The confluence of the coronavirus pandemic, massive unemployment, and civil unrest have refocused attention on the impact of the social determinants of health... The confluence of the coronavirus pandemic, massive unemployment, and civil unrest have refocused attention on the impact of the social determinants of health (SDOH), including racism, in the United States and in healthcare. In 2018, a topic in OJIN: The Online Journal of Issues in Nursing (OJIN) considered various aspects of the social determinants. One article from that topic explored race in nursing and healthcare (Bennett, Hamilton, & Rochani, 2019) and its influence on potentiating multi-generational health disparities in African American and other minority groups (Watts, 2003). D’Antonio (2020), while reflecting on a recent OJIN topic that celebrated nursing history, noted that we cannot read articles about the contributions of past nurses without reflecting on their relevance to present crises, and the implications for nursing education, practice, and research in the future.

In this article, we discuss past and current factors that have contributed to the disproportionate impact of COVID-19 on vulnerable populations. We also explore how the profession of nursing has historically focused on SDOH and social justice in society and propose that there is an ethical mandate to address these issues now and in the future. Recommendations are provided for development of structural competence and inclusion of SDOH in education, policy, practice, and research. We include suggestions for potential research to address and prevent the inequities manifested in the current pandemic, and for the future.

COVID-19 and the Social Determinants of Health

Racial Disparities
COVID-19 has disproportionately affected both minorities and those of lower socioeconomic status. Although all United States (U.S.) residents are equally susceptible to the coronavirus, consequences of the illness have not been experienced evenly. COVID-19 has disproportionately affected both minorities and those of lower socioeconomic status. These adverse mortality and morbidity patterns can be mapped to zip codes. The maps reflect ways that groups of concern lack adequate housing and/or food security and may live in multi-family or generational homes where physical distancing is impossible. In addition, working from home may not be an option and many have jobs that expose them to the virus (Galea & Abdella, 2020; Metzl, Maybank, & De Maio, 2020).

Migrant farm workers and indigenous populations share an increased vulnerability to the virus and to disease in general. It is estimated that over 40% of the Navajo nation lack access to running water, making it difficult to comply with handwashing recommendations. The low number of intensive care hospital beds in the Indian Health Services has also limited the ability to provide adequate care for individuals with COVID-19 on tribal reservations (van Dorn, Cooney, & Sabin, 2020). Agricultural communities in Florida, where essential itinerant workers often live and work in close proximity, have been described as “cradles of coronavirus infection” (Mazzei, 2020, p. A6).

...working from home may not be an option and many have jobs that expose them to the virus... Although few studies have assessed COVID-19 disparities among the Asian-American population in the United States and the racial category is broad, Asian populations were disproportionately affected by COVID-19 in a small number of hotspot counties (Moore et al., 2020). In San Francisco, where Asian-Americans comprise one third of the population, they have experienced four times the mortality rate than that of the overall population. These increased numbers may result from limited access to healthcare due to lack of insurance, language barriers, or unknown factors to date (Moore et al., 2020; Yan, Ng, Chu, Tsoh, & Nguyen, 2020). Use of the term “China Virus” also puts Asian-Americans at risk for harassment and physical injury (Cuellar et al., 2020).

Psychosocial, Environmental and Economic Factors
Additional social determinants relevant to COVID-19 include a 12^th grade education or less and no health insurance or having to self-ration healthcare. Risk factors for the virus such as diabetes, hypertension, or asthma can also be related to environmental and sociological influences as much as racial differences in biology (Hooper, Napoles, Perez-Sable, 2020; Owen, Carmona, & Pomeroy, 2020). As components of historical trauma theory (see Table 1), these psychosocial and environmental stressors not only create susceptibility to disease, but act as a direct pathogenic mechanism that affects biological systems in the body and potentiates multi-generational health disparities (Carron, 2020; Sotero, 2006). Table 1 provides common definitions related to factors that impact SDOH.

Table 1. Definition of Terms

These same social and environmental determinants, among others, also contributed to the excessive mortality rate in cities such as New York and Chicago during the 1918 influenza pandemic which resulted in the loss of over 675,000 lives in the United States. (Bambra, Riordan, Ford, & Matthews, 2020; Clay, Lewis, & Severini, 2019). As Berwick (2020) observed in his discussion of the moral determinants of health, despite decades of research on these true causes of disease, and voices of public health advocacy, “this underinvestment in actual human well-being” has not changed (p.E1).

