Opportunities for Improving Population Health in the Post–COVID-19 Era

Article Type
Changed
Thu, 03/18/2021 - 14:28

The novel coronavirus disease of 2019 (COVID-19), caused by the SARS-CoV-2 pathogen, has resulted in a health crisis unlike any other experienced in the past century, with millions of people infected and over one million people dying from COVID-19 worldwide. The pandemic has disproportionately impacted historically marginalized groups, resulting in higher rates of infection, hospitalization, and death in racial/ethnic minority populations, including Black, Hispanic/Latinx, and Native American populations, compared with the White population.1 Statistics suggest that it is not just socioeconomic differences but also structural racism that has played a role in worse health outcomes in minority populations. However, the health inequities uncovered by the pandemic represent an opportunity—a “plastic hour” in which improvements at the population level may be uniquely possible.2 As healthcare providers, we must take advantage of this moment and work toward improving healthcare and increasing health equity in the post–COVID-19 era. We highlight three strategies to guide us toward achieving this goal: (1) prioritizing health system equity and government improvements to population health, (2) fostering community resilience, and (3) promoting equity in economic sustainability.

HEALTH SYSTEM AND GOVERNMENT IMPROVEMENTS TO POPULATION HEALTH

The COVID-19 pandemic has revealed deep-seated structural and medical vulnerabilities in the US healthcare system, with distressing racial/ethnic differences in COVID-19 infection continuing to emerge.3 Despite variation in the availability and quality of these data, disparities observed in COVID-19 have tracked closely with historical inequities in access to healthcare and discrimination within the healthcare system.4 Any approach to addressing these inequities must appreciate the intersection between social and medical vulnerabilities.

It is notable that healthcare systems serving the most vulnerable populations have borne the brunt of the economic toll of COVID-19. Hospitals in socioeconomically challenged areas lost millions of dollars due to the postponement of elective procedures and reallocation of most resources to COVID-related hospital admissions. Many community-based practices, already stretched in caring for medically and socially complex patients, had to shut their doors. These losses have left patients without the support of their network of healthcare and community service organizations—at the same time that many of them have also lost support for food and housing, employer-based health insurance, and in-person schooling and childcare.

The current circumstances due to the COVID-19 pandemic, therefore, require us to reconsider many aspects of both healthcare and the social safety net, including the reliance on financial penalties as a strategy to improve health quality, which ultimately has a disproportionate impact on communities of color.5 The present situation may also allow for the federal, state, and local governments, as well as health systems and payers, to make targeted investments in healthcare, public health, and community programs. For example, an increased healthcare system investment on preventive and primary care will be essential to reducing the chronic risk factors that underlie COVID-19 infection and death. Efforts by payers to reduce economic incentives for unnecessary elective procedures, while simultaneously providing incentives to increase the focus on preventive care, would further stimulate this effort. Although there is controversy over the inclusion of social risk in financial and value-based health system payment models, novel approaches to this problem (eg, consideration of improvement over achievement of static targets) may provide an opportunity for struggling health systems to invest in new strategies for underserved populations. Additionally, investing in a care system that allows racial, language, and cultural concordance between clinicians and patients would both promote a diverse workforce and improve quality of care. Health system equity will also depend upon bold policy advances such as expansion of Medicaid to all states, separation of health insurance from employment, and targeted government and health system investments around social risk (eg, food and housing insecurity). These programs will help vulnerable communities close the gap on disparities in health outcomes that have been so persistent.

Some of these specific concerns were addressed by the Coronavirus Aid, Relief, and Economic Security (CARES) Act that was implemented by the US Congress to address the broad needs of Americans during the acute crisis.6 The CARES Act provided supplementary funding to community health centers and healthcare systems caring for the uninsured. Cash assistance was provided to most US taxpayers along with financial support to those experiencing unemployment through July 31, 2020, measures that have yet to be extended. In addition to the CARES Act, policymakers proposed establishing a COVID-19 Racial and Ethnic Disparities Task Force Act to drive equitable recommendations and provide oversight to the nation’s response to COVID-19.7

While these measures were critical to the immediate pandemic response, future US congressional relief plans are needed to ensure equity remains a tenet of state and federal policy post COVID-19, particularly with respect to social determinants of health. Additional recommendations for federal relief include rent assistance for low-income families, eviction stoppages, and increased funding for short-term food insecurity. With respect to long-term goals, this is the time to address broader injustices, such as lack of affordable housing, lack of a sensible national strategy around food security, and a lack of equitable educational and justice systems. This moment also offers an opportunity to consider the best way to address the impact of centuries of structural racism. If we place equity at the center of policy implementation, we will certainly see downstream health consequences—ones that would begin to address the health disparities present long before the current pandemic.

