Abstract
Background
Systemic racism is built upon the racial exploitation of minorities and has been further exposed inequalities amidst the COVID-19 global pandemic. The historic reliance of undocumented migrant Latino laborers continues to influence the modern-day work conditions Latinos face such as low wages, limited benefits, and an emphasis on productivity over safety, which also increases their risk for adverse health outcomes.
Objective
This narrative review aims to describe and highlight key risk factors on the impact of systemic racism and how it shapes the work and occupational health experiences of Latino laborers in the US, as well as strategies to overcome barriers.
Method
In this review, we explore empirical studies, news reports, and policy briefs that highlight the social factors impacting occupational health outcomes for undocumented Latino migrant laborers and synthesize the information to report major challenges experienced during the pandemic and propose recommendations for improving conditions and occupational health of these groups.
Results
Existing literature demonstrated that (1) documentation status was a barrier to federal relief programs during COVID-19; (2) though categorized as essential workers, workplace conditions were harmful towards preventing infection and transmission of COVID-19; and (3) there was an increased burden particularly for undocumented Latino women both in the workplace and at home during the pandemic. Recommendations include prioritization of undocumented immigrants in government relief, and addressing both individual and environmental level stressors in the workplace to promote inclusivity and reduce unnecessary suffering of Latino migrant workers.
Conclusion
Latino laborers should be treated with dignity and respect with workplace protections as they are designated as essential workers during the COVID-19 pandemic.
Keywords: Systemic racism, Latino labor, Latino health, Occupational health, Undocumented Latino migrants, COVID-19
1. Introduction
In November 2020, it was reported that supervisors and managers at a meat processing center in the US Midwest were participating in a “winner-take-all betting pool” wagering on the number of Latino migrant workers that would become ill from COVID-19 (National Public Radio [NPR], 2020). These employers were aware of the poor working conditions facing Latino migrant workers and saw racial humor in guessing the number of workers that would contract COVID-19. The dehumanization of Latino laborers has been routine in the food processing industry, with this type of work often being referred to as “dangerous, dirty, and demanding” and can lead to detrimental occupational health outcomes (Ramos et al., 2021). The COVID-19 pandemic exacerbated the racially exploitative conditions of many meatpacking factories, where Latino laborers were designated as “essential workers” yet omitted from policies to support worker safety. The meatpacking factories which were taking bets on workers' lives were quickly exposed to be far from compliant with the important health guidelines set by the Centers for Disease Control and Prevention (CDC) (Rubenstein et al., 2020), and there was little being done to protect workers from contracting the virus (National Public Radio [NPR], 2020). As a result, Latino food processing workers faced a significantly higher infection and transmission rate during the early period of the pandemic (Rubenstein et al., 2020).
The CDC report on this issue (Rubenstein et al., 2020) found that the behavior of Latino laborers was not to blame, as they reported higher mask usage, and more compliance with social guidelines compared to the average American. The higher risk factors were found in the workplace conditions, which limited practical social distancing, access to personal protective equipment (PPE), poor ventilation, and lack of physical barriers on processing lines (Rubenstein et al., 2020). This is a global problem occurring in developed nations that have large numbers of meatpacking migrant workers. The US government issued an executive order that forced the opening of these meatpacking factories, even though they had no preventative health standards to manage the pandemic (Rubenstein et al., 2020), which has major implications for the spread of COVID-19.
Systemic racism in US society plays a significant role in shaping the way social institutions treat racial minorities. Scholars have addressed the need to bring in the context of systemic racism for understanding undocumented immigration (Romero, 2008); the persistent global exploitation of the undocumented (De Genova, 2004; Golash-Boza, 2015); and the worsening health outcomes for undocumented immigrants over time (Cavazos-Rehg et al., 2007). This is a centuries-long process in the making, as the US has relied on the exploitation of migrants throughout history, that links to modern day racial inequalities (Ngai, 2014). Undocumented Latino immigrants continue to be among the most marginalized minorities, regulated to essential sectors of the US workforce where they are the most vulnerable to harmful conditions that impact their occupational health outcomes.
