The convergence of the COVID-19 pandemic, social unrest unleashed by the killing of George Floyd, and centuries of systemic racism marks an important crossroads for the nursing profession. Nursing leadership and persistence in addressing disparities in health outcomes and health care services in 2020 and beyond will create a lasting legacy regarding the value and relevance of nursing and nurses. It is imperative that nurses widely embrace the changes in thinking and actions required to prompt meaningful and systemic change and commit individually and as a profession to a robust and sustained response. Nurses must get political. Not embracing change or politics perpetuates poor health outcomes and health disparities and places the nursing profession in peril.
Meeting Social Needs Is Necessary, but not Sufficient
One way to grasp what is needed for addressing the root causes of racism from which disparities arise is to look at the confusion evident when nurses refer to addressing social determinants (or drivers) of health (SDOH) when in actuality they are meeting the social needs of individuals, not addressing the factors that shape the health of a population. Meeting social needs is necessary and a hallmark of nursing practice, but it is not sufficient for ameliorating the untoward effects certain populations experience because of social, economic, environmental, and other circumstances.
Poor Health Outcomes and Persistent Disparities Are a Result of Social Inequities
The disparities seen in health and health care among U.S. racial, ethnic, and other minority populations reflect the complex interplay of power and politics. Disparities refer to differences between population groups that share similar characteristics, such as age, race/ethnicity, socioeconomic status, geography, gender identity, sexual orientation, and disability status (Artiga et al., 2020). Health inequities experienced by certain populations are mostly attributed to SDOH. The World Health Organization (n.d., para. 1) defines SDOH as, “the conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels.” Addressing SDOH goes beyond dealing with individual circumstances to dealing with social structures, institutions, and policies that afford some populations advantages, often referred to as privilege, and leave other populations on the margins of society experiencing pervasive disadvantages.
The County Health Rankings model (University of Wisconsin Population Health Initiative, 2018) depicts the many factors that impact population health and are the focus of efforts to improve health by addressing the systemic factors that drive health outcomes. A key point illustrated in the data-based model is that health outcomes are influenced most by contextual factors. Health outcomes are measured equally as length and quality of life in the model. The modifiable drivers of health comprise four categories: (a) health behaviors, (b) clinical care, (c) social and economic factors, and (d) the physical environment. The influence of these four factors on health outcomes has been determined to be 40% for social and economic factors, 30% for health behaviors, 20% for clinical care, and 10% for the environment.
The focus of this discussion is disparities that are avoidable and, therefore, considered unjust because they represent an inequality (Whitehead, 1991; WHO, n.d.). Equality is a quint-essential American value. Equality is frequently likened with equity, but they are not the same. Equality is an aspirational outcome. An equity approach (or process) is needed to achieve equality. An equity approach is characterized by assuring that those who have the least get the most instead of everyone receiving equal portions or treatment. According to the Robert Wood Johnson Foundation ([RWJF], n.d.a):
Health equity means that everyone has a fair and just opportunity to be as healthy as possible. To achieve this, we must remove obstacles to health—such as poverty, discrimination, and deep power imbalances—and their consequences, including lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care.
This definition comes from a prior RWJF–commissioned paper (Braveman et al., 2017).
COVID-19 Pandemic Highlights Longstanding Disparities
African American individuals are more likely to be uninsured, unemployed, have fewer years of formal education, be incarcerated, lack access to health care services, have less wealth and lower median household income, and not own their home than their White counterparts (Assari, 2018; Hanks et al., 2018; Luhby, 2020; Sharkey et al., 2020). The COVID-19 pandemic further reveals and exacerbates long-standing disparities experienced by African American individuals. Across the country, fewer African American individuals have been tested for COVID-19, more have been hospitalized, and more are dying. In mid-April 2020, 2,002 African American people represented 54% of the population in Shelby County, Tennessee, but 70% of the COVID-19 cases and 71% of deaths (Weathersbee et al., 2020). A similar pattern was seen in Chicago. African American people represent 32% of the population and 67% of the deaths attributed to COVID-19 (Thebault et al., 2020).
What explains these differences? Differences seen in the seriousness of infections and deaths were first attributed to underlying health and economic conditions (Koma et al., 2020). Underlying conditions, including diabetes, hypertension, and obesity are the most common comorbidities for COVID-19. These comorbidities are more prevalent among African American individuals than among other racial and ethnic groups (Koma et al., 2020; Richardson et al., 2020). Among African American individuals ages 50 to 64 years, 61% have hypertension compared with 41% of White American individuals. The rates for diabetes are 23% and 14%, respectively, and 43% and 33% for obesity (Centers for Disease Control and Prevention, n.d.). Lower household income, as well as lack of insurance, imposes greater COVID-19 risk (Koma et al., 2020). However, the underlying conditions are only the tip of the iceberg.
Racism, Not Race, Must Be Addressed
For decades, race has been cited as a health determinant. However, it is racism, not race, that imposes a negative burden on health and causes disparities among Black and other minority populations. People of minority populations have a greater exposure to traditional stressors, such as unemployment and psychosocial distress due to discrimination, as well as unequal access to health care and the social services and environments that can positively impact health outcomes and reduce disparities (RWJF, n.d.b).