 

 

FOSTERING COMMUNITY RESILIENCE

While national, state, and local responses to COVID-19 are required to bolster population health when we emerge from the COVID-19 crisis, a focus on community resilience is also needed. Community resilience, or the ability to prevent, withstand, and mitigate the stress of a disaster like COVID-19, requires integration of emergency preparedness practices into community disaster programs, with ongoing efforts to mitigate disparities in chronic disease management. A framework for community resilience includes (1) engaging with communities in planning, response, and post–COVID-19 recovery, (2) ensuring communities have access to high quality, culturally concordant health and social services, and (3) developing robust community networks to mobilize individuals, community services, and public health infrastructure in times of emergency.8

After seeing the devastating effects of Hurricane Katrina in 2005, researchers, public health officials, and community leaders founded the Los Angeles County Community Disaster Resilience (LACCDR) project. Through this collaborative effort, the LACCDR established partnerships across 16 communities to foster community resilience during health emergencies against the backdrop of daily chronic stressors such as violence, segregation, poverty, and homelessness.8 A model such as this to improve health systems and public health integration post-COVID will support health provisions and help build trust in communities wherein there is a high distrust of the healthcare system. Engaging with community partners early to ensure that its members have access to basic needs (eg, food, water, shelter), public health needs (eg, timely information, personal protective equipment such as face coverings and cleaning supplies), and affordable testing and vaccination will help prevent disparities that could affect the most vulnerable in future phases of the COVID-19 crisis.

PROMOTING EQUITY AS A SUSTAINABLE ECONOMIC STRATEGY

Over 40 million Americans were seeking unemployment benefits at the peak of the economic repercussions of the COVID-19 pandemic. Unfortunately, low-income, rural, and minority communities disproportionately experienced this economic shock. Given the relationship between wealth and health, successfully achieving equity post-COVID-19 will require deeper financial investments in underserved communities.9 Healthcare organizations, which represent 18% of the United States gross domestic product and employ nearly 9% of all working individuals, are uniquely positioned to have a direct influence on this strategy.

One equity-based strategy is for healthcare institutions to pursue an anchor mission. Anchor missions have increased a health system’s investment in social services, including providing housing and food resources.10 Additionally, hospitals such as Brigham and Women’s, Boston Children’s Hospital, and Bon Secours Health System, are working with a diverse group of entrepreneurs to create jobs and build wealth in underserved communities by employing local and minority-owned businesses to support critical supply chain purchasing decisions regarding food, maintenance, and construction projects.11 These local and inclusive hiring and procurement measures can be bolstered by continued place-based investments by all health system leaders in vulnerable communities.

CONCLUSION

Since the first enslaved Africans were brought to America over 400 years ago, racial and ethnic minorities have experienced struggle and triumph, sadness and joy. The bonds of a long legacy of discrimination are so deep that we must be intentional in our pursuit of equity—during and beyond the COVID-19 pandemic. Placing equity at the center of healthcare system practice and policy implementation, fostering community resilience and emergency preparedness, and prioritizing equity in economic strategic planning are key steps toward addressing the population-level inequities exposed by the COVID-19 pandemic. As the once touted “great equalizer” rages on, we must remember that we are all jointly affected by the distress caused by the novel coronavirus and we also must be more aware than ever of our interconnectedness. We can use this time of pandemic to fight more than ever to ensure that all populations can enjoy just and optimal health.

Acknowledgments

The authors would like to thank Dr Denise Polit for her review of this manuscript.

