Your Degree, Job, and Chronic Stress: Addressing the Social Determinants of Health

Today is the first post from our 2017-18 Autry Fellow, Rishi Jaswaney. We’re happy to have him at MDC and writing for the State of the South blog!

We’ve all felt it before. That sinking feeling before a big exam, an interview, or when your favorite character on Game of Thrones is “removed from casting” in the throes of battle.

Stress. Side-effects may include: nausea, indigestion, headaches and excessive perspiration.

In limited amounts, stress can motivate us to pursue our personal and professional goals. As stressors pass in and out of our lives, the stress hormone, cortisol, naturally fluctuates, but as challenges persist, cortisol levels remain elevated. When stress is a chronic condition, it can be linked to anxiety, depression, and other developmental and psychological issues. Research documenting income-based patterns in health outcomes—including disparities in who is more likely to experience chronic stress—raises new questions regarding the state of health equity in our nation.

As seen in the Centers for Disease Control and Prevention (CDC) chart below, serious psychological distress is associated with severe health problems, including chronic obstructive pulmonary disease (COPD), heart disease, and diabetes. Even more concerning is the disproportionate clustering of these conditions in high-poverty communities, as reported by the CDC: “A total of 8.7 percent of adults with income below the federal poverty level had serious psychological distress, compared with 1.2 percent of adults with incomes at or above 400 percent of the poverty level.”

The daily economic, educational, and social challenges facing those in poverty can create barriers to health services and lead to poorer health outcomes. This idea is captured in the Social Determinants of Health framework, which The World Health Organization (WHO) has defined as the “the conditions in which people are born, grow, live, work and age.” The general argument is that people in high poverty communities are more susceptible to certain illnesses, have less access to health care providers, and are frequently forced to delay care or medicine for financial reasons. The proximity of clinics, public transportation options, and the quality of food vendors, all affect one’s ability to address health concerns and seek care. As the social determinants of health concept has taken hold, organizations like Kaiser Family Foundation have adopted more nuanced definitions, incorporating more detailed categories, as shown below.

The WHO and others have emphasized how money, power, and the distribution of resources (through institutional decisions and policy implementation) shape community conditions and drive health outcomes. In places where education, employment, and accessibility are falling behind national averages, health outcomes are trailing along with them. For example, in North Carolina, counties with the lowest rates of postsecondary attainment and employment (Robeson and Warren counties) also rank poorly on measures of low birthweight, obesity, and diabetes prevalence. Counties with the highest rates of postsecondary attainment and employment (Wake and Orange counties) have the lowest rates of these indicators.

Source: National County Health Rankings

Source: National County Health Rankings

If education and employment are key drivers of upward economic mobility, then people must be healthy enough to take advantage of these opportunities. There are many narratives about educational attainment as a predictor of health outcomes. Formal education often provides foundational principles of nutrition, healthy behaviors, and general health literacy. Education is also an avenue for insurance benefits through school plans or future employment opportunities.  Lastly, education provides individuals with an intangible set of resources such as social networks, norms, and relationships that can cultivate healthy practices.

It is important to recognize that poorer health outcomes in high poverty areas have been driven by policy that marginalizes low-income communities. The provisions of the Affordable Care Act made strides in addressing issues of healthcare access, but in order to holistically address health equity, we must also consider the underlying environmental, social, and economic factors that enable good health. Improving preventative initiatives, health education, and access to nutritious foods are a few measures that could begin to eliminate these disparities, improve public health, and encourage, rather than hinder, economic mobility. Throughout my Autry year with MDC, I hope to continue shedding light on the social determinants of health that persistently marginalize low-income communities. Stay tuned for more posts on how these issues play out in Southern communities!

Fuel for the Future: Food Insecurity Threatens Long-term Mobility

Many of us think of food as soon as we think of home: traditional dishes, daily staples, favorites from childhood. Our ties to those conceptions of home and nourishment develop at an early age, when breastfeeding transitions to—ideally—a nutritious, balanced diet that leads to positive, long-term health behaviors, outcomes, and relationships with food. But it’s difficult to develop healthy habits and foundational memories when nourishing meals are hard to come by. That’s often the case for households where lack of income and disconnection from food production and supply put sufficient food out of reach. At the same time, through collaborative community efforts in both rural and urban food deserts, there are opportunities to sustain stores that carry fresh produce and local foods; to give children and their families a taste of what fresh food is like and where it comes from; and to provide education, empowering households to access healthy food and prepare balanced meals.