For example, there was a 2019 immigration raid targeting US meatpacking processing centers in the state of Mississippi where 700 migrants were arrested. Among them was Edgar Lopez, who despite living 22 years in the US, was deported to Guatemala, and left behind his wife, 3 children, and 4 grandchildren in Jackson, Mississippi. Tragically, in January 2021 Lopez was found dead amongst several Guatemalan migrants traveling through Mexico during the dangerous journey back to his family (Mora and Green, 2021). This is one of the many stories of Latino laborers navigating US society, living in fear of an undocumented status, facing workplace injustice, separated from families, and leading to harmful violent conditions.
2. Systemic racism and Latino migrant exploitation
Latino migrant laborers in the United States face intersecting forms of oppressive labor conditions through systemic racism and migrant exploitation. Systemic racism is a conceptual framework to analyze the extent of racial oppression faced by Blacks, Latinos, and racial minorities in US society (Feagin, 2013). Racial minorities face recurring oppressive practices based on racial ideologies that reinforce stratification along social, political, and economic lines (Feagin, 2013). Historically, Latino migrant laborers have faced labor abuse, poor living conditions, and low pay for agricultural and food processing work (Gonzalez, 2015). Racial ideologies had played a role in the historic treatment of Latino migrants who were seen as inferior and disease-ridden (Molina, 2006). For instance, during the US Bracero Guest Worker Program's (1944–1964) migration processing, millions of Mexican migrant laborers were sprayed with DDT, which is now a banned chemical compound (Gonzalez, 2015).
Currently, research has found that Latino migrant laborers continue to face poor working conditions, have the highest job fatality rate, are paid below minimum wage, and risk consequences for speaking out about safety standards (Hall et al., 2010; Fussell, 2011; Gleeson, 2016; AFL-CIO, 2022). Undocumented Latino migrant laborers feel pressure to go along with these harmful conditions due to fear of deportation and threats to their livelihood because of their legal status (Fussell, 2011). White employers often prefer Latino laborers over white workers for labor-intensive work based on their perceived subservience and lack of speaking up about rights in the workplace (Salinas, 2018).
The COVID-19 pandemic has exposed the vulnerabilities and racial inequalities faced by Latino laborers (Mithani et al., 2020; Waltenburg et al., 2020). This leads to implications on how to address the conditions Latino migrant laborers face. This paper aims to provide an overview of the major factors which affect Latino migrant workers during the pandemic, including structural migration policy, harmful working conditions, and highlight strategies to address the needs of the Latino community.
3. Methods
This exploratory narrative review (Paré et al., 2015) is based on an extensive search of recent research articles that focuses on undocumented Latino migrant workers in the US and their occupational health conditions during the COVID-19 pandemic. Articles retrieved were empirical studies published during the early prevalence of COVID-19 to understand the issues faced by Latino migrant laborers. Databases searched included Google Scholar, EBSCOhost, PubMed, and ProQuest to retrieve current studies and information on Latino migrants and their working conditions, challenges faced, and future directions for improving their health and well-being.
We reviewed online materials published in English using the following keywords: Latino migrants; undocumented migrants; COVID-19; coronavirus 2 (SARS-CoV-2); coronavirus; health; access; occupational health. After reviewing abstracts of the initial results, we examined the full text of relevant articles that pertained to undocumented Latino migrant workers and occupational health during COVID-19. Furthermore, we also hand searched the reference lists of the articles to obtain additional relevant studies. After this process, we categorized and descriptively analyzed the results based on major factors impacting Latino migrant laborers during COVID-19, as well as implications for improving overall health conditions in workplace for these groups (Table 1).
Table 1.
Theme | Impact during COVID-19 | Recommendations for equitable practices |
---|---|---|
Latino Laborers, Health Policies, and COVID-19 |
|
Increase access to federal benefits and prioritize needs of undocumented Latino migrants |
Latino Migrant Workplace Conditions During COVID-19 |
|
Develop culture of safety in the workplace Improve preventive healthcare access and practices to decrease risk of COVID-19 infection |
Latino Families Navigating the Pandemic |
|
Address personal and safety needs of Latino laborers through in-depth understanding of existing challenges |
4. Results
The exposure to COVID-19 has increased the vulnerability of undocumented Latino migrant laborers in the workplace, as they faced even more extreme conditions of systemic racism and migrant exploitation in recent times. Latino migrant laborers comprise a significant amount of the workforce in sectors that remained open as essential services throughout the pandemic crisis. Despite the rapid spike in infection rates, they did not have the option of sheltering in place, and instead faced grueling working conditions during the increased spread of COVID-19 (Larochelle, 2020). The major factors which contributed to negative health outcomes included: (1) documentation status as a factor in the exclusion of federal relief programs, (2) negative impact on occupational health and regulations despite growing COVID-19 cases and (3) increased burden for undocumented Latino migrant families due to workplace conditions. The literature also suggests several recommendations to address these social inequities to improve occupational health outcomes and the well-being of Latino migrant laborers. The results of this review and recommendations for equitable practices are summarized in Table 1.
