By Jessica Paulus, ScD, VP of Research, OM1   |   April 25, 2023

Boston is recognized as a hub for medical advancement, with some of the best hospitals and medical professionals in the U.S. and the world. But what about patients who cannot access advanced care given barriers related to where they live, their available resources or health insurance coverage? With cancer and other chronic diseases on the rise, providing access to advanced medical technology is not a luxury, but a necessity. 

There are profound and well documented disparities in the burden of chronic diseases across different social determinants of health, including race, ethnicity, income, home ownership, marital status and more. As one example, Black women have slightly lower risk of breast cancer than white women, but experience breast cancer death rates that are nearly 40% higher. Improving access to screening technologies that identify cancers at an earlier stage could be a key part of addressing this disparity. OM1 developed a large real-world data network to evaluate breast cancer screening effectiveness that included over 2.5 million mammograms from more than a million women. The study found that 3D mammograms indeed detected more cancers for every screen compared to 2D images, perhaps due to improved visualization of dense breast tissue. Unfortunately, this state-of-the-science technology is not currently equally accessible across all American women. In another investigation of this real-world data platform, Black women had less access to the more advanced 3D mammography technology as compared to white women.

It matters a lot about where you live, and your health insurance status, that’s where the access comes in. Since mammography devices are typically purchased by a health system or hospital, it’s not ‘choices’ that providers or patients are making. It’s a matter of structural issues around where the state of the art devices are located.

To continue to work to improve health equity for all, we must first understand the social determinants of health (SDoH) that cause these illnesses. In an article published from the Harvard T.H.Chan School of Public Health, Professor David R. Williams, and Risa Lavizzo-Mourey, president and CEO of the Robert Wood Johnson Foundation reviewed various ways in which BIPOC populations “face illnesses earlier, experience illnesses more severely, deal with more rapid progression of illnesses, and suffer higher rates of impairment and death.” 

There are also profound impacts of financial assets on individual health. In an analysis of over 1 million patients with major depressive disorder, those with household income levels under $25,000 per year (approximately the threshold for the United States federal poverty level) had more severe depression scores at the time of diagnosis, and these differences by income persisted over time even through the course of depression treatment. In the same analysis, even more dramatic disparities in major depression burden were noted by patient race – even the most financially affluent Black patients had more severe depression at diagnosis than white patients under the poverty line.

As we deepen our understanding of the role of social determinants of health in health and illness, one critical step is to examine interactions and links between social, environmental and biological determinants. In the United States there are dramatic relationships between race and financial assets and security that may underlie disparities in chronic disease burden. “In 2013, for every household income dollar earned by whites, Hispanics earned 70 cents and Blacks just 59 cents. These economic disparities affect where people live, learn, work, play, and worship—and all of these factors can in turn impact health”, Williams says. He shares an example that some BIPOC can only afford to live in poorer neighborhoods, where they may face greater exposure to toxic chemicals, or have limited access to health care or healthy foods.

Racial disparities in health also stems from systematic racial biases embedded in the healthcare enterprise. While the role of racism may be surprising to some given positive changes in the racial attitudes of white people over the last decades, the impact of deeply ingrained implicit and unconscious bias continues to have pernicious effects on equity in healthcare delivery. Deconstructing this bias “begins with awareness of the pervasiveness of disparities, the ways in which bias can influence clinical decision making and behavior, and a commitment to acquiring the skills to minimize these processes.”  

“To dismantle health inequities across historically disadvantaged groups, interventions must be targeted broadly across the breadth of their impact – from understanding root cases to the present impact on patients struggling to access high quality care for their health condition.  Real-world and SDoH data offer powerful vehicles to shed light on the magnitude of gaps in care, access and treatment responsiveness.”