Health Disparities at the Intersection of Racism, Social Determinants of Health, and Downstream Biological Pathways

Despite overall improvements in the accessibility, quality, and outcomes of care in the U.S. health care system over the last 30 years, a large proportion of marginalized racial and ethnic minority (minoritized) groups continue to suffer from worse outcomes across most domains. Many of these health disparities are driven by inequities in access to and the scope of society's health-affirming structural resources and opportunities commonly referred to as structural drivers or social determinants of health-SDoH. Persistently health-undermining factors in the social environment and the downstream effects of these inequities on neurocognitive and biological pathways exacerbate these disparities. The consequences of these circumstances manifest as behavioral, neurohormonal, immune, and inflammatory and oxidative stress responses, as well as epigenetic changes. We propose a theoretical model of the interdependent characteristics of inequities in the SDoH driven by race-based discriminatory laws, policies, and practices that eventually culminate in poor health outcomes. This model provides a framework for developing and validating multi-level interventions designed to target root causes, thereby lessening health disparities and accelerating improved health outcomes for minoritized groups.