May 2021 Newsletter

May marks Mothers’ Day and during the pandemic women who are mothers, or stood in for mothers, deserved our recognition every day. We repeatedly hear how the pandemic has forced many women to leave the workforce to care for children and aging parents. We need better services and supports for women to have the same options as men.


Welcome to my May 2021 Living Conditions and Health newsletter. You can find past newsletters with additional background materials, and different stories and initiatives on my website and in my LinkedIn articles or posts. Join me in identifying and coordinating initiatives that advance health, health equity and community and healthcare redesign.

Shannah’s Insights and Reflections

May brought many major changes in the health status of our country that feel like a new and perhaps sustainable direction. It also marked the one-year anniversary of George Floyd’s murder that has yielded some steps in the right direction, but we also witnessed many more people of color being murdered by police.

The New York Times has a timeline of good and bad events and changes that have occurred across the country since George Floyd’s death. The overall trends give me some hope. The same day in the New York times there was a discussion of how the economy during the pandemic yielded increased tax revenues for many states and perhaps the funding in the latest economic assistance packaged should be repurposed for some of the infrastructure investments. I would love to see incentives that redirect the investments to underserved communities hardest hit by the pandemic. States will not necessarily invest in these communities without encouragement.

Viola Fletcher the oldest survivor of the Tulsa Massacre, age 107, testified before Congress  and seeks justice! To ignore the past is to risk repeating past atrocities. There are too many indicators, including the many ways our most vulnerable populations have been hardest hit during the pandemic, that should convince all companies, organizations, communities and individuals that the time for systematic and structural change is now.

Dr. Anthony Fauci, in his commencement address at Emory College of the arts and sciences emphasized our societal failings that have caused the COVID19 disparities and the disparities that have existed for decades. He emphasized that racism and the many social determinants of health (SDOH) that have caused these deadly disparities will continue long after the pandemic. He noted that “Righting this wrong will take a decades-long commitment,” he said. “I strongly urge you to be part of that commitment.” I am extending his recommendation to all of us that recognize the need for change.

The founder and president of Socially Determined, published a peer exchange article about remedying low health literacy to address SDOH. You’ve likely heard me talk about the term “social determinants of health” before and in each newsletter when I use my preferred term living conditions and health. The article highlights 90 million Americans with low health literacy scores and 52% of Americans never having heard of SDOH! Neither number surprises me. The article goes on to discuss the importance of engaging people where they are; this means using language that is accessible and readily understood. How often do governments, industries/companies, academia and research institutions develop unique terms and acronyms? I think we all eventually realize it has to be publicly translated for a much broader audience. This is communication 101.  We should all recognize that eventually we need to explain what we do and how it is relevant in easy-to-understand terms and start with that goal in mind.

The President’s budget has substantial increases in healthcare spending and some explicit spending on racial equity. There is notable healthcare expenditures designed to improve state and local public health resources. There are some explicit expenditures on equity, but the Acting OMB director notes it should be baked into every agencies’ programs.  The targeted expenditures are moving in the right direction.  They also have a way to go before they will move the needle on balancing investments in social services and infrastructure in comparison to clinical care.

The Office of Management and Budget published a request for information (RFI) on Methods and Leading Practices for Advancing Equity and Support for Underserved Communities Through Government. It is intended to inform the Executive order on advancing racial equity and support for underserved communities that I have discussed in past newsletters. The due date for public comments is July 6, 2021. If you have ideas, research or examples of success or failures now is the time to weigh in. If you are part of an underserved community, or working to help one, consider commenting on how best to engage your community and others like yours to improve how government programs and services help enable sustainable improvements for the communities.