These same social and environmental determinants...contributed to the excessive mortality rate in cities such as New York and Chicago during the 1918 influenza pandemic... The effects of the COVID-19 outbreak demonstrate what Laster Pirtle (2020) describes as racial capitalism, a system that constructs the social and environmental conditions that facilitate pandemics. As introduced by Robinson (1983), racial capitalism refers to the mutually constitutive relationship between racialized exploitation and capital accumulation. The Flint, Michigan water crisis in 2014 was an example of racial capitalism in which the people were “so devalued that their lives are subordinated to the goals of municipal fiscal solvency . . . this devaluation is based on both their blackness and their surplus status, with the two being mutually constituted” (Pulido, 2016, p. 1).

Similarly, in nearby Detroit and surrounding communities of color, COVID-19 inequities are shaped by racial capitalism. As of November 1, 2020, 36% of the state’s 7, 419 deaths were African Americans even though they make up only 14% of the population and more than 75% of those deaths were in Detroit. The death rate for Michigan’s black residents is 1,738 per 1 million people, more than four times the rate of 525 per 1 million for white residents (Michigan, 2020). A study of nine other major U.S cities with counties where the majority of the population is non-white reported death rates nine times higher compared to those counties where the majority is white (Adhikari et al., 2020). Those who were hospitalized in April during the height of the pandemic in similar racially and economically segregated areas of New York City were often treated in under resourced public hospitals. While private, well-financed hospital networks could access sufficient personal protective equipment, nurses and physicians in one public institution in Brooklyn resorted to wearing tarps and using duct tape to secure their face shields (Caress, 2020).

...nurses and physicians in one public institution in Brooklyn resorted to wearing tarps and using duct tape to secure their face shieldsEconomic effects of the coronavirus have also been unequal with higher unemployment rates among black (10.8%) and Hispanic (8.8%) workers compared to white workers (6%) (U.S. Bureau of Labor Statistics, 2020). The deaths of Ahmaud Aubrey, Breonna Taylor, and George Floyd, together with the pandemic and massive, unexpected unemployment have resulted in a level of civil unrest not seen since 1968.

Historical Focus: Nursing Profession and SDOH

In pre-pandemic 2019, The Robert Wood Johnson Foundation commissioned a report to document the historic role of nurses to advance health and to provide background for the National Academy of Medicine Committee on the Future of Nursing 2020-2030. In Activating Nursing to Address Unmet Needs in the 21^st Century, author Patricia Pittman noted, “The deteriorating epidemiological profile in the United States requires more than a traditional medical response” (2019a, pp.3). She argued that medical care alone was insufficient to address diseases of despair and those economic and social inequities that negatively affect population health outcomes, especially among those who are members of marginalized or minoritized communities.

This expanded vision is one guided by a holistic understanding of patients in the context of their lives as members of families, workplaces, and communities. Pittman and others proposed that the nursing profession could address this crisis by refocusing and expanding the original vision of nursing practice as conceived by Florence Nightingale and Lillian Wald. This expanded vision is one guided by a holistic understanding of patients in the context of their lives as members of families, workplaces, and communities. It is also one in which nurses, as the largest health workforce across the world, are recognized as natural leaders in health service delivery (Pittman, 2019a; 2019b; Carryer, 2020).

Nursing, Social Ethics, and Social Justice
Nurse ethicist and historian, Marsha Fowler, pointed out that modern American nursing began during the Civil War and subsequently adopted the Nightingale educational model in the 1870s. (Fowler, 2016). From the beginning, the profession of nursing has been a social enterprise, recognizing that the health, or the illness, of an individual or population, was as much a function of social support structures as the disease process itself. As a result, persons who have had fewer social supports in place, such as clean air and water, nutritious food, safe housing and neighborhoods, educational opportunities, strong family and community identification, preventative healthcare, and access to affordable health treatment, have experienced disproportionate disease burdens with multi-generational consequences. Fowler stated, “While the rich and enduring tradition of nursing’s ethics has been concerned about individual patients and their relational nexus, nursing ethics has from the beginning been a social ethics, intimately concerned both for the shape of society and for social change” (Fowler, 2016, p.S9).