References
  1. Williams DR, Cooper LA. COVID–19 and health equity–a new kind of “herd immunity”. JAMA. 2020;323(24):2478-2480. https://doi.org/10.1001/jama.2020.8051
  2. Packer G. America’s plastic hour is upon us. The Atlantic. October 2020. Accessed September 28, 2020. https://www.theatlantic.com/magazine/archive/2020/10/make-america-again/615478/
  3. Gross CP, Essien UR, Pasha S, Gross JR, Wang SY, Nunez-Smith M. Racial and ethnic disparities in population-level Covid-19 mortality. J Gen Intern Med. 2020;35(10):3097-3099. https://doi.org/10.1007/s11606-020-06081-w
  4. Institute of Medicine (US) Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care, Smedley BD, Stith AY, Nelson AR, eds. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. National Academies Press (US); 2003. https://doi.org/10.17226/12875
  5. Zuckerman RB, Joynt Maddox KE, Sheingold SH, Chen LM, Epstein AM. Effect of a hospital-wide measure on the readmissions reduction program. N Engl J Med. 2017;377(16):1551-1558. https://doi.org/10.1056/nejmsa1701791
  6. Cochrane E. House passes relief for small businesses and aid for hospitals and testing. New York Times. April 23, 2020. Accessed May 21, 2020. https://www.nytimes.com/2020/04/23/us/politics/house-passes-relief-for-small-businesses-and-aid-for-hospitals-and-testing.html
  7. Harris announces legislation to establish task force to combat racial and ethnic disparities in COVID-19. News release. Kamala D. Harris US Senator for California; April 30, 2020. Accessed May 21, 2020. https://www.harris.senate.gov/news/press-releases/harris-announces-legislation-to-establish-task-force-to-combat-racial-and-ethnic-disparities-in-covid-19
  8. Chandra A, Williams M, Plough A, et al. Getting actionable about community resilience: the Los Angeles County Community Disaster Resilience project. Am J Public Health. 2013;103(7):1181-1189. https://doi.org/10.2105/ajph.2013.301270
  9. Rawshani A, Svensson AM, Zethelius B, Eliasson B, Rosengren A, Gudbjörnsdottir S. Association between socioeconomic status and mortality, cardiovascular disease, and cancer in patients with type 2 diabetes. JAMA Intern Med. 2016;176(8):1146-1154. https://doi.org/10.1001/jamainternmed.2016.2940
  10. Horwitz LI, Chang C, Arcilla HN, Knickman JR. Quantifying health systems’ investment in social determinants of health, by sector, 2017-19. Health Aff (Millwood). 2020;39(2):192-198. https://doi.org/10.1377/hlthaff.2019.01246
  11. Nanos J. Diverse, locally owned food start-ups make the menus at Harvard, UMass, and BC. Boston Globe. January 24, 2020. Accessed September 28, 2020. https://www.bostonglobe.com/business/2020/01/24/diverse-locally-owned-food-start-ups-make-menus-harvard-umass-and/WwJFew6KVgXu1NyIK1BNqI/story.html
Article PDF
Author and Disclosure Information

1Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; 2Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; 3Center for Health Equity Research, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina; 4 Department of Social Medicine and Department of Medicine, University of North Carolina-Chapel Hill School of Medicine, Chapel Hill, North Carolina.

Disclosures

The authors have nothing to disclose.

Funding

Dr Corbie-Smith received grant support from the National Institutes of Health. Dr Essien is a government employee and authored this paper as part of his official duties.

Issue
Journal of Hospital Medicine 16(1)
Publications
Topics
Page Number
J. Hosp. Med. 2021 January;16(1):53-55. Published Online First December 23, 2020. DOI: 10.12788/jhm.3546
Sections
Author and Disclosure Information

1Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; 2Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; 3Center for Health Equity Research, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina; 4 Department of Social Medicine and Department of Medicine, University of North Carolina-Chapel Hill School of Medicine, Chapel Hill, North Carolina.

Disclosures

The authors have nothing to disclose.

Funding

Dr Corbie-Smith received grant support from the National Institutes of Health. Dr Essien is a government employee and authored this paper as part of his official duties.

Author and Disclosure Information

1Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; 2Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; 3Center for Health Equity Research, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina; 4 Department of Social Medicine and Department of Medicine, University of North Carolina-Chapel Hill School of Medicine, Chapel Hill, North Carolina.

Disclosures

The authors have nothing to disclose.

Funding

Dr Corbie-Smith received grant support from the National Institutes of Health. Dr Essien is a government employee and authored this paper as part of his official duties.

Article PDF
Article PDF
Related Articles

The novel coronavirus disease of 2019 (COVID-19), caused by the SARS-CoV-2 pathogen, has resulted in a health crisis unlike any other experienced in the past century, with millions of people infected and over one million people dying from COVID-19 worldwide. The pandemic has disproportionately impacted historically marginalized groups, resulting in higher rates of infection, hospitalization, and death in racial/ethnic minority populations, including Black, Hispanic/Latinx, and Native American populations, compared with the White population.1 Statistics suggest that it is not just socioeconomic differences but also structural racism that has played a role in worse health outcomes in minority populations. However, the health inequities uncovered by the pandemic represent an opportunity—a “plastic hour” in which improvements at the population level may be uniquely possible.2 As healthcare providers, we must take advantage of this moment and work toward improving healthcare and increasing health equity in the post–COVID-19 era. We highlight three strategies to guide us toward achieving this goal: (1) prioritizing health system equity and government improvements to population health, (2) fostering community resilience, and (3) promoting equity in economic sustainability.

