Abstract
The coronavirus disease 2019 (COVID-19) pandemic in the United States provides yet another example of the enduring and pernicious effect of social determinants of health (SDH) on African American communities. SDH, as defined by the Healthy People 2020 SDH framework, include domains of economic stability, education, social and community context, health and health care, and neighborhood and built environment. 1 Within each domain, key areas represent elements of focus for the decade (Box). Compared with non-Hispanic White people, African American people have higher rates of COVID-19 cases (2.6 times higher), hospitalization (4.7 times higher), and death (2.1 times higher).2-4 Although the pandemic is ongoing, it is not premature to call attention to the root causes of health inequity in the United States that have persisted for decades and are being highlighted in the current crisis.
Healthy People 2020 Social Determinants of Health Framework 1
The disparities in COVID-19 case fatality rates between African American and White people have been referred to as a “perfect storm.” 5 Such a comparison obfuscates the larger social and political circumstances that structure poor health. Unlike a storm, which is a natural phenomenon that cannot be prevented, the higher rate of COVID-19 deaths among African American people was predictable and preventable because of racial injustice. These deaths were predictable because of the long history of health inequities in the United States and preventable through systemic changes to eliminate systemic racism and improve SDH. The social and political will needed to correct these injustices historically has been, and continues to be, lacking. SDH underlie health disparities that increase the potential for exposure to, and higher death rates from, COVID-19 among African American people across the United States.2-4 We provide a framework-based explanation on how systemic racism gives rise to differences in SDH that affect differences in health outcomes, including COVID-19, and make a call for change.
Social Determinants of Health and Systemic Racism
We begin by outlining how systemic racism influences SDH using the Healthy People 2020 Social Determinants of Health Framework. 1 SDH have been shown to contribute to a wide range of health disparities in the United States and are interrelated with systemic racism. 1 We define systemic racism as the exploitative and discriminatory practices, unjustly gained resources and power, and maintenance of major resource inequalities by ideological and institutional mechanisms that are controlled by White people. 6 Systemic racism underlies many aspects of SDH.
Education
Although the racist practice of educational segregation formally ended in public schools in 1954, the residual effects remain in our current educational system.7-9 Race/ethnicity, class, and neighborhood are highly interrelated in the United States, from where children attend school to the quality of schools. 10 African American children, on average, attend schools where they are of the majority race, yet they also disproportionately attend schools with the highest poverty concentrations and lower-than-average test scores. 11 Data from fall 2015 indicate that 58% of African American students (vs 5% of White students) enrolled in public schools attended a school in which the combined enrollment of racial/ethnic minority students was at least 75% of enrollment. 12 Disparities among African American people in education persist into adulthood: fewer African American people than White people enroll in college and complete a bachelor’s degree (26.1% vs 40.1%), which leads to income inequalities across the lifecourse. 13
Economic Status
African American people have been disproportionately affected economically through practices of systemic racism that have made it difficult for them to accumulate wealth over generations. 14 Wealth is the total market value of all assets available to an individual or family. 15 It is created over time and has intergenerational effects that perpetuate, provide opportunities, and allow for the pursuit of education and increased choice in employment. Creating wealth is particularly challenging for African American people for multiple reasons, including systemic racism that exists in employment, hiring practices, pay, housing discrimination, and the justice system. 16 African American adults are more likely to be unemployed (11.8% men, 10.1% women) than non-Hispanic White adults (5.1% men, 4.6% women), even when controlling for differences in education, age, and experience (data averaged from 1994 to 2016). 16
Housing
Quality and stability of housing are important for human health. Systemic racism historically has manifested in segregation and housing discrimination in the form of “redlining.” Redlining is the systematic denial of services (banking, insurance, health care, retail) by the government and/or private sector to residents of specific neighborhoods (typically based on racial/ethnic composition), either directly or through selectively raising prices for certain neighborhoods. A result of redlining is the de facto racial segregation of neighborhoods, which shapes social conditions for individuals and communities and underlies the health disparities between African American people and White people. 17 Despite federal and state legislation to combat these racially motivated practices, redlining is perpetuated through the weakening of federal protections for fair financial lending, the reduction of federal funding for community investment, and current zoning practices, all of which disproportionately affect African American people.18,19 The effects of these practices are seen in the intersection of place, race, and health disparities in chronic conditions.