Concern with social justice within the nursing profession, as a component of social and nursing ethics, was apparent in early education requirements such as those established by the National League for Nursing Education (NLNE) in 1917 (as cited in Fowler, 2015). Instruction was to include lectures about ethical theory, principles, and social virtues as applied to community life. State boards of nursing also identified curricular content in social ethics for registered nurses (RNs) that addressed housing reform, modern industry, and “the spirit of youth and the city streets” (California State Board of Health, Bureau of Registered Nursing, 1916 as cited in Fowler, 2015).

As a global concern, the duty to address health disparities generated by the SDOH and promote social justice is addressed in several nursing codes of ethics... As a global concern, the duty to address health disparities generated by the SDOH and promote social justice is addressed in several nursing codes of ethics, including: the International Council of Nurses Code of Ethics (2012); the Canadian Code of Ethics for Registered Nurses (2017); and the Code of Ethics for Nurses with Interpretive Statements (ANA, 2015). Provision 8 of the latter obligates the individual nurse in all roles and positions to collaborate with healthcare professionals and the public to “protect human rights, promote health diplomacy, and reduce health disparities” (ANA, 2015, p.31). Provision 9, added in 2001 and refined in 2015, specifies the moral obligations of the profession and professional organizations to “integrate principles of social justice into nursing and health policy” (ANA, 2015, p. 34).

To address violations of social justice, one must first recognize the inherent dignity of all people. To address violations of social justice, one must first recognize the inherent dignity of all people. The belief in the inherent dignity of persons is foundational to nursing care. In practice, when the nurse provides care for an individual, the focus is appropriately on the individual and the acute care need. Under these conditions, societal concerns may not be prioritized until several individuals are seen and exhibit similar needs. One of the great strengths of Florence Nightingale was her ability to identify patterns and establish metrics to evaluate both these patterns and the effectiveness of care provided in response to them.

Establishing social justice within society requires awareness of patterns of entrenched deficiencies and development of strategic actions to address those deficiencies. Recently, one of the authors (JS) experienced significant water damage to her home. Factors that contributed to the damage were longstanding but went unrecognized until the damage occurred. The process of restoration included three distinct phases. First, find the source and remove the causative agent. Second, mitigate the effects of the damage so further harm is contained. And finally, restore the property to the desired condition. In theory, the same pattern of correction at the source, mitigating efforts to contain further damage, and restoration would be applicable to injustices within society that directly affect the health and well-being of all persons. In reality, social justice issues are highly dynamic, often insidious in nature, and those at greatest risk are those who have the least power in society.

...social justice issues are highly dynamic, often insidious in nature, and those at greatest risk are those who have the least power in society.The perspective of health, illness, or disease as a constellation of precipitating factors influenced nursing pioneers, such as Lillian Wald, to embark on comprehensive reforms to improve individual health through social action. In the late 19^th century, Wald realized that the crowded and unhygienic living conditions of many impoverished immigrants who resided in slums or tenements in New York City contributed to the spread of infectious disease, infant mortality, and other health concerns. She and Mary Brewster founded the Henry Street Settlement in 1893 and sent trained, visiting nurses to care for the sick in their homes. While providing this direct, clinical care Wald and her colleagues also worked to improve living conditions through health promotion efforts that addressed hygiene and sanitation. They included frequent visits to ensure compliance with recommendations. They partnered with community organizations to obtain donations of food and medicine, arranged loans, and offered education and job-training (Pittman, 2019b).

Recognizing increased mortality rates in immigrant and African American communities, Henry Street nurses hired and educated individuals from those areas to provide care. This was a time when few, if any, nursing schools in the United States admitted black students (Bennett et al, 2019; Jones & Saines, 2019). Wald also advocated for policy reform regarding housing, workplace conditions, and education, and lobbied for insurance coverage for preventive care. This nursing model addressed factors associated with the SDOH at all three levels: upstream, midstream, and downstream (see Table 2; Abbott & Elliot, 2016; Pittman, 2019a; 2019b).

