African Americans comprise approximately 14% of Michigan’s population, yet 40% of the state’s COVID-19-related deaths were among African Americans. In Chicago, those numbers were 30% and 72%, respectively. Although Native Americans represent just 11% of New Mexico’s population, Native Americans made up half of the state’s COVID-19 death toll.
How a Global Pandemic Became a Case Study in Social Determinants of Health
In New York City, the epicenter of the coronavirus outbreak in the U.S., case numbers varied profoundly by zip code. Manhattan, the city’s most densely populated borough, accounted for the lowest percentage of COVID-19 cases, hospitalizations and deaths; at the time of writing, the Bronx had the highest numbers across all three categories and more than twice the number of cases as Manhattan. A JAMA research letter on the disparity in New York notes the Bronx “has the highest proportion of racial/ethnic minorities, the most persons living in poverty, and the lowest levels of educational attainment.”
Examples such as these are myriad, and more will undoubtedly be forthcoming as better data comes to hand. Rarely do we get as concrete and concentrated an opportunity to examine the health disparities that exist in today’s society as in the case of a pandemic virus — one to which everyone is equally susceptible, but not at equal advantage.
The World Health Organization defines social determinants of health (SDoH) as “the conditions in which people are born, grow, live, work and age…shaped by the distribution of money, power and resources at global, national and local levels.”
Just as population density alone is not an indicator of COVID-19 concentration, a single factor often does not determine a health outcome; rather, there are a number of physical, social, behavioral, environmental and other factors to consider. For example, residents of food deserts — areas with limited access to affordable and nutritious foods — are shown to have disproportionately higher rates of chronic disease. Relevant to COVID-19, a person with a job that can be done remotely is better equipped to adhere to stay at home orders and social distancing rules than one who must commute to what has been deemed an essential business.
Healthcare experts have been vocal from the start that there are certain individuals who are more vulnerable to severe effects of COVID-19 — older adults and those with serious underlying medical conditions. From a medical standpoint, this is logical enough. Certain chronic diseases and medications can weaken or suppress the immune system, making it more difficult to fight off infection. Older people have a higher prevalence of one or more chronic diseases, in addition to the natural effects of aging on the immune system.
But it is clear from the data that there are other, deeper, underlying factors at play. For one, a person’s susceptibility to chronic disease is in itself rooted in SDoH. Low-income communities are at a statistical disadvantage with regard to COVID-19, which, among many social determinants, is likely attributed to situational factors such as limited access to testing and the occupational health hazards of low-wage, high-risk work. In New York City, the most densely populated borough also happens to be the wealthiest, affording many residents the opportunity to leave the city for second homes or rentals in lower risk areas.
Underscoring the gravity of these health disparities is the fact that some racial and ethnic minorities are contracting and dying of COVID-19 at vastly disproportionate rates. A new study from Yale has put a number to the impact, finding that black people are over 3.5 times more likely to die of COVID-19 than white people — Latinos, nearly twice as likely.
Much of the current data on COVID-19 is far from perfect. With regard to the aforementioned study, many states aren’t tracking the race and ethnicity of pandemic-related deaths, and those that are don’t account for age differences among population groups. Testing still lags in many areas, making it difficult to understand and assess the pandemic’s full impact. Determining who has died as an outcome of the virus is also a challenge — one Scientific American says is more likely to be resulting in underreporting than the converse. By these measures, with more widespread testing and reporting will likely come more sobering statistics.
Calling attention to the significance of social determinants to population health is hardly the discovery of a new phenomenon; we are merely seeing it play out through a crisis that can serve as a microcosm of the nation’s systemic health disparities.
As the emergence of a novel coronavirus has sounded the alarm on the urgent need to mitigate future outbreaks, the alarm should be ringing just as loudly on what this says about the state of healthcare — and how we must work to eradicate these disparities along with the virus.
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