Disparities as Symptoms

Amid all the American fault-lines exposed by the COVID-19 pandemic, none is more alarming than the disparate impact of the disease on racial and ethnic groups. According to the Centers for Disease Control and Prevention (CDC) data, both non-Hispanic black and Hispanic/Latinx Americans have three times the risk of getting COVID-19 than white populations. They are five and four times respectively more likely to be hospitalized, and most alarmingly, the death rates for each group within age categories are at least six times that of the white population. These are not small measures of statistical significance, but huge effect sizes that should alarm and mobilize every one of us.

For those of us who work in public health, while these numbers are tragic, they are not surprising. Decades of research have highlighted disparities in premature death, disease prevalence, and overall well-being based on one’s race/ethnicity and/or neighborhood of residence. The COVID experience is just another piece of evidence that something is really wrong with the society that we have built and maintained. These disparities are not isolated occurrences but symptoms of a much larger problem.

The problem is that we have created a society that limits access and opportunity for many. It starts with something as simple as food. In a New England Journal of Medicine article released this week, Dr. Matthew J. Belanger and colleagues described the connection between nutrition, obesity, and COVID-19. They illustrate the connection between the disease and the society we have created that allows more than one in ten households to be food insecure and many communities in which access to healthy foods is severely limited. These characteristics disproportionately affect people of color. The authors argue:

“The U.S. health care system needs a renewed and increased focus on health inequities, inclusiveness, resilience, and chronic-disease prevention. Public health policies and legislative initiatives that reduce food insecurity and food deserts in vulnerable communities are urgently needed to address the upstream determinants of health”

COVID-19 and Disparities in Nutrition and Obesity. Belanger et al., 2020

Those “structural and social determinants” of health are the subject of an article in the American Journal of Respiratory and Critical Care Medicine, by Dr. Neeta Thakur and colleagues. They identified drivers of these disparities including gaps in risk exposure, access to information, and access to health services. We have set up a society in which Americans of color are much more likely to be essential workers who work in the most dangerous environments during the pandemic. We have set up a society where Americans of color are more likely to live in crowded conditions. We have set up a society where Americans of color are most at risk of losing income during challenging economic times.

All these things are sad but true. Yet, they are grounded in structural systems that were created over many decades. If they are structural, however, it means that that we can tear them down to build something new. We just need the political will to do so. We can create a country in which everyone has access to healthcare. We can create more investment in communities to sustain healthy lifestyles. We can create health systems that prioritize patients over profits. We can create communities where the color of your skin or the neighborhood that you live in do not determine dramatic spikes in your risk of death.

In their Health Affairs post, Leana Wen and Nakisa Sadeghi suggest a series of policy solutions to address these disparities. In the near-term, they highlight the need for an equity lens in thinking about the ways in which testing will be made available, contact tracing will be conducted, and quarantine will be supported with sound information, trusted leadership, and supportive fiscal policies. These should be “no-brainers”, but the lack of coordinated leadership often exhibited throughout the pandemic to date may inhibit these efforts. They also suggest some more progressive ideas by ensuring that healthcare costs related to CVOID-19 are covered. While this would require some significant effort, it is critical as the long-term effects of a COVID-19 hospitalization could be catastrophic– if not for health — for the economic viability of the family

Wen and Sadeghi also correctly point out that we will need longer-term investments in eradicating the conditions that led us to this place. We absolutely need more resources dedicated to social determinants of health and public health in general. They also raise the powerful point that we should attend to equity as we think about how the first vaccine(s) to address COVID-19 will roll out. In a society with unequal access and purchasing power, will we exacerbate these inequalities by settings up inaccessible systems for vaccinating the population, systems that may exclude those most at risk? We must learn from the past and not repeat those mistakes, as they strongly state:

Lack of thoughtful planning will inevitably lead to a situation where those who are well-connected and well-resourced can obtain scarce resources, leaving many others to go without them.

Addressing Racial Health Disparities in COVID-19 Pandemic: Immediate and Long-Term Policy Solutions (Wen & Sadeghi, 2020)

COVID-19 will not be the last challenge we face. We have often not got it right in the past. We should do our best to not repeat those mistakes again in the future and to, at long last, take this time as an impetus for action to reduce these inequities and create communities where everyone has the opportunity to thrive.

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