Table 2. Social Determinants of health and COVID-19

Adapted from Gray et al. (2020).

Future Directions: Nurses and SDOH

The story represents the fundamental challenge facing the U.S. healthcare delivery system, which largely focuses on downstream activities. The upstream-downstream framework, credited to medical sociologist, Irving Zola, is a well-known public health allegory in which the central character is standing alongside a river slowly filling with drowning people. The protagonist starts pulling people from the water, an impossible task which prevents traveling upstream to determine how they came to be in the river in the first place. The story represents the fundamental challenge facing the U.S. healthcare delivery system, which largely focuses on downstream activities. While the system provides interventions to repair the damaged or dysfunctional body, it is not equipped to address the many upstream or midstream factors that contribute to illness and poor healthcare outcomes downstream, as made manifest in the current pandemic (Gray, Ayane-Yeboa, Balzora, & Issaka, 2020; NASEM, 2019) (Table 2). Healthcare providers, including nurses, may not have acquired the knowledge and experience necessary to assess and address these factors, including those which may be more complex and less apparent (e.g, adequate housing, job security).

Chronic underfunding of the public health infrastructure has limited the ability to effectively respond to the pandemic and maintain routine functions of public health departments. Although undergraduate curricula may contain content related to SDOH in community and public health courses, inclusion of such content in graduate programs varies based on program concentration. With only 1.4% of the RN workforce employed in public health, there have been calls from various organizations (e.g., AACN, NASEM) (AACN, 2021; NASEM, 2021) to better prepare nurses for practice outside the acute care environment. Chronic underfunding of the public health infrastructure has limited the ability to effectively respond to the pandemic and maintain routine functions of public health departments. For example, in the public health sector there has been a loss of over 55,000 workers since 2008, with nurses comprising the largest segment. (Edmonds, Kneipp, & Campbell, 2020; McKillop & Ilakkuvan, 2019; Smiley et al., 2019).

Structural Competence
Nurses should be prepared both academically and experientially to manage illness and address SDOH through assessment, collaboration, and policy development (Drevdahl, 2018; National Advisory Council on Nursing Education and Practice [NACNEP], 2019; Persaud, 2018). Structural competence enables nurses and other healthcare professionals to identify and react to connections among morbidity, mortality, and SDOH. Whereas cultural competence/humility is the ability to effectively work within the client’s cultural context, structural competence is recognition of economic and political conditions that produce health inequalities in the first place. Structural competence is the ability to understand how institutions, markets, or healthcare delivery systems shape symptom presentations, and to mobilize to correct health and wealth inequalities in society (Drevdahl, 2018; Metzl, Petty, & Olowojoba, 2018; Metzl et al., 2020).

...structural competence is recognition of economic and political conditions that produce health inequalities in the first placeWhile other health disciplines have begun to include a focus on structural competence in the curricula (Metzl & Hansen, 2014; Metzl et al., 2018) only one pilot study has explored a similar initiative in nursing (Woolsey & Narruhn, 2019). A structural competency requirement would present a more accurate description of the SDOH factors that affect health, and perhaps correct the tendency to “blame” patients for their current conditions. Integration of content about racism, health equity, and implicit or unconscious bias as it relates to structural competence is needed across the academic continuum in didactic, simulation, and clinical experiences (Scott, Johnson, & Ibemere, 2020; Thornton & Persaud, 2018). Clinical opportunities beyond the acute care environment and in partnership with communities may provide the necessary knowledge, skills, and abilities required to promote health equity and eliminate disparities (NACNEP, 2019; Sharma, Pinto, & Kumagai, 2018). These experiences may also promote and increase the public health nursing workforce, identified as “key to our nation’s health” (Kovner, 2020; NACNEP, 2014, p.1).

Implicit Bias and Racism
Racism and discrimination are upstream SDOH factors that perpetuate social injustice and impede health equityRacism and discrimination are upstream SDOH factors that perpetuate social injustice and impede health equity (America Public Health Association [APHA], 2020a, b). The ethical obligation of nurses to acknowledge and confront these factors at the personal, institutional, and systemic levels is addressed explicitly in recent documents issued by several organizations, including the American Nurses Association ([ANA], 2018) and the American Academy of Nursing (ANA, 2020). Recognizing individual implicit or unconscious bias is proposed as an initial first step.

