Social Work Practice and Achieving Health Equity Podcast

Editor's note: This text-based course is a transcript of the Social Work Practice and Achieving Health Equity Podcast, presented by Judy Barnstone, MSW, PhD LCSW, LISW, and Benjamin T. Bencomo, DSW LISW, LCSW.

Learning Outcomes

• After this course, participants will be able to:
  • Define social determinants of health.
  • Identify how social determinants of health are tied to health disparities.
  • Determine how social workers can work with individuals, families, and communities to achieve health equity.

Dr. Bencomo: I am Dr. Ben Bencomo, and welcome to this Continued Social Work Podcast. I am very excited for our conversation today. Today's topic is social determinants of health and wellbeing, and I am joined by my good friend and colleague Dr. Judy Barnstone. Dr. Judy Barnstone is an associate professor of social work at the Facundo Valdez School of Social Work at New Mexico Highlands University, where she is been teaching macro social work courses in the areas of research, policy and political advocacy for more than 14 years. While much of her work has been focused on government sponsored social welfare programs like SNAP and Medicaid, her passion is for prevention and the promotion of health, mental health, and wellbeing through community level and government interventions.

She recently authored a report entitled, "Health In All Policies for New Mexico”, a review of social and economic policies that can promote healthy development by addressing the social determinants of health. Dr. Barnstone, thank you for joining me for this conversation today and for sharing a little bit about your work and experience. I'm excited to have this conversation with you today.

Dr. Barnstone: I'm glad to have it too. 

Dr. Bencomo: Dr. Barnstone, can you begin by giving us a little bit of background in terms of your path to social work and a little bit about your practice and research history and how you became interested in looking at how environmental factors in particular influence overall health and wellbeing?

Dr. Barnstone: Sure. I can give a little bit of background. Really it is many different experiences and learning opportunities I have had that pushed my focus towards the macro, but I actually began my social work career as a medical social worker. And I was working in primary healthcare in the 1990s. We were kind of ahead of the curve and I was asked to come in and help support people who had chronic health conditions, like diabetes or lung disease, people recovering from heart attack. And what I saw was that the factors that placed people at risk for those health conditions before their medical crisis, persisted even after their treatment, which made recovery and behavioral change hard. They were still living in the same circumstances that placed them at risk to begin with.

I moved from there onto my doctoral work, where I focused on health decisions, decisions about condom use, for instance, and I was really focused on the cognitive aspects. Like, what do people know? What do they think? What do they believe? And in my work I realized I did not actually have the language for it then, but now I do. I learned that our choices, our health behaviors are bound by our chances. Again, what is going on outside of the person's decisions, like what is influencing it? After I finished my doctoral work, I started teaching policy. I actually, when I first moved to New Mexico, I was teaching in a place, I was living in a place that didn't have a school of social work at the time, which is Albuquerque.

Has one now, it is where I work. But I started teaching in the department of sociology. And I was asked to teach classes in social problems, which are about the disparities that we see in the incidence of problems at the community level. And I taught a class in social epidemiology, and those experiences really made me want to find the bridge between the systemic and structural factors and health and wellbeing. So I started doing a lot of reading about it. I thought I would create an elective at our school of social work. I watched an excellent film series, which is getting a little old now, but still completely relevant. It is called "Unnatural Causes: Is Inequality Making Us Sick". And I think it just really opened my mind to how social and economic policy, environmental policy and educational policy can all influence health. So, like I said, it is kind of been a whole career in the making for me.

Dr. Bencomo: Absolutely. Yeah, absolutely. That is really interesting. I love the way you put that, our choices are determined by our chances. I know that I have often had the conversation with my own students in class about how environmental factors impact our ability and our access to power and privilege. But I think that is a very profound way to put it. I may use that way of putting that in the future, but I promise I will give you credit for it.

Dr. Barnstone: Oh, I was going to say it does not come from me. It comes from the field of the social determinants of health, this idea that our life chance, our life choices are determined by our life chances. So I did not make it up but I grabbed onto it as well. It is a powerful phrase.

Dr. Bencomo: Absolutely. Absolutely. So, along with that, you introduced the term social determinants of health. If you could, what does that term, that terminology, what does social determinants of health mean and what are included when we say social determinants of health?

Dr. Barnstone. If I take a step back, for a long time, it was assumed that health was an outcome of our genetics, right? That is like our parents' generation. That is what they believed. I am destined to have heart disease cause my mother had heart disease. Later, we started talking about health behaviors, nutrition, exercise, substance use, and so on. But now we really understand that these behaviors, as we just talked about, life chances, life choices, it depends on our environments. So the social determinants of health are conditions of living. It is how and where we live. It is the circumstances of our lives that affect our health, our mental health and children's development. So the resources, opportunities, hazards that are present in our environment.