Former and current redlining practices continue to shape the built environment of predominantly African American neighborhoods. African American neighborhoods are more likely than neighborhoods of other racial/ethnic composition to be exposed to poisonous toxins and chemicals such as lead. 20 One example is the water crisis in Flint, Michigan, where 54% of the population is African American and 40% of the total population lives below the federal poverty level.21,22
Community
Injustices rooted in systemic racism have been noted at every level of the US criminal justice system, including policing, pretrial detention, sentencing, parole, and post-parole. 23 As a result of inequitable processes across all levels of the criminal justice system, African American people are incarcerated at more than 5 times the rate of White people and receive longer sentences. 23 In addition to injustices concomitant with the broader criminal justice system, African American people are also more likely to encounter lethal force from law enforcement officers than their non-Hispanic White or Hispanic counterparts. 24 Furthermore, some police practices, such as “stop and frisk,” target African American people. Such practices constitute a public health problem because they perpetuate stress and trauma by translating Blackness into deviance. 25 Mass incarceration not only affects the people in the criminal justice system, it also affects the families and communities left behind by causing family disruptions, financial strain, and emotional difficulties. 26
Access to Health Care
The experience of the health care system may further exacerbate risks for mortality among African American people as a result of systemic racism. Implicit bias on the part of health care providers may affect clinical decision making in diagnosis, treatment, pain management, and referral. 27 As a result, the prevention and management of chronic morbidities are affected. Persistent and well-documented inequities exist in access to health care among African American people. Compared with non-Hispanic White people, African American people are less likely to be insured 28 and, even with access to health care, are less likely to use health care services because of a distrust in health care providers rooted in a history of systemic racism in health care. 29
Social Determinants of Health and Health Disparities Among African American People
We now focus on how differences in SDH that are rooted in systemic racism are responsible for persistent health disparities. When we think about limitations in access to housing, education, economic status, health care, and equity in the criminal justice system, one outcome is poor health. African American people are significantly more likely than non-Hispanic White people to receive a diabetes diagnosis and die as a result of diabetes, 40% more likely to have high blood pressure, and 8.4 times more likely to be diagnosed with HIV/AIDS. 30 African American women have higher obesity rates than women of any other racial/ethnic group, and they have a 20% higher chance of having asthma, a 40% higher chance of dying from liver cancer, and nearly 4 times the death rate from breast cancer than non-Hispanic White women, despite similar rates of diagnosis. 30 Survival rates among African American men are, on average, 5 years lower for many common cancers, and the death rate from liver cancer is 60% higher, than among non-Hispanic White men. 30 Overall, the lifespan for African American men is 4.5 years lower than for non-Hispanic White men. 31
Social Determinants of Health and Increased Exposure to COVID-19 Among African American People
Now we focus on how systemic racism and social determinants of health are affecting African American people during the COVID-19 pandemic. Social distancing, the measure that the United States has taken as the largest effort to prevent the spread of COVID-19, is an SDH. The ability to social distance is a privilege linked to key areas of housing, community, and economic status. Lower-wage jobs are often jobs that cannot be translated to work from home, have been deemed essential, and may involve increased interaction with the public (eg, cashiers, sanitation workers, home health aides, food service workers). Although African American people account for just 13.4% of the US population, 32 they account for a larger percentage (17.1%) of the service sector, including cashiers (19.9%), bus drivers (27.0%), taxi drivers (29.5%), housekeeping (14.4%), janitorial staff (18.2%), and sanitation workers (18.2%). 33 Such jobs are less likely than office-based jobs to be able to be performed from home via teleworking strategies, thereby increasing exposure to community-acquired COVID-19. African American people are also more likely than people of any other racial/ethnic group to use public transit, 34 which may provide increased exposure to community-acquired infection.
In addition to social distancing, a recent Centers for Disease Control and Prevention (CDC) guideline has been to wear masks when going out in public. Wearing a mask is problematic for African American people, who have expressed fear of being mistaken for criminals; it is compounded by a longstanding conflation of race and criminality. 35 Incarceration is linked to health disparities among African American people, through both the disproportionate number of African American people who are imprisoned and, during the COVID-19 pandemic, the inability to social distance in a prison or jail setting. Inconsistent policies have been placed across the country in terms of protections for incarcerated people during COVID-19. In one example, it led to an ACLU class-action lawsuit against the Dallas County Jail for its management of inmate exposure to the virus. 36
Social Determinants of Health and COVID-19 Mortality Among African American People
Preliminary data also indicate higher COVID-19 mortality rates among African American people than among White people in the United States.2-4 These deaths are likely linked to underlying conditions such as type 2 diabetes, hypertension, and asthma, from which African American people have disproportionately higher rates than non-Hispanic White people. 30 CDC has reported that risk factors for serious illness when contracting COVID-19 include older age and underlying medical conditions, including chronic lung disease, asthma, heart conditions, immunocompromised states (ie, a common result of treatment for cancer or HIV/AIDS), severe obesity, diabetes, chronic kidney disease, and liver disease. 37 These disparities are often a result of race-based inequities among SDH in areas of education, economic status, housing, community context, and access to health care. 1 When the risk of death from COVID-19 is higher among people with underlying health conditions, it is clear that African American people will be more at risk than populations without higher rates of chronic disease.
Moving Toward Health Equity During the COVID-19 Pandemic and Beyond
Systemic racism is an aspect of public health that underlies health inequities and results in unequal health outcomes in society. Whether past or present, overt or covert, intentional or subconscious, racism must be rooted out in our society in all its forms. By examining the relationship between systemic racism and SDH, we call for the implementation of widespread, societal change that extends beyond the interpersonal to permeate the systems in which racism operates. In terms of COVID-19, an impetus for societal change will involve robust research that collects representative data as the pandemic continues. This information will inform government, employers, providers of social services, and society as a whole in the ways that current policies negatively influence SDH and outcomes of COVID-19. This work will not only inform the current COVID-19 pandemic, but can also inform planning for future emerging infectious diseases. In addition, it will highlight the ongoing need to address SDH to reduce a multitude of health disparities in the United States that affect the quality of life and lifespan of African American people.
As the Healthy People 2020 goals draw to a close, SDH should be a continued priority for the United States, as inequities in socioeconomic status and links to health outcomes persist. This pandemic underscores the systemic racism and disparities that have persisted for decades. Now is the time to rework our government, our public health and medical systems, our workplaces, our criminal justice systems, and our communities with a centering foundation of health equity for African American people.
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support with respect to the research, authorship, and/or publication of this article.
