A large body of literature has established that Asian, African American/Black, and Hispanic/Latinx populations in the U.S. have a greater incidence of systemic lupus erythematosus (lupus) than do people who are non-Hispanic white. They also have greater severity of lupus, a complex autoimmune disease, as well as poorer outcomes and higher complication and mortality rates.

A recent scientific statement by The Lupus Foundation of America’s Health Disparities Advisory Panel addresses the relationship between social determinants of health and racial and ethnic disparities in lupus. It also recommends interventions that might reduce these health disparities.

Karen H. Costenbader, MD, MPH, director of the Lupus Program at Brigham and Women’s Hospital and the Michael E. Weinblatt, MD distinguished chair in Clinical Rheumatology, Candace Feldman, MD, MPH, ScD, a rheumatologist in the Brigham Division of Rheumatology, Inflammation, and Immunity, Joy Buie, PhD, MSCR, RN, of The Lupus Foundation, and colleagues published the statement in ACR Open Rheumatology.

Methods

In October 2020, the Foundation convened a panel of 10 experts to study health disparities in people with lupus and the potential to overcome them. AstraZeneca and the Pharmaceutical Research and Manufacturers of America supported the effort.

The panel included patients and individuals from academic medical centers and medical societies. All members had expertise in health disparities research, lupus, and challenges related to achieving health equity. They searched PubMed for relevant studies published between 2011 and 2023 and gathered information from other sources, including CDC data and study bibliographies.

Results and Recommendations

The panel presents evidence that numerous social determinants of health could underlie the racial and ethnic health disparities observed in lupus in the U.S.:

• Economic instability
• Neighborhoods and built environments (specifically, exposure to crime and food and housing insecurity)
• Racism
• Discrimination
• Stress
• Abuse
• Adverse childhood experiences
• Poor access to high-quality education and healthcare

Therefore, the advisors recommend the development of policies and interventions to:

• Promote economization
• Reduce poverty, economic inequities, racism, discrimination and racial segregation
• Reduce the economic burden of medicine
• Promote safer, cleaner, and more walkable neighborhoods
• Promote food security
• Promote high-quality education with a focus on health promotion
• Promote care coordination, health literacy, equitable inclusion of racial/ethnic minorities in clinical research, and equitable practice guidelines free of bias

Knowledge Gaps

The panel also identified knowledge gaps and areas for further study:

• The impacts of social determinants of health on American Indian/Alaska Native individuals with lupus

• How social determinants of health influence specific outcomes, such as cutaneous lupus, cardiovascular disease, and hospitalization outcomes

• What additional factors related to neighborhoods and built environments may affect lupus outcomes, such as transportation accessibility, internet access, and exposure to air pollution

• The role of social and community context related to attitudes and health-seeking behaviors among patients with lupus

• The potential benefits of multidimensional interventions (e.g., whether patients with severe disease activity and depression could benefit from interventions focused on improving physician communication and interpersonal skills)

• The role of genetic or epigenetic factors in disparities among racial and ethnic groups

The Need to Swing the Pendulum

Health disparities in lupus were brought into stark relief during the COVID-19 pandemic. The Lupus Foundation hopes its scientific statement will be used by clinicians, researchers, public health practitioners, industry leaders, and policymakers to keep moving toward health equity for historically marginalized individuals living with lupus.