Social Determinants, Including Racism, Are Major Drivers of Health Inequity, Watson Says

Social determinants of health (SDOH) are major drivers of the inequities seen in health outcomes, and racism is clearly a social determinant tied to life expectancy, said Karol Watson, MD, PhD, in talk Sunday at the 2022 Congress of the American Society for Preventive Cardiology, held in Louisville, Kentucky.

Watson, a professor of Medicine/Cardiology at the David Geffen School of Medicine at UCLA, began with data that has helped drive the conversation about SDOH across medical specialties: the outsized effect on mortality that the COVID-19 pandemic had on people of color.

“Just as the rich seem to get richer, and the poor seem to get poorer, that was the same with life expectancy lost during the pandemic.”

In 2018, she said, overall life expectancy in males was 78.8 years, although there were disparities by race. By 2020, at the peak of the pandemic, the overall life expectancy for males had dropped to 75.1 years—but for Black males, it fell to 68.3.

“That is 3 years after you hit Medicare age—that is probably around the time you’re having your first grandchild,” Watson said. “That is shocking and unacceptable.”

These racial differences in outcomes occur, she said, even though genetically, the difference between the races is barely detectable—there’s only about 0.1% difference in DNA.

“Race is social construct, not based on biology or genetics,” Watson said. Rather, “Race refers to a group of people who typically share some physical characteristics.” Ethnicity refers to a group of people who share a culture; Watson said race refers to how people look, while ethnicity refers to how people live.

And yet, because of racism, many characteristics related to life expectancy segregate along racial lines. “So, it’s not an entirely useless social construct,” Watson said.

She highlighted the influence of the Swedish botanist Carl Linnaeus, called the “father of modern taxonomy” for his work categorizing plants, animals, and later, humans. Except, his descriptions of the various races was quite racist. White people, Watson explained, were “gentle and inventive,” while Black people were “impassive and lazy.”

“This is where we get our races,” she said. “It started out with racism.”

With Wendy Post, MD, MS, of Johns Hopkins as first author, Watson just published results in Circulation that show Black participants in the MESA study had a 34% higher hazard from all-cause and cardiovascular disease mortality. “Clearly, we see differences in life expectancy.”

In that study, she and Post controlled for SDOH factors, which eliminated some of the differences, but not all.

Watson has seen the effects up close. She described patient who had just been discharged after an uncomplicated STEMI. He was given dietary advice; doctors made sure he was given generic prescriptions, and he was signed up for cardio rehabilitation. But at the patient’s next appointment, he reported having a tough time affording the medications, which were $5 to $8 a month. And because he had 2 jobs, including 1 on the weekends, he was missing the rehab visits.

She described the frustration of seeing patients come to clinic with McDonald’s bags. “None of us like to see this.” But a patient told her that’s the breakfast he could afford, and the Wi-Fi is free.

“We have to understand that the social determinants account more than so many other things for many of our patients,” Watson said.

There are many modifiable factors that influence health, but income trumps so many others. She pointed to the famous Whitehall study of British civil servants, which compared mortality among social classes. The hypothesis that high-ranking executives would have worse mortality turned out to be completely wrong; the lowest-ranking workers fared worst.

“The impact of social advantage on health is substantial,” she said. There is a 14-year difference in cardiovascular mortality in different regions of the country based on socioeconomic differences.

And as hard as it is to measure, “We can’t forget racism.”

Overly racist acts are easy to recognize, she said. But unconscious bias is not—and structural racism is “almost invisible.”

Social determinants of health, she said, start at birth and exist as people grow, work and age, and must be accounted for. “Health differences are health differences,” Watson said. “Health inequities are those that are unjust and unfair.”