As we cross the one year mark of the COVID-19 pandemic’s arrival in North America, data and headlines continue to reveal the significant disparities in the impacts of the virus. In the U.S., Black and Latinx people across all age groups are generally three times as likely to become infected and close to twice as likely to die from COVID-19 than white people. According to the CDC, even after accounting for the agency’s imperfect data, American Indian and Alaska Native populations in 23 states were 3.5 times as likely as white populations to get the virus, and are at a higher risk for severe COVID-19 related outcomes. In Martin Luther King Jr. Community Hospital in Los Angeles, one of the hardest-hit hospitals in the hardest-hit county in California, eight out of ten individuals who have died of COVID-19 have been Hispanic, and county data reveals that the most impoverished residents have been dying of the disease at nearly four times the rate of the wealthiest residents.
Though these numbers are deeply unsettling, they should not be surprising. The pandemic has forced us to confront uncomfortable and longstanding realities about the health disparities facing racialized and otherwise marginalized communities throughout the country. Notably, the healthcare system remains stacked against Black, Hispanic and Native Americans, as well as those who are poor. These groups are disproportionately uninsured and underinsured, with approximately 11% of Black, 20% of Hispanic and 22% of Native Americans living without access to insurance and basic health care services.
Massive expansion of access to healthcare is frequently posed as a solution to the disparities described above. A single-payer model of universal healthcare, funded through a progressive financing strategy, could simultaneously reduce per capita healthcare spending in the United States while ensuring that all Americans have access to hospital and community healthcare services with no cost at the point of service.
However, this solution on its own is unlikely to entirely erase the health disparities we are seeing. In Canada, for instance, where the Canada Health Act of 1984 sealed a decades long post-WWII trajectory of expansion and evolution of provincially administered and funded hospital and community-based medical services, and the concept of universal health care is a point of national pride, inequities abound.
While Canadians have the right to access comprehensive healthcare services without the burden of payment or the necessity of private health insurance, Canada nevertheless struggles to address inequities in its healthcare provision and outcomes. While these disparities exist at a different scale than the U.S, they are still worth noting. A recent Ministry of Health report in the province of British Columbia found that Indigenous people, for instance, are 75% more likely to end up in the ER due to lack of access to primary care doctors, and to experience widespread racism, stereotyping and discrimination in the healthcare system. Anti-Black racism is also a significant problem within Canadian healthcare environments, and Black and other racialized Canadians have been disproportionately affected by the COVID-19 pandemic. The Canadian example demonstrates that universal access may only go so far in eliminating entrenched health inequities.
As we collectively look to build more just health systems in the post-COVID world and address the health inequities that have been highlighted during the pandemic, we offer two important points for consideration:
1) Social Determinants of Health
We have long known that the single largest means by which health inequities facing Black, Indigenous, People of Color (BIPOC), and other marginalized persons, can be resolved is likely through massive investment in social equity outside of the health sector.
While underlying health conditions and lack of access to healthcare do explain some of the COVID-19 disparities we are seeing, they are also linked to a broader set of social, political and economic factors. Uneven access to these “social determinants of health” manifests in the health inequities that we observe. These determinants range from tangible needs like quality housing, education, nutritious food, to intangibles including clean air, access to public transportation, and physical security.
This group of nonbiological, nonmedical variables is estimated to account for 80 percent of health outcomes and their distribution is undeniably affected by the entrenched oppression and racism within our public policies and institutions. These systemic inequities result in the constant undermining of the mental and physical well-being of BIPOC as well as vast inequities in opportunity, income and wealth. Though public health experts have been discussing these linkages for several decades, public officials and the general public are becoming increasingly vocal about this issue with more than 20 states, counties and cities declaring racism, itself, a public health crisis.
Consequently, public policies and programs that address the unequal access to social determinants of good health have the power to improve health equity at the population level. A recent epidemiological analysis led by Harvard Medical School researchers suggests, for example, that reparation payments for slavery could have significantly reduced the inequitable disease burden of COVID-19 on Black communities by reducing the racial wealth gap.
Progressive policy proposals that promote social equity in order to advance public health will require substantial political capital, but many worthwhile efforts are already in process. The Green New Deal, with its emphasis on racial and economic equity as means of achieving climate justice, is one example of a progressive policy agenda that has significant potential to positively impact health equity through the social determinants of health, if its recommendations are adopted.
2) Beyond Access to Care
Mere access to healthcare is not sufficient. Structural oppression and violence are deeply embedded at all levels of care. As a result, BIPOC and other marginalized groups experience not only overt incidents of racism and intentional medical violence, but are also at risk of receiving a poorer standard of care than privileged social groups. In the long term this leads to mistrust and underutilization of otherwise accessible health services. This reality is actively manifesting as COVID-19 vaccine hesitation in non-white communities.It is therefore essential to dismantle entrenched systems of oppression within the healthcare sector in order to achieve high quality, equitable health service delivery.
While improving representation of BIPOC in the healthcare leadership is an especially important step, all healthcare professionals must be trained to better understand their role in either perpetuating or dismantling oppressive structures that significantly impact the health outcomes of patients and the communities to which they belong. This awareness can help begin to build relationships and foster trust with individuals and communities that are rightfully skeptical of a healthcare system that continues to treat them unfairly.
Finally, we must also build robust systems to systematically track inequities and hold the health sector accountable for disparities in quality of care to marginalized groups. This commitment will require long-term investment, but progress toward health equity must ultimately become a standard measure of the quality of healthcare systems.
The significant disparities in the impacts of COVID-19 should serve as a rallying cry for reforming our policies, practices and attitudes within the healthcare system but also beyond. If we genuinely hope to achieve health equity in a post-COVID world, we must understand that universal access to healthcare is a fundamental stepping stone, but is not enough. Access must be pursued in tandem with significant efforts to guarantee that all people have equitable access to the social determinants of good health, and to ensure that as marginalized communities seek out care, they are treated by the healthcare system with justice, dignity and the highest standard of care.