Duke Medical Ethics Journal
Determining Health for the Marginalized
By: Eugene Cho
There is a plethora of disparities in healthcare. From individuals who are from minority backgrounds, to those with disabilities, healthcare is not accessible and affordable to all. An underlying factor to all of these healthcare inequalities and disparities is unmet social needs. Although the quality and affordability are important components of healthcare, social determinants of health (SDOH) and the access to SDOH are extremely important and can influence individuals’ health. SDOH are conditions in which we live, learn, work, and play daily and those conditions directly affect our health . SDOH is impacted by various social, political, and economic factors and oftentimes are even more impactful to one’s health than direct medical care [2, 3]. It is estimated that medical care is only responsible for 10-15% of preventable mortality in the United States, which emphasizes the importance of social needs . SDOH ensures that there is quality food and reliable housing for individuals, and many of these factors contribute to the vulnerability of individuals to certain chronic and short-term illnesses in the future. Individuals from minority backgrounds are most affected by unmet social needs, and although there have been many efforts from organizations to address SDOH, adverse events like the COVID-19 pandemic have exacerbated those unmet needs. It is essential for policymakers, stakeholders, and community members to address unmet social needs through various programs and data collection methods to keep our communities healthy and safe.
“Institutionally, there have been many barriers placed on individuals from minority backgrounds, preventing them from having equitable access to a variety of resources, which further contributes to their poor health outcomes.”
There are a number of social determinants of health, including but not limited to food insecurity, income inequality, housing insecurity, and transportation access . Food insecurity refers to individuals and families having access to quality and affordable food to avoid hunger . Housing is another SDOH because healthy communities originate from all individuals having access to safe, affordable, and reliable housing . Housing is connected even to education, as housing segregation is known to be connected to disparate education outcomes and educational resources . America’s history of racial segregation in housing contributes to this disparate housing opportunities among race. Transportation can also affect individuals’ access to educational opportunities, work, and healthcare . The lack of transportation can especially affect individuals residing in rural areas. Food insecurity, housing, and transportation are important, but by no means the only examples of SDOH that greatly impact community members.
Different communities of individuals and even individuals within communities experience different SDOH. Marginalized individuals and communities are more likely to experience unmet social needs in their livelihoods in the form of unsafe or unreliable housing, food insecurity, and lack of affordable access to medicine and medical care. Neighborhood conditions can influence one’s health, as it can determine the quality of education one receives, the facilities that one resides close to, as well as transportation . However, it is often found that individuals will reside with those who are from similar backgrounds as them, whether it be based on socioeconomic class or race. Therefore, individuals who are more marginalized will experience poorer living conditions and be surrounded by factors that will further influence their physical health.
Beyond the physical effects that unmet social needs can have on individuals, there are also mental health and financial effects. Social and political stressors, especially to marginalized communities, will increase their susceptibility to mental health challenges. The lack of resources that one has in their community will further impact their ability to access mental health resources, worsening their mental healths and therefore, their physical states. Financially, it was estimated that from 2003 to 2006, the elimination of health disparities could have reduced $230 billion worth of medical expenditures . In addition to these expenses, indirect costs to society could have been reduced by more than $1 trillion, through the sustained productivity of individuals as well as lack of premature death . This data is evidence that not only does the reduction of health disparities result in healthier individuals, but it can contribute to society as a whole as well, by reducing costs and increasing productivity. With the varying
effects of unmet social needs on communities, it is important to collect data on these measures and SDOH to find ways for policy and organizations to make changes.
Healthy People is an initiative that measures national health promotion and disease progress since the 1970s. In recent decades, they have begun measuring SDOH . For example, the purpose of Healthy People 2020 was to identify major SDOH that are plaguing the communities in the US in order to find the most effective ways various programs and organizations can help address health inequalities . Ultimately, these initiatives hope to eliminate health disparities that exist on the basis of factors like race and socio-economic status. When looking at trends like infant mortality, historically, the mortality rates for African American infants are twice that of white infants . Other health outcomes like obesity have also been known to trend according to race, in which African Americans are more likely to be affected by obesity than whites. Furthermore, health outcomes like mental health also are experienced differently by race. African Americans are more likely to report feeling discriminated against or experiencing poor mental health outcomes due to increased anxiety and depression, leading to increased susceptibility to substance use and psychological distress . Healthy People 2020’s initiatives have found consistent trends in the different health outcomes based on race, further suggesting that the investment in and attention to SDOH is a way to lessen the gap in health disparities and to address health inequities amongst marginalized communities. Institutionally, there have been many barriers placed on individuals from minority backgrounds, preventing them from having equitable access to a variety of resources, which further contributes to their poor health outcomes.
