The COVID-19 pandemic has drawn attention to some of the deep disparities in healthcare, some of which are being exacerbated or risk widening even further. Health inequities have repeatedly been shown during this health crisis. Overall, the pandemic has significantly stressed public health systems around the world and exposed vulnerable populations in health care. Decades of systemic underinvestment have contributed to these health disparities.
Historically, the United States has made major investments in global initiatives that have largely contained threats and promoted global security, stability, and prosperity. Examples include human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) treatment, infectious disease surveillance and response, vaccine development, and maternal and child health improvement. These investments have also benefited the U.S. businesses both in terms of enabling a growing base of healthy, prosperous customers, as well as ensuring the safety of U.S. multinational operations around the world, and facilitated the continued leadership of the United States in research and development in the biomedical sciences. On the whole, old threats like these, as well as the re-emergence of measles, disruptive new technologies like electronic cigarettes, increased challenges including drug-resistant organisms, and new threats like climate change and politicized misinformation, show that a major investment of resources is necessary. This would help achieve health equity and make health systems strong, healthy, and vigorous.
The most prevalent disparities have been observed among African Americans, Latinos, American Indians, Alaska Native, and Pacific Islander populations. In multiple geographic regions and areas, preliminary prevalence and mortality estimates have shown a consistent pattern of racial and/or ethnic differences. These underlying causes of these health disparities are complex and caused by a wide variety of factors, including social and structural determinants of health, racism and discrimination, economic and industrial advantages, health care access and quality, individual behavior, and biology. Marginalized races are overrepresented in poverty rates. Therefore, poor communities may face challenges implementing social distancing guidelines due to housing density and overcrowding. Minority populations are also overrepresented in congregate settings, such as homeless shelters and prisons, which increase exposure risk. Additionally, it has been shown that racial/ethnic minority populations have higher rates of existing disparities in underlying conditions associated with more severe forms of COVID-19 and mortality, such as hypertension, cardiovascular disease, kidney disease, and diabetes. Although these conditions are largely preventable and/or compliant with medical treatment, these chronic conditions are more common, less likely to be controlled, and more likely to occur at younger ages in these communities. To explain, children may lack basic micronutrients and have immune systems that are tuned down, which may not be able to resist disease. Health care access is also a serious problem and contributing factor to COVID-19 mortality due to inadequate or no insurance coverage and a lack of availability of healthcare services and culturally-competent care. Minority and vulnerable communities are also overrepresented in the low-wage and essential workforce. Furthermore, racial/ethnic minorities and poor people in urban settings are more likely to be employed in public-facing occupations, such as services, transportation, hospitals, and nursing homes, which would increase exposure risk.
Some hospitals and healthcare systems have already worked to address these health inequities in various ways. One of these ways is by educating in ways that sympathize with every patients’ experiences. Hospitals and health care systems continue to educate their patients and communities on the prevention, social distancing, and how to deter the spread of COVID-19. Some hospitals have also created public health announcements educating people on COVID-19 symptoms, test sites, and their care options (if their symptoms progress).
Another way hospitals and health care systems have done this is by leveraging community partnerships. For example, SoHum Health in Garberville, Calif., Henry Ford Health System in Detroit, and Loyola University Medical Center in Chicago are using their pre-existing partnerships to strengthen community efforts. They are using these to get messages out in various ways to communities that may lack local newspapers or previously depended on public gatherings to spread the latest community news about COVID-19. Also, many faith leaders are offering services via videoconferencing and expressing the importance of staying home.
Finally, one other way that hospitals and health systems are doing this is by advocating efforts to raise awareness on COVID-19 disparities. The American Health Association and American Nurses Association asked the Department of Health and Human Services to organize and prepare their agencies to identify and address disparities in their response to COVID-19. The associations also called for an increase in the availability of testing, ensuring access to treatment, and spreading timely, relevant, and culturally-sensitive information to the public.
But, to fully achieve health equity, we need to reach beyond the healthcare system. By implementing new social policies, we could not only help advance both health equity, but the COVID-19 response as well. One of the ways we could do this is by establishing a universal food income. Food insecurity is already a health equity issue that affects racial and ethnic minority groups higher than other groups. Even though the Supplemental Nutrition Assistance Program (SNAP) is effective, it has its limitations. The benefit levels are often insufficient to permit a healthy diet, and, as well as that, many people with an income above the SNAP cutoff are still food-insecure. The Universal basic income is now a serious policy consideration in the United States, but objections that unconditional cash payments might be used are common. Alternatively, we could also establish a universal food income that provides all households with a monthly electronic benefit transfer payment, whose use would be restricted to SNAP-eligible food.
Secondly, we could improve unemployment insurance. Working conditions vary considerably by race and ethnicity. Insecure employment, low wages, and a lack of benefits could undermine pandemic-control efforts. Before COVID-19, the unemployment insurance system had seen declining income-replacement levels and had not adapted to the current labor conditions. For example, despite representing a developing segment in the workforce, independent contractors and labor markets that are characterized by the generality of short-term contracts and/or freelance work are ineligible.
By increasing the income-replacement rate and establishing an unemployment-insurance reform, we could help enable social distancing by allowing more people to stay home, improve health equity by giving workers a better bargaining position and make workers feel less pressure to accept dangerous or inequitable working conditions.
Lastly, we could also have policies that support investment in community development. Some of the key causes of disparities are neighborhood-level differences, such as housing availability, education, and economic differences. Segregation, redlining, and underinvestment have led to a lack of high-quality, affordable housing and depleted neighborhood resources. Community-development and benefit institutions and corporations should help build and develop an area’s assets by expanding affordable housing conditions, reducing toxic environmental conditions, and increasing local economic opportunity.
Overall, the COVID-19 pandemic affects everyone, but not equally. The same patterns of power, privilege, and health inequality have been recapitulated during this health crisis. If we want to achieve health equity for all, we must think big and reach beyond the health care system, by implementing new policies, educating others and raising awareness, leveraging community partnerships, and advocating on efforts to address these disparities.
References
[1] American Hospital Association. (2021, January). 5 Actions to Promote Health Equity During the COVID-19 Pandemic. Resources. Retrieved February 19th, 2021, from https://www.aha.org/resources/2020-04-24-5-actions-promote-health-equity-during-covid-19-pandemic
[2] Pan American Health Organization, World Health Organization, & Benjamin, G. C. (2020, October 26th). Ensuring health equity during the COVID-19 pandemic: the role of public health infrastructure. Articles. Retrieved February 28th, 2021, from https://www.paho.org/journal/en/articles/ensuring-health-equity-during-covid-19-pandemic-role-public-health-infrastructure
[3] Berkowitz, S. A., Cené, C. W., & Chatterjee, A. (2020). Covid-19 and Health Equity — Time to Think Big. The New England Journal of Medicine. https://www.nejm.org/doi/full/10.1056/NEJMp2021209
[4] Hooper, M. W., Nápoles, A. M., & Pérez-Stable, E. J. (2020, May 11th). COVID-19 and Racial/Ethnic Disparities. JAMA Network, 323(24), 2466-2467. https://doi.org/10.1001/jama.2020.8598
[5] Bibbins-Domingo, K. (2020). This Time Must Be Different: Disparities During the COVID-19 Pandemic. Annals of Internal Medicine. ACP Journals. https://doi.org/10.7326/M20-2247