CDC changed the mask requirement for people who are vaccinated, but it’s an honor system. We are still seeing people refusing to wear masks even in crowded tight spaces, e.g., planes. We have people who are immune compromised left feeling isolated and at risk, and we have uncertainty or possible acceptance that we won’t reach herd immunity — a large enough percent of the population vaccinated or previously infected to have minimal and manageable risks of infection.  Deaths and infection rates continue to drop in the US, while other countries are experiencing the height of their pandemic. In a world with global travel resuming, new variants of the virus, and uncertainty about how long vaccine immunity lasts, substantial risks remain.  The mask requirement decision complicates navigating those risks.

A story  of two young African American girls with Sickle Cell anemia who suffered unnecessarily from strokes demonstrated some disease specific disparities warrant immediate investment and change. I have mentioned previously that we are too focused on disease specific health disparities over the broader issues driving inequity. However, when it is a matter of life and death, we must hold doctors and health systems accountable.

The AMA released a strategic plan to “dismantle structural racism” in healthcare, starting with the AMA organization. The 3-year plan is designed to address 5 core strategies: embed equity; build alliances and share power, ensure equity in innovation, push upstream (to address SDOH) and foster truth, reconciliation, racial healing and transformation. Perhaps all health professional organizations can adopt a similar approach.

Homelessness needs to be at the top of the agenda with more extensive investment. An article in the Washington Post “The right to be homeless?” Explains how tolerance models in CA and elsewhere do not benefit the populations or help people address the underlying causes of homelessness. The model usually allows people to set up tent communities that after some time has passed are no longer tolerated. Meanwhile justice and prison systems put people back on the street without help, municipalities do not provide adequate mental health and rehabilitation services and leave individuals without the means to work or afford housing. This dynamic often leads to inadequate supports and cyclical problems. The author notes that until conservatives and progressives recognize the need to invest we cannot advance to more substantive freedom for the underserved.

Stanford Innovation review discusses the need for equity in implementation science. They reference the term ‘syndemic’ meaning an epidemic that is “influenced and sustained by a broader set of political, economic, and social factors.” (Also an example of inaccessible language discussed earlier.) The article focuses on the role of living conditions in historically underserved populations on COVID19 and mental health. They go on to state 3 calls to action to address these effects to avoid or minimize the impact of future epidemics.

#1: Engage with historically underserved community members and collaborate with other disciplines for evidence development with equity at the forefront.

#2: Pay attention to intervention selection and outcomes measurement by examining their relationship to social determinants of health.

#3: Develop equitable implementation strategies.

“With a more mature understanding of the social determinants of health, we must respond to immediate needs while also advocating for and proffering longer-term strategies that address the ways systems have marginalized people.”

During my ongoing monitoring of resources and research relating to living conditions and health, I came across two documents that may be helpful for communities seeking to improved referrals to needed social supports.

First, a NORC study sponsored by the Assistant Secretary for Planning and evaluation at HHS that looked at how three community resource referral platforms were implemented and lessons learned.

Second, Kaiser Permanente’s Social Health Playbook, based on their experience during the pandemic and ongoing efforts to incorporate social health practices that address living conditions that drive health disparities. This is very much a how to book with tools and links to resources in the states where Kaiser has a substantial presence.


CMS’ Office of Minority Health hosted a two day virtual forum in April “The Road to Equity: Examining Structural Racism in Health Care”. Panels with government and industry representatives focused on a broad range of health equity topics and issues including data, solutions, access to care and coverage, COVID-19 impacts on disparities and promoting equity. Recordings from the forum are now available here.

The RISE Summit on Social Determinants of Health June 13-15 live and virtual.

Health Disparities Research Institute (HDRI) virtually August 9-13, 202,

The Root Cause Coalition National Summit on Social Determinants of Health is being held virtually October 4-6.

Background and Definition

I have chosen the phrase “Living Conditions” rather than social determinants of health (SDOH) to make the concept more accessible.  This focus tracks with the Centers for Disease Control and Prevention’s SDOH definition “as conditions in the environments in which people live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.”

Go here for more information from CDC on its organizing SDOH framework in Healthy People 2020