5. Latino laborers, health policies, and COVID-19
While Latino migrants were among the most highly impacted groups during the economic downturn of the pandemic crisis, those with an undocumented status were largely excluded from COVID-19 income stimuli, rental subsidies, and other federal relief programs (Gelatt, 2020). Many Latino immigrants navigate having an undocumented status where they face state-sanctioned deportation threats, increasing their risk for poor health outcomes (Cavazos-Rehg et al., 2007; Menjívar and Abrego, 2012; Hill et al., 2021). Often, migrant workers continue to report to work despite illness or health concerns out of fear of deportation or losing their employment (Fussell, 2011). This has major consequences for reporting abuse, exploitation, unsafe or unfair labor conditions (Fussell, 2011).
Although the US government has increased funding for COVID-19 testing and treatment, insurance coverage remains low or nonexistent to many Latino migrant groups, and accessible options for healthcare services significantly contributes to high risk of disease transmission, susceptibility, and increased rates of mortality in groups which are already highly vulnerable communities (Gelatt, 2020). Undocumented Latino migrants in industries such as farming and meat production usually do not have access to health insurance (Van Dorn et al., 2020), and there has been no order or plan to protect these essential workers who also may have pre-existing health risks (Larochelle, 2020). The failure to provide adequate health coverage and federal protection to minority workers is a consequence of structural racism, which puts communities of color at risk and has been identified as a root cause of health disparities (Yearby, 2020; Johnson-Agbakwu et al., 2020).
6. Latino migrant workplace conditions during COVID-19
The organizational structure of meat processing factories and other labor-intensive workplaces are highly racialized institutions, in which racism, discrimination, and inequality parallels the mistreatment of minorities in society (Ray, 2019). Migrant meatpacking workers have routinely faced occupational hazards leading to injuries, chemical exposure, and even limited restroom access (Human Rights Watch, 2019). The dehumanization of Latino migrant workers is evident within these settings, with little attention to safety issues if it intercedes with productivity (Human Rights Watch, 2019). A recent study on Latino laborers in meatpacking revealed the workers perceived companies favor production over employees’ personal well-being, in addition to feeling powerlessness to address and cope with increasingly precarious workplace issues (Ramos et al., 2021).
Limited access to resources, inadequate health promotion, and mental health burdens have been even more apparent during the pandemic crisis. For example, Latino migrants do not have access to enough PPE in the workplace to provide minimal protection against contracting COVID-19 (Guadagno, 2020). They often work in dense, close quarters with frequent and prolonged contact with coworkers, particularly in meat and poultry facilities, in which social distancing to reduce exposure risk is not possible (Dyal, 2020). In addition, these workplaces do not consistently maintain appropriate or healthy levels of sanitation and disinfection procedures (Waltenburg et al., 2020). These conditions can contribute to poor occupational health outcomes that have an impact on Latino communities and families.
7. Latino families navigating the pandemic
Research analyzing the perspectives of Latino migrant workers during COVID-19 has identified specific barriers that have become increasingly burdensome during the pandemic. These barriers include challenges obtaining a living wage, locating adequate housing, and accessing reliable transportation (Quandt et al., 2020). Many US states do not allow undocumented migrants to obtain drivers licenses, leading to shared commutes among high numbers of food processing workers. The frequent contact with others in dense areas, along with their situational circumstances of residing in crowded multigenerational settings puts them at increased risk of disease transmission (Rubenstein et al., 2020). Recent research has found that Latina migrant women in particular may work in occupations that face greater exposure to COVID-19, leading to higher physical and emotional burdens both from the hardship at work, as well as being the primary caretakers of families at home (Marban, 2020). An increase in maternal stress from economic hardship can also have negative consequences for their children and families, especially due to insufficient support of Latina mothers during the pandemic crisis (Hibel et al., 2021).
