Nancy Krieger is a professor of social epidemiology at the Harvard T.H. Chan School of Public Health. Krieger is known for her theory of ecosocial disease distribution, which examines how different historical, societal, and ecological conditions are made manifest in the health outcomes of different social groups — in other words, how factors like economic inequality affect public health. Fifteen Minutes spoke with her about how the coronavirus pandemic has revealed the social determinants of health inequality and what we can do to alleviate those inequities. This interview has been edited for clarity and concision.
Fifteen Minutes: Could you tell us about your work as an epidemiologist?
Nancy Krieger: I’m a social epidemiologist; this means that my focus is on the societal structures and forces that drive population health and its patterns and, particularly, health inequities. Health inequities are differences in health status between social groups that are in principle unfair, avoidable, and preventable.
I do work that’s more etiologically-focused, which means looking at the causes: How do we understand what is causing the patterns that are observed? The first thing you have to do is observe the patterns, then you have to try to explain the patterns. But I also do work as a social epidemiologist on the theoretical frameworks that help you ask these kinds of questions. So I’ve spent a lot of time developing the ecosocial theory of disease distribution that takes into account the kinds of ways in which people actually embody inequality but also can embody justice. So it’s not only about health inequities, it’s also about the conditions that make it possible for people to thrive — all people, with dignity.
FM: A lot of your work centers on the social determinants of health. Could you explain what a social determinant is?
NK: The framework of social determinants of health became very popular in the latter part of the 2000s. The social determinants were seen — they could be policies, they could be forms of governance in societies — as these large macro-structural determinants, whether they were histories of racial inequality, or the history of gender relations or things like that. So it’s also an attempt to no longer look just at the people who are doing worse, but what the relationship is between the people doing worse and doing better. In a more conventional approach, social determinants are things like housing, education, green space, places to play and to recreate, income — and those are important, but you have to step back and ask what’s driving the distribution.
FM: What are some ways in which the COVID-19 pandemic has impacted social inequality? How is it related to these social determinants of health?
NK: The COVID-19 pandemic has pulled a thread that is showing how everything is actually connected. So there were health inequities, social inequities, and economic inequities, all kinds of injustice. But COVID-19 has opened up a space for much more visible discussion. You have to think about where people are located, where they’re living at home, with whom, in what conditions, how crowded, how many people per room, how many people are in a household, who is very much exposed to different kinds of people and their work context.
So you’re going to start to see questions of who has what kind of jobs that would increase their risk of being exposed. In those jobs, who’s provided with protective equipment, who’s provided now with gloves and masks? In the hospitals, who’s getting what kinds of exposures — for example, the people who are doing the food services, the people doing the deliveries, the people doing the cleaning and the maintenance — what kinds of protections do they have? So how does that relate to questions of what become occupational disparities?
There seems to be good evidence that having what are called comorbidities, other kinds of chronic diseases — diabetes, cardiovascular disease, other kinds of respiratory diseases — could make you more at risk for contracting the virus. So who has those diseases? For example, you have higher rates of hypertension, diabetes, etc., amongst many populations of color, particularly black and American Indian populations compared to white, non-Hispanic populations. COVID-19 is entering into a society where there already are huge health inequities in relation to the very conditions that make people more susceptible to becoming very ill from COVID-19. This is where the social lens comes in — not giving people individual-level advice and saying “wash your hands,” “cover your face,” “don’t go to work” — it’s actually addressing the context that makes any of that possible.
FM: Some people have talked about this global pandemic as a great equalizer. How do social determinants complicate this assertion?
NK: There are two parts to that. In one sense, it’s true that it is a great equalizer — all humans can get infected. All humans can potentially get sick, and all humans can potentially die. But there are also ways it is not a great equalizer — it is showing all the inequities in our society. The United States is an extensively well-resourced country, but there are enormous gaps in how those resources are distributed. If people are worried about medical resources being overwhelmed in Boston, which is a leading medical center, imagine the situation in countries which barely have a health system in comparison — what’s going to happen?
FM: How do prevention and relief measures such as social distancing or stay-at-home orders affect different groups disproportionately?
NK: People who are considered essential workers — transportation workers, people staffing grocery stores, etc. — have not been treated well and have not been paid well. COVID-19 has illuminated that vividly. So then we want to have these policies that some states are enacting — not just the federal government — to build social and economic buffers so that people can protect their communities and their own health.
FM: Do you think that the pandemic will help ignite a push for different kinds of public health policies in the future? What kinds of policies would address the social determinants of pandemics in order to prevent an event similar to the one we are currently experiencing?
NK: This situation underscores that actually having a health equity perspective is important. It’s all connected. So I wouldn't say it’s only public health policies. It’s about asking how we have policies and programs that are set up so that they’re geared to help people thrive.
For example, air pollution increases risk of potential morbidity and mortality as tied to COVID-19. The current attacks to undo air pollution regulations are obviously not public health policy. Some things are very specific to public health, but other things are about economic policy. Another example is good sick leave policies so workers who are sick don’t go into work when they are sick. That really is not very hard to get your head around, but is hard to mobilize employers around.
FM: Barring larger structural change, is there anything that policymakers can do right now to mitigate the disproportionate effect of the pandemic on marginalized groups?
NK: Absolutely. I mean, steps are being taken to deal with people who are incarcerated in relation to COVID-19 to try to get early release, about making sure that people are not put in detention for nonviolent offenses. There’s stuff going on in legislatures about immediate relief packages, making sure that those packages are going directly to affected families instead of corporations, making sure that testing for COVID is at no cost. So there’s a lot that’s in the immediate here and now.
FM: How do you anticipate this crisis impacting scholarly research in your field in the future?
NK: This is the era of non-communicable diseases, but communicable diseases still really matter. I think that it’s going to call more attention to social determinants, potentially in good ways. I think the idea of developing more robust infrastructure to monitor population health dynamically and rebuilding the hollowed-out shells of health departments will become more prominent.
FM: How do you think we can learn from this crisis to ensure a more equitable response in the future?
NK: First, it’s a reminder of our common humanity. And we have to draw on that common commitment to protect people and care. Second, I think that it is bringing together many groups who have been working on different facets of all the things that COVID-19 is bringing together, as I said — the housing crisis, the environmental crisis, racial injustice. Also, issues around gender relations, what does it mean to ask people to shelter at home, if there are possibilities of domestic violence — it’s making people see the connections. Part of what I do is help with the theoretical framing of things. And in the ecosocial theory of disease distribution, there is an emphasis on embodiment: How do people embody? Our bodies don’t care if you want to parse it out: This is a housing crisis. This is an economic crisis. This is racial injustice. This is gender inequity. Right now, people through their bodies are showing what the problems are in our society, but also what the potential is for people coming to work together to make a better world — one where people can thrive, with dignity, with their rights, in a sustainable way.
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