Racism and the Social Determinants of Equity: Camara Jones at Beyond Flexner 2015

At the recent “Beyond Flexner 2015” conference in Albuquerque, one of the featured speakers was Camara Phyllis Jones, MD, MPH, PhD. Dr. Jones, a family physician and epidemiologist, is Senior Fellow at the Satcher Health Leadership Institute at Morehouse School of Medicine in Atlanta, and formerly with the Centers for Disease Control and Prevention (CDC), and is currently President-Elect of the American Public Health Association, APHA. (Her election site contains a good biography, and this segment from “Unnatural Causes” a superb interview.) I was truly honored to meet her the day before (we were in the last row of a van headed to visit a clinic in Albuquerque’s International District; she told me her name and I responded with “the Camara Jones?!”) because I have long admired her work, and have used her “Cliff Analogy” for the Social Determinants of Health (SDOH) regularly in lectures to medical students, as well as in this blog (e.g., “Delmar Boulevard, Geo-mapping, and the Social Determinants of Health”, August 16, 2014; ACA after the election: Is it is the "fiscal cliff" or the social cliff that matters to people?”, November 17, 2012).

In brief, the Cliff Analogy portrays the healthcare system as a cliff face, which may or may not have a fence to keep people from falling off (primary prevention), a safety net part-way down to catch those who fall before they hit the ground (secondary prevention), and an ambulance to take them to the hospital at the bottom (tertiary “prevention”). The presence or absence of these, and how fast the ambulance comes, impacts access to health care. But along the top of the cliff, the nearness to the edge represents the social determinants of health, how vulnerable people are to falling off, how their life circumstances (poverty, housing, food, education, dangerousness of where they live) make it much easier for a gust of wind, or tripping (or a disease) to not just knock them down but throw them over the cliff.

It is a powerful and effective method of illustrating the SDOH, but Dr. Jones has other allegories that are also effective, in particular in describing the various forms of racism that exist within our society, and the impact of them on the lives and health of people. Several of these are presented in her wonderful TED talk, given at Emory University in 2014. She describes 3 levels of racism: institutionalized racism that, whether through laws or common practice, keeps its victims down in the underclass with less opportunity and hope; personalized racism, the actions and attitudes of people that perpetuate racial victimization; and internalized racism, by which members of the oppressed group come to believe in their own inferiority, that “the white man’s ice is colder”. All of these are important; efforts to demonstrate that “black is beautiful” and “I am somebody” can work to combat the psychological stigma from internalized racism, but without structural change can go only so far.

Dr. Marc Nivet, Chief Diversity Officer of the Association of Medical Colleges (AAMC), gave an earlier speech, in which he also provided a powerful metaphor, of opportunity in America being an escalator or a staircase. In it he describes the children of the privileged as having an escalator to take them to the top; even if they “bump their heads” or otherwise falter and fall back, it will continue to bring them quickly back up. Others, the children of the poor, have to climb the stairs, and when they fall it is a long and difficult way back up; they have to run very fast and are unlikely to ever catch up. This is a great way of illustrating not only the social determinants of health but of opportunity; it provides a dynamic metaphor to accompany the famous quote from former University of Oklahoma football coach Barry Switzer that “some people are born on third base and think they hit a triple”. Dr. Nivet includes his own children in those who are on the escalator; since he is African-American, this might be seen as support for the argument that the difference in opportunity is due to class (or as Americans like to call it to make it sound more random and less generational, “socioeconomic status”) rather than race.

But Dr. Jones asks us why people of some races are disproportionately represented in the lower class; she coins the phrase “the Social Determinants of Equity”. She helps illustrate this with “the Gardener’s Tale”, beginning with a (possibly true) story of when she and her husband bought their first house, with a lovely wrap-around porch with many flower boxes. In Spring, they discovered only some had soil, so they went and bought potting soil to fill the others, and planted marigolds in all of them. But some weeks later some plants were doing great, and others were struggling; it was clear that those in the old rocky soil were not on a par with those in the new soil. To be sure, some seeds in each box were stronger and doing better than others, but the strongest flowers in the poor soil could barely keep up with the weakest in the good soil.

