Health Equity in the Time of Coronavirus

As Dr. Campbell wrote in last month’s NCEAS blog, the SARS2/CoV-2 pandemic is expected to exacerbate health inequities in communities across the United States for a multitude of reasons. Social determinants of health are not equally distributed. There are fewer opportunities to socially distance oneself in lower income neighborhoods. Occupational hazards, lack of childcare and fear of job loss as the unemployment rate rises are bigger concerns for the working class than the wealthy. The implicit biases of clinicians put people of color at risk for unequal testing and treatment. As the New York Times wrote, “Still, a kind of pandemic caste system is rapidly developing: the rich holed up in vacation properties; the middle class marooned at home with restless children; the working class on the front lines of the economy, stretched to the limit by the demands of work and parenting, if there is even work to be had.”¹

People from communities across the nation are seeking help in addressing their social needs. A study of frequency of 2-1-1 calls showed a striking uptick in the number of calls placed looking for resources.² Comparing the same dates in March 2019 to March 2020 across 23 states, the researchers noted that all states had at least twice as many calls about food needs and half had a 500% increase in calls. Additionally, food delivery requests were up anywhere from 150 to 10,000%. The number of requests for rent assistance in the 1^st quarter of 2019 was 14,268. This number doubled to 39,903 in the first quarter of 2020, with a large jump in the number calls starting March 18^th, 2020, just 1 week after the WHO declared a pandemic.²

Data is currently lacking but there are some early indicators that support that poor and underserved communities are being hit hardest by the pandemic. For instance, The New York Times reported that an early study out of New York City using geospatial coding revealed increase rates of confirmed SARS2/CoV-2 in lower income zip codes.³ In fact, 19 of the 20 neighborhoods with the lowest prevalence of confirmed SARS2/CoV-2 had the highest median incomes. Hospitals located in lower income neighborhoods are being hit harder, with more patients and fewer resources. Access to the healthcare system can also be a barrier for lower income communities, whether that is distance traveled (such as for rural communities) or lack of insurance and underinsurance.³

This disparity in the prevalence of the virus is likely the result of multiple factors. For one, it is more difficult to isolate someone with symptoms when living in a small apartment or with many people. Individuals with lower incomes may be reliant on public transportation, and may have jobs that are less flexible where working from home is not an option.⁴ Think of the people still working construction, in grocery stores and restaurants, doing delivery services and so on. They certainly put themselves at risk as they show up to work and yet are not fairly compensated for the risk.

Underlying health conditions especially in older adults puts those who contract the virus at higher risk for complications including death. Yet, health conditions are not equally distributed across the population.⁵ Too often wealth equals health. Moreover, there are well-documented disparities even during the best of times, such as higher rates of asthma and diabetes in African Americans compared to whites.⁶ How these pre-existing health disparities impact infection rates and complications from SARS2/CoV-2 infection has yet to be established.

Income disparities impact health in obvious ways, but we should also consider the digital divide and how caps on data usage plans impact patients’ ability to access telehealth visits now being offered by healthcare providers across the country. Long-term health outcomes can also be impacted in more insidious ways by the rich-poor divide. Those families with reliable Internet and sufficient broadband have more schooling options for their children who are now at home. Virtual classrooms are being created, yet only those with the hardware and Internet access can take advantage of them. As daycares close in response to shelter at home orders and social distancing best practices, those with the means to stay at home with their kids or find alternative means of childcare have better job security.¹

The role of implicit bias about race is well documented. For example, multiple studies have demonstrated African Americans have their pain treated less often than their white counterparts.⁷ This raises real concerns for equitable treatment during the pandemic. Since demographic information has yet to be published, it’s impossible to tell if offers of testing, admission to the hospital, and quality of care are occurring at equitable rates across races/ethnic groups.⁶

The good news is that healthcare professionals and advocates throughout the country are responding to the needs of our more vulnerable communities. In fact, this is a prime time for clinical educators to model and incorporate their learners into our response to these inequities. Sometimes students aren’t waiting for faculty role models – they are finding ways to contribute all on their won. Medical students – having been removed from clinic rotations and in-person lectures – are coming up with creative ways to support their communities. Students from the University of Minnesota created the MN CovidSitters group, offering childcare services to anyone working in the healthcare setting.⁸ At my home institution, University of Cincinnati, medical students have created a program to pair younger and lower risk students with older adults to aid them in grocery shopping and prescription pick up. They also call them a couple times per week to ease the burden of isolation and subsequent loneliness.⁹