HEALTH SYSTEM AND GOVERNMENT IMPROVEMENTS TO POPULATION HEALTH

The COVID-19 pandemic has revealed deep-seated structural and medical vulnerabilities in the US healthcare system, with distressing racial/ethnic differences in COVID-19 infection continuing to emerge.3 Despite variation in the availability and quality of these data, disparities observed in COVID-19 have tracked closely with historical inequities in access to healthcare and discrimination within the healthcare system.4 Any approach to addressing these inequities must appreciate the intersection between social and medical vulnerabilities.

It is notable that healthcare systems serving the most vulnerable populations have borne the brunt of the economic toll of COVID-19. Hospitals in socioeconomically challenged areas lost millions of dollars due to the postponement of elective procedures and reallocation of most resources to COVID-related hospital admissions. Many community-based practices, already stretched in caring for medically and socially complex patients, had to shut their doors. These losses have left patients without the support of their network of healthcare and community service organizations—at the same time that many of them have also lost support for food and housing, employer-based health insurance, and in-person schooling and childcare.

The current circumstances due to the COVID-19 pandemic, therefore, require us to reconsider many aspects of both healthcare and the social safety net, including the reliance on financial penalties as a strategy to improve health quality, which ultimately has a disproportionate impact on communities of color.5 The present situation may also allow for the federal, state, and local governments, as well as health systems and payers, to make targeted investments in healthcare, public health, and community programs. For example, an increased healthcare system investment on preventive and primary care will be essential to reducing the chronic risk factors that underlie COVID-19 infection and death. Efforts by payers to reduce economic incentives for unnecessary elective procedures, while simultaneously providing incentives to increase the focus on preventive care, would further stimulate this effort. Although there is controversy over the inclusion of social risk in financial and value-based health system payment models, novel approaches to this problem (eg, consideration of improvement over achievement of static targets) may provide an opportunity for struggling health systems to invest in new strategies for underserved populations. Additionally, investing in a care system that allows racial, language, and cultural concordance between clinicians and patients would both promote a diverse workforce and improve quality of care. Health system equity will also depend upon bold policy advances such as expansion of Medicaid to all states, separation of health insurance from employment, and targeted government and health system investments around social risk (eg, food and housing insecurity). These programs will help vulnerable communities close the gap on disparities in health outcomes that have been so persistent.

Some of these specific concerns were addressed by the Coronavirus Aid, Relief, and Economic Security (CARES) Act that was implemented by the US Congress to address the broad needs of Americans during the acute crisis.6 The CARES Act provided supplementary funding to community health centers and healthcare systems caring for the uninsured. Cash assistance was provided to most US taxpayers along with financial support to those experiencing unemployment through July 31, 2020, measures that have yet to be extended. In addition to the CARES Act, policymakers proposed establishing a COVID-19 Racial and Ethnic Disparities Task Force Act to drive equitable recommendations and provide oversight to the nation’s response to COVID-19.7

While these measures were critical to the immediate pandemic response, future US congressional relief plans are needed to ensure equity remains a tenet of state and federal policy post COVID-19, particularly with respect to social determinants of health. Additional recommendations for federal relief include rent assistance for low-income families, eviction stoppages, and increased funding for short-term food insecurity. With respect to long-term goals, this is the time to address broader injustices, such as lack of affordable housing, lack of a sensible national strategy around food security, and a lack of equitable educational and justice systems. This moment also offers an opportunity to consider the best way to address the impact of centuries of structural racism. If we place equity at the center of policy implementation, we will certainly see downstream health consequences—ones that would begin to address the health disparities present long before the current pandemic.

 

 

FOSTERING COMMUNITY RESILIENCE

While national, state, and local responses to COVID-19 are required to bolster population health when we emerge from the COVID-19 crisis, a focus on community resilience is also needed. Community resilience, or the ability to prevent, withstand, and mitigate the stress of a disaster like COVID-19, requires integration of emergency preparedness practices into community disaster programs, with ongoing efforts to mitigate disparities in chronic disease management. A framework for community resilience includes (1) engaging with communities in planning, response, and post–COVID-19 recovery, (2) ensuring communities have access to high quality, culturally concordant health and social services, and (3) developing robust community networks to mobilize individuals, community services, and public health infrastructure in times of emergency.8