8. Recommendations for equitable practices
8.1. Increase access to federal benefits
As essential workers, especially with an undocumented status, Latino laborers urgently need access to federal and local programs to protect their well-being, such as unemployment benefits, COVID-19 relief programs, and food vouchers and economic assistance. The systemic racism and nativist sentiment at the root of excluding undocumented Latino immigrants from benefits and protections threatens to increase the longevity and spread of the COVID-19. The process of creating a healthier society and eliminating COVID-19 first includes prioritizing the most vulnerable essential workers that sustain our society. Allowing Latino laborers access to the same stimulus resources would match their designated essential status as food processing workers.
8.2. Improve workplace conditions
Strategies to promote safe practices and effective health communication to improve the safety of workers have been implemented in a variety of ways to focus on migrant workers’ needs and risks (Vigoroso et al., 2020). During these challenges of the pandemic, there should be a priority to disseminate consistent messages, policies, and regulations based on scientific guidelines to prevent COVID-19 infection. The communication to migrant workers should also be sensitive of the diversity of the workforce as well as cultural and linguistic considerations (Quandt et al., 2020). Previous research has shown there are challenges to training for occupational safety practices and risks faced by migrant workers (Ramos et al., 2021). Studies have also shown that inadequate and impractical preventive practices must be significantly altered at workplace organizations (Rubenstein et al., 2020). There is need for employers to take a stronger stance on occupational health outcomes through workplace policies to protect migrant workers (McClure et al., 2020).
8.3. Address personal safety and health needs of Latino migrants
There is a critical need to center the voices of Latino laborers in the workplace to address their experiences with occupational health during COVID-19. Many Latino immigrant workers deal with occupational hazards that are not adequately addressed that can lead to poor health outcomes and workplace injuries (Moyce and Schenker, 2018). Latino laborers spend long hours as essential workers and require the normalization of safety over productivity, as well as assurances from employers that there are significant efforts to support their occupational health (Ramos et al., 2021). It is important to promote a culture of positive health in the workplace that will implications for their families and community in the fight against inequality during the COVID-19 pandemic.
9. Conclusion
Systemic racism is an ongoing problem in US society and has a major impact on the ethical treatment and life experiences of undocumented Latino migrant workers. Overlooking the work conditions of Latinos devalues their labor and reinforces their position at the bottom of the racial hierarchy. As essential workers, Latino laborers are the backbone of the US workforce, yet have become further marginalized through their explicit exclusion from health policies, regulations, and protections. Their precarious migration status makes them susceptible to exploitation with little room for recourse due to the fear of retaliation from those in positions of power in the workplace (Fussell, 2011; Salinas, 2018).
The COVID-19 pandemic produced the perfect storm to reveal the consequences of these exploitative conditions, where Latino migrant workers are excluded from federal health protections, face unsafe workplace conditions, and have intersectional burdens navigating the pandemic within their families and communities. Having a deeper understanding of the immediate needs of Latino migrant workers is essential to decrease delays in addressing occupational health needs that may arise with future pandemic waves. Employers and policymakers must prioritize the health and safety of marginalized laborers to maintain safer workplace conditions for Latino migrant workers.
The recent pandemic crisis serves as a wake-up call on how society must challenge the social mechanisms that lead to labor exploitation, workplace racism, productivity over safety, and retaliation for those speaking out. It is necessary to continue to explore strategies towards Latino labor rights, efforts for enhancing workplace safety culture, and how workplaces can give Latinos a space to voice their concerns about occupational health. This requires the humanizization and ethical treatment of Latino workers, respecting and dignifying them with a living wage, and acknowledging that essential workers deserve essential support.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Declaration of Competing Interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
The authors declare the following financial interests/personal relationships which may be considered as potential competing interests:
References
- AFL-CIO (American Federation of Labor and Congress of Industrial Organizations) Death on the job: the toll of neglect. Retrieved from https://aflcio.org/reports/death-job-toll-neglect-2020.
