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Excerpted From: Ruqaiijah Yearby, Structural Racism and Health Disparities: Reconfiguring the Social Determinants of Health Framework to Include the Root Cause, 48 Journal of Law, Medicine & Ethics 518 (Fall, 2020) (68 Footnotes) (Full Document)
Since 2010, the United States has tried to address racial health disparities using the Social Determinants of Health (SDOH) framework that recognizes social factors, outside an individual's control, cause these disparities. The SDOH framework identifies five key areas of social factors connected to racial health disparities: economic stability; education; social and community context; health and health care; and neighborhood and built environment. As of 2018, racial health disparities continue and are estimated to cost the United States $175 billion in lost life years (3.5. million lost years times $50,000 per life year) and $135 billion per year in excess health care costs and untapped productivity. These disparities persist because of the failure to account for and address structural racism, the root cause of racial health disparities.
Structural racism is the way our systems (health care, education, employment, housing, and public health) are structured to advantage the majority and disadvantage racial and ethnic minorities. More specifically, it produces differential conditions between whites and racial and ethnic minorities in the five key areas of the SDOH, leading to racial health disparities. Law is one of the tools used to create these differential conditions by structuring systems in a racially discriminatory way. For example, during the Jim Crow era (1875-1964), the government used law to structure the employment system in a manner that benefited whites and harmed racial and ethnic minorities.
Specifically, many laws that expanded collective bargaining rights either explicitly excluded racial and ethnic minorities, or allowed unions to discriminate against racial and ethnic minorities. These employment laws create differential conditions between whites and racial and ethnic minorities that benefited whites by providing them with access to rights and unions that resulted in paid sick leave coverage. However, it left racial and ethnic minority workers without union representation and paid sick leave, forcing them to go to work even when they were sick. This issue persists today and is one of the causes of racial disparities in COVID-19 infections and deaths. Many racial and ethnic minorities do not have paid sick leave, so they must go to work even when they are sick, while most whites have paid sick leave and can stay at home. Consequently, racial and ethnic minorities without paid sick leave are more likely than whites to be exposed to COVID-19 in the workplace, resulting in racial and ethnic disparities in COVID-19 infections and deaths. Structural racism produced racial differences in who has paid sick leave, which is a major cause of these health disparities. Yet, structural racism is often ignored as a root cause of racial health disparities.
This commentary not only describes the ways that structural racism causes racial health disparities, but also highlights the need for a multi-layered approach to the SDOH framework in order to achieve racial health equity. The commentary proceeds as follows: Part II outlines how the current SDOH framework fails to include many of the integral factors causing racial health disparities, such as structural racism and the law. Next, Part III uses the plight of home health workers to explore the ways that law is used to structure the employment system in a racially discriminatory way, resulting in racial health disparities. Finally, Part IV provides a reimagined SDOH framework with a multi-layered approach to address racial health disparities and achieve racial health equity.
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To eliminate racial health disparities, the SDOH framework must include the root cause of racial health disparities and a multi-layered approach. Other scholars have proposed different models to show how discrimination influences health. For instance, Professors Chandra Ford and Collins Airhihenbuwa, who created the public health critical race praxis (PHCR), noted structural determinism (which I call structural discrimination) and racial categories are the bases for ordering society, which contributes to racial health disparities. Building on these models, my reimagined SDOH Framework, shown in Figure 3, makes changes that are easy to adopt as part of the 2030 Healthy People Objectives, which have not yet been published.
First, in recognition of the work of social epidemiologists, I have changed key areas to systems because American systems structured in a racially discriminatory way reinforce discriminatory beliefs, values, and distribution of resources, leading to racial health disparities. Second, public health is an integral factor in racial health disparities, and thus must be included in the SDOH Framework as a key system that impacts health. I recommend that “health” should be removed from the health and health care area because it is an outcome of the social determinants of health, not a factor. It should be replaced by public health. Health and wellbeing are then shown as the outcome from each of the key systems.
Third, the social and community area is made up of discrimination, civic participation, and incarceration. I moved civic participation from social and community context to the neighborhood and built environment system, since it is tied to neighborhood and incarceration is linked to the built environment. Additionally, because structural racism is a root cause of racial health disparities, which influences all of the key systems of my revised SDOH framework, it does not fit under social and community context. Therefore, in my framework, I have deleted social and community context, leaving four key systems that impact health and wellbeing.
Fourth, structural discrimination, which includes structural racism, is separate from the key systems and so is law. As black feminist and feminist theorists have noted, the law often reinforces discrimination, protecting those with power and leaving those without power susceptible to mistreatment, especially women. Thus, structural discrimination is shown as the root cause of health disparities, while law is show as the tool. Finally, in my framework, although not shown in Figure 3, individual and institutional discrimination are present in each of the four key systems because they reinforce differential conditions in the system that benefit whites and harm racial and ethnic minorities.
The purpose of my reimagined SDOH framework is to provide the root cause and tool used to structure systems in a racially discriminatory manner that prevents racial health equity. When using the framework, government and public health officials are primed to make the connection between structural discrimination, law, systems, and racial health disparities. Yet, this is just the beginning.
To achieve racial health equity, government and public health officials must aggressively work to end structural racism and revamp all of our systems, especially the public health system, to ensure that racial and ethnic minorities are not only treated equally, but also receive the material support they need to overcome the harms they have already suffered. Only then can we truly begin to work towards improving the health and wellbeing of racial and ethnic minorities, so that we can achieve racial health equity.
Ruqaiijah Yearby, J.D., M.P.H., is the Co-Founder and Executive Director of the Institute for Healing Justice and Equity at Saint Louis University and Professor of Law and Member of the Center for Health Law Studies, Saint Louis University.
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