4 Social Determinants of Health and COVID-19

Unit Four, Social Determinants of Health and COVID-19, provides insight into some of the stark inequities that were uncovered during the COVID-19 pandemic. This unit begins by defining social determinants of health, and then explores inequities that were found related to race-ethnicity, income, immigration status, and employment among different populations. This unit also addresses inequities that were found in housing and healthcare.

The introductory video defines what social determinants of health are and provides specific examples.

From Video: Social Determinants of Health – An Introduction (Ranil Appuhamy)

Social determinants of health are the conditions in which people are born, grow, work, live, and age and people’s access to power, money, and resources. The social determinants are the major drivers of health inequities – unfair, avoidable, and remediable differences in health between social groups.

From: COVID-19 and the social determinants of health and health equity: evidence brief (World Health Organization)

SDOH includes domains of economic stability, education, social and community context, health and health care, and neighborhood and built environment.

From: Social determinants of health and health disparities: COVID-19 exposures and mortality among African American people in the United States (Maness et al.)

The Healthy People 2030 SDOH framework outlines 5 key, place- based areas that impact overall health and well-being, including economic stability, social and community context, health and health care, neighborhood and built environment, and education access and quality.

From: COVID-19, Social Determinants of Health and Opportunities for Preventing Cardiovascular Disease (Russo et al.)

Older people, men, people with chronic non-communicable diseases, and people with disabilities appear to have greater biological susceptibility to SARS-CoV-2 infection, and, or propensity to develop harmful pulmonary inflammation from COVID-19.

From: COVID-19 and the social determinants of health and health equity: evidence brief (World Health Organization)

Health Equity

“Health equity is achieved when every person has the opportunity to attain his or her full health potential and no one is disadvantaged from achieving this potential because of social position or other socially determined circumstances. Health disparities or inequities, are types of unfair health differences closely linked with social, economic or environmental disadvantages that adversely affect groups of people.”

From: Promoting Health Equity: A Resource to Help Communities Address Social Determinants of Health (Centers for Disease Control and Prevention)

“This is the second World Health Day to fall during the COVID-19 pandemic – the world’s worst peacetime health crisis in a century. It comes amidst grueling and painful times for the world’s people who are dealing with the impacts of the pandemic, including those working in the health sector.” The cost of COVID-19 is so high that it demands we do things differently: that we commit to building a fairer and healthier world by taking health equity much more seriously than before – and meet head-on the social and economic factors that cause health inequities.”

From: Health Equity and the Determinants (World Health Organization)

The CDC’s website focusing on Health Equity including reports and resources. This website is no longer being updated but contains important historical data.

From: Health Equity (Centers for Disease Control and Prevention)

Intersectionality

“Now more than ever, it’s important to look boldly at the reality of race and gender bias — and understand how the two can combine to create even more harm. Kimberlé Crenshaw uses the term “intersectionality” to describe this phenomenon; as she says, if you’re standing in the path of multiple forms of exclusion, you’re likely to get hit by both.”

From Video: The Urgency of Intersectionality (Kimberlé Crenshaw)

This open-source textbook is an entry point for understanding intersectionality by querying who has access to knowledge, what kind of knowledge, and for what purposes.

From: A Student Primer on Intersectionality: Not Just A Buzzword (Silberstein et al.)

“Very few theories have generated the kind of interdisciplinary and global engagement that marks the intellectual history of intersectionality. Yet, there has been very little effort to reflect upon precisely how intersectionality has moved across time, disciplines, issues, and geographic and national boundaries.”

From: Intersectionality: Mapping the Movements of a Theory (Carbado et al.)

Data available in the early months of the pandemic indicated age-adjusted COVID-19 rates of infection, hospitalization, and death were highest among Black Americans, with a disproportionate pandemic burden across all structurally marginalized and minoritized groups.

From: The State of Black America and COVID (Black Coalition Against COVID)

Disadvantaged ethnic groups have had higher rates of infection with SARS-CoV-2 and of mortality from COVID-19.

From: COVID-19 and the social determinants of health and health equity: evidence brief (World Health Organization)

Preliminary data indicate higher COVID-19 mortality rates among people with underlying health conditions, placing African American people at higher risk than populations without higher rates of chronic disease.

From: Social determinants of health and health disparities: COVID-19 exposures and mortality among African American people in the United States (Maness et al.)

This article discusses the effects of the pandemic on black workers from various types of employment including unemployment and health effects.

