Social determinants of health are essential to understanding systemic lupus erythematosus (SLE). Poverty, fragmented care, access barriers, neighborhood resources, chronic stress, and structural inequities can compound disease burden among patients who are already at higher risk for severe disease. Additional data continue to highlight the importance of addressing these issues, as noted at the recent Congress of Clinical Rheumatology (CCR) – East 2026 meeting.

Following this presentation, featured expert Rosalind Ramsey-Goldman, MD, DrPH, was interviewed by Conference Reporter Associate Editor-in-Chief Christopher Ontiveros, PhD. Clinical perspectives from Dr Ramsey-Goldman on these findings are presented here.

What are the social determinants of health? They are conditions in the environment in which people are born, live, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks. We should also define “health” as laid out by the World Health Organization (WHO): “a state of complete physical, mental and social well-being and not merely the absence of death or infirmity.”

In people with SLE, where disease disproportionately impacts certain communities, the biologic factors do not fully explain or address the differences in disease outcomes. So, it is important to think about the impact of social determinants of health on disease outcomes because this provides a more comprehensive understanding of the reasons why some individuals with SLE in certain communities experience disproportionately higher rates of disease, health care utilization, and bad outcomes, including death.

First, we should think about who gets lupus. Black, Hispanic/Latina, American Indian/Native Alaskan, Asian/Pacific Islander, and other women of medically underserved racial and ethnic backgrounds are disproportionately affected. These individuals develop the disease at a younger age and experience more severe disease manifestations, such as kidney disease. Regarding health care access for lupus, if you live in an area that is below the poverty line, you are less likely to get the treatment that you might need, which is further magnified if you are a person with low income yourself. It is not just where you live but also your personal experiences.

Our 2017 study illustrating the impact of these social determinants of health factors looked at SLE care fragmentation, cardiovascular disease, stroke, kidney disease, and serious infections requiring hospitalizations. We found that the more care fragmentation that patients with SLE have, the more likely they are to have one of these bad outcomes.

Some other social determinants of health include your access to care, where you live, whether you have economic instability, whether you utilize public aid, and whether you have access to the resources you need. For example, if you have SLE and live in a neighborhood that does not have a grocery store, you may have to eat mainly local fast food, which means that you cannot effectively implement the lifestyle habits that can help you have better health. Additionally, if you are on public aid and have to decide between feeding your family and taking expensive medication(s), what do you think is going to happen? You are going to feed your family. Or, if you are on, for example, 5 different medicines but can really only afford 1 medication, you are in pain, and the lupus medicines have side effects, you might decide to treat the pain as a priority and not the broader disease. Finally, if you have to take, for instance, 3 buses to get to a clinic, do not have child care, and/or are a day worker, accessing health care may mean that you lose income—and that is a problem.

If you are living under this type of chronic stress, your body’s physiology can change. If you have chronic stress, whether it is inherited stress or your own stress added on top of it, your body responds in a different way than somebody who does not have this problem. Stress also affects your immune system, and that can impact your susceptibility to developing an autoimmune disease such as lupus.

At CCR East 2026, the poster abstract by Min Kyung Chung, MD, and colleagues on disparities in outcomes among patients with SLE by hospital teaching status and urbanicity used national inpatient survey data to see who made it to the hospital and what happened to them. The study found that there was no disparity in terms of mortality during hospitalizations in rural and urban nonteaching institutions compared with urban teaching institutions, but there were longer lengths of stay and higher total costs in urban teaching institutions compared with rural and urban nonteaching institutions. This is consistent with what we have seen (ie, that patients in underresourced and marginalized urban centers often have more severe disease).

Perhaps most striking are the data from the Centers for Disease Control and Prevention (CDC) WONDER Multiple Cause of Death database showing that SLE ranks among the top 10 causes of death for women aged 15 to 24 years. For Black and Hispanic women, SLE ranks among the top 5 leading causes of mortality in early adulthood, highlighting persistent and unacceptable disparities in disease severity, access to care, and outcomes. These disparities also disproportionately affect other racial and ethnic minority populations, including American Indigenous and Alaska Native communities, who also demonstrate more severe outcomes. Health care disparities in SLE affect both morbidity and mortality. Paying attention to more than just the biology of SLE is important.