Throughout history, one of the most marginalized groups of America’s population has been the poor. Those who belong to a lower socioeconomic group ultimately bear the brunt of widespread disease. With the COVID-19 pandemic continuing to rage worldwide, it is imperative—now more than ever—to evaluate and act on the long-standing factor of income in our population’s health. Historically, we can show that income plays a large factor on the well-being of individuals.
In a study published in 2016, it was found that in the United States, the gap in life expectancy between the richest 1 percent and the poorest 1 percent was 14.6 years for men and 10.1 years for women between 2001 and 2014 with the gap increasing theresince (1). This does not come as a surprise, as those who are from lower socioeconomic groups tend to have to prioritize their use of time. In the podcast, The Dose, from The Commonwealth Fund, 100 low-income patients shared stories about their healthcare experiences. A common theme among these accounts was difficulty finding time to seek medical care. If one is supporting a family and living paycheck-to-paycheck, it is difficult to pay for child care facilities, figure out transportation and forego the amount of time—and consequently the amount of money—they could use if they spent that time working (2). These logistics, alongside the growing costs of long-term medical care, impedes low-income citizens from utilizing healthcare to the same extent as more affluent individuals.
As one would expect, these concerns have only been exacerbated by the drastic nature of the COVID-19 pandemic. It is known that under-resourced communities have less access to high quality health care and suffer from more chronic illnesses such as diabetes, heart disease and pulmonary issues, which can make them more vulnerable to the effects of COVID-19 (3). Choosing to go to work rather than staying at home and not getting paid increases their likeliness of contracting the virus. In a study published in June, it was found that the number of deaths confirmed to be caused by COVID-19 seemed to be relatively higher in impoverished areas later in the pandemic (4). The disproportionately negative impact of COVID-19 on poorer communities highlights America’s failure to address this issue despite its repeated offense to our society.
In addition, with such drastic differences in healthcare between socioeconomic classes, there comes drastic differences between healthcare administered to different racial populations as well. According to the 2018 US Census Bureau’s Current Population Survey, Blacks and Hispanics experience much higher poverty rates than the national poverty rate at 11.8%. For instance, 20.8% of Black Americans and 17.6% of Hispanics experience poverty, whereas whites and Asians experience poverty rates of 8.1% and 10.1%, respectively (5). For these people of color (POC), this difference has been fundamental in the onset of COVID-19 and ultimate prognosis.
According to a podcast from the CommonWealth Fund featuring Dora Hughes, associate professor of health policy at George Washington University, the number of Black Americans hospitalized in Sutter Health Hospitals due to COVID-19 is 2.7 times higher than the number of white Americans (6). In addition, in early April, the Washington Post did its own analysis of how COVID-19 cases are particularly impacting Black Americans. They found that counties with primarily Black residents have three times the rate of infections and approximately six times the rate of deaths than counties where white Americans are the majority (7).
These data beg the question: why is the difference in COVID-19 cases between these two racial groups so drastic? The answer lies in a culmination of factors. Dr. Charles Modlin, executive director of Minority Health at the Cleveland Clinic, believes that COVID-19 disproportionately affects African-Americans due to a predisposition to chronic disease, greater exposure to viral infection, potential biological differences in terms of immunoreactivity to viruses and lower health literacy (8).
Black Americans have higher rates of diabetes, obesity, hypertension, heart disease, and asthma, which have been linked with more severe COVID-19 infections as well as poorer outcomes (8). Hughes, however, cites a study done by Sutter Health Hospitals, showing that even when correcting for such underlying chronic conditions, minorities are still likely to have a higher incidence of COVID-19 cases (6). This is demonstrative of “social determinants of health” influencing the presence of COVID-19 in these populations. An example of a “social determinant” is that minorities are 50 percent more likely to work in the service industries (i.e. grocery stores, custodial services, etc.) and are thus more likely to be exposed to infection (6). In addition, minorities are more than 25 percent more likely to live with multiple generations in the same household, making it difficult to socially isolate and increasing the likelihood of transmitting the virus to an older, at-risk family member (6).
Unlike the previous examples of social determinants, perhaps a more elusive determinant is systemic racism. In an editorial from the New England Journal of Medicine, doctors highlight that discrimination and racism are very important social determinants of health. According to their review of previous literature, “discrimination and racism as social determinants of health act through biologic transduction pathways to promote subclinical cerebrovascular disease, accelerate aging and impede vascular and renal function, producing disproportionate burdens of disease on Black Americans and other minority populations” (9). Although this presents racism in slightly different contexts, we should remember that racism is not an isolated occurrence but rather pervades all areas of health care.
The authors continue to cite another study, which showed how inherent disregard for predominant minority backgrounds led to racial bias within an algorithm used to predict the needs of patients with uncontrolled illnesses. The algorithm failed to recognize that differences in access end up resulting in lower spending on black patients (9). Racism is found at the smallest scale as demonstrated by the previous example but also can be blatantly seen by examining our doctoral population. Black patients are more likely to trust Black physicians and are more likely to seek preventative care when assigned a racially concordant doctor. However, Black patients are less likely to find a racially concordant physician as compared to Asian-American and white patients (10). This discrepancy can largely play a part in the quality and effectiveness of care received. Alsan et al. estimated that Black doctors could reduce the cardiovascular mortality gap between Black and white patients by 19 percent if such biases did not exist within the medical atmosphere (10).
As a country, one of our most praiseworthy qualities is that we come from such wide and diverse backgrounds. We are one of a few countries that boasts such a heterogeneous population, yet our disregard for historically marginalized groups creates a toxic social atmosphere and presents such diversity as a mode of disunity. If we are to create a stronger community, it is not only our responsibility to address such social ails but also act on them accordingly.
Edited by: Ryan Chang