In late March, when TV journalist Chris Cuomo announced that he had COVID-19, his brother Andrew, the governor of New York, tweeted in response: “This virus is the great equalizer.”
Around the same time, Madonna expressed a similar sentiment. Posting a video filmed in a bathtub filled with rose petals, she said, "That's the thing about COVID-19. It doesn't care about how rich you are, how famous you are, how funny you are, how smart you are, where you live, how old you are, what amazing stories you can tell."
Technically, it's true that a virus doesn't care how much money you have, if you need to be on TV the following night, or run a country—all it "wants" is to find a host to infect so as to replicate itself. In this way, a global pandemic might be conceived of as a levelling force, indiscriminately threatening all echelons of a society.
That's what happened, to some extent, in past pandemics. In 1630, when the plague hit Northern Italy, it killed 35 percent of the population. Jacob Soll, a professor of history at the University of Southern California, recently wrote in Politico that the mass casualties of the Black Death set the stage for the Italian Renaissance.
The plague slowed down economic inequality—so many people had died that there was an increase in wages and affordable housing. The city government became open to people in lower guilds and literacy levels skyrocketed. "For a time, Florence’s economy bounced back with remarkable social mobility, and it became Europe’s premier center of artistic, cultural and scientific creativity,” Soll wrote.
This is not what is happening in the United States with COVID-19. Instead of evening the playing field, the pandemic has instead exposed how deep and embedded our social inequities are, and amplified how much factors like income, education, housing, race, and social status can impact health outcomes.
These factors are known as “social determinants of health." They are influences that go beyond just the biological processes of a disease, like access to health insurance, food security, housing security, transportation, personal safety, structural racism, and more. By some estimates, the social determinants of health contribute to 80 to 90 percent of our public health outcomes.
Public health experts have been ringing alarm bells about the social determinants of health for decades. Yet the U.S. spends an extraordinary amount of money on individual healthcare once people are sick, while often ignoring the ways wealth gaps and racism contribute to worsening health. COVID-19 could serve as a wake-up call. If COVID-19 is an exam for how we were doing on social determinants, the United States isn't receiving a passing grade.
People who were already struggling are losing their jobs, housing, and suffering higher mortality rates from COVID. The Color of Coronavirus project, which tracks how COVID-19 is disproportionately affecting certain communities, found that as of July 21st, there continue to be large disparities in deaths in Black, Indigenous, and other populations of color compared to white people.
Addressing social determinants could make a meaningful difference to health if we consider that poverty, racism, and housing aren’t just correlated with poor outcomes, but can actually cause them. COVID-19 is laying that truth bare, and presenting us with an opportunity for policy making that aggressively hones in on social determinants—both to get us out of the pandemic safely, and for future health outcomes.
“It’s basically been a three-month crash course on what we’ve known for centuries,” said Atheendar Venkataramani, a health economist, internal medicine physician, and assistant professor at the Perelman School of Medicine at the University of Pennsylvania. “Which is that the risk of disease and the outcomes of disease follow unequally from the circumstances the people find themselves in life.”
In an essay about Albert Camus' novel The Plague, British academic Jacqueline Rose responded to the notion that we are all in this together—this, being the pandemic. "The frailty of that ‘we’—has never been so obvious," she wrote in the London Review of Books.
In the United States, that "we" has splintered along racial lines. COVID-19 is infecting mostly-Black counties at rates three times more than mostly-white ones, and their mortality rates are six times higher. Data released from large cities paint a stark picture. Though Black people account for only 30 percent of Chicago’s population, over 50 percent of COVID-19 cases there are of Black people, and almost 70 percent of the deaths are within the Black community. Michigan’s population is 14 percent Black, but Black people make up 41 percent of COVID-19 deaths. Illinois’ population is also 14 percent Black, and their COVID-19 deaths are 32.5 percent Black. Black people are 33 percent of Louisiana’s population, but more than 70 percent of coronavirus deaths. In New York City, Black and Latino people are two times more likely to die than white people.