And I will just take a little detour to say that there is a tendency of health providers to think that if they refer to social work, to get someone on SNAP or to help them find transportation, they've addressed the social determinants of health. But the social determinants of health are actually way more upstream than that. And so I might use the stream metaphor, health problems occur downstream, but upstream, we have the social determinants of health. And this includes access to all kinds of things, access to medical care. That is what people tend to think of first, access to health insurance to pay for medical care, access to accurate health knowledge. But it also includes access to healthy nutrition and other resources to meet needs, access to education, which helps us consume information, opens doors of opportunity for us particularly related to employment and helps us critically think about our health, right?

So quality education and job training, and related to that employment opportunity, the kinds of jobs that are available to us, but also the safety of our workplaces. And we will go into a little more detail about what that means, but our workplaces can, they can be sources of stress, but there can actually be hazardous equipment for instance, or just a high risk of accidents, for instance. So employment opportunity and safe workplaces, access of course, to adequate income and the chance to accumulate wealth. I think the pandemic we can talk about later, but I think it is really highlighted how much having a cushion is important to health and wellbeing. Affordable housing, quality housing, safe neighborhoods, these are all social determinants of health.

Safe opportunities for recreation, for exercise, for stress management and then the social environment, social connection and support. So access to those things and the converse of that are the absence of hazards. So the social determinants of health include pro-health factors as well as factors that work against health hazards. So physical hazards like poor quality air, water, toxins in the land, extreme weather and climate events, I know up where you live, you are worried about fires, that is a health hazard. And so we could talk about that as well. The pandemic has highlighted the role of infectious agents in our physical environment as well. So physical hazards, but also in our environment, chronic and acute stress and arousal.

Violence, which exposes us not only to distress, but the risk for injury and death, and then discrimination in our environment, which can place not only increased stress, but place barriers before us every step of the road in terms of education, healthcare, justice system, money lending, employment, you know about this. So those are some of the social determinants and we could take this idea of environment in terms of resources and hazards like even a step, excuse me, further, the folks who write about the social determinants of health often break it down into the physical environment, the social environment, the built environment and the service environment. So in the physical environment, that is where we can put that water, land, air, temperature, weather.

In the service environment, this is our grocery stores, our healthcare services. Sanitation, like sanitation is a health factor, right? Public safety. And what is available for sale in our community, not just grocery stores, but in New Mexico we have just legalized the retail sale of cannabis. But even before that, we had retail sale of alcohol, vaping products, cigarettes, those are social determinants. So that is the service environment. The built environment are those things that we put in our environment. So our parks, our sidewalks and walking trails, street lights, shade, there is this growing body of research that I am fascinated by that shows disparities within the same city in shade and temperature. The average difference in temperature between resourced neighborhoods, filled with people earning higher incomes and lower income neighborhoods and neighborhoods where people of color are concentrated, seven degrees difference in one city.

And so on average, in some cases, 10, 15 degrees difference between one neighborhood and another in the same city and it has a whole lot to do with shade. And if you think about the people that are in those hotter neighborhoods, they may also be the people who have less sufficient heating and cooling and ventilation. And so it is a real health hazard. So there is the built environment, parks, trails, street lights, shade, the quality of our housing, whether we have carbon monoxide, whether we have asbestos in our houses, lead paint still on the walls. So that is our built environment. And then there is that social environment where violence can happen, but also where people can support one another, where discrimination can happen, but also where people can empower one another. So that was a really long answer to a short question, but those are the social determinants health. Basically everything but what you inherited from your parents. So yeah. Long answer, sorry.

Dr. Bencomo: No, no, no, no, thank you. I think that is an important answer. We often have the conversation and looking at people's overall health and wellbeing and we go upstream a bit. We may talk about access to healthcare, I think that is more and more, that is a part of our national conversation, but then how much farther upstream, to piggyback on your metaphor, do we actually go. And when we look at this, and we look at all these different social circles and spheres of influence in the environment, it is important to realize that almost every, like you said, almost every aspect of our lives impact our overall health and wellbeing. And I don't know that I had ever really fully given much thought to what all can be included when we talk social determinants of health.

Dr. Barnstone: Along with that, Dr. Barnstone, why are social determinants of health important? Why is this conversation so important for us? And specifically, why are social determinants of health so important as a social work issue?

Dr. Barnstone: Well, let me take the first part first. Why are social determinants of health important? And you talked about healthcare access, or I had talked about it and you acknowledge this focus on healthcare access. Well, if we focus only on healthcare, think about who accesses healthcare. It is primarily people with a health condition. And by then people are already suffering under the weight of their health condition. So I gave you the downstream upstream metaphor for getting at predisposing factors. There is a metaphor I really love and I talk about it in like every class I teach, every presentation I give. Dr. Camara Jones who used to be at the CDC, I think she is at Harvard now, she talks about the cliff of good health.

And it is a great analogy for me when I think about why are social determinants of health important? She notes that so much of our health system is focused on treating people after they get sick. And so if you can imagine a cliff, right, and people are on top of this cliff and they fall over into a medical crisis, whether it is lung disease, heart disease, diabetes, or a behavioral health condition like addiction or major depression. So you have people at risk, and we tend to catch people when they have a real crisis. And so Camara Jones imagines that as an ambulance catching people down, once they have fallen off the cliff, they are down, they have crashed, they have broken some bones and then we start helping them.

