Teaching the social determinants of health during the COVID-19 pandemic

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I teach an undergraduate course called Cultural diversity, structural barriers, and multilingualism in clinical and healing encounters at the University of Chicago. The title is a mouthful, and the course can be thought of as one that combines medical anthropological perspectives and a social determinants of health framework. A social determinants of health framework examines the “causes of the causes” of health inequalities (Marmot, 2005: 1101), and, according to the WHO and CDC, the forces and systems that shape the conditions in the places where people are born, live, work, and learn, and play. Last year, I taught this course in a beautiful, oak-paneled classroom at the University’s campus in the Hyde Park neighborhood of Chicago. This spring, like most college instructors, I will teach this course from my kitchen while staying in place during the COVID-19 pandemic. This global pandemic will make my students and I rethink the ways we engage with one another and it will amplify the significance of this framework.

Some have suggested that COVID-19 and public health responses represent a unique moment that unites us. The pop icon Madonna called Coronavirus the ‘great equalizer’ that does not distinguish based on wealth or neighborhood. I love Madonna, but this overlooks how some segments of the population are at a heightened risk of infection and face significant barriers in seeking care. Existing inequalities that place individuals and groups in unequal social positions will exacerbate the harmful effects of the COVID-19 for these individuals and groups. Moreover, responses to COVID-19 —both government-sanctioned public health measures such as staying in place, as well as misguided fear and blame for the spread of COVID-19 —may provoke new forms of vulnerability. As scholars and teachers of medical anthropology, health equity, and the social determinants of health, we need to ask ourselves and our students, questions such as: What occupations are considered essential and how do those who perform these occupations experience heightened risk of infection? How do stay-at-home orders provoke new forms of vulnerability? What are the mental health effects of racism stoked by fears of COVID-19?

There are a number of concepts to understand how the social determinants of health translate to the poor health outcomes faced by individuals. ‘Structural vulnerability’ is a term medical anthropologists have used to explain how broader power relationships and local hierarchies exacerbate the health problems faced by individuals (Bourgois, Holmes, Sue, & Quesada, 2017: 301). In other words, these authors suggest that because of the unequal positions of individuals and groups in society, they may face greater exposure to risk, their ability to live healthy lifestyles may be hampered, and they may be unable to pursue health care when they need it. While structural vulnerability was initially conceptualized to examine the social position of undocumented Latino immigrant workers in the United States, the term applies to people who are poor, uninsured (or underinsured), sexually stigmatized, people of color, people with disabilities, and people who are incarcerated (Quesada, Hart, & Bourgois, 2011: 346). In my class, structural vulnerability is a concept my students and I use to understand the unique experiences of marginalized individuals as they navigate encounters with health care professionals.  

Much of the world has taken notice of the severity of COVID-19 and governments have implemented drastic measures to limit the movement of people and the spread of infection. The March 21st cover of the Economist magazine features an illustration of the globe covered by a large “Closed” sign. While many are working remotely and undertaking creative projects and push up challenges, others still have to go to work. In the city of Chicago, where I write these words, city buses and the L, the city’s partially elevated train system, are still running, the 7-Eleven across the street from my house is still open, and all the grocery stores in my neighborhood about as busy as they are on the day before Thanksgiving. Despite the Governor’s March 21st Executive Order to stay at home and maintain social distance, those who maintain vital transportation, postal, and health care infrastructures and those who operate essential businesses and operations, like grocery stores, cannot stay at home. An article about a woman who worked in a supermarket in Brescia in the north of Italy and who died—supposedly from Covid-19, but she did not live long enough to be tested—highlights the heroism and risk of those working at the front line of contagion. The article also reminds us that many people who perform low-paid occupations do not have the luxury of working from home. These occupations may also have less robust health insurance benefits and little or no paid time off.

In the COVID-19 pandemic, people who fill essential but low-paid jobs, such as grocery store clerks and those who deliver groceries, cannot maintain a safe social distance and come into frequent contact with people who may be infected. If they do develop symptoms, they may not be able to stay at home and self-quarantine, lest they risk losing their job. Or if they can self-quarantine, they may live with family in multi-generational households or with roommates and therefore risk exposing others, including individuals who fall into higher risk groups. And they may delay seeking health care services.

But it is not just individuals who must still go to work to provide essential services who face unique risks in the context of COVID-19. An article in the New York Times reported that the closing of schools and workplaces means that women and girls may have to hunker down with their abusers. This article also projects that the frequency and severity of abuse may increase, that being isolated with an abuser could take additional tolls one’s mental health, and that people who wish to seek medical care may avoid doing so out of fear of being infected or being suspected of being infected and therefore getting kicked out. Individuals who identify as LGBTQ may have to move in with unsupportive or abusive parents.

Many have also lost their jobs due fears about the economic toll of COVID-19 or due to the uncertainty of when businesses would reopen, if ever. At the time of writing, nearly 3.3 million people in the U.S. have filed for unemployment benefits in the past week. In states like Illinois that have passed shelter in place orders, restaurants and bars have shuttered and there is a great deal of uncertainty whether they will reopen when this passes. People who are undocumented and work in the restaurant industry or as housekeepers are particularly vulnerable, and they are likely to be excluded from any federal stimulus relief. More broadly, people who are undocumented may fear seeking medical services if they present with severe symptoms of COVID-19 infection for fear that they might be detained or apprehended in hospitals and risk deportation. 

Individuals who are incarcerated, those seeking asylum, or who are living in refugee camps are at a heightened risk of exposure. Because of their confinement, they may be unable to practice social distancing and because of the conditions of where they reside, they may not be able to practice safe hygiene to prevent the spread of COVID-19. Moreover, the closing of the border to people seeking asylum and attempts to deport individuals from the United States and Mexico could risk spreading COVID-19 to Central America.  

