54 The great undoing: a multigenerational journey from racism to social determinants of health

Nkem P. Nonyel, PharmD, MPH, BCPS

Lakesha Butler, PharmD

Vibhuti Arya, PharmD, MPH, FAPhA

Introduction

The COVID-19 pandemic called attention to the need to revisit systemic racism and its influences on social determinants of health (SDH/SDOH) within the United States. Healthy People 2030 defined SDH/SDOH as the “conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.”¹ According to Gee and colleagues, systemic racism is “the macro-level systems, social forces, institutions, ideologies, and processes that interact with one another to generate and reinforce inequities among racial and ethnic groups.”² These include policies and practices that propagate racial inequities and health disparities, and subsequently impacts the living conditions and the clinical, economic, and humanistic outcomes of the populations. Consequently, systemic racism has been described as “a public health emergency and a root cause of social determinants of health.”³

Health disparities are negative (and preventable) differences in health outcomes between groups of people; these are widely connected with and created by systemic racism for the minoritized and marginalized patient populations. The term “minoritized” is used to emphasize the social oppression that categorizes individuals from the minority populations into racialized hierarchy, thereby differentially delegating advantages and disadvantages to various groups in society. The term “marginalized” is used in this context to illustrate the powerlessness of these minoritized populations that experience disparities due to their SDH because of systemic racism.

Minoritized and marginalized populations experience stress due to racism, which has hazardous and harmful health impacts. Empirical research has demonstrated that self-reported discrimination is inversely correlated with good mental health. Indeed, exposure to racism increases the risk of depressive symptoms and psychological distress, as well as formally diagnosed depressive and anxiety disorders.⁴ Parental exposure to racism can even result in adverse outcomes for children related to mental health symptoms and disorders.⁴ Physiological impacts of experiencing racism are also present, with documentation of hemodynamic and vascular stress responses evident purely from the anticipation of prejudice in social interactions.⁵ These impacts create the significant health disparities experienced by minoritized and marginalized populations in terms of disease morbidity, mortality, disability and injury.⁶

Pharmacists can play a role in addressing SDH/SDOH and dismantling systemic racism, beginning with self-awareness and cultural competency. They can engage colleagues and trainees in conversations about our roles as healthcare professionals, including education, advocacy, community engagement, research, empowerment, and leadership. In the clinical setting, pharmacists can discuss with patients how racism and SDH/SDOH may be impacting their care and goals, promote exposure and learning about dermatological disorders on skin of different colors, confront harmful stereotypes from discredited race science that impact quality of care, and work to earn the trust of communities who have experienced historical and current harms in their medical care.

Case

CC: “I’m having a hard time catching my breath”

Patient: GW, a 58-year-old Haitian immigrant (64 in, 97.1 kg) with COPD, arrived at the clinic today and is in the waiting room. You could hear her wheezing very loudly. She is on portable oxygen at 2 L/min via the nasal cannula.

HPI: GW received a prescription two weeks ago for fluticasone/salmeterol (Advair Diskus), umeclidinium (Incruse Ellipta) and albuterol HFA (Proventil HFA). However, she was unable to pick up any of these from the pharmacy due to cost concerns.

PMH: HTN; mixed HLD; chronic systolic heart failure; COPD; T2DM; recurrent cerebrovascular accidents (embolic); thrombosis of precerebral artery

FH:

• Mother: deceased (lung cancer); HTN, mixed HLD, diabetes, stroke
• Father: deceased (stroke); mixed HLD, diabetes
• Brother (living): mixed HLD, prostate cancer
• Son (age 22): asthma
• Two daughters (ages 28 and 32): asthma

SH:

• 96 pack-year smoking history
  • Quit cigarettes two years ago
  • Uses smokeless tobacco three times daily
• Drinks two bottles of beer daily

Surgical/procedural history:

• Right cardiac catheterization (four years ago)
• C-section x 2
• Coronary angioplasty with stent placement

ROS:

• Decreased range of motion on right shoulder
• Swelling of right arm with swelling and decreased strength
• Posterior tibial pulse are +1 on both left and right sides

VS:

• BP 120/70 mmHg
• HR 75 bpm
• Temp 98.6°F
• Pulse ox 98% on RA

Labs Drawn at last visit one month ago:

Medications (all oral unless specified otherwise):

• Proventil HFA 90 mcg/actuation 2 puffs every four hours PRN wheezing or SOB
• Advair Diskus 500-50 mcg/dose inhaler 1 puff twice daily
• Incruse Ellipta 62.5 mcg/actuation inhaler 1 puff once daily
• Praluent 150 mg/mL pen injector subcutaneously every two weeks
• Insulin NovoLog 8 units subcutaneously three times a day with meals
• Eliquis 5 mg twice daily
• Brilinta 90 mg twice daily
• Entresto 49-51 mg twice daily
• Metformin 1000 mg twice daily
• Jardiance 10 mg once daily
• Rosuvastatin 40 mg once daily at bedtime

SDOH: GW’s house is located on 17-acre farmland in a rural community, which has no sidewalks and no public transportation; she has lived there for the past 25 years. Prior to moving to the rural area, GW worked as a waitress in an urban area for about 10 years.