In fact, we can apply this to social conditions of living as well, like homelessness, chronic unemployment. We help people after they are in that situation. We have got the ambulance, it is that tertiary care, if you think of it, the ER, the hospital care. We sometimes are able to catch people after they fall off the cliff. And that is when someone's got the first warning signs of a heart attack or they have suffered their first DUI or something. And so we start intervening then, right? We have primary healthcare at the top of the cliff making a fence that keeps us from falling over. But even that requires that we identify, okay, which of you are most at risk. Let us send you to the dock, making sure that you get your routine screenings and your preventive medications and so on.

What Camara Jones says we should be doing is moving everybody away from the edge of the cliff and focusing on prevention by investing like in whole groups of people, rather than helping people one at a time. And so the CDCs research shows that 97% of all health and mental healthcare dollars are spent on treating conditions, less than 3% is spent on prevention. And so that is why it is important. We could prevent suffering if we invest in moving whole communities, which is a community level intervention, but whole communities away from the edge of the cliff. So I like that metaphor. Sometimes you hear the root tree branch metaphor, growing healthy communities grows good health and the leaves and the flowers out at the branches. But I really grab onto that cliff metaphor. So the second part of your question was about social work, is that right?

Dr. Bencomo: Yes. So the second part is why are social determinants of health a social work issue? Why should we as social workers be having this conversation and be focusing on these social determinants of health?

Dr. Barnstone: Absolutely. So there is a number of reasons. It is in our code of ethics to promote social welfare and wellbeing, and to advocate to improve social conditions and expand opportunity. That is a community based intervention and that is what is tied to the social determinants of health and wellbeing. So it is in our code of ethics that we should be advocating to improve social conditions. And I just highlighted some of the ways in which they can be different. It is also part of our values, our social work principles in the code as well to promote social justice and equity. And I am going to talk a little bit about this idea of health equity, the equal chance for healthy lives, right? And that is a social work principle or value, equity.

We also are super well positioned. I sit in a lot of meetings with public health practitioners on the one side and clinical practitioners on the other and social works in between, right? So we are well positioned to find the connection between the person and the environment. It is what guides everything we do, right? So we are well positioned, but we also have the skills. We have the research and assessment skills. We are good at networking and relationship building, which is how you get change made. We are good at communication. We are good at advocacy and all of that can be used to promote change. 

But if we think about Camara Jones cliff, if we improve our environments, it is preventive So would you rather treat someone who's experienced a lot of trauma, loss, suffering, hardship or would you like to prevent that person from experiencing that in the first place? And so I think while it is not explicitly, prevention is not explicitly in the code of ethics, at least not in my memory, maybe I am forgetting it, but I think prevention is part of what we value as well. So those are some reasons why I think it is a social work issue.

Ben Bencomo: Oh my gosh, in every way. Yes, absolutely. Thank you for sharing that. So I know that often in our classrooms with social work students will have the conversation about environmental factors, right? We talk about systems theory. We talk about the person in environment approach. With that in mind, can you explain maybe some of the different pathways through which social determinants of health affect health?

Dr. Barnstone: Sure. There are several pathways that I usually break down when I talk about this. Environmental hazards, which I have touched on, health behavior, stress, development and discrimination. So I will take a few minutes if that is okay to talk about each of those. So environmental hazards, toxins in the air, it increases the likelihood of childhood asthma, which increases the likelihood of adult lung and health problems, right? It is pretty obvious. 

This is a traditional public health model, focus on the vectors and the hazards and the environment. So there is environmental poor quality water. I was in a meeting just yesterday. I serve on this public health task force and they were talking about in Southern New Mexico in the borderlands, how many people lack regular access to clean water.

It is critically important for health. We saw that in the pandemic, in terms of even just washing up, right? So, anyway, air, water, soil quality, which affects the quality of our food, infectious agents, climate, like I mentioned. This idea of connecting social work to the social determinants of health or traditional social work practice, clinical practice, I read a study that was done in England, which found that those who had experienced flooding had four times the rate of poor mental health compared to those who did not. Four times, and that was trauma symptoms, depression, and anxiety. 

So climate, there is a growing interest in environmental justice and environmental action as a way to promote health. Environmental hazards is one pathway. It is the obvious pathway. It affects people's health. It affects children's development. Health behavior, which is really a critical part of this. We need to have access to affordable and nutritious food, which requires access to full service grocery stores. I do not know if you have heard the phrase food deserts. I cannot remember the number, I have it somewhere, but it is something like, I do not want to say the wrong number, it is something like three quarters of our counties in New Mexico. The people who are listening to this may not know New Mexico is so rural, but something like three quarters, and I made that number up. Three quarters of the population of New Mexicans are in a food desert, meaning that they have to travel a distance greater than one mile in an urban area, greater than 10 miles outside of that to access groceries.

