Beyond the COVID-19 pandemic: The importance of social determinants of health in educating healthcare leaders

As scholars of color and educators in the health professions, we are compelled to advocate for the inclusion of the study of health disparities and social determinants of health (SDOH) throughout higher education to understand, analyze, and effectively respond to healthcare access disparities, including COVID-19 disparities, in Black and Latinx communities across the United States.¹ In addition to our identities and lived experiences, healthcare access disparities and their root causes are woven throughout the courses that we teach in the departments of social medicine, social work, and social and behavioral sciences. We are also fortunate to educate in schools that have been programmatically intentional about emphasizing the multilevel, ecological factors that contribute to healthcare disparities. Educating future physicians, public health practitioners, and allied health professionals offers us the opportunity to examine new and persistent medical access struggles magnified by the COVID-19 pandemic. We write this commentary to advocate for the integration of SDOH curricula in medicine, public health, and social work to prepare a workforce that can address the existing healthcare disparities in order to strengthen healthcare systems to address unforeseen epidemics.

It is up to us as educators to integrate empirical evidence linking SDOH to healthcare access disparities. For instance, we know that Black and Latinx individuals are not biologically more or less susceptible to COVID-19 infection than other racial/ethnic groups in the United States, and the distribution of their COVID-19 safety practices does not appear to differ by racial/ethnic group.¹ So, how do we explain the disproportionate mortality rates among Blacks and Latinx communities? We argue that educators should use the pandemic as a real-time case study in medicine, public health, and allied health (e.g. nursing, pharmacists) professions that need to understand how SDOH explains many of the whys and hows of Black and Latinx mortality disparities. For example, we know that having pre-existing cardiometabolic and pulmonary conditions, such as diabetes, asthma, hypertension, and heart disease, are proximal mortality causes for patients in the severe stage of COVID-19 syndrome.² These conditions are disproportionately prevalent in Black and Latinx communities.³ At the same time, a host of medical procedures and treatments deemed non-critical, including healthcare maintenance appointments (e.g. physicals, routine follow-ups), were canceled.⁴ Subsequently, hospitalizations for chronic conditions unrelated to COVID-19 decreased while mortality from dementia, cardiovascular disease, and diabetes increased. In addition, rates of preventive screenings for cholesterol screening and glycated hemoglobin testing fell, as did new prescriptions for statins and metformin.⁵ Despite the re-opening of healthcare services, COVID-19-related precautions (e.g. limited capacity for face-to-face appointments, additional time to sanitize equipment, extended wait times) continue to pose threats to effective adherence and self-management. These systems-level disparities, well documented within healthcare facilities predominantly located within marginalized communities, coupled with disparities in digital and linguistic access to telemedicine services, continue to exacerbate disparities in effective medication adherence and chronic disease self-management within Black and Latinx communities. There is a need to improve the implementation of community-based interventions (e.g. community health workers) to promote self-monitoring, as well as the opportunity to couple these interventions with user-centered no-cost medication adherence apps, and the use of non-clinical patient navigators, which can help build patient trust and increase healthcare engagement.^6,7 SDOH helps health professional students better understand how to design and deliver strategies to reduce excess mortality from chronic diseases on the basis of a comprehensive understanding of the existing chronic disease and SDOH burden in Black and Latinx communities.

During the initial COVID-19 outbreak in places like New York City, those with the financial means were able to leave for their second homes, once again documenting the importance of housing as an SDOH. Working-class and low-income New Yorkers more often than not reside in crowded buildings and neighborhoods, thus increasing their odds of community spread in basic sustaining activities such as buying groceries or going to the drug store. Furthermore, US studies have documented geographic disparities in equitable access to effective COVID-19 therapies (e.g. Lagevrio and Paxlovid), with dispensing rates in high-vulnerability zip codes at approximately one half the rates in medium- and low-vulnerability zip codes.⁸ Additional studies have documented that pharmacy deserts were persistently more common in Black and Latinx neighborhoods, and that pharmacies within these neighborhoods were less likely to offer immunization, 24 h, and drive-through services than pharmacies in other neighborhoods.⁹ These are just some of the multilevel, ecological factors that we teach our students to take into account instead of the popular messaging of behavioral shortcomings of Blacks and Latinx, thereby blaming those most victimized by this pandemic. We instruct students on needed efforts, with an emphasis on reaching high-vulnerability areas, which include increasing access to authorized prescribers, continuing education and outreach to patients, and reinforcing messaging on the importance of seeking medication early after the onset of COVID-19 symptoms, taking into account structural–cultural–historical barriers to care for low-income, racial minority neighborhoods in the New York metropolitan area.

Historically, Black and Latinx communities have faced multiple hurdles to achieving equitable health. The passing of the Affordable Care Act (ACA) in 2010 presented an opportunity to address SDOH on a national scale, but the Act has been challenged through partisan maneuvers, resulting in some of its regulatory statutes being repealed.¹⁰ As Black and Latinx communities grapple with the effects of SDOH, healthcare policies, including their implementation and enforcement, interfere with timely access to care and perpetuate health disparities in historically medically underserved communities.¹⁰ Before COVID-19, the US healthcare system had the highest gross domestic product (GDP) healthcare expenditures of any industrialized nation, yet the life expectancy indicators have been significantly below other countries that invest fractions of their GDP in healthcare expenditure in comparison with the United States.¹⁰

For those of us who study the health of marginalized communities and the ecological factors that impact health, it is disheartening that many medical and allied health programs have been sluggish to integrate the SDOH into curricula. SDOH content must be incorporated into curricula to critically examine the history and the continuation of unjust systems and policies that contribute to COVID-19 disparities and other chronic disparities. When the path to good quality health is unequal and unjust, priorities must include eliminating historical barriers to equitable health and creating strategies to increase the odds of health and longevity. Therefore, we must prepare students to challenge the status quo that turns a blind eye to how marginalized communities fare in the healthcare system. To do so, we must have academic leadership that will insist that SDOH and health disparities be central to student learning:

Our students are the future leaders of our health systems, and it is paramount that we teach the next generation of healthcare leaders to think holistically in addressing the multi-level, ecological factors that contribute to healthcare disparities. With curricula that emphasize health disparities and the SDOH, we stand a better chance of training health professionals with greater intentionality to systems reform.