Communities are working together to identify and distribute resources. UCSF’s SIREN network has long provided information to healthcare workers about how to best meet the social needs of their patients. They now have a COVID-19 page of resources specific to the pandemic. In Cincinnati, my colleagues (Dr. Anna Goroncy, Dr. Shanna Stryker, and fourth-year medical student Caroline Hensley) and I created a virtual notebook on a note-sharing application to track the ongoing updates on resources specific to our community. This includes food resources for kids now that school are closed – a potential hardship for families with a lower income who utilized the free lunch program to stretch their budgets – as well as housing, employment, child education and self-care resources. The resource guide is updated daily on a webpage and a PDF version has been distributed to nearly every health system in the area.

Advocacy has long been the best response to identified social needs and it is more important now than ever before. Many professional organizations are working at a federal level to get policies in place that protect vulnerable populations. For instance, the American Civil Liberties Union has called for protections of people currently incarcerated, requesting that governors grant commutations of sentences for individuals at high risk of complications from SARS2/CoV-2, that police stop arresting individuals for minor crimes (but still issue a citation), and that prosecutors allow those who are awaiting trial to do so outside of jail without a cash bail requirement whenever possible.¹⁰ They are similarly advocating for immigrants without documentation who are currently held in detention centers.¹¹ Activism on a local level is also critical. In Cincinnati, for instance, physicians who care for patients experiencing homelessness are working with hospitals to create safe discharge plans in the case of confirmed COVID, and with city council to find the funds to use hotels to isolate those who may still be infectious.

For educators and advocates the expression “we are building the plane while flying it” has never felt truer. But we are finding ways to respond, both to the social needs and health inequities revealed by the pandemic. Now is the time to share widely our efforts, and to encourage and support learner participation. After all, as Gail Christopher, Executive Director of the National Collaborative for Health Equity, said, “If this [pandemic] doesn’t illustrate the meaning of ‘social determinants of health,’ nothing does.”⁶

-Megan Rich, MD, MEd, Community of Practice Member

Dr. Rich is an Associate Professor in the Department of Family & Community Medicine at University of Cincinnati and the Program Director of the Christ Hospital/UC Family Medicine Residency Program.

1. Scheiber N, Schwartz ND, Hsu T. ‘White Collar Quarantine’ Over Virus Spotlights Class Divide. The New York Times. 2020 Mar 27.
2. Health Communication Research Lab. Focus-19: Measuring the daily social impact of COVID-19 in the U.S. Washington University in St. Louis. https://hcrl.wustl.edu/1088-2/
3. Valentino-DeVries J, Lu D, Dance G. Location Data Says It All: Staying at home during coronavirus is a luxury. The New York Times. 2020 Apr 3.
4. Buchanan L, Patel JK, Rosenthal BM, Singhvi A. A Month of Coronavirus in New York City: See the hardest-hit areas. The New York Times. 2020 Apr 1.
5. Whyte LE, Zubak-Skees C. Underlying Health Disparites Could Mean Coronavirus Hits Some Communities Harder. National Public Radio. 2020 Apr 1.
6. Williams JP. Rumor, Disparity and Distrust: Why Black Americans Face an Uphill Battle Against COVID-19. US News and World Reports. 2020 Mar 25.
7. Chapman EN, Kaatz A, Carnes M. Physicians and Implicit Bias: How doctors may unwittingly perpetuate health care disparities. Journal of General Internal Medicine. 2013. 28(11):1504–10. DOI: 10.1007/s11606-013-2441-1
8. Elassar A. Meet the Medical Student Who Launched a Program to Offer Childcare to Hospital Workers Fighting the Coronavirus Pandemic. CNN. 2020 Mar 23.
9. WLWT digital staff. Cincinnati College Students Will Pick Up Groceries, Prescriptions and Check On Seniors. WLWT Channel 5 News. 2020 Mar 30.
10. ACLU demands the release from prisons and jails of communities vulnerable to COVID-19. American Civil Liberties Union. 2020 Mar 18. Accessed from https://www.aclu.org/press-releases/aclu-demands-release-prisons-and-jails-communities-vulnerable-covid-19.
11. ACLU urges federal court to release people in immigration detention who are vulnerable to coronavirus. American Civil Liberties Union. 2020 Mar 24. Accessed from https://www.aclupa.org/en/press-releases/aclu-urges-federal-court-release-people-immigration-detention-who-are-vulnerable.