From: Black workers face two of the most lethal preexisting conditions for coronavirus—racism and economic inequality

Race- based trauma rose during the COVID- 19 pandemic. High-ranking political leaders referring to the SARS- CoV- 2 as the “China Virus” and COVID- 19 as the “Kung Flu” fostered anti- Asian discrimination, leading to increases in hate crimes and violence against Asian Americans.

From: COVID-19, Social Determinants of Health and Opportunities for Preventing Cardiovascular Disease (Russo et al.)

COVID-19–related discrimination is common, and it appears that the pandemic has exacerbated preexisting resentment against racial/ethnic minorities and marginalized communities.

From: COVID-19-related discrimination among racial/ethnic minorities and other marginalized communities in the United States (Strassle et al.)

National and local inequities in the burden of Covid-19. “Inequities in the burden of Covid-19 have been uncovered among vulnerable populations across the world and are particularly striking in racial and ethnic minorities in the United States”

From: A systems approach to addressing COVID-19 health inequities (Wilkins et al.)

Comparisons between gender and racial-based differences as related to COVID-19 are shared and discussed.

From: Racial and Gender-Based Differences in COVID-19 (Kopel et al.)

“Describes the racial inequities and emerging health disparities data related to the COVID-19 pandemic and provides strategies to address them.”

From video: A Framework to Approach Racial Health Inequities during the COVID-19 Pandemic (Douge, J. & Rhea, B.)

This article describes “the challenges of race/ethnicity data collection, how the pandemic has affected Asian Americans in aggregate, and what we know about its effect on the six largest Asian American subgroups.”

Found in: Asian American Subgroups and The COVID-19 Experience: What We Know And Still Don’t Know (Chin et al.)

Household poverty was shown in many studies to be significantly associated with worse COVID-19 outcomes, independently of or in addition to other factors, such as household density, age, health status (pre-existing health conditions), occupation, access to hand-washing facilities and health services.

From: COVID-19 and the social determinants of health and health equity: evidence brief (World Health Organization)

Financial outcomes by race during COVID-19: Report on findings associated with discrepancies in financial outcomes by race during the COVID-19 pandemic.

Found in: Financial outcomes by race during COVID-19 (J.P. Morgan)

Before the pandemic, many consumers were financially fragile. Half of consumers reported they could cover expenses for two months or fewer if their household lost its main source of income. Nearly 40 percent had difficulty paying a bill or expense in the 12 months before June 2019. 1 So when the number of unemployed consumers nearly quadrupled from 6.2 million in February 2020 to 22.5 million in April, it appeared likely that many American consumers were just steps away from financial disaster.

Found in: Consumer Finances during the Pandemic (Consumer Financial Bureau)

“This article describes the impact the COVID-19 pandemic has had on price changes for food categories within the U.S. Bureau of Labor Statistics import/export price indexes, producer price indexes, and consumer price indexes. In addition, the article assesses the pandemic’s impact on price data collection efforts. Safety precautions established during the pandemic created data collection challenges for some price indexes more than others.”

Found in: The impact of the COVID-19 pandemic on food price indexes and data collection (Mead et al.)

“Even before COVID-19, New York was already defined by a gap between the rich and poor. Yet during the pandemic, wealth has become a determinant of survival. The pandemic hit New York in the spring, with almost 800 people dying from COVID-19 each day in April. The city has been uneasy since then. People’s lives have been shaken by months of stay-at-home orders, changing public health measures, “Black Lives Matter” protests, the presidential election, and above all the economic consequences of the pandemic, including ever-widening inequality between New Yorkers. Stefanie Dodt and Christiane Meier are the creators of “New York City Rich and Poor – The Inequality Crisis.” They spent more than eight months following the lives of three New York families who inhabit the different strata of New York society – the bottom, the top and the middle.”

Found in video: New York City rich and poor — the inequality crisis | DW Documentary

Resources (i.e., new reports, data, perspectives) from the University of Minnesota on the health, economic, and social impact of COVID-19 on immigrants and refugees in the United States.

Retrieved from: Immigrants in COVID America (umn.edu)

Article discusses some of the COVID-19 related concerns seen in low-income immigrants located in the Bronx, NY.

Retrieved from: The Disproportionate Burden of COVID-19 for Immigrants in the Bronx, New York (Ross et al.)