And what if the gardener decides to plant red and pink flowers, but likes red better, and plants them in the good soil? And when they do better, s/he says “See? I knew red were better!”. And, if the flowers were perennials and went to seed and regrew each year, they would perpetuate, if not worsen, the difference, the inequity. And if the gardener said “these pink flowers are going to do poorly anyway”, and deadheaded the weakest, allowing them no chance at all? And in future generations if her children and grandchildren always grew up knowing that red flowers did better than pink? But why, someone asks Dr. Jones (not in this conference!) should the red flowers give up or share their soil?

Because, she answers (obviously, at least to many of us), the soil does not belong to the red flowers, although they have benefited from it, but to the gardener. It could easily be redistributed by her, and the flowers would have an equal chance to grow. Maybe generations of selection would take a few years to compensate for, or maybe because only the stronger pink seeds survived, they would do even better than the red given the chance to have the same opportunity to grow. We cannot be sure until that opportunity is comprehensively and completely available.

Dr. Jones’ allegories are very helpful in increasing our understanding.

• We cannot truly improve health without addressing the Social Determinants of Health.
• We cannot address the impact of racism without recognizing its many faces and forms, and its self-reinforcing nature.
• We cannot adequately remediate the effect of class upon health without changing how some people and groups are disproportionately represented in the underclass, the Social Determinants of Equity.

Dr. Jones’ allegories can help us understand, but real change will take concerted and sustained action.

Delmar Boulevard, Geo-mapping, and the Social Determinants of Health

The social determinants of health are those factors that affect people’s health status that are the result of the social situation in which they find themselves. Thus, in the well-known graphic from Healthy People 2010 (dropped, for some reason, from Healthy People 2020), which I have reproduced several times, they complement the other determinants such as the biological (genetics), but are represented in most of the other areas. Physical environment and socioeconomic environment, certainly, but even “behaviors” are affected by the circumstances into which one is born and lives. So is biology, actually, as we learn more about genetic coding predisposing some people to addictive behaviors. Certainly it is not all volitional or evidence of weak character.

The social determinants of health can be partially enumerated, and include adequate housing (including sufficient heat in the winter), adequate food, education, and also a reasonable amount of nurturing

and support from your family. In short, they are “the rest of life”, outside and often ignored by the healthcare system. Camara Phyllis Jones, in her wonderful “cliff analogy” (which I have also reproduced before) creates a metaphor in which medical care services are provided for those who need them (or “fall into them”) along a cliff face, while the social determinants of health are represented by how far a person, or a group of people, lives from that cliff face. As such, it illustrates the degree of protection that we all have from falling off that cliff, more for some and less for others.[1]

One of the clearest ways to show the impact of these determinants is by a technique called “geo-mapping” in which certain characteristics (income, educational level, gang violence, drug use, number of grocery stores or liquor stores, public transportation routes, whatever you can think of) are laid over maps of a city, town, or region. We have seen these portrayed on TV or in the newspapers as national and state maps for political events (such as what areas voted for who), but they can also be very useful for understanding the different challenges faces by people living in different areas. The work of Steven Woolf and his colleagues at Virginia Commonwealth University has greatly contributed to this work; in addition to their incredibly useful County Health Calculator, has produced graphs that can be found on the Robert Wood Johnson Commission for a Healthier America site that show how life expectancy can vary dramatically in different neighborhoods, as in the map displayed of the Washington, DC area, mapped along Metro lines for greater effect, or the one of my area, Kansas City, Missouri (which doesn’t have a Metro!)