After seeing the devastating effects of Hurricane Katrina in 2005, researchers, public health officials, and community leaders founded the Los Angeles County Community Disaster Resilience (LACCDR) project. Through this collaborative effort, the LACCDR established partnerships across 16 communities to foster community resilience during health emergencies against the backdrop of daily chronic stressors such as violence, segregation, poverty, and homelessness.8 A model such as this to improve health systems and public health integration post-COVID will support health provisions and help build trust in communities wherein there is a high distrust of the healthcare system. Engaging with community partners early to ensure that its members have access to basic needs (eg, food, water, shelter), public health needs (eg, timely information, personal protective equipment such as face coverings and cleaning supplies), and affordable testing and vaccination will help prevent disparities that could affect the most vulnerable in future phases of the COVID-19 crisis.

PROMOTING EQUITY AS A SUSTAINABLE ECONOMIC STRATEGY

Over 40 million Americans were seeking unemployment benefits at the peak of the economic repercussions of the COVID-19 pandemic. Unfortunately, low-income, rural, and minority communities disproportionately experienced this economic shock. Given the relationship between wealth and health, successfully achieving equity post-COVID-19 will require deeper financial investments in underserved communities.9 Healthcare organizations, which represent 18% of the United States gross domestic product and employ nearly 9% of all working individuals, are uniquely positioned to have a direct influence on this strategy.

One equity-based strategy is for healthcare institutions to pursue an anchor mission. Anchor missions have increased a health system’s investment in social services, including providing housing and food resources.10 Additionally, hospitals such as Brigham and Women’s, Boston Children’s Hospital, and Bon Secours Health System, are working with a diverse group of entrepreneurs to create jobs and build wealth in underserved communities by employing local and minority-owned businesses to support critical supply chain purchasing decisions regarding food, maintenance, and construction projects.11 These local and inclusive hiring and procurement measures can be bolstered by continued place-based investments by all health system leaders in vulnerable communities.

CONCLUSION

Since the first enslaved Africans were brought to America over 400 years ago, racial and ethnic minorities have experienced struggle and triumph, sadness and joy. The bonds of a long legacy of discrimination are so deep that we must be intentional in our pursuit of equity—during and beyond the COVID-19 pandemic. Placing equity at the center of healthcare system practice and policy implementation, fostering community resilience and emergency preparedness, and prioritizing equity in economic strategic planning are key steps toward addressing the population-level inequities exposed by the COVID-19 pandemic. As the once touted “great equalizer” rages on, we must remember that we are all jointly affected by the distress caused by the novel coronavirus and we also must be more aware than ever of our interconnectedness. We can use this time of pandemic to fight more than ever to ensure that all populations can enjoy just and optimal health.

Acknowledgments

The authors would like to thank Dr Denise Polit for her review of this manuscript.

The novel coronavirus disease of 2019 (COVID-19), caused by the SARS-CoV-2 pathogen, has resulted in a health crisis unlike any other experienced in the past century, with millions of people infected and over one million people dying from COVID-19 worldwide. The pandemic has disproportionately impacted historically marginalized groups, resulting in higher rates of infection, hospitalization, and death in racial/ethnic minority populations, including Black, Hispanic/Latinx, and Native American populations, compared with the White population.1 Statistics suggest that it is not just socioeconomic differences but also structural racism that has played a role in worse health outcomes in minority populations. However, the health inequities uncovered by the pandemic represent an opportunity—a “plastic hour” in which improvements at the population level may be uniquely possible.2 As healthcare providers, we must take advantage of this moment and work toward improving healthcare and increasing health equity in the post–COVID-19 era. We highlight three strategies to guide us toward achieving this goal: (1) prioritizing health system equity and government improvements to population health, (2) fostering community resilience, and (3) promoting equity in economic sustainability.

HEALTH SYSTEM AND GOVERNMENT IMPROVEMENTS TO POPULATION HEALTH

The COVID-19 pandemic has revealed deep-seated structural and medical vulnerabilities in the US healthcare system, with distressing racial/ethnic differences in COVID-19 infection continuing to emerge.3 Despite variation in the availability and quality of these data, disparities observed in COVID-19 have tracked closely with historical inequities in access to healthcare and discrimination within the healthcare system.4 Any approach to addressing these inequities must appreciate the intersection between social and medical vulnerabilities.