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These disparities didn’t come out of nowhere, but reflect how strongly social determinants of health dictate COVID-19 risk. Social determinants increase the chances of someone being exposed to the virus in the first place. We’ve been told to stay at home—but who has the income to stay at home, or a job where it’s possible to work remotely?
In a preprint study from May, which hasn't been peer reviewed, researchers found that in areas with lower incomes, there were both greater percentages of people of color and higher numbers of essential workers and healthcare workers that used the subway more during the pandemic. Using the subway was associated with higher rates of COVID-19.
“We feel comfortable saying that being on a subway can cause COVID-19,” said Venkataramani. “I think we feel less comfortable to ask, why are people still riding the subway?”
There was also an assumption that sheltering in place was a safe option, said Rachel Hardeman, an associate professor at the University of Minnesota's School of Public Health. But for people in crowded households, sometimes multigenerational ones that include at-risk older people, staying isolated at home doesn't necessarily protect from infection.
Hardeman said this is a direct result of the legacy of redlining, racist policies which denied Black people mortgages, which led to less housing security. In Minneapolis, where George Floyd was killed by police, 75 percent of white people own their home, compared to 25 percent of Black people that do. And for people without homes, COVID-19 risk is even higher: Out of 408 people living in a homeless shelter in Boston, 36 percent were positive for the coronavirus.
“The precariousness due to the social determinants of health is so significant that it doesn’t take much to push folks who are already struggling over the edge.”
Julia Wolfson, an assistant professor at the University of Michigan's School of Public Health, examined how food insecurity impacted people’s ability to follow social distancing guidelines. She and her colleagues asked people whether they were able to comply with recommendations to stock up on food in order to avoid going out. Low-income adults and people who were already food insecure, were not able to do that. They either didn’t have the money or didn’t have access to food in the same way people with higher incomes in different neighborhoods did.
Hardeman said that Black people can have more chronic health conditions, like hypertension, diabetes, and asthma, which can make COVID-19 worse. “But rarely did I see this effort to understand, so why are there more chronic illnesses in Black communities?” Hardeman said, adding that those diseases are influenced by social determinants too.
People of color have less access to health insurance, which can exacerbate chronic conditions. As of 2017, around 55 percent of Black people had private health insurance, while 75 percent of white people did. And according to the weathering hypothesis, coined by public health researcher Arline Geronimus, the cumulative effects of discrimination, racism, and lower socioeconomic status over the course of one’s life leads to poorer health outcomes, and higher risk for many diseases.
People without health insurance are more likely to use emergency health services, and so with the coronavirus overwhelming those facilities, it puts people in “double jeopardy,” during a pandemic, said Gulzar Shah, a public health systems and services researcher at the Jiann-Ping Hsu College of Public Health at Georgia Southern University. “They not only are likely to have multiple chronic conditions, and high vulnerability to COVID-19, the facility closures, and the interrupted delivery of routine healthcare to accommodate COVID-19 care has pushed these vulnerable populations completely out of the healthcare system.”
The pandemic provides example after example of how a person’s life situation can impact their health, that goes far beyond an individual's behavioral choices; it robs people of the choice to act or live in healthier ways. “What COVID has shown is that the precariousness due to the social determinants of health is so significant that it doesn’t take much to push folks who are already struggling over the edge," Hardeman said.
Social determinants have always been able to swiftly impact a person’s health. But the pandemic “has placed a magnifying glass on inequities that used to exist but were often masked in overall averages and small numbers presented in reports," Shah said.
Wolfson agreed. “We’ve been talking in public health about social determinants of health for a very long time. We recognized them as being these critical factors that affect health over the long term. But we sort of thought of them like: This puts you on a different trajectory for health over the long term. What COVID-19 is slapping us in the face with is, no this is the here and now. There's an immediate threat to people's health.”
On February 25, Michael Marmot published the Marmot Review 10 Years On for Health Equity in England—which provided an update to his 2010 report on health disparities, finding that life expectancy, as a measure of overall health and well-being, has continued to stall or get worse.