In addition to using the spread of COVID-19 to justify the closing of borders and limiting travel to the United States, Donald Trump has also used the pandemic to stoke racist sentiments and actions against minority groups, particularly Asian Americans, by referring to Coronavirus as a ‘Chinese virus.’ But an article in The Atlantic has pointed out that Asian Americans and Asian immigrants experienced discrimination, verbal assault, and physical violence even before Trump started calling Coronavirus a Chinese virus. Before state governors shuttered restaurants across states, restaurants in Chinatowns in New York City and elsewhere had already faced a loss of business due to perceptions that people may be at an elevated risk if they dine in these establishments. But this is not the first time that politicians and the general public have associated disease with foreignness or foreigners, which thereby provokes discrimination in certain communities and leaves others with the false sense that they are immune.

COVID-19 is not an equalizer. Rather, it disproportionately harms people of color, people who perform low-paid but essential jobs, people out of work, people who are undocumented, people who must stay at home with abusers, and people who are detained or incarcerated or living in refugee camps. A social determinants of health framework forces us to think of the conditions in people’s homes and workplaces and structural vulnerability allows us to understand how these conditions can result in exacerbated health problems for vulnerable individuals.

My students and I will grapple with how health care practitioners—doctors, psychotherapists, social workers, and caregivers, for example—are faced with the challenge of addressing individual manifestations of disease and disorder resulting from larger social inequalities, such as poverty, racism, and restrictive immigration policies. Scholars of structural vulnerability suggest that practitioners develop structural competency of the institutional forces and social conditions that lead to poor health and prevent people from having healthy lifestyles and seeking care (Bourgois, Holmes, Sue, & Quesada, 2017; Hansen, Riano, Meadows, & Mangurian, 2018; Kirmayer, Kronick, & Rousseau, 2018; Metzl & Hansen, 2014). In his TED Talk, Rishi Manchandra advocates for an upstream approach, where practitioners need to look upstream to the places where health begins, such as one’s home or workplace. Taken together, these perspectives suggest that practitioners can enact structural competence or an upstream approach through advocacy and engagement with community organizations and policy makers. For instance, psychiatrists can potentially address the mental health effects of racism and discrimination based on sexuality and religion by partnering with faith organizations and legal aid groups (Hansen, Riano, Meadows, & Mangurian, 2018).

The COVID-19 pandemic presents new challenges to understand how upstream or structurally competent approaches may be implemented in times of crisis when front line health care workers themselves are at a heightened risk of exposure, when advocacy and faith organizations must work remotely and face economic uncertainty, when hospitals face shortages, and when health care systems are overwhelmed.  

The pandemic also presents challenges for students and instructors learning about a topic that is currently unfolding throughout the world and that may, or may eventually affect those in the course. After spring break (or spring exile), students will join my class remotely from all over the world. At the University of Chicago, nearly all of the campus residence halls have closed and students were expected to move home or to move off campus with very little notice. Their part- or full-time jobs may have evaporated. They may live in houses or apartments without reliable internet connections or they may have to participate in an online class with roommates who are simultaneously participating in their own online classes. They may be separated from family, partners, and friends. They may have to provide care for those in their household. Put briefly, many of the kinds of vulnerability outlined in this article may affect those participating in this class.  

As we adjust to remote courses, we face a great deal of uncertainty and it will be of utmost importance for instructors to be sensitive to the vulnerabilities their students face, and remind their students that nobody signed up for this. I told my students that I was aware that they were likely facing an accumulation of stressors and that I understood that this class may not be a priority, and I planned accordingly. I have been on enough Zoom calls to know that a call with 20 or 30 students will be a struggle, so my class will involve pre-recorded lectures in video, audio, and transcript formats, as well as Zoom calls that are shorter in duration, with small groups of five, and are scheduled at times that work best for best for students.

Works Cited

Bourgois, Philippe, Seth M. Holmes, Kim Sue, & James Quesada. 2017. Structural Vulnerability: Operationalizing the Concept to Address Health Disparities in Critical Care. Academic Medicine 92(3): 299-307.

Hansen, Helena, Nicholas S. Riano, Travis Meadows, & Christina Mangurian. 2018. Alleviating the Mental health Burden of Structural Discrimination and Hate Crimes: The Role of Psychiatrists. American Journal of Psychiatry 175(10): 929-933.

Kirmayer, Laruence, Rachel Kronick, and Cécile Rousseau. 2018. Advocacy as Key to Structural Competence in Psychiatry. JAMA Psychiatry 75(2): 119-120.

Marmot, Michael. 2005. Social determinants of health inequalities. Lancet 365: 1099-1104.

Metzl, Jonathan M., and Helena Hansen. 2014. Structural competency: Theorizing a new medical engagement with stigma and inequality. Social Science & Medicine 103: 126-133.

Quesada, James, Laurie Kain Hart, & Philippe Bourgois, 2011. Structural Vulnerability and Health: Latino Migrant Laborers in the United States. Medical Anthropology 30(4): 339-362.

David Ansari’s research and teaching interests are centered at the intersections of international migration and displacement, trauma and psychotherapy, and human rights. David is currently working on a book project about how millennial psychotherapists have responded to the refugee crisis in the European Union. A former Fulbright Scholar, David completed his graduate work at the London School of Economics, Sciences Po Paris, and the University of Chicago. When not reading, writing, and grading assignments, David runs and takes cooking classes while traveling.