The Institute of Medicine issued a report in 2002 that identified the problem of implicit bias in healthcare (Smedley, Stith, & Nelson, 2003). Several authors have also addressed the presence and management of implicit bias in nursing (Grif-Alspach, 2018; Narayan, 2019). These discriminatory behaviors may negatively affect patient-provider communication and healthcare outcomes and result in patient distrust and subsequent delay in seeking care (Fitzgerald & Hurst, 2017). Although not the only contributing factor, provider unconscious bias may have resulted in minority populations seeking care at later stages and having higher rates of hospital admission for COVID-19 (Azar et al., 2020). While discouraging, there is evidence that once persons are made aware of their biases and receive training and feedback, behaviors can change (Milam et al, 2020). To return to the house analogy, once the source of the water leak is discovered, the process of repair can begin in earnest.

...there is evidence that once persons are made aware of their biases and receive training and feedback, behaviors can changeDismantling racism at the institutional and structural levels in nursing, healthcare, and society will require additional time and work. The notion that, as a profession, nursing is ‘color-blind’ and everyone is treated the same has rendered discussions of racism taboo for decades. To be actively antiracist, rather than non-racist, is to become comfortable using terms such as racism and white privilege. It requires one to engage in uncomfortable conversations within our own institutions and communities in which we listen and hear all voices (Moorley et al., 2020; Villaruel & Broome, 2020).

Disrupting institutional racism may require unlearning what we have been socialized to believe is true and increasing awareness of historical and persistent race issues (Sumpter, 2020). As an example, noting that much of United States history has been transmitted through a white supremacy lens, Sumpter suggests that reexamining black activism during the period of Reconstruction (1865-1877) when 16 African American leaders served in Congress and more than 600 were elected to their state legislatures. Bennett et al. (2019) provide a similar example of unlearning and learning in their study presenting an historical perspective of nursing, racism and health in Charleston, SC from 1883-2016 to students in an undergraduate program.

Policy and Partnerships
As the largest group of healthcare providers, nurses can and should be a formidable, unified force to advocate for social justice policies, a component of structural competence. However, many lack the knowledge and ability to do so. The American Association of Colleges of Nursing (AACN) Essentials draft document includes a domain on population health with identified competencies that cross academic levels. These skills include the ability to advance equitable population health policy, demonstrate advocacy strategies, and engage in effective partnerships (AACN, 2020).

Curricular content that links SDOH with policies not generally viewed as health policies...may enhance structural competence. Curricular content that links SDOH with policies not generally viewed as health policies, such as minimum wage and enforcement of safety standards for employees, may enhance structural competence. Given the increase in telehealth required by COVID-19, students could also examine the effect of state level regulations on reimbursement of telehealth visits and how these policies impact access for underserved areas (Scott et al., 2020). Understanding and advocating for a “health in all policies” approach has the potential to successfully advance health equity (APHA, 2020c).

Practice
Recognizing that nurses cannot address health inequities generated by SDOH alone, Williams, Phillips, & Kovama (2018) suggested that those in practice inquire about internal and external organizational partnerships that identify and address social needs, or midstream factors such as housing, food security and transportation, among others. One example is Kaiser Permanente’s Thrive Local, a partnership with Unite US that connects patients with community-based care that can provide support. The technology is integrated into the Kaiser Permanente electronic health record (EHR) and enables providers to view the specific SDOH(s) appropriate to an individual patient and the social services available to address the need(s). During the initial months of the pandemic, use of this network ensured that resources such as emergency housing and food were available for local communities at risk in Oregon and southern Washington (Ertz-Berger, 2020).

To provide high quality care at the downstream level, nurses must practice at the full scope of their education...To provide high quality care at the downstream level, nurses must practice at the full scope of their education, including advance practice nurses who often provide care in underserved areas. More than half of the 28 states that still require physician collaboration or oversight for advanced practice registered nurse practice suspended or waived those requirements due to COVID-19; this initiative should be continued and/or adopted by all states (De Priest, Alexander, & Taylor, 2020).