- Cavazos-Rehg P.A., Zayas L.H., Spitznagel E.L. Legal status, emotional well-being and subjective health status of Latino immigrants. J. Natl. Med. Assoc. 2007;99(10):1126. [PMC free article] [PubMed] [Google Scholar]
- De Genova N. The legal production of Mexican/migrant “illegality”. Lat. Stud. 2004;2(2):160–185. [Google Scholar]
- Dyal J.W. COVID-19 among workers in meat and poultry processing facilities―19 states, April 2020. MMWR Morbid. Mortal. Wkly. Rep. 2020:69. doi: 10.15585/mmwr.mm6918e3. [DOI] [PubMed] [Google Scholar]
- Feagin J.R. Routledge; 2013. The White Racial Frame: Centuries of Racial Framing and Counter-Framing. [Google Scholar]
- Fussell E. The deportation threat dynamic and victimization of Latino migrants: wage theft and robbery. Sociol. Q. 2011;52(4):593–615. [Google Scholar]
- Gelatt J. Migration Policy Institute; Washington, DC: 2020. Immigrant Workers: Vital to the US COVID-19 Response, Disproportionately Vulnerable. [Google Scholar]
- Gleeson S. University of California Press; Oakland: 2016. Precarious Claims: The Promise and Failure of Workplace Protections in the United States. [Google Scholar]
- Golash-Boza T.M. NYU Press; 2015. Deported: Immigrant policing, Disposable Labor and Global Capitalism. (Vol. 6) [Google Scholar]
- Gonzalez G.G. Routledge; 2015. Guest Workers or Colonized Labor?: Mexican Labor Migration to the United States. [Google Scholar]
- Guadagno L. International Organization for Migration; Geneva: 2020. Migrants and the COVID-19 Pandemic: An Initial Analysis. [Google Scholar]
- Hall M., Greenman E., Farkas G. Legal status and wage disparities for Mexican immigrants. Soc. Forces. 2010;89(2):491–513. doi: 10.1353/sof.2010.0082. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Hibel L.C., Boyer C.J., Buhler-Wassmann A.C., Shaw B.J. The psychological and economic toll of the COVID-19 pandemic on Latina mothers in primarily low-income essential worker families. Traumatology. 2021 doi: 10.1037/trm0000293. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Hill J., Rodriguez D.X., McDaniel P.N. Immigration status as a health care barrier in the USA during COVID-19. J. Migr. Health. 2021;4 doi: 10.1016/j.jmh.2021.100036. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Human Rights Watch. (2019). “When we're dead and buried, our bones will keep hurting” workers’ rights under threat in US meat and poultry plants. Retrieved from https://www.hrw.org/sites/default/files/report_pdf/us0919_web.pdf.
- Johnson-Agbakwu C.E., Ali N.S., Oxford C.M., Wingo S., Manin E., Coonrod D.V. Racism, COVID-19, and health inequity in the USA: a call to action. J. Racial Ethn. Health Disparities. 2020:1–7. doi: 10.1007/s40615-020-00928-y. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Larochelle M.R. Is it safe for me to go to work?” Risk stratification for workers during the Covid-19 pandemic. N. Engl. J. Med. 2020;383(5):e28. doi: 10.1056/NEJMp2013413. [DOI] [PubMed] [Google Scholar]
- Marban, E. 2020. Gender inequality in response to the new coronavirus. https://www.isglobal.org/en/healthisglobal/-/custom-blog-portlet/la-inequidad-de-genero-en-respuesta-al-nue vo-coronavirus/5573964/0. Accessed February 15, 2020.; Quandt op cid note.
- McClure E.S., Vasudevan P., Bailey Z., Patel S., Robinson W.R. Racial capitalism within public health—how occupational settings drive COVID-19 disparities. Am. J. Epidemiol. 2020;189(11):1244–1253. doi: 10.1093/aje/kwaa126. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Menjívar C., Abrego L. Legal violence: immigration law and the lives of Central American immigrants. Am. J. Sociol. 2012;117(5) [Google Scholar]
- Mithani Z., Cooper J., Boyd J.W. Race, power, and COVID-19: a call for advocacy within bioethics. Am. J. Bioeth. 2020:1–12. doi: 10.1080/15265161.2020.1851810. [DOI] [PubMed] [Google Scholar]
- Molina N. Univ of California Press; 2006. Fit to Be Citizens?: Public Health and Race in Los Angeles; pp. 1879–1939. (Vol. 20) [Google Scholar]
- Mora, D. and Green E.. 2021. Deported to death vice world news. Retrieved from https://www.vice.com/en/article/epd9qk/edgar-lopez-murder-trump-zero-tolerance- immigration-policy.
