The health impact of the conditions in which people are born, grow, work, live, and age have been recognized for centuries. However, widespread acceptance of this impact remains contentious, as inequities in morbidity and mortality represent the enduring legacies of displacement, oppression, and systemic discrimination. The World Health Organization estimates that social and structural determinants are responsible for 30% to 55% of all health outcomes. Social determinants of health, structural determinants of health, structural violence, and the need for structural competency are four codependent concepts that must be explored together to develop responsive clinical interventions. Social and structural determinants of health include wealth and social status, geography and neighborhood, employment and labor, and education. Racism is a major driver of social and structural determinants of health in the United States. It is important to differentiate between upstream and downstream approaches to addressing health inequities because addressing upstream factors has a greater impact.

Case 2. HW is a 48-year-old American Indian man who presents to urgent care with persistent debilitating headaches. He has seen physicians only intermittingly over the past 20 years, for a herniated disk 8 years ago and for a workplace injury that resulted in a finger amputation 3 years ago. He takes ibuprofen and his wife’s hydrocodone for phantom pain of his amputated finger. He has had frequent early morning headaches, general weakness, and fatigue. Laboratory evaluation results show an A1C of 7.6 and a glucose level of 463 mg/dL (25.7 mmol/L).