There have been many efforts to alleviate the social burden on various underrepresented communities; however, in recent years, the COVID-19 pandemic has exacerbated pre-existing health disparities and influenced the ways SDOH are being addressed. Data from COVID-19 mortality and infection rates show that African Americans were more affected in comparison to their white counterparts. In December of 2020, approximately 97.9 out of every 100,000 African Americans had fallen victim to COVID-19 which is more than double than that of whites . Similar trends can also be observed within other minority groups as well. In California, Latino individuals made up 48% of confirmed COVID-19 cases up to December 2020, however the Latino individuals make up only 39% of the state’s population . These similar trends are prevalent within minority communities which emphasize that marginalized communities are disproportionately affected by COVID-19, when compared to the larger population as a whole.
Solutions to addressing health disparities are much more complex than the execution of one policy or program. The collaboration between various sectors that look to address SDOH is essential to reduce health disparities. Fortunately, there are many initiatives working to address SDOH. Many of these initiatives focus on amending policy and finding ways in non health-sectors to promote healthier and more equitable living. Organizations like Medicaid works to improve medicaid delivery systems and reform for payment . Medicaid also works to link health care to social needs which will lead to better health outcomes overall . Health in All Policies is an approach to identify decisions that are made in various sectors that affect health. This approach allows policy makers to look at the effects that various policies and decisions can have on health, though it may not be directly related. Additionally, there are initiatives that are based on geography, which work to address health care initiatives . The Harlem Childrens’ Zone is an example of an initiative in Central Harlem which focuses on children who have increased chronic disease and increased levels of infant mortality. This organization seeks to improve educational and economic status in order to address those health disparities and inequities . Additionally, the Center for Disease Control and Prevention works with communities to support them financially technically . The Social Determinants of Health Accelerator Plans is an effort to increase the speeds at which state and local jurisdictions work and create action plans to help improve chronic disease outcomes within communities of individuals facing health inequity .
Source: Harlem Children's Zone
There are many challenges in addressing SDOH. The first challenge relates to how there are so many SDOH, that physicians may be discouraged from screening patients for all of the SDOH that have become focused on in literature. SDOH that dominate literature include income, housing, food, transportation, and education . In more recent literature, SDOH like sexual orientation, gender, racism, and social safety net have gained prominence. This long and exhaustive list of SDOH may discourage physicians from taking the time to screen their patients and refer them to all of the services that may be available . Likewise, the ambiguity of the term “social determinants of health” makes it difficult for physicians and stakeholders alike to categorize these SDOH and prioritize certain unmet social needs over others. Another challenge is the need for consistency and follow up. Even if patients are given resources to connect to in response to their social needs, it is essential for other individuals, whether it be from various organizations or volunteer groups, to follow up with these patients to allow for reflection and reevaluation on how those resources are working. These follow up mechanisms are often lacking which may lead to the increase in health disparities, despite efforts to reduce them.
It is unlikely that all social determinants of health for all community members will be met. However, there must be greater efforts made by various organizations and communities to address these social needs. It is important that community members acknowledge that these social determinants of health exist and that they need to take part to take initiative within their communities. Efforts made by students at Duke University in Durham, North Carolina are great examples of how students have worked together to address unmet social needs in their Durham community. The students developed a program called Help Desk to help the healthcare system address various social determinants of health . This project came out of a study conducted by Gottlieb et al. (2016) which determined the effects of social needs screening and resource navigation on child health as it is largely impacted by various environmental and social pressures . By collaborating with other stakeholders in the community as well as centers that provide healthcare, Help Desk has allowed student volunteers to screen patients with unmet social needs and to connect them to resources that will help address those needs . Additionally, by creating a consistent plan on how to address SDOH that can be agreed upon by various communities, it may allow communities to tackle this challenge together.