Discrimination is a risk factor for disease and a contributor to racial disparities (Williams et al., 2019). Discrimination refers to unequal treatment based on physical characteristics or social group assignment. Discrimination is an action, or absence of action, that can be intentional or not, and occurs at the individual or institutional level (Davis, 2020).
Discrimination affects mental health, indicators of physical health, health behaviors, use of health services, and adherence to treatment plans (Davis, 2020; Shattell & Brown, 2017). Discrimination, or even the anticipation of discrimination, can exacerbate stress. This stress is linked to mental health issues, including anxiety and depression (American Psychiatric Association, 2016; Shattell & Brown, 2017).
Discrimination can occur at individual and institutional levels. Institutional racism is defined as, “the structures, policies, practices, and norms resulting in differential access to goods, services, and opportunities of society by race” (Jones, 2002, p. 10). Structural and systemic racism are terms akin to institutional racism. Institutional racism exerts health effects through three mechanisms: psychological stress, access to health and social services, and bodily harm (Davis, 2020).
Linking COVID-19 Disparities and Police Killing of African American Individuals
The killing of George Floyd and the protests that ensued are the result of a confluence of pent-up distress. Three factors placed a disproportionately heavy burden on African American individuals. African American individuals died from COVID-19 at higher rates than other American individuals and experienced economic consequences more acutely. Police killings are another factor. According to the Mapping Police Violence (2020) website, Black American individuals are three times more likely to be killed by police than White American individuals. Lastly, the sharp political divisions in the country and an uptick in overt racism fueled discontent and distress (Horowitz et al., 2019).
The COVID-19 pandemic provides an exemplar of health disparities, their origins in factors that can offer advantages or impose disadvantages on populations, and why upstream interventions are an imperative. The undue burden of the pandemic on Black American individuals and the killing of George Floyd have similar roots. Both require systemic change.
Nurses Must Lead in Promoting Changes Needed to Address Inequities
Addressing social needs and individual problems is a hallmark of good nursing care. However, these efforts will perpetually fall short if we neglect to look at the power dynamics and political and other forces that create situations whereby certain populations have greater unmet needs. These unmet needs impede the attainment of better health and access to equitable health care and a just society. It is important that nurses be leaders in improving health and health care and meeting the needs of marginalized populations through health care system and social changes. Nurses are well-positioned to consider the needs and issues faced by populations with poor health outcomes, consider the specific circumstances of individuals and populations, and address the issues associated with where people live, work, and play
The disparities seen in the incidence, care received, and death rates related to COVID-19 among populations of color and the treatment of George Floyd and other African American men and women resulting in death are signs of systemic racism. In his book, How to be an Anti-Racist, Dr. Ibram Kendi (2019) makes the case that the root of social inequities on display during the COVID-19 pandemic and the police treatment of Black American individuals is power and politics. Improving health outcomes and reducing health care disparities will require systemic change. Addressing social determinants of health is essential and requires addressing major systemic social factors that have a major impact on health and are outside of the health care system. Addressing social determinants of health requires political will and the resources and skills to be effective in changing power and political dynamics.
The American Nurses Association (2015) Code of Ethics obligates nurses to stand-up in opposition to social inequities that are the root of health disparities, and, furthermore, to change the social conditions at the root of inequities. There is a Twitter debate as to whether nursing is a political endeavor. Of course, it is, given that policy shapes health, health care, and nursing practice. Policy is forged in a political environment that must be acknowledged to understand and change policies to address the social conditions that impact health, either positively or negatively (Weitzel et al., 2020). It is distressing that basic human value and dignity have been politicized. However, to honor the value and dignity of people, nurses must be political to advance policies that support equity and health. Direct care of individuals and communities alone will not ameliorate decades of inequities.
Personal and societal racism have been codified into institutional and public policies. Nurses must lead in dismantling policies that perpetuate racial and other disparities and strive for policies that promote equity at the systemic level. What are some specific actions individual nurses can use? A primary action is to be informed about the impact of SDOH and the need for systemic change. Nurses should commit to improving SDOH, in addition to meeting the social needs of patients. To produce systemic change, nurses must embrace policymaking. First and foremost, nurses need to be actively engaged and informed voters. Nurses should align themselves with and actively promote enlightened policy changes and champions who promote improved health and reduction of disparities. A good starting point is access to high-quality, cost-effective, person-centered care and services that improve outcomes.
Nurses need to seize opportunities to be strong leaders in upholding and advancing equity, science-based and person-centered care, personal dignity and accountability, sustained quality improvement efforts, the transformation of the delivery of health care, and cultural respect at the bedside and policymaking arenas. Now is the time!