Shifts in unemployment, inflation, and the price of food are directly related to the prevalence of food insecurity. Transportation and education, essential to economic mobility and scarce in households of low socioeconomic status, are also key to connecting caregivers to the affordable, quality food they need to support a household. It follows that in the wake of the Great Recession, food insecurity rose significantly in rural and urban communities throughout the United States; more recently, with relatively increased economic prosperity, there has been some decline in those numbers. The USDA characterizes households along a continuum of high to very low food security; households that are food insecure fall into these two categories:

  • Low food security: Households reduced the quality, variety, and desirability of their diets, but the quantity of food intake and normal eating patterns were not substantially disrupted.
  • Very low food security: At times during the year, eating patterns of one or more household members were disrupted and food intake reduced because the household lacked money and other resources for food.

Morgan Wittman Gramann, managing director of NC Alliance for Health, writes, “Children across North Carolina are at risk for developing type 2 diabetes, heart disease, some cancers, and other chronic diseases because they lack access to healthy, nutritious food. Families want to be healthy, but too many simply have nowhere to buy affordable lean meats, whole grains, fruits and vegetables.” Here’s what food insecurity looks like in North Carolina counties:

North Carolina Food Insecurity Rates Source: Feeding America

North Carolina Food Insecurity Rates
Source: Feeding America

North Carolina Child Food Insecurity Rates Source: Feeding America

North Carolina Child Food Insecurity Rates
Source: Feeding America

The multi-generational implications of food insecurity compound the need for serious consideration of food systems and culture in the United States. Affordable, nutritious foods are accessible in grocery stores and supermarkets, but low-income neighborhoods, communities of color, and rural areas throughout the United States have few to zero grocery stores and supermarkets.  Almost 350 communities in the state of North Carolina are USDA-classified food deserts, in which residents must travel over 10 miles in rural areas and one mile in urban areas in order to reach a grocery store. Rural communities are particularly vulnerable, according to the Food Literacy Center: the South continues to have the highest poverty rate among people in families living in rural areas, at 23 percent. Seventeen percent of rural households are food insecure—an estimated 3.3 million.

Though it is a daunting challenge, community-based programs, policy reform, and legislation combine food access and education, thus expanding opportunity for families, children, and the community at large. At the national level, in 2020, for the first time ever, the Dietary Guidelines for Americans in the USDA 2014 Farm Bill will include recommendations for birth to age two—supporting healthy eating early in a child’s life that can be sustained over a lifetime. And the SNAP program (commonly known as Food Stamps) requires education programs that include individual or group-based nutrition education and health promotion intervention strategies. Here in North Carolina, Healthy Places NC, a place-based initiative of the Kate B. Reynolds Charitable Trust, is aimed at improving the long-term health and overall quality of life for people in rural areas of North Carolina, like Rockingham County, through projects and partnerships. There, Rockingham County Partnership for Children collaborates with Rockingham Community College to host the Harvesting Health program. Families explore the connections between local food production, healthy lifestyles, and nutrition. The program gives children hands-on opportunities to taste locally grown food, cook with fresh produce, and increase understanding of healthy eating through health and wellness workshops. For more on their work thus far, and future plans within the community, see their feature in the December 2015 Healthy Places NC Community College Learning Network newsletter.

Homes, schools, and communities share in the responsibility of cultivating skills and illuminating opportunity in order to fuel a sustainable future for children—which includes their ability to navigate our complex food systems. To address food insecurity requires addressing the conditions that perpetuate poverty—transportation, education, and employment. We must prioritize the supplemental education, sustainable infrastructure, and healthful behaviors that will give the next generation a solid foundation for economic mobility, longevity, and the energy—fueled by healthy food!—to contribute to a vibrant South.