How are you going to eat well, if what you have got is a seven 11. It is going to be a lot harder. You are going to have to spend a greater percentage of your money on transportation, on gas, and gas prices are high right now to get to a store, assuming you have a working car, and then you are going to have less leftover to buy fresh produce, which is not subsidized the way a lot of our unhealthy foods are through our farm bill. So health behaviors, which is about food access and safe places to exercise. If there is a lot of violence in your neighborhood, you are not going to go outside and go jogging in it, right? Especially if you are a person of color in a neighborhood where that is a target population, right?

So for violence or crime; health behavior, safe places to exercise, relieve stress, recreation, access to information and the opportunity for empowering experiences. I said it before, our life choices depend on our life chances. In health behavior, there is health promoting behavior. Like those, I talked about healthy food, exercise or a non-sedentary lifestyle. 

There are also health risk behaviors; driving without a seatbelt or riding your bike without a bike helmet, and obviously cigarette smoking and vaping, heavy alcohol use and use of other substances. So environmental hazards, health behavior, and then stress. And this is the one I think, like I gave a presentation to our legislature on this, and it was the one thing I got a lot of questions about, is stress.

Stress has been found to be as harmful as smoking for lung and heart health, which I am not sure that people have heard that before. So what stress does, like think of how you feel when you are out hiking and an animal jumps out in front of the path and surprises you, or when you are driving and a car pulls out, just totally misses that stop sign and pulls out right in front of you. You feel your body respond, you have a stress response. Your cortisol goes up, your adrenaline goes up, your glucose goes up, and all of those when they go up and do not come back down because you live in a stressful environment, or because you are experiencing economic hardship, or because you have fear associated with the safety of your home, the people in it, right?

All of that keeps those stress hormones high. And those stress hormones help us respond to crises. But when we live in a stressful environment, when our boss changes our working hours, and now we cannot pay our bills, or when our boss places unreasonable demands on us that we cannot meet, that actually is, keeps those stress hormones higher than normal. And that is called a high allostatic load. It is how stress changes the physiology of your body. And what they found is that people who are low income, people who are in discriminated groups, people in low status jobs, their stress hormones spike higher in the face of threats and come down, their resting level is actually not all the way down.

It is somewhere in between, even when they sleep, and that causes heart disease, that causes a whole host of medical problems. And that is where they say it can be as harmful as smoking. It causes, wear and tear on the body, premature aging, elevated blood sugar, risk for diabetes. So diabetes is not just about poor food choices when we are talking about type two diabetes, it is not just about a sedentary lifestyle. It is about living with stress, right? So diabetes, hypertension, heart disease, obesity, worsened immune system response. Think about the people who did choose to get vaccinated and they still got sick anyway. Sometimes it is because their immune response was not as strong or robust. Stress also causes brain cell damage and pregnancy complications.

So stress has been called toxic stress. And if you think about that toxin it is a toxin that affects our health comparable to nicotine. Real quickly, I had mentioned like the stress of the workplace and kind of going back to this idea of what we used to know about health and what we know now. There is a study that was done in the UK, started in the 1960s. It was longitudinal, went through the 1980s, called the Whitehall Study. And what they did was they looked at civil servants all up the employment grade and their hypothesis going in was that the higher your employment grade, so if you are the boss, the manager, the higher your stress and the worse your health.

This was what they thought, right. And now we know it is exactly the opposite. The idea was that people in those high status jobs have more people to manage, more money to manage, more jobs and responsibilities, but it's the person who lacks control whose boss is directing them to do this and do that without a lot of their own say so, that actually, those are the folks who have worse health. And this was in the 80s controlling for things like smoking and drinking. So someone who was the boss who smoked and drank compared to someone who was not the boss who smoked and drank, the person who was not the boss had the worst health. And even with the person lower status not smoking and drinking, they actually were worse off than the people who did, who were higher up the employment ladder.It was a really eye-opening study at the time. I think it started us on this path of understanding the social determinants of health. 

Two other pathways development, and I can address this quickly. Child development kind of relate directly to what I have already talked about before. If there are toxins in the environment, it can affect a growing brain, a growing heart, a growing immune system. And where there is toxic stress, it can affect a growing brain, a growing immune system, growing organs and all that. And this is not just in the critical periods of development of birth through five and adolescents, but prenatally as well.

I mentioned I was a medical social worker. Half of my time, I was actually a maternity social worker. And that was part of my focus was helping pregnant women get the resources they needed to get ready to raise kids, but also helping them address acute stress. And I did not know that that was going to be affecting their child's development, and now I do. And even before pregnancy, a woman's reproductive system is shaped by stress and exposure to hazards, right. And the last piece I will say, in terms of the pathways between the social determinants and health, behavior, the environment, stress and development is discrimination. And discrimination, like if I were to draw a picture, it would be the umbrella over all of it, because it shapes our opportunities where we can live, what kinds of jobs we can have, what resources we have at our disposal, how we are treated by a health system or a justice system, or at a bank, right?

