a panelist. When I asked why, she stated that my unique perspective as a transitioning Graduate Pharmacist may be of help to those in their  clinical phase of didactic study and those preparing to graduate in 2021.  

Many of us understand that diet, exercise, and genes affect our health.  However, there are so many other determinants of health such as exposure to pollution, quality of education, access to health care, discrimination, racism, incarceration, etc. We know that many of these categories can manifest as trauma in the bodies of individuals and communities.  How does trauma affect health outcomes on the individual level and on a community level? 

There is a large developing movement that is widening the scope and understanding of the workings of trauma. It is becoming pervasive knowledge, now, after the publication of Dr. Van der Kolk’s book and studies by such organizations as the CDC and Trauma Research Institute, that the experiencing of traumas contributes to a multitude of health conditions, as trauma can be experienced long after the ending of the traumatic events have come to a close.

I identify with communities that are living through traumatic events every second of every day. It is a complex thing to explain and it may be hard for me to attempt to do so in this moment. I could ask you to imagine but that would be unfair and impossible. I am a Black Woman; I was born in the West Indies. My parents migrated here when I was four and ultimately immigrated. My culture understands education as the only means of true self-transformation, but in this society, everything about me is perceived and publicized as a threat, including my mind. Expressing your pain becomes an affront to whomever you may come into contact with — those with a shared experience who aren’t ready or equipped to deal with the reality of it and those outside of the experience who may or may not want to help but lack understanding to compassion for it. 

It is stressful. It is exhausting. There is very little trust for your surroundings and systems. Many instances are acts of survival. Everything is more difficult in that state of being. An example that may be better understood is, I am a health professional and even so, the traumas of my past and present that inform my decisions leads me to seek care from female practitioners and/or practitioners of diverse background. It doesn’t always work out but more often than not, I am more comfortable and willing to actively seek the care I need.

How can pharmacists help to alleviate the disparity in health outcomes among marginalized individuals and communities?

Become self-aware. Lean into the things that make you uncomfortable so you can learn from them. Remember that the things that drive and motivate you aren’t all that different from anyone else’s drivers. Have a lot of tact and a little courage — hold yourself and team accountable, who and how you in your role will set the tone as well as impacting any team you’re a part of.  

If participants have one takeaway from the presentation, what do you hope it would be?

​Know yourself so you can know who and how you want to be in all things. It starts there. Your leadership, is you. Your impact, is you. Your advocacy, is you. Your ability to discern and compromise, is all you. If not, when things come as a challenge, and there will be challenges, you may limit your reach.

To learn more about the intersection of pharmacy and social determinants of health, click on the links provided in this article, or feel free to reach out with questions.