Building a Healthy Infrastructure of Opportunity

Pinpointing one all-encompassing reason why healthcare disparities between racial groups in quality and access persist is as unrealistic as waving a magic wand to find a solution. Examining this phenomenon requires us to consider social determinants of health, the historical structures of racism, and the intersection of several public systems.

Last month, the American Public Health Association led this sort of examination in a webinar about systemic racism and assessing inequitable health outcomes. In the discussion, panelists from the University of Illinois School of Public Health, the National Collaborative for Health Equity, and the Mayo Clinic School of Medicine noted that although the Affordable Care Act has increased insurance coverage within racial groups, disparities between groups remain. The tide of healthcare coverage is rising, but individual social determinants of health (age, race, socioeconomic status, place, gender, disability status, etc.) often overlap to keep folks from being able to “float” to the same level of access and quality.

The intersections of disadvantage in health care outcomes across income, race, and place, for example, are not only social and systemic, but also plagued by the psychology of implicit biases. Healthcare professionals, like the rest of us, are human beings with their own set of internalized beliefs about the world. Acting according to implicit bias built from our own identity and experiences is efficient and effortless; our tasks are easier when we rely on this readily-available knowledge-set. But this tendency is dangerous if something as crucial as healthcare provision is largely concentrated in the hands—and therefore the implicit biases—of one segment of the overall population: that is, the white segment of the population.

For example, a study released by the American Association of Medical Colleges shows that from 1980-2004 white physicians have largely dominated the medical field, while black and Hispanic populations are underrepresented. More recently, the Texas Department of State Health Services published data showing that white healthcare professionals in Texas are more likely to hold higher-paying positions such as primary care physicians and less likely to act as community health workers, while the inverse is true for African Americans and Hispanics. The study shows us that even in states where people of color make up a large portion of the population, white people are in more powerful positions in disproportionately large numbers. The faces, experiences, and knowledge-sets of Texas’ healthcare providers, then, cannot truly be reflective of the wide array of needs of the patients requesting care—an argument of provider-patient disconnect that could be extended to other Southern states with similar demographics.

Providing quality healthcare for individuals with an array of identities and experiences should involve an unbiased approach to health assessment and treatment, thoughtfully addressing the realities that lead patients to require the care they’re seeking. Knowing and understanding patients and approaching them as partners in addressing health issues is a valuable framework for equitable treatment. For example, an anonymous article published in the Annals of Internal Medicine last month graphically describes how doctors with privileged identities (e.g. male, white) have acted inappropriately towards patients with less privileged identities (e.g. female, Latina), partially due to a lack of understanding and empathy towards those whose identities and experiences are different from their own. Such a testimonial reveals the necessity for increased representation of the wide range of people—across race, socioeconomic background, gender, etc.—that seek quality healthcare. The author described the need for his piece in the journal as a “silence to break.”

But something else must also be broken: a cycle that perpetuates a relationship between high wealth and better health outcomes. Increasing diversity at all levels of healthcare professions in order to improve health outcomes for people of color becomes rather daunting if you consider that getting the necessary education to hold such positions is influenced by an individual’s health outcomes, and various other interrelating social factors. If we want to address racialized health disparities, we have to look at the whole picture—what our regular readers know we like to call the infrastructure of opportunity. Addressing health disparities within such a framework means asking what public policies, community supports, and social structures are in place to address the ties between health outcomes and other social determinants of health. What is the relationship between upward mobility into quality jobs and the accessibility of quality healthcare?

To address the socially harmful association between wealth and health, we have to understand that access to quality healthcare, as well as housing and transportation, isn’t inevitably set along lines of race and wealth advantage/disadvantage, but is rather intentionally embedded into our society via an economic system that turns rights into privileges. Indeed, focused and justice-oriented action within to change the systemic cycle of low opportunity equating with poor health outcomes can generate hope: we have the power to do better, because we are the architects of the faulty system. A problem-solving lens that focuses on an infrastructure of opportunity allows us to not only address cycles of inequity, but also to build better pathways to equity for future generations. Such a view surely must take healthcare access and quality into account in order to build a (literally) healthy platform for future mobility.

Anna Ormond is MDC’s 2015-2016 Autry Fellow