So it shapes our opportunities, but it is also a stressor. And you may know that African American women, for instance, have higher than average rates of poor birth outcomes, low birth weight, preterm birth, and maternal and fetal mortality as well. And this is true for African American women who have resources, who have education, who live safe and healthy lives. And so discrimination by the health system, but also a lifetime of discrimination can shape their development, such that it makes it harder for them to carry a pregnancy to term. So anyway, that was a long answer again.

Dr. Bencomo: I appreciate it. I am actually going to ask you for more. In thinking about that, you alluded and you mentioned briefly mental health and the connection between stress in particular and mental health. I wonder if you could say a little bit more about how these factors affect mental health and wellbeing specifically.

Dr. Barnstone: I can give a quick answer to that. And basically all of the same environmental risk factors in the physical environment, the social environment, in the built environment, all of these same risk factors can impact emotional wellbeing through the same pathways, through acute stress, chronic stress, traumatic stress. I do not know if you've been following the conversation for children. There is talk of, not just for children, but for adults as well, not talking about post-traumatic stress, but continuous traumatic stress for people who do not get relief. It is accumulation of many hazards. And actually I will real quickly, I should mention the ACEs study, everybody's heard of that, adverse childhood experiences, it found that if there was family violence, if you had a parent who was using substances, a parent who was incarcerated and so on, these family factors affected adult health 40 years on and heart disease in particular, that was the first study.

Well, newer ACE studies are including poverty and neighborhood violence as factors as well, right? So it is kind of like a rethinking of the ACEs. But anyway, so in terms of mental health and wellbeing, acute chronic traumatic stress and the opportunities to build coping mechanisms and put them in place, like those same factors that affect physical health affect mental health. And that's really the beauty of it. The beauty of addressing the social determinants by making safer neighborhoods, better schools, higher wages, better jobs, it can positively impact both health and mental and behavioral health. How we manage our stress affects our health and our mental health, whether or not we can, there is a mind, body connection, whether or not we can invest in ourselves and our own environments, those things can affect both health and mental health.

And it is really funny when I teach this class in social determinants of health and wellbeing, I have my students investigate evidence based intervention, community based interventions to promote health and mental health. And almost every single student comes up with the same solution, no matter what the health condition is. If they're talking about, whether they're talking about hypertension or whether they're talking about anxiety, it is the same interventions, because you are making more robust communities that support people more. So, yeah. So the factors affect health equally to mental health. It is just how it expresses itself.

Dr. Bencomo: Right. Right. So along that same vein, how do these social determinants contribute to observed health disparities? We often have the conversation, or we're engaging in this conversation of disparities and health disparities. So in thinking about social determinants in particular, how do they contribute to these observed health disparities?

Dr. Barnstone: Sure. Well, like you mentioned, there are health disparities. We see differences in morbidity, differences in mortality by race and ethnicity, by income, by zip code. And when we see those patterns, right, when we see whole groups of people having significantly higher rates of say colon cancer, I have not even touched on cancer yet, when you see whole groups of people having higher rates of colon cancer, it cannot just be about individual choices, right? Because within that group, there are going to be people who are making different choices. So it cannot be about individual health behaviors when we see population group differences. And that's really why health disparities clue us in to these social determinants of health. Research uses control variables, like let's control for income.

And when we do that, we see differences by race. Lets control for educational level, and we see differences by race, for instance, with the low birth weight. By the same token, just as an aside, we also see differences for high birth weight, which is also a health hazard for both the mother and the baby, right? High birth weight for instance, occurs in high rates amongst indigenous or native Americans, as opposed to African Americans who are at risk for low birth weight. So we see these differences and it has to do with stress, opportunity for healthy behaviors and opportunities to manage that stress. We also see differences by income, and what's really interesting is childhood income matters almost more than adults income.

There is this really interesting study. I love all these. I do not know if you've read this, maybe this isn't your thing, but I get excited about them, but I've read studies about where they use as a proxy to test your immune strength. They expose you to a cold virus. They take a swab with a cold virus on it and put it up your nose. And then they look to see the characteristics of the people who get sick, how severely they get sick, how long it lasts and so on. And they found that whether or not your parents owned their home when you were growing up is a predictor of whether or not you get a cold as an adult.

And it has to do with the stability of your living environment when you were growing up and probably the resources that were present in it. When you are a renter, there is less stability and probably more economic security. And that might not be true in all communities, but that's an overall pattern. I know in New Mexico, we actually have higher rates of homeowner ownership. So anyway, differences by income, differences by zip code. So health disparities by zip code. And this is really telling to me. The median income of your neighborhood is a better predictor of whether or not you have hypertension than your own income. And it is not just hypertension, it is mental health. A person with fewer resources, so a lower income, a person earning lower incomes in a better off neighborhood has less depression and anxiety than if they were in a poor neighborhood.