The NYC Mayor’s Office for Academic Affairs resource page for immigrant communities. Some resources include healthcare and well-being, food, housing insecurity, and insurance.

Found in: Resources for Immigrant Communities During COVID-19 Pandemic

“In the absence of comprehensive governmental safety nets, New York women banded together, adapted their skill sets, organized aid and fought for policy changes.”

Found in: “We Have to Survive’: Meet NYC Immigrant Women Fighting for Their Communities During the Pandemic”

In the spring of 2020, the COVID-19 pandemic triggered job loss in the labor market on a scale not seen since the Great Depression. A year later, the economic situation had improved. Approximately 60 percent of jobs lost had returned, but employment was still down compared to pre pandemic levels.

From: How did employment change during the COVID-19 pandemic? (Auginbaugh, A. & Rothstein, D.)

The pandemic and related recession are likely to affect income sources, assets, and spending for Americans aged 55 and older, including both older workers approaching retirement and current retirees. Some may be forced to compensate earning loses by withdrawing retirement savings, borrowing more money, or changing the timing of their retirement by claiming Social Security and pension benefits earlier than planned.

From: Potential Impacts of the COVID-19 Pandemic on the Income Security of Older Americans (Congressional Research Service)

Article points out income inequities especially among the “super rich” during the COVID-19 pandemic who could afford luxuries such as yachts, private jets, and private in-home chefs.

From: COVID-19 Is Over (If You’re Rich): How the wealthy have learned to live with the pandemic

In sectors other than health and social care, people in many jobs, predominantly in the service, food, and transport industries, are significantly more exposed to the risk of SARS-CoV-2 infection, due mainly to the difficulty or impossibility of working from home. Greater mobility of low-paid workers in precarious employment increased their risk of exposure to SARS-CoV-2.

From: COVID-19 and the social determinants of health and health equity: evidence brief (World Health Organization)

During the pandemic, dental professionals face the risk of being infected with COVID-19 by their patients or their colleagues as well as carrying the infection to their families, relatives, or infecting their patients during dental practices. During the pandemic period, the stress and psychological pressure on them increased, and situations such as anxiety, fear, and high stress levels could adversely affect their mental health.

From: Anxiety of Dental Professionals during Covid-19 Pandemic (Pinar Karataban)

The Covid-19 pandemic has highlighted that precarious work and exploitative and adverse working conditions intersect with multiple factors, including ethnicity, migrant status, class, and gender, to influence which population groups are most exposed to covid-19 infection.

From: COVID-19 pandemic and the social determinants of health (Paremoer et al.)

City, state, and federal governments provided limited guidance regarding COVID safety practices. Therefore, most workers lacked access to a full range of protections, particularly those in direct service, such as food workers.

From: Protecting Those Who Feed Us: How Employers, Government, and Workers’ Organizations Can Protect the Health, Safety, and Economic Security of Food Workers During the COVID-19 Pandemic and Beyond (Chong et al.)

Crowded housing is associated with increased incidence of and mortality from COVID-19 among the most disadvantaged people. Household transmission is a substantial source of SARS-CoV-2 infection, as crowding and poor ventilation increase exposure to infectious respiratory droplets and aerosols.

From: COVID-19 and the social determinants of health and health equity: evidence brief (World Health Organization)

“Hardships disproportionately faced by communities of color are being exacerbated by the pandemic and require an equitable recovery that reconciles past harms while also providing solutions for current and future challenges.”

From: The Pandemic Has Exacerbated Housing Instability for Renters of Color

NYU’s Furman Center report on the impacts of COVID-19 New York Renters and the Housing Stock.

From: Impacts of COVID-19 on New York Renters and the Housing Stock

Inequitable access to affordable prevention tools, treatment and vaccination remains a major threat to health equity overall, but particularly in the face of addressing the COVID-19 pandemic. Studies in the USA showed that people who had no, or low health coverage were up to twice as likely to require admission to hospital for COVID-19 than those with more extensive insurance.

From: COVID-19 and the social determinants of health and health equity: evidence brief (World Health Organization)

In places where the COVID- 19 burden overwhelmed the health system, there was limited capacity to care for patients with non–COVID-related conditions. Consequently, many state governments began limiting or prohibiting in- person elective or nonemergent medical procedures. Use of telehealth services surged as a result. Preliminary studies indicate that access to telehealth services for health care follow similar patterns; low-income groups and racial and ethnic minority populations used telehealth services less compared with higher-income households and White families.

