On Race and COVID-19: We Need To Talk About the Structural Determinants of Health and Equity

On Race and COVID-19: We Need To Talk About the Structural Determinants of Health and Equity

National data released in early April indicates African Americans in Louisiana, Chicago, and Michigan are being disproportionately impacted by the COVID-19 pandemic. That same week, the message from our national health leadership, and news stories that followed, was that this impact appeared to be attributable to preexisting conditions—high blood pressure, heart disease, diabetesand inadequate access to health care. U.S. Sen. Bill Cassidy said on NPR’s Morning EditionIf you have diabetes, obesity, hypertension, then African Americans are going to have more of those receptors…as a physician, I would say we need to address the obesity epidemic, which disproportionately affects African Americans. That would lower the prevalence of diabetes, of hypertension.”  

I couldn’t believe it.  

Yes, African Americans are more likely to have and die from diabetes compared to the general population. Black U.S. households are also twice as likely to be food insecure as the national average, with one in five families lacking consistent access to enough food. Should it surprise us that diabetes prevented in part by consuming healthy food  is felt more by the Black communitySo why did top health officials stop at chronic disease as the cause? How could they not look at what causes the underlying chronic illness itself and realize a person’s blood pressure, diabetes, heart disease is almost entirely a result of how much money they make, the food they can afford, the neighborhood or home they live in, and the job opportunities they have access to? How could our country’s vocal medical professionals not see that a person’s neighborhood dictates if they are preyed upon by cigarette outlets and fast food entities? And that even THOSE things are downstream of the policies, laws, and discrimination that have forced African American (and Latinx and American Native) populations into certain zip codes without access to clean homes, food, jobs, and health care for decades. 

That many Americans, following this, made sweeping statements about the behavior of black individuals, claiming black people are being infected and killed by COVID-19 at higher rates because they are not taking the threat seriously or social distancing appropriately, should not be surprising. Appalling, yes. And you can see how they were led to those conclusions by the lack of strategic media response or correction from physicians and public health leaders. Physicians, after all, are the most powerful and authoritative voices on health, and they can use this characteristic to champion health in all policies. According to a paper out in JAMA this month, physicians can point to the narratives of their patients and how much of health is determined by forces outside the control of patients and physicians. This is an opportunity for providers to use their knowledge to counter the unsupported narratives in which individuals who have health conditions that are beyond their control are blamed and penalized for their poor health. 

Now don’t get me wrong, there have been several individuals buried in the mass media around COVID-19 that have been attempting to voice how we should stop blaming black people for dying of the Coronavirus. Or that testing for African American communities is essential, as is paying living wages and hazard pay when folks can’t “work in place.” Or even that steps should be taken long term to build an economically resilient society, and that wealth gives people the resilience to weather a crisis without succumbing financially. 

Scott Frank, a professor at Case Western Reserve University’s School of Medicine, speaks to what we are seeing from a vantage point I value and respect: “When someone dies, there are 3 ways to think about what caused it. The first is the straightforward, ‘medical’ cause of death—diagnosable things like heart disease or cancer. The second is the ‘actual’ cause of death—that is, the habits and behaviors that over time contributed to the medical cause of death, such as smoking cigarettes or being physically inactive.” The third is what Frank refers to as the “actual actual” cause of death—the bigger, society-wide forces that shaped those habits and behaviors. In one analysis of deaths in the U.S. resulting from social factors (Frank’s “actual actual” causes), the top culprits were poverty, low levels of education, and racial segregation. 

Can we get to the actual actual cause of death with Coronavirus and see this as an opportunity to change the rhetoric, to redesign our resources and structures so that we are all in on that third death cause Frank refers to? 

Frank’s description called to mind the below graphic I dusted off from literature buried in my public health coursework from a decade ago. I wrack my mind for this image regularly, as it so clearly depicts how much of health is really dictated by much more beyond what we see in the medical sphere. Even beyond what we see in people’s behavioral health! It’s this image I wish our national conversation had focused on much faster with the release of the racial outcomes data.

Adapted by the ACPHD from the Bay Area Regional Health Inequities Initiative, summer 2008.

One of my favorite articles, out of the UK mid-April, cites upstream social inequity data and points to several non-health related factors including income inequality, occupational factors, housing differences, cultural factors, and/or language barriers, that are at the root of the racial divides in hospitalizations and deaths we see.  

As so eloquently pointed out in the Atlantic last week, in the coming months and years, there will ultimately be two pandemics in America. One will be disruptive and frightening to its victims, but thanks to their existing advantages, they will likely emerge from it relatively stable. The other pandemic, though, will devastate those who survive it, leaving lasting scars and altering life courses. We will walk out of this pandemic with a further divided nation if we don’t change the rhetoric, and therefore the resources and structures that allow people to truly be healthyphysically, psychologically, spiritually. The many divides in American society that will shape people’s experience of the pandemic don’t exist in isolation. Instead, they compound and overlap, increasing the risk that certain people will endure the more devastating of these two pandemics. 

Carly Hood-Ronick, CCO Strategy & Health Equity Director

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