Viral diseases can be detrimental to communities already struggling.
COVID-19 continues to dramatically transform daily life for most Americans. Health disparities are glaringly coming into view. And the link between social determinants of health (SDoH) and health outcomes is proving even more prevalent. Much of the dialogue that has dominated the national efforts to control the spread of the virus has focused on avoiding crowds and practicing social distancing, but there's a growing consensus about the role of economic and social conditions during this global pandemic. Issues like poverty, housing, access to care, and paid leave — all social determinants of health — can not only contribute to the spread of viral diseases but exacerbate these issues for individuals and families already struggling.
While population health leaders continue to explore ways to curtail the spread of the virus, they must also take SDoH into account. Otherwise, we risk not only undermining the efficacy of existing efforts but compounding existing inequalities.
Few things so vividly illustrate the complexity of the coronavirus outbreak and efforts to control its spread than the issue of food insecurity. Defined as "lack of consistent access to enough food for an active, healthy life," food insecurity affects 11.1 percent of American households and one in seven households with children for at least some part of the year.
But in light of recent changes, notably the closing of schools and tighter restrictions on large gatherings, along with as many as 47 million adults out of work, that number is likely to go up. Two groups are almost certain to be impacted most acutely: children and senior citizens. Why? Let's start with the former.
Before the outbreak, the National School Lunch Program was providing low-cost or free lunches to roughly 29.7 million children on a daily basis. With schools closing nationwide, that vital food resource is no longer on the table.
What's more, existing data suggest that, among children and adolescents, rates of food insecurity (as well as body weight) tend to spike during the summer months, when they don't have access to the school nutrition programs ordinarily available during the academic year. Barring effective intervention, we may see similar outcomes in the wake of the coronavirus outbreak.
Meanwhile, seniors are being hit hard by similar measures designed to cut down on large gatherings. Doing so, clearly, has been an important and necessary public safety measure — but soup kitchens, senior centers, food pantries, and other critical resources are being closed because of it.
States are responding to these issues in different ways, but distribution remains a central challenge. That's why, in California, for example, the National Guard may be deployed as part of the state's efforts to reduce food insecurity. But until then, for many low-income senior citizens, whose age already places them at elevated risk of mortality from coronavirus, food insecurity will be an ongoing source of anxiety.
"Shelter in place" is a new norm for millions of Americans, with the majority of the country's population now under orders to stay at home as much as possible. Yet as national unemployment rates continue to balloon — and more than three million applying for unemployment benefits in a single week — many of those homes look increasingly precarious. And for the estimated 15,000 families with children under 18 that live for the most part unsheltered, the meaning of "shelter in place" itself remains unclear.
These troubling stats could have dire consequences for the people most directly affected. For example, homelessness has been shown to correlate with poorer physical health generally, including underlying health conditions like tuberculosis, hypertension, asthma, diabetes, and HIV/AIDS that make people especially vulnerable to coronavirus.
The response on the part of the government so far has been mixed. Measures to freeze rent hikes, for example, may offer valuable protection to many who are vulnerable right now, but they'll hardly matter to the more than 500,000 Americans who are currently homeless. Likewise, the Families First Coronavirus Response Act may help mitigate some risks faced by those experiencing housing insecurity — although, notably, the language of the bill does not directly mention the needs of people facing homelessness.
The bigger picture, in both the short and long term, is that more affordable housing options and other solutions are desperately needed.
Access to Exercise Opportunities
U.S. health officials warn that the coronavirus can be spread when traces of the virus are left on commonly used surfaces — say, dumbbells or subway poles. What's more, viruses that cause illnesses like COVID-19 are believed to be able to live on surfaces and inanimate objects for days at a time, which is part of the reason health officials also urge Americans to take precautions when using shared spaces. Not surprisingly, most gyms are now closed in response to the escalating global pandemic.
Over the short term, this is one area where higher-income Americans may directly experience adversity related to the coronavirus outbreak to a larger degree than lower-income peers. Of course, the keyword there is short-term.
The broader, longer-standing and the more deeply entrenched issue is the lack of access to exercise opportunities for lower-income Americans, particularly among those living in urban areas. Multiple studies have documented this need, and others have found a positive association between income and physical activity.
In the context of coronavirus, these findings are not only troubling but highly consequential. "Severe obesity," defined as having a body mass index of 40 or more, disproportionately impacts low-income adults. And according to the Centers for Disease Control and Prevention, people of any age with severe obesity are "at high risk of serious illness from COVID-19."
No doubt, this is part of the reason that lower-income populations continue to be disproportionately impacted by COVID-19 — the short-term solution for which remains to be seen. But over the long term, making affordable, community-based fitness centers more widely available will be an essential step in changing the current correlation between income as an SDoH and overall health.
Even as the coronavirus situation continues to evolve, it has already radically altered the texture of daily life for nearly all Americans. Yet how and where those impacts are felt conform to an all-too-familiar pattern, with lower-income and other vulnerable populations bearing a disproportionate share of the risk. It's a vivid illustration of how closely linked SDoH are to overall health outcomes. Food and housing insecurity, and access to exercise opportunities are only a few factors where we'll continue to see spikes in the number of individuals affected. Public health leaders should expect surges in the number of individuals impacted by social isolation, unemployment, and changes in income.
To lessen those risks and help drive better outcomes, policymakers, payors, and others must keep SDoH top of mind as they carry out the vital work of treating patients and preventing the further spread of the virus. And to support mobilization efforts, Healthify is working with payers, providers, and community organizations to fulfill critical social needs.