It is notable that healthcare systems serving the most vulnerable populations have borne the brunt of the economic toll of COVID-19. Hospitals in socioeconomically challenged areas lost millions of dollars due to the postponement of elective procedures and reallocation of most resources to COVID-related hospital admissions. Many community-based practices, already stretched in caring for medically and socially complex patients, had to shut their doors. These losses have left patients without the support of their network of healthcare and community service organizations—at the same time that many of them have also lost support for food and housing, employer-based health insurance, and in-person schooling and childcare.

The current circumstances due to the COVID-19 pandemic, therefore, require us to reconsider many aspects of both healthcare and the social safety net, including the reliance on financial penalties as a strategy to improve health quality, which ultimately has a disproportionate impact on communities of color.5 The present situation may also allow for the federal, state, and local governments, as well as health systems and payers, to make targeted investments in healthcare, public health, and community programs. For example, an increased healthcare system investment on preventive and primary care will be essential to reducing the chronic risk factors that underlie COVID-19 infection and death. Efforts by payers to reduce economic incentives for unnecessary elective procedures, while simultaneously providing incentives to increase the focus on preventive care, would further stimulate this effort. Although there is controversy over the inclusion of social risk in financial and value-based health system payment models, novel approaches to this problem (eg, consideration of improvement over achievement of static targets) may provide an opportunity for struggling health systems to invest in new strategies for underserved populations. Additionally, investing in a care system that allows racial, language, and cultural concordance between clinicians and patients would both promote a diverse workforce and improve quality of care. Health system equity will also depend upon bold policy advances such as expansion of Medicaid to all states, separation of health insurance from employment, and targeted government and health system investments around social risk (eg, food and housing insecurity). These programs will help vulnerable communities close the gap on disparities in health outcomes that have been so persistent.

Some of these specific concerns were addressed by the Coronavirus Aid, Relief, and Economic Security (CARES) Act that was implemented by the US Congress to address the broad needs of Americans during the acute crisis.6 The CARES Act provided supplementary funding to community health centers and healthcare systems caring for the uninsured. Cash assistance was provided to most US taxpayers along with financial support to those experiencing unemployment through July 31, 2020, measures that have yet to be extended. In addition to the CARES Act, policymakers proposed establishing a COVID-19 Racial and Ethnic Disparities Task Force Act to drive equitable recommendations and provide oversight to the nation’s response to COVID-19.7

While these measures were critical to the immediate pandemic response, future US congressional relief plans are needed to ensure equity remains a tenet of state and federal policy post COVID-19, particularly with respect to social determinants of health. Additional recommendations for federal relief include rent assistance for low-income families, eviction stoppages, and increased funding for short-term food insecurity. With respect to long-term goals, this is the time to address broader injustices, such as lack of affordable housing, lack of a sensible national strategy around food security, and a lack of equitable educational and justice systems. This moment also offers an opportunity to consider the best way to address the impact of centuries of structural racism. If we place equity at the center of policy implementation, we will certainly see downstream health consequences—ones that would begin to address the health disparities present long before the current pandemic.

 

 

FOSTERING COMMUNITY RESILIENCE

While national, state, and local responses to COVID-19 are required to bolster population health when we emerge from the COVID-19 crisis, a focus on community resilience is also needed. Community resilience, or the ability to prevent, withstand, and mitigate the stress of a disaster like COVID-19, requires integration of emergency preparedness practices into community disaster programs, with ongoing efforts to mitigate disparities in chronic disease management. A framework for community resilience includes (1) engaging with communities in planning, response, and post–COVID-19 recovery, (2) ensuring communities have access to high quality, culturally concordant health and social services, and (3) developing robust community networks to mobilize individuals, community services, and public health infrastructure in times of emergency.8

After seeing the devastating effects of Hurricane Katrina in 2005, researchers, public health officials, and community leaders founded the Los Angeles County Community Disaster Resilience (LACCDR) project. Through this collaborative effort, the LACCDR established partnerships across 16 communities to foster community resilience during health emergencies against the backdrop of daily chronic stressors such as violence, segregation, poverty, and homelessness.8 A model such as this to improve health systems and public health integration post-COVID will support health provisions and help build trust in communities wherein there is a high distrust of the healthcare system. Engaging with community partners early to ensure that its members have access to basic needs (eg, food, water, shelter), public health needs (eg, timely information, personal protective equipment such as face coverings and cleaning supplies), and affordable testing and vaccination will help prevent disparities that could affect the most vulnerable in future phases of the COVID-19 crisis.

