Many nurses and healthcare workers have been exposed to conversations, seminars, and discussions on addressing the social, economic, and environmental factors shaping people's lives and impacting health, the social determinants of health (SDoH). These conversations are important and necessary but insufficient to move forward the agenda of advancing health equity. For many, there is an eagerness to move beyond basic conversations and surveillance of communities and toward action in communities through policy and practice using what we already know about health equity and SDoH. In Baltimore, a grassroots network of action-oriented individuals led by nurses successfully transitioned from a community action model to a policy-mandated taskforce.
In 2015, a group of health equity promoters across multiple SDoH sectors deliberately started a multisectoral working group to address adverse social factors contributing to Baltimore's health inequities. Maryland State Senator Shirley Nathan Pulliam (recently retired), a nurse and health equity policy maker, convened a workgroup to address SDoH in Baltimore City. As a legislator, she is well known for her commitment to health equity policy for over three decades. She gathered health equity promoters, including community members, representatives from academics, nonprofits, governmental agencies, legal partners, policymakers, and health institutions, into a SDoH workgroup. The workgroup was charged with identifying mechanisms for collaborative action across different sectors to improve the socioeconomic conditions and quality of life and health for individuals, families, and communities within one legislative district in Baltimore. To establish approaches for shared vision and accountability for addressing SDoH, monthly multisectoral meetings were held where participants shared information, identified points of overlap and gaps in resources for SDoH, and began to advocate for change with community members and policymakers collectively.
The workgroup started by first listening to community members to hear their ideas, priorities, and recommended solutions. Community members described intergenerational, vicious cycles of challenges with violence, poverty, substandard housing, and substance abuse. They identified the most critical change areas as improved housing and economic empowerment. They rated these needs higher than addressing violence, believing that wealth inequity was the root cause of their challenges. A few months into the workgroup's efforts, the community was heavily impacted by the death of Freddy Gray, a community member in the selected legislative district. He died while in the custody of the police. With the civil unrest and anger after his death, national media attention expanded around communities in Baltimore and exposed decades of gross disinvestment and neglect within many marginalized communities, and interest in the SDoH Taskforce grew.
From 2015 to 2017, the workgroup continued community convenings with information sharing and collective action across SDoH sectors. Collectively, the workgroup advocated with the community to support employment for returning citizens, improved safety through upgraded community lighting, and spurred old and new generations to believe that a small group of committed individuals could make a difference. However, as the workgroup immersed deeper into the challenges, it became clear that addressing social justice and health equity required individuals and teams who were bold, dynamic, flexible, strategic, coordinated, and trustworthy. It also required funding and accountability.
As 2017 ended, additional workgroup power was needed to address the systemic issues that underlay poor housing, substandard educational opportunities, transportation, and community violence. The workgroup consensus was that the path to success would be through policy change. So, under the guidance of Maryland State Senator Nathan Pulliam, a bill was drafted to mandate an official taskforce. The grassroots workgroup members testified at the state senate and the house of delegates on the importance of addressing SDoH and witnessed their grassroots efforts become policy change. As a result, on May 15, 2018, Governor Larry Hogan signed Senate Bill 444, the Taskforce on the Social Determinants of Health in Baltimore City.
With the passing of Senate Bill 444 in the Maryland General Assembly, a 7-year taskforce was established in 2018, chaired by a nurse, the author of this commentary. The taskforce is charged with identifying and analyzing the cyclical, multigenerational negative social factors that create hardship for residents of Baltimore City and with designing and implementing solutions to improve the environment in which Baltimore City residents live, work, play, and worship. Now in its fourth year, the taskforce has learned many compelling lessons but will share lessons learned and activities over the past 2 years.
1. The ongoing COVID-19 pandemic shined a spotlight on well-known inequalities and opportunities for addressing SDoH in Baltimore City. Unfortunately, those communities and populations that have historically been most affected by social and economic inequalities are also the communities with the most remarkable inability to overcome new challenges imposed by the pandemic.
2. Broadband connectivity emerged as a significant determinant of social, educational, economic, and health-related outcomes among Baltimore City residents. Increasingly, elementary, secondary, and postsecondary education is offered in online formats. The lack of affordable connectivity effectively precluded some students' ability to participate in the educational process. The same is true for primarily online job applications. Lack of connectivity effectively inhibits residents from applying for most employment opportunities. The problem even manifests in the healthcare sector, where persons have inequitable access to telehealth and other mobile services. Individuals residing in marginalized communities are also at the highest risk of being in poor health and at the most significant risk of being unable to connect with health providers, thus further exacerbating health outcomes. Given this "gatekeeping" function that broadband connectivity is playing, it may well be prudent to consider broadband connectivity as a new SDoH and the first superdeterminant of health. Broadband connections increasingly connect to all other facets of life.
3. Workforce training, or upskilling as it is sometimes referred to, also remains a considerable need among many residents of Baltimore City. However, as the country continues to struggle with the broader impacts of the ongoing pandemic, the reality exists that many who complete traditional workforce readiness and job training programs may still be unable to find actual employment. At the same time, the city and our nation are grappling with a dearth of needed employees in the technology services sector. These technology employment opportunities are emerging as future jobs and usually pay higher-than-expected wages for those who get the jobs. There exists an opportunity to reimagine job training programs to include programs that provide participants with the skills needed for these emerging digital and technological employment opportunities. Many skills needed to fill these jobs do not require college diplomas. Instead, shorter-term (3-6 months) specialized training is often all that is needed. For example, Google now offers online training programs for $50 per month. They offer 6-month program certifications and guarantee those who complete the training employment opportunities that generally start at $80,000. There are tremendous opportunities for partnering with schools and organizations like Google to provide 21st-century skill training to residents of Baltimore city so that they can effectively compete for these high-quality jobs of today and tomorrow.
4. Affordable and safe housing remains a significant challenge for many residents of Baltimore city. Current solutions, although helpful, are not enough to meet the current need. The moratoriums on foreclosures and evictions offered during the pandemic expired, yet housing problems are likely to worsen in the foreseeable future.
The taskforce and subcommittee accomplishments to address some of these challenges are detailed in the table below. In closing, the grassroots workgroup purposefully requested a 7-year commitment for this state-mandated taskforce because addressing SDoH through policy recommendations and practice will take time, effort, and sustained commitment from health equity promoters. Nurses are well positioned to make a difference in SDoH policy for effective action in local communities across the country. This case study serves as one approach that may be replicated to work with grassroots organizations and policymakers to make a difference. To learn more about the Social Determinants of Health Taskforce of Baltimore City, go to https://www.umaryland.edu/sdh-taskforce/.