Life expectancy hasn't decreased in the same way for everyone. It’s a social gradient: The more deprived an area is, the higher the mortality, the shorter life expectancy. Marmot, a professor of epidemiology and public health at University College London and director of The UCL Institute of Health Equity, said it’s not just lack of money that leads to these inequities, but an inability to socially participate and lead a dignified life in which one has control over their circumstances.
Based on data from England, Marmot has been finding that COVID-19 mortalities are falling along a similar gradient. “That implies that the social determinants of inequalities in COVID-19 overlap with the social determinants of ill health more generally,” he said.
Marmot has been studying how inequity influences health for decades, and is one of the most well-known champions for the social determinants of health. Even coming into the pandemic, he said we were facing a public health crisis.
“We were ill-prepared in health terms and ill-prepared in public expenditure,” Marmot said. “We've reduced spending on social care. Health service expenditure failed to rise in line with inflation. We were not in a good state. Then the pandemic crashed upon us.”
The situation in the United States mirrors what Marmot has found in England. For the last four years, life expectancy has either been going down, or not improving, and lags behind other rich countries. The United States currently is 28th among Organization for Economic Cooperation and Development (OECD) countries for life expectancy at birth.
The United States spends more money on healthcare, per person, than any other country, yet doesn’t have the health outcomes to show for it. Countries that spend thousands of dollars less per person still have higher life expectancy than the US.
A 40-year-old man who is in the poorest 1 percent of the US population will die, on average, 14.6 years sooner than a man in the top 1 percent. For women, the gap is about 10 years. In Baltimore, Maryland, there can be a 20-year disparity in a man's lifespan in a poor neighborhood, compared to a man's in a wealthy one.
"In some ways this is highlighting the unique failures of the American healthcare system and the American focus on pulling yourself up by your bootstraps,” Wolfson said. “Obviously there is poverty and inequality everywhere. But other high-income countries invest in the well-being of their population from a societal perspective, much more than we do.”
This scarcity of public health has led to dramatic health outcomes long before COVID-19. In Flint, Michigan, the water crisis that led to lead poisoning was something that a strong public health system might have been able to surveil and handle more quickly. In 2017, there was a resurgence of hookworm in the U.S. south among poor Black communities—a disease that was all-but eradicated through the Rockefeller Foundation's efforts in the 1920s.
“We were not in a good state. Then the pandemic crashed upon us.”
"Healthcare in the United States has worked as an industrial complex, motivated primarily by profiteering, with a focus on curing the sick rather than preventing people from getting sick,” Shah said. “Though the quality of care is better due to competition, profitability and high cost are the hallmarks of the societies where market forces are left unchecked.”
Researchers have evidence that policies that change people's social determinants, end up changing their health. For example, being part of the Deferred Action for Childhood Arrivals, or DACA, which integrates immigrants into the U.S. labor market, has been shown to positively affect the health of children with DACA-eligible mothers. In contrast, banning affirmative action programs negatively affects minority youth health. The federal minimum wage is currently $7.25, or about $15,000 a year for a full-time employee before taxes. In 2001, researchers estimated the effects of increasing the federal minimum wage to $11, and predicted that it would lead to substantial health improvements like a decrease in the risk of premature death, and reduction of sick days, disability, and depression.
There is progress being made. Some healthcare facilities have started providing housing assistance to homeless people, and finding that as a result, ER visits go down, inpatient admissions go down, and there’s a decrease in overall costs for the hospital, sometimes dramatically.
In the _International Classification of Diseases_’ (ICD) tenth edition, there are now codes a doctor can record in a patient's electronic health record that account for social determinants like homelessness, disappearance and death of family members, problems in relationship with spouse or partner, or problems related to education and literacy.
But research has found that these codes are rarely used. Only 1.4 percent of Medicare patients in 2016 and 2017 had claims that included social determinants codes; the most commonly used one was homelessness. A study from 2019 found that just 24 percent of hospitals and 16 percent of physician practices asked people about things like food insecurity, housing instability, transportation needs, and violence in their personal lives.