PROMOTING EQUITY AS A SUSTAINABLE ECONOMIC STRATEGY

Over 40 million Americans were seeking unemployment benefits at the peak of the economic repercussions of the COVID-19 pandemic. Unfortunately, low-income, rural, and minority communities disproportionately experienced this economic shock. Given the relationship between wealth and health, successfully achieving equity post-COVID-19 will require deeper financial investments in underserved communities.9 Healthcare organizations, which represent 18% of the United States gross domestic product and employ nearly 9% of all working individuals, are uniquely positioned to have a direct influence on this strategy.

One equity-based strategy is for healthcare institutions to pursue an anchor mission. Anchor missions have increased a health system’s investment in social services, including providing housing and food resources.10 Additionally, hospitals such as Brigham and Women’s, Boston Children’s Hospital, and Bon Secours Health System, are working with a diverse group of entrepreneurs to create jobs and build wealth in underserved communities by employing local and minority-owned businesses to support critical supply chain purchasing decisions regarding food, maintenance, and construction projects.11 These local and inclusive hiring and procurement measures can be bolstered by continued place-based investments by all health system leaders in vulnerable communities.

CONCLUSION

Since the first enslaved Africans were brought to America over 400 years ago, racial and ethnic minorities have experienced struggle and triumph, sadness and joy. The bonds of a long legacy of discrimination are so deep that we must be intentional in our pursuit of equity—during and beyond the COVID-19 pandemic. Placing equity at the center of healthcare system practice and policy implementation, fostering community resilience and emergency preparedness, and prioritizing equity in economic strategic planning are key steps toward addressing the population-level inequities exposed by the COVID-19 pandemic. As the once touted “great equalizer” rages on, we must remember that we are all jointly affected by the distress caused by the novel coronavirus and we also must be more aware than ever of our interconnectedness. We can use this time of pandemic to fight more than ever to ensure that all populations can enjoy just and optimal health.

Acknowledgments

The authors would like to thank Dr Denise Polit for her review of this manuscript.