Social determinants of health are the foundation to many health inequities and disparities. Individuals who are unable to access safe and affordable housing, experience food insecurity, and do not have reliable transportation or medicine, are more prone to chronic diseases and other adverse health outcomes. Unfortunately, individuals who are Black or originate from marginalized communities are most affected by the lack of social needs met. These individuals often are uninsured, do not have reliable housing, experience food insecurity, and all of these factors impact their health. This problem is twofold because these individuals experience the greatest health disparities and the largest financial burden when it comes to health financing. It is important for stakeholders, community organizations, and individuals to become aware of these SDOH that plague the lives of those living in marginalized communities. There must be efforts made to monitor the effects of unmet social needs on individuals as well as for there to be increased resources and opportunities for these individuals to be referred to. Efforts like the Harlem Childrens’ Zone, as well as the efforts made by the Duke University Help Desk, are examples of small steps that can be made to promote healthy communities with access to various efforts. The health opportunities and outcomes should not be determined for marginalized individuals, rather there must be efforts made to decrease health disparities and to increase resources to help address unmet needs.
Review Editor: Eric lee
Design Editor: Eugene Cho
 Social Determinants of Health | CDC. (n.d.). Retrieved November 26, 2022, from https://www.cdc.gov/chronicdisease/programs-impact/sdoh.htm
 Islam, M. M. (2019). Social Determinants of Health and Related Inequalities: Confusion and Implications. Frontiers in Public Health | Www.Frontiersin.Org, 7, 11. https://doi.org/10.3389/fpubh.2019.00011
 Braveman, P., & Gottlieb, L. (2014). The Social Determinants of Health: It’s Time to Consider the Causes of the Causes. Public Health Reports, 129, 19.
 Achieving Health Equity in the United States. (n.d.). Retrieved November 27, 2022, from https://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2019/01/29/achieving-health-equity
 Artiga, S., & Hinton, E. (2018). Beyond Health Care: The Role of Social Determinants in Promoting Health and Health Equity | KFF. https://www.kff.org/racial-equity-and-health-policy/issue-brief/beyond-health-care-the-role-of-social-determinants-in-promoting-health-and-health-equity/
Beyond Health Care: The Role of Social Determinants in Promoting Health and Health Equity | KFF. (n.d.). Retrieved November 26, 2022, from https://www.kff.org/racial-equity-and-health-policy/issue-brief/beyond-health-care-the-role-of-social-determinants-in-promoting-health-and-health-equity/
 Help Desk Model – Help Desk: Duke Student Community Resource Navigators. (n.d.). Retrieved November 26, 2022, from https://sites.duke.edu/sdohhelpdesk/help-desk-model/
 Transportation Models - RHIhub SDOH Toolkit. (n.d.). Retrieved November 26, 2022, from https://www.ruralhealthinfo.org/toolkits/sdoh/2/built-environment/transportation
 Gottlieb, L. M., Hessler, D., Long, D., Laves, E., Burns, A. R., Amaya, A., Sweeney, P., Schudel, C., & Adler, N. E. (2016). Effects of Social Needs Screening and In-Person Service Navigation on Child Health: A Randomized Clinical Trial. JAMA Pediatrics, 170(11), e162521–e162521. https://doi.org/10.1001/JAMAPEDIATRICS.2016.2521
 Braveman, P., Egerter, S., & Williams, D. R. (2011). The Social Determinants of Health: Coming of Age. Annu. Rev. Public Health, 32, 381–398. https://doi.org/10.1146/annurev-publhealth-031210-101218
 Reyes, M. V. (2020). The Disproportional Impact of COVID-19 on African Americans. Health and Human Rights, 22(2), 299. /pmc/articles/PMC7762908/
 Riley, A. R., Chen, Y.-H., Matthay, E. C., Glymour, M. M., Torres, J. M., Fernandez, A., & Bibbins-Domingo, K. (2021). Excess mortality among Latino people in California during the COVID-19 pandemic. SSM - Population Health, 15, 100860. https://doi.org/10.1016/j.ssmph.2021.100860