A longstanding failure of the U.S. health care system is that minority and vulnerable populations experience poorer health outcomes and higher death rates. The Covid-19 pandemic and other public health emergencies extend and deepen this failure.
Some see this as a symptom that the country needs more health professionals, especially in the context of looming shortages of primary care and other clinicians. But just adding more clinicians won’t solve this vexing issue. What we need is a health care workforce that has been trained to not only understand that social determinants — things like access to healthy food, a safe place to live, access to health services, and the like — have important effects on health but are able to respond to them.
The impact of social and economic determinants on public health crises is not new. We saw it during Hurricane Katrina in August 2005 and the influenza A (H1N1) pandemic that began in January 2009. But the uncertainties about the transmission of Covid-19 and appropriate diagnostics and therapies present new challenges.
To date, the best strategies to prevent or combat SARS-CoV-2, the virus that causes Covid-19, are influenced by structural inequalities. People in minority groups often live in more densely populated areas and have more people per household, making it difficult to follow social distancing recommendations. They also disproportionately work jobs currently considered essential, and without the luxury of working from home may be at higher risk of exposure to the virus.
How health professionals are educated reflects the investment our society places in improving public health and preventing societal injustices. That’s why educational institutions need to increase their capacity to convey the importance of addressing the social, physical, and environmental factors that determine health and how providers can use their expertise and influence to advance the health of individual patients and communities. It is vitally important that educators show trainees the proximity of these social inequalities and stress their capacity to improve them.
Recognizing the relationship between homelessness and Covid-19, for example, does not explain the most effective method of reducing the transmission of Covid-19 among the homeless population. We know individuals experiencing homelessness and insecure housing cannot practice safety measures, but that’s not enough. Health professionals should have the ability to advocate for a foreclosure and eviction moratorium for single family homeowners and offer mobile public health services to make sure health screening, education, and support services reach unsheltered individuals.
For years, medical schools have largely followed the same format for teaching students: two years of basic science curricula combined with an additional two years of rotations in clinical settings. This approach teaches individuals how to think and solve problems, but the emphasis is on individuals and disease states. While this is a foundational component of becoming a physician, it is not sufficient.
We need to offer future providers more training on how to manage the health of populations and the disparities that influence their health and well-being. We believe education must be rooted in the concept of social mission. There are undoubtedly many ways to do this. One we are familiar with is the Beyond Flexner Alliance, a national movement committed to social mission for which one of us (I.C.) is an unpaid volunteer board member. The alliance focuses on training health professionals as agents of more equitable health care. This movement takes us beyond old conventions and trains health professionals to build a system that is not only better, but fairer.
This could be illustrated by third-year year medical students being required to deliver treatment plans that include social determinants of health on the list of factors that affect the health of their patients. For vulnerable populations experiencing the Covid-19 pandemic, for example, asking standardized questions during a history and physical examination is not enough. You may be able to explain the nature of disease by asking these simple questions, but not what puts someone at risk of serious illness or death. Students should be taught how to broaden their focus to include the patient’s values and social constructs, while using a team-based approach. The education of health professionals needs to allocate more resources that prepare them to understand and respond to the pandemic. This will not only provide immediate enhancement to students’ learning but prepare them to be better providers for future generations.
Before medical students graduate to residency programs, they take two medical licensing examinations that evaluate their ability to apply knowledge, concepts, and competencies that are important to the health of individuals and communities. But these examinations focus mainly on concepts of science basic to practice of medicine and offer little in the way of assessing students’ understanding of the root causes of socioeconomic determinants and their implications on health and cost. Board certifications and continuing medical education should be held accountable for their commitment of preparing providers that can adapt to the ever-changing society.
Modifications of medical curricula are largely influenced by oversight bodies and educators’ perceived value of including social inequalities in their curriculum is guided by these accrediting institutions. The Liaison Committee for Medical Education and its sponsoring organizations institute benchmarks based on peer assessments, with the ultimate goal of improving academic quality. Accreditation bodies remain a cornerstone for establishing the standards, at minimum for the priorities that the health care system measures. Yet accrediting organizations are not focusing on broader approaches that address social, economic, and environmental factors that influence health.
A number of educational institutions and organizations have committed to fortifying their contributions to health equity. A.T. Still University of Health Science, for example, partnered with the National Association of Community Health Centers to train physicians to help fill the anticipated needs for community health care providers. At the ATSU School of Osteopathic Medicine in Arizona, students spend their second through fourth years in one of 11 community campuses nationwide based in community health centers. Advances like these and others are promising but represent only a fraction of the commitment needed to address the scope of change.
The long-term solution will, of course, take multilevel efforts across all major health care institutions, not just the educational system. Nevertheless, the goal of all educational institutions should be to graduate competent providers who do not simply treat patients but recognize and address the barriers that hinder their patients’ ability to attain their full health potential.
How would our nation look now had its health care workforce been trained and empowered to address the individual and systemic inequalities that have obstructed its ability to provide high-quality care? Perhaps more physicians would have recognized that their patients drove buses or worked as cashiers in grocery stores, propelling them to navigate resources for obtaining personal protective equipment for them. Perhaps more physicians would have recognized that their patient’s occupation, ZIP code, and income level contributed to their being hospitalized for Covid-19, ultimately helping provide better preventive measures.
As public health emergencies continue to arise, the challenge for newer members of the healing professions becomes clearer: They must master the art of providing evidence-based care while understanding the complexities of social determinants and how they lead to health disparities and inhibit the quality of care. Yet they cannot accomplish this task without being equipped with the proper tools. We must provide students with the training, skills, and support they need to take this agenda forward.
The purpose of education is knowledge not merely of truths but also of values. There may be moments in our lifetime when we feel helpless to prevent the inequalities and injustice in our society, but there must never be a time when we fail to try to overcome them.
Jamar Slocum is a general preventive medicine fellow at the Johns Hopkins Bloomberg School of Public Health. Isabel Chen is an Instructor of health system science at Kaiser Permanente School of Medicine. Natalie Kirilichin is an assistant professor of emergency medicine at the George Washington University Department of Emergency Medicine.