References
  1. Williams DR, Cooper LA. COVID–19 and health equity–a new kind of “herd immunity”. JAMA. 2020;323(24):2478-2480. https://doi.org/10.1001/jama.2020.8051
  2. Packer G. America’s plastic hour is upon us. The Atlantic. October 2020. Accessed September 28, 2020. https://www.theatlantic.com/magazine/archive/2020/10/make-america-again/615478/
  3. Gross CP, Essien UR, Pasha S, Gross JR, Wang SY, Nunez-Smith M. Racial and ethnic disparities in population-level Covid-19 mortality. J Gen Intern Med. 2020;35(10):3097-3099. https://doi.org/10.1007/s11606-020-06081-w
  4. Institute of Medicine (US) Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care, Smedley BD, Stith AY, Nelson AR, eds. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. National Academies Press (US); 2003. https://doi.org/10.17226/12875
  5. Zuckerman RB, Joynt Maddox KE, Sheingold SH, Chen LM, Epstein AM. Effect of a hospital-wide measure on the readmissions reduction program. N Engl J Med. 2017;377(16):1551-1558. https://doi.org/10.1056/nejmsa1701791
  6. Cochrane E. House passes relief for small businesses and aid for hospitals and testing. New York Times. April 23, 2020. Accessed May 21, 2020. https://www.nytimes.com/2020/04/23/us/politics/house-passes-relief-for-small-businesses-and-aid-for-hospitals-and-testing.html
  7. Harris announces legislation to establish task force to combat racial and ethnic disparities in COVID-19. News release. Kamala D. Harris US Senator for California; April 30, 2020. Accessed May 21, 2020. https://www.harris.senate.gov/news/press-releases/harris-announces-legislation-to-establish-task-force-to-combat-racial-and-ethnic-disparities-in-covid-19
  8. Chandra A, Williams M, Plough A, et al. Getting actionable about community resilience: the Los Angeles County Community Disaster Resilience project. Am J Public Health. 2013;103(7):1181-1189. https://doi.org/10.2105/ajph.2013.301270
  9. Rawshani A, Svensson AM, Zethelius B, Eliasson B, Rosengren A, Gudbjörnsdottir S. Association between socioeconomic status and mortality, cardiovascular disease, and cancer in patients with type 2 diabetes. JAMA Intern Med. 2016;176(8):1146-1154. https://doi.org/10.1001/jamainternmed.2016.2940
  10. Horwitz LI, Chang C, Arcilla HN, Knickman JR. Quantifying health systems’ investment in social determinants of health, by sector, 2017-19. Health Aff (Millwood). 2020;39(2):192-198. https://doi.org/10.1377/hlthaff.2019.01246
  11. Nanos J. Diverse, locally owned food start-ups make the menus at Harvard, UMass, and BC. Boston Globe. January 24, 2020. Accessed September 28, 2020. https://www.bostonglobe.com/business/2020/01/24/diverse-locally-owned-food-start-ups-make-menus-harvard-umass-and/WwJFew6KVgXu1NyIK1BNqI/story.html
References
  1. Williams DR, Cooper LA. COVID–19 and health equity–a new kind of “herd immunity”. JAMA. 2020;323(24):2478-2480. https://doi.org/10.1001/jama.2020.8051
  2. Packer G. America’s plastic hour is upon us. The Atlantic. October 2020. Accessed September 28, 2020. https://www.theatlantic.com/magazine/archive/2020/10/make-america-again/615478/
  3. Gross CP, Essien UR, Pasha S, Gross JR, Wang SY, Nunez-Smith M. Racial and ethnic disparities in population-level Covid-19 mortality. J Gen Intern Med. 2020;35(10):3097-3099. https://doi.org/10.1007/s11606-020-06081-w
  4. Institute of Medicine (US) Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care, Smedley BD, Stith AY, Nelson AR, eds. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. National Academies Press (US); 2003. https://doi.org/10.17226/12875
  5. Zuckerman RB, Joynt Maddox KE, Sheingold SH, Chen LM, Epstein AM. Effect of a hospital-wide measure on the readmissions reduction program. N Engl J Med. 2017;377(16):1551-1558. https://doi.org/10.1056/nejmsa1701791
  6. Cochrane E. House passes relief for small businesses and aid for hospitals and testing. New York Times. April 23, 2020. Accessed May 21, 2020. https://www.nytimes.com/2020/04/23/us/politics/house-passes-relief-for-small-businesses-and-aid-for-hospitals-and-testing.html
  7. Harris announces legislation to establish task force to combat racial and ethnic disparities in COVID-19. News release. Kamala D. Harris US Senator for California; April 30, 2020. Accessed May 21, 2020. https://www.harris.senate.gov/news/press-releases/harris-announces-legislation-to-establish-task-force-to-combat-racial-and-ethnic-disparities-in-covid-19
  8. Chandra A, Williams M, Plough A, et al. Getting actionable about community resilience: the Los Angeles County Community Disaster Resilience project. Am J Public Health. 2013;103(7):1181-1189. https://doi.org/10.2105/ajph.2013.301270
  9. Rawshani A, Svensson AM, Zethelius B, Eliasson B, Rosengren A, Gudbjörnsdottir S. Association between socioeconomic status and mortality, cardiovascular disease, and cancer in patients with type 2 diabetes. JAMA Intern Med. 2016;176(8):1146-1154. https://doi.org/10.1001/jamainternmed.2016.2940
  10. Horwitz LI, Chang C, Arcilla HN, Knickman JR. Quantifying health systems’ investment in social determinants of health, by sector, 2017-19. Health Aff (Millwood). 2020;39(2):192-198. https://doi.org/10.1377/hlthaff.2019.01246
  11. Nanos J. Diverse, locally owned food start-ups make the menus at Harvard, UMass, and BC. Boston Globe. January 24, 2020. Accessed September 28, 2020. https://www.bostonglobe.com/business/2020/01/24/diverse-locally-owned-food-start-ups-make-menus-harvard-umass-and/WwJFew6KVgXu1NyIK1BNqI/story.html
Issue
Journal of Hospital Medicine 16(1)
Issue
Journal of Hospital Medicine 16(1)
Page Number
J. Hosp. Med. 2021 January;16(1):53-55. Published Online First December 23, 2020. DOI: 10.12788/jhm.3546
Page Number
J. Hosp. Med. 2021 January;16(1):53-55. Published Online First December 23, 2020. DOI: 10.12788/jhm.3546
Publications
Publications
Topics
Article Type
Sections
Article Source

© 2021 Society of Hospital Medicine

Citation Override
J. Hosp. Med. 2021 January;16(1):53-55. Published Online First December 23, 2020. DOI: 10.12788/jhm.3546
Disallow All Ads
Correspondence Location
Utibe R Essien, MD, MPH
Email: uessien@pitt.edu.
Content Gating
Open Access (article Unlocked/Open Access)
Alternative CME
Disqus Comments
Default
Use ProPublica
Hide sidebar & use full width
render the right sidebar.
Conference Recap Checkbox
Not Conference Recap
Clinical Edge
Display the Slideshow in this Article
Medscape Article
Display survey writer
Reuters content
Article PDF Media