Cara Lichtenstein, MD, MPH, Discusses Social Determinants of Health as Part of Lecture Series

September 14, 2020
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The first in a series of lectures on anti-racism, racism, and health disparities -- hosted by the George Washington University School of Medicine and Health Sciences (SMHS) Anti-Racism Coalition -- kicked off on Sept. 1 with a discussion from Cara Lichtenstein, MD, MPH, associate professor of pediatrics at SMHS, discussing “Understanding the Connection Between Racism and the Social Determinants of Health.”

Lichtenstein began her talk by asking the listeners to come up with their own definitions for four words: bias, prejudice, discrimination, and racism.

Bias, she explained, is a preference in favor of, or against, a person, group of people, or a thing. Prejudice is a preconceived judgment or attitude about another person or group of people that is based on stereotype.

Discrimination, she said, is an action or behavior based on prejudice. And racism is the systemic conditions that provide some people more consistent and easier access to opportunities based on perceived race or ethnicity; it’s commonly defined as prejudice plus power, she said.

Lichtenstein went on to talk about how race is a social construct and does not biologically exist. It was a concept, she explained, that came into existence early in America’s history in an effort to justify the enslavement of African people and the destruction of Native American societies. 

“Nonetheless, although race has no genetic or scientific basis, the concept of race is important and consequential because as a social construct it has been used  to establish and justify systems of power, privilege, disenfranchisement, and oppression,” she said. 

Much of Lichtenstein’s presentation focused on helping attendees gain a deeper understanding of how structural racism has led to social determinants of health.

One example of how racism can negatively impact a person’s health is through chronic stress, Lichtenstein noted.

“Prolonged chronic stress leads to increased and prolonged levels of exposure to stress hormones and oxidative stress at the cellular level. Prolonged exposure to stress hormones such as cortisol leads to inflammatory reactions that predispose individuals to chronic disease through dysregulation of the immune, endocrine, and circulatory system,” she said. 

Widespread damage from chronic stress also can lead to modification of DNA in the cells, she added, which then can change gene expression and be passed on over time.

Lichtenstein also spoke to how high incarceration rates in Black communities can have negative health impacts not only on those individuals and their families, but also on their neighborhoods.

“Although Black people make up about 13% of the U.S. population, they represent almost 40% of the prison population,” she said. “How did that come to pass? If we go back to the in 1970s and ’80s and the war on drugs and tough on crime mentalities, you can see laws that disproportionately target Black people for incarceration that left a legacy where Black Americans are incarcerate at more than five times the rate of white Americans.”

Incarcerated individuals, she added, have increased prevalence of infectious diseases such as HIV and Hepatitis B, and increased prevalence of substance abuse and mental health disorders.

She also discussed ways income affects health. Higher incomes allow people to afford a healthy diet, access to a gym and safe places to exercise, and the ability to afford housing in a healthy neighborhood.

However, lack of income may cause problems when it comes to access to transportation, childcare, job security, and food and housing. “That all can lead to increased stress, and we saw earlier on in this presentation what increased stress can do to health,” Lichtenstein said. 

Income inequality also has grown substantially in the past decades, she noted. The median household income for Black families trails that of all other races, she said, and when it comes to net worth, Black families have 10 cents for every dollar of wealth held by white families.

Last, Lichtenstein also spoke about the importance of neighborhood environment, noting that where we live has an effect on our health even at the most basic level. 

“Access to healthy food can be dependent on where you live. I’m sure many of us are familiar with the term ‘food desert,’ an area where there is low access to healthy and affordable food, but ‘food swamps’ are becoming more of a problem. A food swamp is an area inundated with low-quality, fast food options. Being exposed to either of these makes healthy food choices beyond difficult,” she said.

Lichtenstein ended with ways the health professions can help to end structural racism and the health disparities that creates. “Educational series like these are a great first step, but there is more work to be done. Integrating this kind of education longitudinally throughout all of medical school training will have a lasting effect,” she said. “In addition, clinicians can implement systems in their practices that ensure all patients and families know they are welcome, they will be treated with mutual respect and that high-quality care will be delivered regardless of background.” 

She added that we should aim to recognize and name racism in our own work and interactions, which will advance understanding of the distinction between race and racism and allow for efforts to combat racism. 

Lichtenstein was part of a fall educational series sponsored by the Anti-Racism Coalition, which is housed within the SMHS Office of Diversity and Inclusion. Find out more about the coalition and upcoming talks

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