And by the same token, a wealthy person or person with high income living in a poor neighborhood has more mental health problems than someone living in a better off neighborhood. So your neighborhood, we see disparities there, and there is this whole, like a mapping thing that goes on in epidemiology and you see the dark colors are the places where there is high rates of disease. And what's really fascinating about these maps is you'll see if you are looking at colon cancer, the places where it is dark, where there is right rates compared to the places where it is light and there are low rates for colon cancer, heart disease, addiction and substance use disorder. All of these things, the maps look the same in almost all cases, which is just tells you that we have disparities based on zip code.

So the social determinants, whether it is exposure to stress and discrimination, whether it is exposure in terms of environmental justice, to worse air, less clean water, whether it is hotter temperatures, more likely like for instance, hurricane Katrina in New Orleans really showed us like that the people who earned lower incomes were higher and were more likely to be people of color, they were in the places that got flooded. So exposure to these climate events, all of those contribute to disparities that are explained in part, at least, I would say in more than in part by the social determinants of health. I just love this idea of zip code, or it is not even zip code, cause there are differences within a zip code.

I remember going to a lecture where someone talked about growing up in New York city and one zip code, one side of the street was public housing and very few resources. And the other side of the street was fancy apartments. So it is not just zip code, but there was a great study out of Atlanta that found that the walkability of a neighborhood, like whether there was sidewalks and street lights and crosswalks and that your distance to a full service grocery store is a great predictor of heart health, independent of income or these other factors. So again, we're seeing disparities based on geography. So population differences by race, by income, even by zip code, it cannot be explained by individual choices. There is just too much of a pattern cause you are always going to  have individual variation within that community.

Dr. Bencomo:. Right. And so along that vein of thought, that variation, recently, we saw that highlighted on a large scale when we think about the COVID 19 pandemic, I think that for the first time maybe, people outside of this field of study were looking at social determinants of health in a different way because we saw this inequity and we saw these differences based upon different communities. So how has the pandemic helped to draw attention to this field of study?

Dr. Barnstone: Well, I think that one of the unique things about this pandemic is we were getting real time data in a way we've never been able to before. And so you could see what the rates were last week and you could map it geographically and you could look at the characteristics. But we saw disparities in rates of infection and rates of getting sick and rates of being hospitalized, and rates of death and rates of vaccination. We saw differences by race, by income and by zip code, especially in the first year of the pandemic. And so what was this about? Well, I think of it as like the disparities that existed before became salient. So the people who got sicker once exposed, they had preexisting health conditions because their conditions of living were harder, right? 

So they were more likely to get sick and they were sadly more likely to die because they had those preexisting health conditions, the poor lung health and the diabetes and so on, obesity. And so I think there were disparities before the pandemic, but during the pandemic, especially if you remember to that first year, who was at work in person, who lost their job and who was working from the safety of their own homes? So disparities during the pandemic, certain groups were more likely to be exposed to the virus. People with less educational attainment, people in low skilled jobs, again, that status and control in the workplace, they were more likely to be working in essential industries, grocery stores, gas stations, and so on with no option to work from home and no paid sick leave, which meant that even if they started to have symptoms, they could not  necessarily take the time off work if they wanted to buy groceries that week or pay their rent or their utilities.

So essential industries, they were more likely to rely on public transportation in our urban areas, which means they are around more people. They were more likely to have barriers to healthcare access. They lived further from healthcare providers, not having insurance coverage, even though the federal government very quickly decided like, Hey, testing is something that we can get people, later vaccination will get people without regard to insurance coverage. I am not sure that the people who are busy taking care of their basic needs had time to get that message. So more barriers to healthcare access. They were disproportionately likely to live in crowded institutions like jails or shelters. So higher rates of exposure plus we are starting places for health.

People were more likely to get sick. And then if we bring it kind of up to the present, we have differential access to health information and trusted messengers. So imagine that you are an immigrant in a time when there is anti-immigrant rhetoric that is prevalent. You may not have the same trusted messengers. And if it is delivered in a language that is different from your own, or if you have low literacy, just reading, not even health literacy, the information is not necessarily coming to you in the path that you want. So I think in the pandemic we got data, we've been getting data daily and therefore there have been people tracking it. And they are like, why is it that poor people and that people of color have higher rates?

Why is it that they are dying at higher rates? Well, there is a lot of good reasons for it. And I think we can expect disparities in long term effects as well. Not just long COVID for the people who've been infected, but this period of economic insecurity due to lost wages, food insecurity, housing insecurity, the more difficult access to formal support systems like healthcare facilities, mental health facilities, schools, higher levels of stress. I think these could be things that we might see just like with the ACEs studies, long term health effects. and if we think about children, there was this really interesting RAPID-EC study, I think it was out of Oregon. And I do not remember what RAPID stands for, but the EC was early childhood, and they saw, they did some studies where they identified what they called a hardship chain reaction, where parents who had more economic insecurity experienced more stress, but so did their kids.