- Moyce S.C., Schenker M. Migrant workers and their occupational health and safety. Annu. Rev. Public Health. 2018;39:351–365. doi: 10.1146/annurev-publhealth-040617-013714. [DOI] [PubMed] [Google Scholar]
- National Public Radio [NPR]. (2020). Tyson foods fires 7 plant managers over betting ring on workers getting COVID-19. Retrieved from https://www.npr.org/sections/coronavirus-live-updates/2020/12/16/947275866/tyson-foods-fires-7-plant-managers-over-betting-ring-on-workers-getting-covid-19.
- Ngai M.M. Princeton University Press; 2014. Impossible Subjects: Illegal Aliens and the Making of Modern America. [Google Scholar]
- Paré G., Trudel M.C., Jaana M., Kitsiou S. Synthesizing information systems knowledge: a typology of literature reviews. Inf. Manag. 2015;52(2):183–199. [Google Scholar]
- Quandt S.A., LaMonto N.J., Mora D.C., Talton J.W., Laurienti P.J., Arcury T.A. COVID-19 pandemic among Latinx farmworker and nonfarmworker families in North Carolina: knowledge, risk perceptions, and preventive behaviors. Int. J. Environ. Res. Public Health. 2020;17(16):5786. doi: 10.3390/ijerph17165786. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Ramos A.K., Carvajal-Suarez M., Trinidad N., Quintero S., Molina D., Rowland S.A. No somos máquinas”(We are not machines): worker perspectives of safety culture in meatpacking plants in the Midwest. Am. J. Ind. Med. 2021;64(2):84–96. doi: 10.1002/ajim.23206. [DOI] [PubMed] [Google Scholar]
- Ray V. A theory of racialized organizations. Am. Sociol. Rev. 2019;84(1):26–53. [Google Scholar]
- Romero M. Crossing the immigration and race border: a critical race theory approach to immigration studies. Contemp. Justice Rev. 2008;11(1):23–37. [Google Scholar]
- Rubenstein, B.L., Campbell, S., Meyers, A.R., Crum, D., (2020) Factors that might affect SARS-CoV-2 transmission among foreign-born and U.S.-born poultry facility workers morbidity and mortality weekly report CDC. [DOI] [PMC free article] [PubMed]
- Salinas J. In: Latino Peoples in the New America: Racialization and Resistance. Cobas J.A., Feagin J.R., Delgado D.J., Chávez M., editors. Routledge; 2018. Pro-Latino’ racial framing: how white employers justify the exploitation of Latino laborers. [Google Scholar]
- Van Dorn A., Cooney R.E., Sabin M.L. COVID-19 exacerbating inequalities in the US. Lancet. 2020;395(10232):1243. doi: 10.1016/S0140-6736(20)30893-X. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Vigoroso L., Caffaro F., Micheletti Cremasco M., Bagagiolo G., Cavallo E. Comprehension of safety pictograms affixed to agricultural machinery among Pakistani migrant farmworkers in Italy. J. Agromed. 2020;25(3):265–278. doi: 10.1080/1059924X.2019.1673269. [DOI] [PubMed] [Google Scholar]
- Waltenburg M.A., Victoroff T., Rose C.E., Butterfield M., Jervis R.H., Fedak K.M., Honein M.A. Update: COVID-19 among workers in meat and poultry processing facilities―United States, April–May 2020. Morb. Mortal. Wkly. Rep. 2020;69(27):887. doi: 10.15585/mmwr.mm6927e2. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Yearby R. Structural racism and health disparities: reconfiguring the social determinants of health framework to include the root cause. J. Law Med. Ethics. 2020;48(3):518–526. doi: 10.1177/1073110520958876. [DOI] [PubMed] [Google Scholar]