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Social Determinants of Health and Health Disparities

As we begin a unique Prostate Cancer Awareness Month in 2020, the coronavirus pandemic has brought many pre-existing health justice issues into a brighter light. Inequities in health are drawn along lines of race and ethnicity, as we see vast disparities in health care and outcomes for Black and brown communities in prostate cancer, COVID-19, and many other diseases.

For COVID-19, multiple analyses of data from many different sources reveal the same troubling results: a disproportionate incidence, higher risk of hospitalization, and higher mortality rate in communities of color. In the US, the death rate from COVID-19 among African Americans is 2.4 times higher than that of whites, and death rates for American Indian and Alaskan Native as well as Hispanic/Latino and Pacific Islander populations are 1.5 times higher. Many of the underlying causes are well-documented, including disproportionate numbers of people of color in “essential” jobs who lack paid sick time and sufficient protection in the workplace; households in which multiple family members must go out to work, making social distancing nearly impossible; less access to critical health care, including COVID-19 testing; and higher rates of comorbidities that make people more susceptible to severe illness from COVID-19. Comorbidities, or co-existing, underlying diseases, include diabetes, obesity, lung disease, and cancer.

Collectively, these factors are all referred to as social determinants of health that contribute to a greater burden of many types of illness among people of color. Social determinants of health can be attributed to systemic or structural racism that has created and reinforced institutions that sustain these inequities. Sadly, knowing that these factors already existed, the consequences of COVID-19 were not a surprise.

Cancer Disparities

Scarlett Lin Gomez, MPH, PhD

In the US, Black men are 80% more likely to be diagnosed with, and twice as likely to die of prostate cancer, compared to White men. In some areas, such as the South, this disparity is even wider. In fact, this pattern is seen almost universally across all cancer sites, and, as illustrated by the stark reality of the COVID-19 pandemic, this pattern is seen across many other health outcomes. Some, but not all, studies show equivalent survival between Black and White cancer patients within equal-access health systems, and/or when holding treatment constant in statistical models. Similar patterns play out with other communities of color and underserved communities. What can we hypothesize about the commonalities of these pervasive and longstanding disparities across different cancer types, and across different health outcomes? Black and other communities of color are more likely to be exposed to adverse conditions and toxic stressors throughout their life, and often need to exert more effort just to even the playing field. Years and years of this type of active coping, coined “John Henryism” by Dr. Sherman James, results in “weathering” (hypothesis by Dr. Arline Geronimus), or biological wear and tear. Effectively, the increased and prolonged levels of social stress eventually gets under the skin. In prostate cancer, we are testing these hypotheses by studying the impacts of structural racism and discrimination on tumor genomics and biology among Black men. More of such types of studies are needed, but in the meantime, we need to recognize that health inequities are rooted in and continue to be maintained by structural institutions, and thus, policies and measures to address disparities must fundamentally start with addressing these structural factors.

Cancer is another disease in which people of color are disproportionately affected [see sidebar]. Guest author Dr. Scarlett Gomez is a professor of epidemiology and biostatistics at the University of California, San Francisco, and an expert on the effect of social determinants of health on cancer disparities.

Compared to COVID-19, a quieter, less acute disparity exists for African American men and prostate cancer. African American men are over 75% more likely to be diagnosed with prostate cancer and more than twice as likely to die vs. non-Hispanic white men. The reasons for this are still under study. We know that there are genetic factors that make some men of African descent at higher risk for aggressive disease. Evidence suggests that social determinants of health – which may include access to PSA screening, access to the latest imaging techniques and treatments, and health behaviors such as diet and exercise – also play a role. When Black men with prostate cancer had access to the same care as Caucasian men (in the VA and in clinical trials), death rates from prostate cancer were the same.

Dismantling systemic inequities will require sweeping, long-term commitment to change. At the same time, focused efforts are needed to address individual diseases. Since its launch, PCF has been committed to solving the African American prostate cancer disparity. We have funded 25 awards totaling over $16 million and helped to secure $27M in investment for the PCF-NCI RESPOND initiative to study why African American men have a greater burden of prostate cancer related to genetic, social, and other factors. Our PCF-VA network serves as a model for American health care on ways to combat prostate cancer disparities among men of African ancestry. Our researchers are developing strategies to increase access to research cohorts and clinical trials for black men. PCF is catalyzing the effort to build the largest genetic data set of Black men affected by prostate cancer to study how genetics, tumor characteristics, and lifestyle factors contribute to the development of prostate cancer. And, in July, we announced an award from noted philanthropist Robert F. Smith, founder, chairman and CEO of Vista Equity Partners, to accelerate work on a non-invasive genetic test that will identify a man’s lifetime prostate cancer risk from a single sample of saliva or blood. Smith’s generosity will allow the research team to increase the representation of African American men in the study and optimize the test among this population.

How do social determinants of health and health justice relate to our theme of healthy eating? Food insecurity and diet are core social determinants of health. You already know that for optimal health, we advocate lots of fresh vegetables balanced with legumes, healthy fats, whole grains, and minimal animal products and processed foods. For many reasons, communities of color are less likely to have access to the very foods that may help protect them from developing cancer and the comorbidities linked to COVID-19 complications.

There is much more work to do.

Cancer Disparities

Scarlett Lin Gomez, MPH, PhD

In the US, Black men are 80% more likely to be diagnosed with, and twice as likely to die of prostate cancer, compared to White men. In some areas, such as the South, this disparity is even wider. In fact, this pattern is seen almost universally across all cancer sites, and, as illustrated by the stark reality of the COVID-19 pandemic, this pattern is seen across many other health outcomes. Some, but not all, studies show equivalent survival between Black and White cancer patients within equal-access health systems, and/or when holding treatment constant in statistical models. Similar patterns play out with other communities of color and underserved communities. What can we hypothesize about the commonalities of these pervasive and longstanding disparities across different cancer types, and across different health outcomes? Black and other communities of color are more likely to be exposed to adverse conditions and toxic stressors throughout their life, and often need to exert more effort just to even the playing field. Years and years of this type of active coping, coined “John Henryism” by Dr. Sherman James, results in “weathering” (hypothesis by Dr. Arline Geronimus), or biological wear and tear. Effectively, the increased and prolonged levels of social stress eventually gets under the skin. In prostate cancer, we are testing these hypotheses by studying the impacts of structural racism and discrimination on tumor genomics and biology among Black men. More of such types of studies are needed, but in the meantime, we need to recognize that health inequities are rooted in and continue to be maintained by structural institutions, and thus, policies and measures to address disparities must fundamentally start with addressing these structural factors.