And so these are early childhood, birth through five, their kids showed more signs of acute stress through the pandemic with their parents' economic hardship. So they call it this chain reaction. So it means we need to promote resilience and good health and coping now because it could be affecting kids long term as well as the rest of us. 

Dr. Bencomo: Yeah, absolutely. So I think one of the outcomes of having this real time data that you speak of and having this be a part of the national conversation, because we're confronted with these disparities in a very real way, is that we've started to hear more and more of this term health equity. What is meant by health equity?

Dr. Barnstone: It is really just the other side of the disparity coin. Equal opportunity for good health. And we talk in social work about systemic inequities in general, differences in opportunity that are built into our systems, our health system, our educational system, our employment system. And it leads to groups being affected unequally while health equity, promoting health equity is about correcting these inequities, reducing gaps and resources, reducing gaps in opportunity, for instance, for healthy behavior, for employment, for education, for living wages and so on. So we reduce those inequities and we will end up having the beneficial effect of reducing gaps or inequities in health outcomes. The key with equity is this idea that we do not assume a one size fits all approach is the best approach.

What helps one person, or if you think macro one community may differ. So we should tailor our prevention efforts to the communities, just as we've been trying to tailor our vaccination messages, for instance, to our communities, because the barriers to health can vary. So health equity is just really about finding where those disparities are, identifying what's needed in the different communities and targeting your interventions there.

Dr. Bencomo: And so we social workers, I think you mentioned to this earlier, we are uniquely positioned, I think, to have a really good understanding of what is needed in terms of health equity. So what can social workers do, first at that micro level, if they are practicing at that micro or individual level, and then at the larger macro community level to help address some of these disparities?

Dr. Barnstone:  Sure. So at the micro level, even though I kind of was a little dismissive before when I talked about health providers and clinicians who say refer a social worker, help someone get resources and that will solve it. Well, that is not addressing the social determinants of health, but it is critically important, right? So there is the stress across the lifespan and the deprivation or hardship across the lifespan. But you can actually like do something now to help change it going forward. So helping promote access to resources and services, a direct practitioner, this is what distinguishes social work from say, psychology is that we are always doing that assessment to identify needs. And when we see needs, we should work to address them.

So promote access to resources. We can also help support people for behavioral change because if you have, for instance, the early signs of heart disease, well, there is things you can do. It is hard to take a medication every day. It is hard to change your diet and get salt out of it. And so helping support people make the behavioral change that they need to prevent their health condition from getting worse. So clinicians can help with that. But the thing that I think is really important, cause I called it toxic before is helping people figure out how to manage stress and not doing what some people, what some physicians will do where they will say, okay, just work on relaxing more, maybe get out and exercise.

Like figure out actually what people, what is reasonable for people to do. If they live in a place where exercise outdoors isn't safe, help them think about what they can do sitting in their chair to reduce stress, mindfulness based stress reduction techniques, meditation, stretching, and yoga. So thinking about what social worker, taking the time to figure out what is feasible for them, do not say, go join a gym, cause a lot of the people social workers work with cannot. So I think direct practitioners can help really teach people how to manage stress and that might help lower the allostatic load going forward. They may have some thickening of the arteries because of the chronic stress that led up to it. But making that change midway is worth it.

Dr. Bencomo: So what about the social workers that are working at the community level?

Dr. Barnstone: So, social workers at the community level, they can gather data and they can gather stories and they can communicate about it, identify the hazards in your community. I remember one time being part of an assessment where I walked the streets of my neighborhood to look at the safety of our sidewalks. And it turns out it was really hazardous if you were pushing a stroller and a wheelchair. But even if you were not, there was tree roots, there was these steep drops to each driveway and in a lot of places there was not a safe place to cross the street. So identify the hazards, identify those risks and communicate about it. Social workers are good at advocacy and that helps promote getting these issues addressed, street lights that are out, alcohol retail outlet density, or honestly, in my part of town, I do not know what it is like in your part of town, but now it is going to  be cannabis retail outlet density.

So how many can you fit on Nob Hill in Albuquerque? There is a lot already, and it is only been like three weeks. But anyway, so perhaps promoting zoning to make sure that we do not have for hazardous retail items or items that have the potential to be hazardous, let's make sure that we do not have too many in close proximity. Lets try to spread them out just a bit. So identifying those hazards, advocate for resources, help apply for grants for resources, you want to fix up your park and your neighborhood. Well, social workers know how to talk to the lawmakers to get money allocated for that using their grant writing skills or advocacy. But I also think that facilitating connections, that's what social workers do.

And the research shows that social isolation, which happens amongst the elderly, it happens amongst people where neighborhoods are unsafe. Building social connections actually protects health. Those same like studies where they infect people with cold virus by sticking a swab up their nose, they found a relationship between the number of people you can count as a social tie and the severity of your cold after being exposed to a virus. So if you have fewer social connections, you are more likely to get a cold than it is likely to be more severe and last longer, isn't that weird, right? So facilitating connections, community capacity building, creating those health fairs, those farmers markets, those social opportunities in your community. So I think there is a lot that social workers could do.