From: COVID-19, Social Determinants of Health and Opportunities for Preventing Cardiovascular Disease (Russo et al.)

Neighborhood food landscapes have changed dramatically during the COVID-19 pandemic, with restaurants closing at record rates. An evaluation of food outlets in New York City found that a greater percentage of food outlets closed in immigrant enclaves and low-resourced neighborhoods compared with high- income neighborhoods. Urban flight also increased during the pandemic. Individuals living in densely populated cities are leaving to seek more space in the suburbs, and the populations leaving are disproportionately.

From: COVID-19, Social Determinants of Health and Opportunities for Preventing Cardiovascular Disease (Russo et al.)

Article identifying the essential role that women played during the COVID-19 pandemic, especially in healthcare. Pay gap discrepancies are discussed.

From: Women Represent Majority of Workers in Several Essential Occupations

“Too little attention has been paid to the consequences of the escalating COVID-19 pandemic for women of color, even as it exacerbates existing disparities and further undermines their families’ economic stability and survival.”

From: On the Frontlines at Work and at Home: The Disproportionate Economic Effects of the Coronavirus Pandemic on Women of Color (Jocelyn Frye)

Large cluster outbreaks of COVID-19 have occurred in prisons. Older people have borne a disproportionate burden of deaths from COVID-19. Homeless people have a higher risk of COVID-19. Stigmatization of particular higher-risk social groups has emerged as a darker side of COVID-19, pitting different ethnic groups and generations against each other. Not even health workers have been spared

From: COVID-19 and the social determinants of health and health equity: evidence brief (World Health Organization)

Articles, tools, and resources from the CDC for supporting homeless populations during COVID-19 (i.e., vaccine information, housing, screening information)

From: Homeless Populations-Resources to Support People Experiencing Homelessness

“COVID-19 has caused unprecedented challenges in nursing homes. In this scoping review, we aimed to describe factors that contributed to the spread and mortality of COVID-19 in nursing homes and provide an overview of responses that were implemented to try to overcome such challenges.”

From: Nursing homes during the COVID-19 pandemic: a scoping review of challenges and responses.

CDC’s COVID-19 related resources and recommendations for nursing homes and long-term care facilities.

From: Nursing Homes and Long-Term Care Facilities

“The COVID-19 pandemic has reshaped health care delivery for all patients but has distinctly affected the most marginalized people in society. Incarcerated patients are both more likely to be infected and more likely to die from COVID-19. There is a paucity of guidance for the care of incarcerated patients hospitalized with COVID-19. This article will discuss how patient privacy, adequate communication, and advance care planning are rights that incarcerated patients may not experience during this pandemic.”

From: Care for Incarcerated Patients Hospitalized with COVID-19.

The Prison Policy Initiative has curated much of the key research about the impact of COVID-19 on the criminal justice system.

From: COVID-19 The pandemic’s impact on prisons and jails

Once touted as the “great equalizer,” the COVID-19 pandemic has amplified the health disparities that have beset our nation for decades. Racial or ethnic minority populations and lower-income groups, already significantly burdened with greater risk and other chronic health conditions, have experienced a disproportionate share of the COVID-19 morbidity and mortality. COVID-19 and the response to the pandemic may have impacted population-level, lifestyle, behavioral, and health risk factors among different sociodemographic groups and exacerbated health disparities.

From: COVID-19, Social Determinants of Health and Opportunities for Preventing Cardiovascular Disease (Russo et al.)

Auginbaugh, A. & Rothstein, D. (Jan. 2022). How did employment change during the COVID-19 pandemic? United States Bureau of Labor Statistics. Retrieved from https://www.bls.gov/opub/btn/volume-11/how-did-employment-change-during-the-covid-19-pandemic.htm

Black Coalition Against COVID. The state of Black America and COVID-19. A two-year assessment.

Carbado, D. W., Crenshaw, K. W., Mays, V. M., & Tomlinson, B. (2013). Intersectionality: Mapping the Movements of a Theory. Du Bois review: social science research on race, 10(2), 303-312.