Additional context: GW has insurance coverage but worries about her co-pays, especially for some medications, since they seem to keep changing year to year. She reads well, has good health literacy, and overall understands her conditions and that the medications help her. Nonetheless, she is overwhelmed by her medications and how all this fits into her daily lifestyle while she also must take care of her farm. She has a car and can drive to the clinic but shares this with some other neighbors in the community so they, too, can make their clinic appointments. GW also enjoys her time with her faith-based community that is strong and relies on them for support and strength.

Case Questions

1. What social determinants of health might impact GW?

2. What are some questions you may ask GW to better learn about the social factors in their life?

3. How can you as a practitioner better engage the community in learning about barriers and opportunities to care that is unique to the patients you serve? Hint: use the following websites to assist:

1. https://www.cdc.gov/nccdphp/dch/programs/healthycommunitiesprogram/tools/pdf/sdoh-workbook.pdf
2. https://www1.nyc.gov/assets/doh/downloads/pdf/dpho/race-to-justice-action-kit-language-use-guide.pdf
3. https://www1.nyc.gov/assets/doh/downloads/pdf/dpho/race-to-justice-action-kit-communication-tips.pdf

4. Using the above reference guides, identify 1-2 priorities that you can address immediately to address some social determinants of health at an individual/pharmacy/local community level.

5. In determining next steps, create SMARTE (Specific, Measurable, Achievable, Realistic, Timely, Equitable) goals that can help you work towards addressing health inequities within your communities or patients.

Author Commentary

Understanding the past and present implications of historical discrimination against minoritized individuals is an important step for pharmacists and student pharmacists in addressing systemic racism and mitigating health disparities. Systemic racism is the most profound and pervasive form of racism that oftentimes is difficult to recognize without intentionality and raised awareness. Numerous historical examples of racism in healthcare are known. However, this same racism and bias continues today slowing our progress towards health equity, which is the attainment of the highest level of health for all people and requires valuing everyone equally. For everyone to be valued equally, superiority and inferiority ideologies must be deconstructed. Also understanding the social determinants of health and how they contribute to disproportionate poor health outcomes in minoritized groups is critical for pharmacists and student pharmacists. Consistent interpersonal work such as self-awareness assessment, checking biases, education, growth, and development in diversity, equity, inclusion and anti-racism is encouraged.

While systemic racism has emerged as a conversation following events of the Black Lives Matter protests in response to continued police brutality, specifically towards Black people in 2020, it has been present in conversations among marginalized communities for quite some time. Systemic racism is rooted in US history and historic policies and practices that continue to perpetuate racial disparities across health, education, income inequality, among other social factors. Faculty and students should start to engage in dialogue around systemic racism and how it impacts not only our patients, but also our colleagues and professional community. This is a longitudinal discussion that must be continued in understanding the knowledge, but also the perceptions and attitudes we are all conditioned with through our own socialization, experiences, and messages we receive via the media and across the various institutions we engage with (e.g., educational systems, faith-based groups, community organizations, healthcare systems, etc.). Being aware of implicit biases we all have will help our professional community bring this awareness to our interactions with each other and our patients. Over time, we can start to unravel some of the awareness around systemic racism, identify gaps and opportunities where pharmacists may be able to screen for social determinants of health and ask questions to better understand our patients’ lived experiences without making sweeping assumptions.

Patient Approaches and Opportunities

Minoritized patients with uncontrolled disease states and non-adherence to medications and lifestyle recommendations may be viewed as difficult patients and may be further marginalized by healthcare professionals through sub-par patient interactions. Pharmacists and student pharmacists can take responsibility to deepen their awareness of systemic racism, social determinants of health and how these factors affect their patients.

Practitioners should use open-ended questions like, “what barriers do you have that may cause you to forget to take your medicines?” to better identify patients’ needs. Pharmacists and student pharmacists should work collaboratively with patients to better understand factors that are contributing to poor health outcomes. Understanding a patient’s situation may be a more important factor in disease state management than the disease itself. Building a trusting, non-judgmental relationship encourages trust between the patient and provider and can often be the key to better shared decision-making and ultimately better health outcomes.