Dr. Bencomo: Wow, well on this theme and on this same vein of thought, talking about our spheres of influence as social workers, let's take it out even one step further now and talk about social workers who may be involved in policy advocacy. What can social workers who are working at that level do to address social determinants and help to promote health equity?

Dr. Barnstone: Yeah, well we have advocacy skills. We are trained in it in our schools of social work. But even if that's not the work that we do, we take those same communication skills, those same negotiation and mediating skills, those same relationship building skills. And we take it to our decision makers and the people who hold the purse strings, right? And then we advocate to reduce the gaps between the haves and the have nots and between our communities of color and our other communities. We want to reduce those gaps. And we do that by promoting wage law so that the minimum wage gets boosted, but also taxation so that the haves contribute their fair share, reducing that inequality. Inequality is corrosive for health.

There is research that shows the gap between the haves and the have nots, associates with worse health for an entire society, if we look at the really macro level like countries and states. So reducing those gaps through wage loss so people have the resources that they need and tax law so that those people who are down on the economic ladder can keep more of their resources. And we offset that by taxing those who can contribute more, they can contribute what is sometimes called their fair share. Of course we have to, we're still going to, even though we want to move people away from the edge of the cliff and not just treat people who've been identified at risk or who have health conditions, we still need to promote health and behavioral healthcare access for early identification and intervention before things get worse.

So that is something we are working to expand access to insurance and promote the number of providers and their accessibility. So healthcare policy, health insurance policy, early childhood services. Early child is a critical period of development. So investing in support for new parents of babies, new children, quality daycare, quality preschool, that prepares kids to be successful in education and move on to that higher wage earning job where they are more empowered. So early childhood services, of course, making education more accessible our state, leading the nation now in making higher ed accessible. So education, which correlates with employment opportunity. But additionally, we want to recruit employers, give them the incentives that they need to go in the communities where jobs are far away, right?

So that people can have the work that they need. We also need to think about regulation, both environmental protections, regulating of oil and gas, pollution industry and so on, but also regulation of things like retail, gun sales, vaping products. I mentioned alcohol, right? Law enforcement practices, the criminal code, all of those can actually promote health. And what you are seeing here is I am promoting a health in all policies approach, right? Social and economic policy are health policy and all of that requires taxation. So I talked about very briefly about this metaphor of the root tree branches. If the roots of a tree of good health are strong community that grows community services, that grows health for individuals out on those branches.

Well, the soil in which that tree grows is revenue. And so we actually need taxes to pay for everything else that I just said. So we have to tax our industries in our corporations. This is my view. We need to tax those who can afford to pay more in taxes, such that we can actually have the money for the things that we need. So, anyway, in terms of the soil, our environments cultivate our communities, our communities nurture our health, but only if we invest in those environments. And so housing policy, employment policy, early childhood and education policy, tax policy, that's all health policy. It is a health in all policies approach.

Dr. Bencomo: Yeah, absolutely. Thank you for that. This is fascinating. This conversation is fascinating. I wonder, Dr. Barnstone, do you have any recommendations for the people who are listening if they want to learn more about social determinants of health, if they want to learn more about health equity, where can they go?

Dr. Barnstone: Sure. Well, I mentioned before, something that was a turning point for me, and that was watching a PBS series put out by California news reel called, "Unnatural Causes: Is Inequality Making Us Sick". It may be at your local library. It may be in your institution's library, depending if you are at a hospital or an academic institution, you can also rent it on Vimeo. And sometimes it still shows up on PBS. So keep your eye out for "Unnatural Causes". But if you also want to read more, the CDC and health.gov, as well as your state health departments, they have written on this topic a lot, especially the CDC and health.gov, depends on your state otherwise.

In terms of research foundations, Kaiser Family Foundation is a research institute focused on health insurance and healthcare. But even they are saying, well, it is not just about healthcare. But Robert Wood Johnson foundation, if you go to their website, they are focused completely on health equity, that is their mission, right? So Robert Wood Johnson and the Kaiser Family Foundation, the American Public Health Association, and if you are a clinician, a clinical social worker, the APA and the American Psychiatry Association are writing about the causes of the causes. The causes of the causes of poor health, the causes of the causes of poor mental health. And so that is going beyond the precipitating event and going upstream. So I think any of those resources, there is a growing body of information that is at your fingertips now.

Dr. Bencomo: Thank you. Thank you for that. Dr. Barnstone, this conversation has been fascinating and incredibly enlightening. I want to thank you for your time. I want to thank you for your important work in this area and for engaging in these courageous conversations to help us look at what some of these social determinants of health are. Thank you so much for your time. And thank you for being here. I really appreciate it. 

Dr. Barnstone: Thanks for inviting me, Dr. Bencomo.

Dr. Bencomo: Thank you.

References

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