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Social Determinants of Health and COVID-19

By Shivan Lala


COVID-19 has emphasized the role of equitable labor and housing policy in shaping public health. Incomplete policies that directly contribute to disparate health impacts on Black, Latinx, and Indigenous populations must be expanded to ensure health protection for these at-risk populations.


Photo by Chris Grafton on Unsplash

What are Social Determinants of Health?

Simply put, social determinants of health refer to living and working conditions that have a significant impact on health outcomes. Conditions include unstable housing, overcrowding, occupational hazards, pre-existing susceptibility, and substandard education – all of which contribute to widespread differences in social position and subsequent exposure to infectious disease. Historically, minority communities have suffered the most from these differences. During the 1918 Spanish Flu pandemic, Native Americans experienced a disease-specific mortality rate 4x that of other ethnic groups, while health data from the H1N1 pandemic demonstrated that African Americans and Latinos were overrepresented among hospitalizations for H1N1 infection.

The driving force behind this imbalance is clear, as a national survey showed that racial and ethnic minorities were unable to practice social distancing or stay at home during the H1N1 pandemic because they could not work at home and lacked paid sick leave or access to healthcare. Disparities in exposure among minorities have continued during the COVID-19 pandemic, driven by CDC findings that jobs deemed “essential” are composed of primarily Black and Latinx workers in healthcare and agricultural industries. In developing pandemic preparedness and treatment plans, the federal government must pay attention to policy-driven systemic inequality that causes avoidable differences in infectious disease exposure and susceptibility.

Policy Shortcomings

Incomplete labor and historically racist housing policy directly contribute to negative health outcomes, causing differential exposure and susceptibility for minority populations. However, it is important to note that the following policy shortcomings are far from a comprehensive list – decades of policy-driven systemic racism must be overturned before meaningful change can be made.

First, the Fair Labor Standards Act (FLSA) directly contributes to disparate exposure for minority populations by excluding coverage of many “essential” jobs staffed by minorities. The FLSA does not cover domestic, agricultural, and service workers, meaning these workers are unable to receive overtime and typically are paid fifty cents less than minimum wage. While this protects large companies by limiting employee costs, minority workers are at an extreme disadvantage as lower incomes mean they cannot miss work, even when sick. This issue is not limited to agricultural workers, either. Home health care workers, a population mainly composed of nonwhite women, are also not completely covered by the FLSA. While considered an essential job, home health care workers are classified as “independent contractors” by the FLSA, meaning common benefits such as paid sick leave are not provided to those directly interacting with many COVID-19 patients on a day-to-day basis. These findings are especially concerning given the fact that 1/5 of home health care workers live below the federal poverty line.

In addition to increased exposure risk, Black, Latinx, and Indigenous populations suffer from increased susceptibility due (in part) to discriminatory housing policy and its contribution to various comorbidities. The most well-known example of this is “redlining”, a housing practice in which the Federal Housing Administration refused to insure mortgages in predominantly African-American neighborhoods. This explicitly segregationist policy, in turn, led to the development of low-income minority communities that receive less economic investment and fewer public resources. This correlates with increases in pollution, noise, and overcrowding in these neighborhoods, which then increases the risk of asthma, obesity, and cardiovascular disease among the resident populations (particularly among Black women). While Title X of the Housing and Community Development Act (HCDA) addresses these issues, it is the only federal housing law that addresses housing-related health hazards. While this may seem like a step forward, Title X still does not include requirements such as clean running water, plumbing with hot and cold water, a flushing toilet, bathtub/shower, kitchens with sinks and faucets, stoves, ovens, and refrigerators – many resources that are essential to reduce comorbidity risk in low-income neighborhoods.

Solutions

The first step that must be taken to address these issues is comprehensive expansion of the FLSA and HCDA. To adequately cover the populations that are most at risk, the FLSA must expand to include all domestic, agricultural, and service workers (even those labeled as independent contractors), allowing them to access key aspects of financial stability such as a minimum wage, paid sick leave, and overtime. Doing so will significantly decrease the level of susceptibility many essential workers face, allowing sick individuals to stay home without fear of losing wages or employment. The HCDA must also expand beyond its Title X protections, ensuring housing contains bare necessities that are known to impact the health of its residents. A larger-scale solution involves the introduction of a universal basic income (UBI) for essential workers, following the mold of policy initiatives such as the Alaska Permanent Fund to ensure a baseline income for those most at risk of contracting COVID-19 and future infectious diseases.

To implement a short-term solution, policymakers must provide financial stability to vulnerable populations by expanding the CARES act. Expansions must adequately cover documented and undocumented immigrant populations, as well as direct care workers; twelve states have adopted these practices but significant results will only be seen if this is done nationwide. By providing more accessible means of financial stability and safe housing, policymakers can go a long way in mitigating the disparate impact of pandemics on Black, Latinx, and Indigenous communities. Coupling these changes with accessible healthcare has the potential to significantly reduce disproportionate infection and mortality levels in minority populations, and can represent a big step forward in addressing systemic racism in healthcare. While these methods may be effective in their role, it is again important to note that these do not represent the comprehensive range of policy changes that must be enacted to fully protect these communities.

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