Research
Research is needed to identify best practices to incorporate information about SDOH and structural competence in nursing education and practice. Demonstration projects that establish a standard set of competencies, in addition to comparisons of education models and interventions, should be explored to determine effective approaches. Despite past and current evidence of the impact of disparities and outcomes related to SDOH, there is limited research to support best practices that incorporate them as part of a structural competence framework. Further research is needed to identify or develop effective practices that eliminate gaps and promote health equity (Drevdahl, 2019; NAENCP, 2019).

Further research is needed to identify or develop effective practices that eliminate gaps and promote health equityAdditional avenues for nurse researchers to address the inequities manifested in the current pandemic may include greater understanding about the role of stress as a risk factor for obesity, heart disease, and other illnesses. Condon et al. (2019) explored associations between maternal experiences of discrimination and child indicators of toxic stress in a multiethnic, urban sample of mothers and children (age 4–9 years). Children may not only experience stress in response to personal instances of racism and discrimination but also by exposure to experiences of their caregivers (e.g., witnessing these behaviors in a store or restaurant).

Noninvasive biomarkers across a range of physiological systems associated with the stress response were examined, including a saliva test to assess immune function. The findings suggested that maternal experiences of discrimination were associated with a significantly elevated pro-inflammatory cytokine in children (Condon et al., 2019). Increased levels of this cytokine, IL-6, have been associated with behavioral problems, mental health disorders, and sleep disturbances. Understanding physiologic mechanisms through which this vicarious racism may influence child health is an important step toward developing interventions designed to eliminate such inequities across the SDOH (Condon et al., 2019; Heard-Garris, Cale, Camaj, Hamati, & Dominguez, 2019).

Conclusion

Nurses, in all levels of education and practice, must be knowledgeable about the impact of SDOH on healthcare outcomes such as COVID-19. Addressing the disparities that have led to the disproportionate impact of COVID-19 on vulnerable populations will require resolve and structural competence. Nurses, in all levels of education and practice, must be knowledgeable about the impact of SDOH on healthcare outcomes such as COVID-19. Education that targets behaviors and attitudes is critical if nurses expect to positively address SDOH and advance our professional, ethical mandate for social justice.

The contributions of Lillian Wald and Florence Nightingale are due, in part, to their willingness to serve marginalized communities, champion reform, and engage with community and political leaders to bring about change. To make lasting changes in population health, nurses of today must be active participants and work together as strategic disrupters of the status quo, in the tradition of these respected nurse leaders.

Authors

Catherine Robichaux, PhD, RN
Email: robichaux@uthscsa.edu

Catherine Robichaux is assistant professor, adjunct at the UT Health School of Nursing in San Antonio, TX and the University of Mary in Bismarck, ND. She has taught critical care and ethics and the undergraduate and graduate levels and serves as thesis/capstone advisor in a nurse educator program. Dr. Robichaux has conducted and published research on several ethical issues including moral distress and the ethical climate in an academic medical center, ethical issues with the electronic health record, and ethical care of the IDD population. She is editor of the Springer publication, Ethical Competence in Nursing Practice (2017). Dr. Robichaux is a former member of the ANA Ethics Advisory Board and current member of the ANA Ethics Education Subcommittee.

Jeanie Sauerland, MA, BSN, HEC-C
Email: Jeanie.sauerland@uhs-sa.com

Jeanie Sauerland is the Director of Ethics Services at University Health System in San Antonio, Texas. She completed an MA in Bioethics and Health Policy from Loyola University Chicago; a BSN from the University of Texas Health Science Center San Antonio, and a BS in Community Health Education from Texas A&M University with an emphasis/internship in Health Systems Planning. She helped found the Nurse Ethics Council at University Hospital and continues to mentor the interdisciplinary group. She was actively involved in developing how the system would respond in Crisis Standards of Care. Jeanie has a special interest in the ethical care of vulnerable populations, particularly persons with Intellectual and developmental disabilities. She a co-author for the ANA Position statement on the Ethical Care of Persons with Intellectual and Developmental Disabilities and enjoys volunteering with groups that provide services for this population. In 2020 she was awarded the ANA Leadership in Ethics Award.