Hardeman is working on a project in Minnesota to figure out the best way to track social determinants. “I don't think it's the solution,” she said. “But it's important to say, we're thinking about this. We're measuring that. We're capturing this, we have information about it.”
Prioritizing social determinants of health requires efforts from outside of healthcare and medicine too. “So many social determinants of health really come back to economic policies,” Wolfson said. And it means considering health more holistically, including aspects that may not be obviously connected to disease or illness. In a lecture in Berkeley in 2018, Marmot described telling first-year medical students that when calculating an ideal minimum income for healthy living for an older person, it must account for enough money to buy presents for their grandchildren.
“A chief executive from this health care organization started to weep,” Marmot remembered. “And he said, choking up, 'Recently my mother told me that my grandad used to go without meals to buy us birthday presents.' That’s part of leading a dignified life. Having enough money to buy your children, your grandchildren, a present. And in a rich society, we ought to be able to organize our affairs so everybody could do that.”
Social determinants of health have often been thought of as “wish list” items, complex issues to address someday, and not in the immediate present. “I’ve been doing research on inequalities in health for 40 years or more,” Marmot said. “And for the last 40 years, I’ve been hearing people say, ‘Yeah, but that’s long term. What should we do tomorrow?’”
Our government is currently hemorrhaging money on stimulus bills to keep the economy from collapsing, and while some Paycheck Protection Program loans go to billionaires, that same money could be funneled into social determinants-focused programs that actually can influence health relatively quickly. We've seen this before in policies like expansion of the earned income tax credit, Medicaid expansion, and minimum wage hikes. In 1965, when President Johnson said hospitals had to be desegregated to get Medicare fundings, it led to reductions in infant mortality from preventable diseases within a year. In this way, addressing social determinants should be thought of as evidence-based treatment options that can lower mortality or sickness, not a goal on a bucket list.
It can even be cost effective: A study from 2018 measured the impact of social determinants of health-type services on Medicaid and Medicare Advantage patients, finding that they could save more than $2,400 per person on their health care when they were referred to organizations that provided assistance for things like secure housing, medical transportation, healthy food programs, and utility and financial assistance.
COVID-19 has taught us it is possible to address some social determinants of health rather quickly—like expanding unemployment, finding places for homeless people to sleep at night, or closing down streets to traffic so that people in areas without parks have more room for exercise and recreation.
What else might a social-determinants approach to COVID-19 look like? It would still include healthcare initiatives, of course. More than five million people have lost their health insurance because of COVID-19. The fact that when you lose your job due to a COVID-19 layoff, you lose your health insurance, is uniquely American phenomenon, compared to our peer countries.
“Decoupling health insurance from employment or dare I say it, having universal health care, that would go a long way to addressing some of these problems and the disparities that really are unique to the U.S.,” Wolfson said.
“Is COVID-19 the wake up call? Yes, it is among many people.”
It would also incorporate health-adjacent measures, like moratoriums on evictions, releasing people from jails where COVID-19 is spreading, and expanding access to food programs or universal childcare. We need to help people be financially stable while we wait for a vaccine. That might involve extending unemployment benefits, no-interest micro-financing, or the government paying companies to keep employees at 80 percent of their wages—like other European countries have done.
What’s crucial is not to let the reminder of how critical the social determinants of health are fade away after the pandemic. The World Economic Forum reported that the pandemic could push half a billion people in the world into poverty. That means our focus on social determinants can’t end with COVID-19, but intensify to deal with its aftermath.
The progress on social determinants may feel slow, but Marmot said that he’s thrilled it’s making its way into discussions of health and policy now. “When I say I've been doing research on this for 40 years, that may sound like I'm bitter or despondent,” he said. “I’m not in the least bit. I'm delighted that the language of social determinants of health is nearly in common parlance. We are getting on the agenda. Is COVID-19 the wake up call? Yes, it is among many people.”
COVID-19 can help obviously connect the dots between a person's wages, where they live, and their race to their physical health. “It's both a tsunami of a public health crisis and potentially a tsunami of real understanding and enlightenment," Venkataramani said.
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