Chin, M., Đoàn, L., Chong, S., Wong, J., Kwon, S., & Yi, S. (May 2021) Asian American subgroups and the COVID-19 experience: What we know and still don’t know. Health Affairs. Retrieved from https://www.healthaffairs.org/do/10.1377/forefront.20210519.651079/

Chong, VP et al. Protecting Those Who Feed Us: How Employers, Government, and Workers’ Organizations Can Protect the Health, Safety, and Economic Security of Food Workers During the COVID-19 Pandemic and Beyond. CUNY Urban Food Policy Institute, March 2022

Congressional Research Service. (Nov. 2020). Potential Impacts of the COVID-19 Pandemic on the Income Security of Older Americans. Retrieved from https://crsreports.congress.gov/product/pdf/R/R46617.

Consumer Financial Bureau. (Dec. 2021). Consumer finances during the pandemic. Retrieved from https://permanent.fdlp.gov/gpo173272/cfbp_making-ends-meet-survey-insights_report_2021-12.pdf

Frye, J. (April 2020). On the Frontlines at Work and at Home: The Disproportionate Economic Effects of the Coronavirus Pandemic on Women of Color. Retrieved from https://www.americanprogress.org/article/frontlines-work-home/

COVID-19 and the social determinants of health and health equity: evidence brief. Geneva: World Health Organization, 2021. License: Attribution-NonCommercial-ShareAlike 3.0 IGO (CC BY-NC-SA 3.0 IGO)

Giri, S., Chenn, L. M., & Romero-Ortuno, R. (2021). Nursing homes during the COVID-19 pandemic: a scoping review of challenges and responses. European Geriatric Medicine, 12(6), 1127-1136.

Gould, E. & Wilson, W. (June 2020). Black workers face two of the most lethal preexisting conditions for coronavirus—racism and economic inequality. Retrieved from https://www.epi.org/publication/black-workers-covid/.

Jacobsen, A. P., Robledo-Gil, T., Nahas-Vigon, J. H., Epstein, J. A., Berger, Z. D., & Sufrin, C. B. (2021). Care for incarcerated patients hospitalized with COVID-19. Journal of general internal medicine, 36(7), 2094-2099.

J.P. Morgan. Financial outcomes by race during COVID-19. Retrieved from https://www.jpmorganchase.com/institute/research/household-income-spending/financial-outcomes-by-race-during-COVID-19.

Karataban, P. (July 2021). Anxiety of Dental Professionals during Covid-19 Pandemic. Retrieved from https://www.intechopen.com/chapters/77579.

Kopel J, Perisetti A, Roghani A, Aziz M, Gajendran M and Goyal H (2020). Racial and gender-based differences in COVID-19. Front. Public Health 8:418. doi:10.3389/fpubh.2020.00418

Laughlin, L. & Wisniewski, M. (March 2021). Women Represent Majority of Workers in Several Essential Occupations. Retrieved from Unequally Essential: Women and Gender Pay Gap During COVID-19 (census.gov)

Maness, SB et al. Social determinants of health and health disparities: COVID-19 exposures and mortality among African American people in the United States. Public Health Reports 2021, Vol 136 (1): 18-22.

Mead, D., Ransom, K., Reed, S., and Sager, S. (Aug. 2020). The impact of the COVID-19 pandemic on food price indexes and data collection. Monthly Labor Review, U.S. Bureau of Labor Statistics, Retrieved from https://doi.org/10.21916/mlr.2020.18

Paremoer L et al. COVID-19 pandemic and the social determinants of health. BMJ 2021, 372: n 129.

Ross J, Diaz CM, Starrels JL. The Disproportionate Burden of COVID-19 for Immigrants in the Bronx, New York. JAMA Intern Med. 2020;180(8):1043–1044. doi:10.1001/jamainternmed.2020.2131

Russo RG et al. COVID-19, social determinants of health and opportunities for preventing cardiovascular disease: A conceptual framework. Journal of the American Heart Association 2021: 10: e022721.

Serhan, Y. (Feb. 2022). COVID-19 Is Over (If You’re Rich): How the wealthy have learned to live with the pandemic. Retrieved from COVID-19 Is Over (If You’re Rich) – The Atlantic

Silberstein, Elodie; Tramontano, Marisa; and Nayak, Meghana V., “A Student Primer on Intersectionality: Not Just A Buzzword” (2020). Open Educational Resources. 3. https://digitalcommons.pace.edu/oer/3

Strassle PD et al. COVID-19-related discrimination among racial/ethnic minorities and other marginalized communities in the United States. American Journal of Public Health March 2022, Vol. 112, #3: 453-466.

Wilkins CH et al. A systems approach to addressing COVID-19 health inequities. NEJM Catalyst Vol 2, #1 January 2021.