A recent contribution to this field has been made by Melody S. Goodman and Keon L. Gilbert, of Washington University in St. Louis, who mapped the dramatic differences across Delmar Boulevard in that city, in “Divided cities lead to differences in health”. Their graphic shows the disparities in education, income, and housing value, and, unsurprising, racial composition, on either side of Delmar. This work was covered in a BBC documentary. Dr. Goodman, speaking to a symposium from her alma mater, the Harvard School of Public Health, is quoted as saying “Your zip code is a better predictor of your health than your genetic code.”

This is a pretty sad commentary, given not only the incredible amount of money that has been spent on unraveling the genetic code but the amount of faith and expectation that we have been convinced to have in how this new genetic knowledge will facilitate our health. By knowing what we are at risk for, genetically, the argument goes, science can work on “cures” that target the specific genes. This is a topic for a different discussion, but in brief one problem is that the most common diseases we suffer from are not the result of a single gene abnormality. It is probable that, at least in the short-to-medium term, knowledge of our genetics will be more likely to lead to higher life insurance rates than cures of our diseases. The more profound issue, however, is that there is evidence from the social determinants of health, from the work of Woolf and Goodman and many others, that we do not address the causes of ill health even when we know what they are.

Why is this so? Why is there such great resistance to understanding, believing, that investment in housing, education, jobs, and opportunities will have a much greater impact on people’s health than more and more money spent on high-tech medical care (and, of course, profit for not only the providers, but the drug and device companies and middleman insurance companies)? It is in part because we hope (and, when we are more privileged, expect) that we will be the beneficiaries. And it is also because we choose to believe that those who do not have the benefits we have (of money, education, family) somehow “deserve” it because of character flaws.

The issue of “fault” is articulately addressed by Nicholas Kristof in a New York Times Op-Ed on August 10, 2014, “Is a hard life inherited?” Kristof argues that it is, not genetically but because the circumstances to which one is born and in which one grows up, the presence of caring parents who read to you rather than beat you, who take care of you instead of abusing drugs, as well as adequate food and housing make a tremendous difference in how you turn out.

Indeed, another major study by Johns Hopkins sociologist Karl Alexander, to be published in his “life’s work”, “The Long Shadow: Family Background, Disadvantaged Urban Youth, and Transition to Adulthood”, and covered on NPR, confirms this. Alexander and his colleagues tracked nearly 800 children for more than 20 years, and found that those from less privileged backgrounds with lower incomes and less supportive families did worse. Only 33 of the children moved from the low income to the high income bracket. Problems with drugs and alcohol were more prevalent among white males than other groups, but they did better financially anyway. Some people, rarely, overcome the deck being stacked against them, but most of those who do well after being born with relative privilege would likely not be among them had they been in the same situation.  Kristof writes:

ONE delusion common among America’s successful people is that they triumphed just because of hard work and intelligence. In fact, their big break came when they were conceived in middle-class American families who loved them, read them stories, and nurtured them with Little League sports, library cards and music lessons. They were programmed for success by the time they were zygotes. Yet many are oblivious of their own advantages, and of other people’s disadvantages. The result is a meanspiritedness in the political world or, at best, a lack of empathy toward those struggling…

That lack of empathy leads to a lack of action; we are willing to accept people living in conditions that we would never accept for our family and neighbors, not only across the globe but across town, or even across a street. From the point of view of health, our priorities and investments are misplaced when we do not address the social determinants of health as well as cures for disease. When we do not try to change the known factors of zip code that impact our health as we investigate those of the genetic code.

If there are to be “cures” that come from our understanding of genetics, there is every reason to expect that they will be one more thing that is available to the people on the south side of Delmar Boulevard in St. Louis long before they are to those on the north side of the street.

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[1] Jones CP, Jones CY, Perry GS, “Addressing the social determinants of children’s health: a cliff analogy”, Journal of Health Care for the Poor and Underserved, 2009Nov;20(4):supplement pp 1-12. DOI: 10.1353/hpu.0.0228