Carole R. Myers, PhD, RN, FAAN
University of Tennessee
College of Nursing & Department of
- American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. https://www.nursingworld.org/practice-policy/nursing-excellence/ethics/code-of-ethics-for-nurses/coe-view-only
- American Psychological Association. (2016). Stress in America™: The impact of discrimination. https://www.apa.org/news/press/releases/stress/2015/impact
- Artiga, S., Orgera, K. & Pham, O. (2020, March4). Disparities in health & health care: Five key questions & answers. https://www.kff.org/racial-equity-and-health-policy/issue-brief/disparities-in-health-and-health-care-five-key-questions-and-answers
- Assari, S. (2018). Unequal gain of equal resources across racial groups. International Journal of Health Policy Management, 7, 1–9 doi:10.15171/ijhpm.2017.90 [CrossRef] PMID:29325397
- Braveman, P., Arkin, E., Orleans, T., Proctor, D. & Plough, A. (May01, 2017). What is health equity?https://www.rwjf.org/en/library/research/2017/05/what-is-health-equity-.html
- Centers for Disease Control and Prevention. (n.d.). African American health. https://www.cdc.gov/vitalsigns/aahealth/index.html
- Davis, B. (2020, February25). Discrimination: A social determinant of health. https://www.healthaffairs.org/do/10.1377/hblog20200220.518458/full/
- Hanks, A., Solomon, D. & Weller, C. E. (2018, February21). Systemic inequality: How America's structural racism helped create the Black-White wealth gap. https://www.americanprogress.org/issues/race/reports/2018/02/21/447051/systematic-inequality/
- Horowitz, J. M., Brown, A. & Cox, K. (2019, April9). Race in America 2019. https://www.pewsocialtrends.org/2019/04/09/race-in-america-2019/
- Jones, C. P. (2002). Confronting institutional racism. Phylon, 50(1), 10.
- Kendi, I. X. (2019). How to be an antiracist. One World.
- Koma, W., Artiga, S., Neuman, T., Claxton, G., Rae, M., Kates, J. & Michaud, J. (2020, May7). Low income & communities of color at higher risk of serious illness if infected with coronavirus. https://www.kff.org/coronavirus-covid-19/issue-brief/low-income-and-communities-of-color-at-higher-risk-of-serious-illness-if-infected-with-coronavirus/
- Luhby, T. (2020, June3). US black-white inequality in 6 stark charts. https://www.cnn.com/2020/06/03/politics/black-white-us-financial-inequality/index.html
- Mapping Police Violence. (2020, November11). Black people are the most likely to be killed by police. https://mappingpoliceviolence.org
- Richardson, S., Hirsch, J. S., Narasimhan, M., Crawford, J. M., McGinn, T. & Davidson, K. W.Northwell COVID-19 Research Consortium. (2020). Presenting characteristics, comorbidities, & outcomes among 5700 patients hospitalized with COVID-19 in the New York City area. Journal of the American Medical Association, 323, 2052–2059 doi:10.1001/jama.2020.6775 [CrossRef]
- Robert Wood Johnson Foundation, (n.d.a). Defining health equity. https://healthequityguide.org/about/defining-health-equity/
- Robert Wood Johnson Foundation. (n.d.b). Race, racism, & health: Examining the connections between race, racism, & health in the United States. https://www.rwjf.org/en/library/collections/racism-and-health.html
- Sharkey, P., Taylor, K.-Y. & Serkez, Y. (2020, June19). The gaps between White and Black America, in charts. https://www.nytimes.com/interactive/2020/06/19/opinion/politics/opportunity-gaps-race-inequality.html
- Shattell, M. & Brown, P. (2017). Black mental health matters: What nurses need to know about chronic stressors of people of color. Journal of Psychosocial Nursing and Mental Health Services, 55(9), 3–5 doi:10.3928/02793695-20170818-07 [CrossRef]
- Thebault, R., Tran, A. B. & Williams, V. (2020, April7). The coronavirus is infecting & killing black Americans at an alarmingly high rate. https://www.washingtonpost.com/nation/2020/04/07/coronavirus-is-infecting-killing-black-americans-an-alarmingly-high-rate-post-analysis-shows/?arc404=true
- University of Wisconsin Population Health Initiative. (2018). 2018 county health rankings key findings report. http://www.countyhealthrankings.org/explore-health-rankings/rankings-reports/2018-county-health-rankings-key-findings-report
- Weathersbee, T., Douglas, D. & Thomas, W. C. (2020, April10). Why is COVID-19 cutting a lethal swath through black Shelby County? And how can it be stopped?https://www.commercialappeal.com/story/news/2020/04/11/covid-19-african-americans-shelby-county-memphis/5134096002/
- Weitzel, J., Luebke, J., Wesp, L., Graf, M. D.C., Ruiz, A., Dressel, A. & Mkandawire-Valhmu, L. (2020). The role of nurses as allies against racism and discrimination: An analysis of key resistance movements of our time. Advances in Nursing Science, 43(2), 102–113 doi:10.1097/ANS.0000000000000290 [CrossRef] PMID:32345799
- Whitehead, M. (1991). The concepts and principles of equity and health. Health Promotion, 6(3), 217–228 doi:10.1093/heapro/6.3.217 [CrossRef]
- Williams, D. R., Lawrence, J. A., Davis, B. A & Vu, C. (2019). Understanding how discrimination can affect health. Health Services Research, 54, 1374–1388 doi:10.1111/1475-6773.13222 [CrossRef].
- World Health Organization. (n.d.). Social determinants of health. https://www.who.int/social_determinants/sdh_definition/en