The COVID-19 pandemic has highlighted preexisting economic, social, and health inequities in the United States and has exposed the nation’s deficient public health and health care infrastructure. Recent data from the Centers for Disease Control and Prevention show that Black Americans are nearly three times more likely to be hospitalized from COVID-19 and close to twice as likely to die from COVID-19 than non-Hispanic white Americans.[i]

Racism and its manifestations within our institutions is a fundamental cause of racial and ethnic health inequities. Dr. Camara Phyllis Jones, a former American Public Health Association president, defines racism as:

A system of structuring opportunity and assigning value based on the social interpretation of how one looks (which is what people call race) that unfairly disadvantages some individuals and communities, unfairly advantages other individuals and communities, and saps the strength of the whole society through the waste of human resources.[ii]

To be a healthier country and to reach health equity, it is important that we name racism as a root cause of increased morbidity and mortality among Black people and develop solutions that target and dismantle racism within systems of power.

Social Drivers of Health

In the United States, social stratification based on race disproportionately structures access to health protective resources like stable housing, employment, healthy foods, and medical care. Racism created vulnerabilities in Black and other racial and ethnic minoritized communities well before the COVID-19 pandemic. The legacy of historically racist policies combined with current, more covert forms of racism have created conditions for poor health outcomes among Black populations.

Housing and Neighborhood Quality

• The conditions in which we live have the greatest impact on our health outcomes. Black people are more likely to be poor, given the country’s racialized economic system, and many of our neighborhoods are under-resourced. The places we call home have limited access to affordable and healthy foods, are far from primary care facilities for prevention and chronic disease management, and lack safe streets and green spaces for physical activity and general wellbeing. The absence of critical resources and services in Black communities is a direct result of redlining, segregation, gentrification, and other discriminatory policies and practices that intentionally strip resources from Black people and our neighborhoods. The conditions of these neighborhoods contribute to increased stress and poorer, chronic health outcomes, leading to increased risk for COVID-19 susceptibility, severity, and mortality.

Economic Security

• Black, Indigenous, and poor people disproportionately make up the working class because the economic system of the United States is built off racial capitalism. During the pandemic and subsequent economic shutdown, we were overrepresented in low-wage jobs that were newly deemed essential, putting us at greater risk of infection. Black people were also more vulnerable to job loss, which increased our susceptibility to a multitude of social and economic risk factors. Often, when people have to choose between paying for medical services or putting food on the table, medical treatment gets de-prioritized.

Access to Quality Health Care

• Health care utilization has been traditionally lower among Black Americans than other racial and ethnic groups. This is due in part to structural barriers to accessible health care and, in part, due to the historical and current reality of US medical institutions acting as agents of violence against Black bodies. For example, during segregation, Black people were treated in separate, underfunded, and understaffed facilities. We remember the Tuskegee Study of Untreated Syphilis in the Negro Male and the theft of Henrietta Lacks’ cells. This violence continues today. We are bombarded with a steady stream of stories about Black birthing people not being listened to or Black patients being refused pain management. Medical systems have been structures of oppression for Black people for centuries, resulting in inaccessible, poor quality, and untrustworthy care.

New Paths Forward

To move towards a more equitable future, we must interrogate and dismantle the racist structures that lead to vulnerability and invest in the creation of strategies that seek justice and center the voices and experiences of marginalized peoples.

Community Based Health

• People want to receive care in trusted places where they feel safe. Black people should establish our own spaces to educate ourselves on preventive health and provide vital resources and services in our neighborhoods. We can take lessons from the community organizers of our past. The Black Panther Party established community clinics in 13 cities across the country to provide health education, mobilize resources to mitigate diseases and other chronic illnesses, and provide housing assistance and legal aid. Community-based health care is an effective model to provide culturally responsive care in communities where economic, political, and social barriers prevent people from accessing quality services. The clinics that the Panthers ran were critical in the fight to overcome the structural racism and economic inequality that prevented many Black people from going to hospitals and other care facilities.

Training of Health Care Professionals

• Medical schools and training centers must be more intentional about naming racism as a cause of health inequity, and they must develop curriculums to teach this. Medical schools still use race to pathologize racial and ethnic minoritized patients. For example, medical students are taught that being Black is a risk factor for a varied number of medical conditions. In reality, racism is why Black people face a disproportionate burden of illness. To transform how medical care is delivered, educators must recognize that medical instruction is biased and must be reevaluated using an anti-racist lens. Frameworks such as Critical Race Theory and the social determinants of health can be used to advance students’ understanding of the fundamental causes of health inequities.

Equitable, Tech-Enabled Care

• As technology plays a larger role in care both in and out of medical spaces, it is essential that these solutions — such as machine learning, big data, and virtual engagement— are designed with empathy for marginalized groups who are most vulnerable. Often, these tools mirror the racialized biases of their creators and our society. During the pandemic, we saw a huge shift to telemedicine that allowed doctors to provide care to patients from the safe distance of their homes. But this benefit also has the potential to build further barriers to health-promoting services due to our nation’s racialized digital divide. If we are going to create new tech-enabled models for servicing patients, we need to ensure that they improve health outcomes for those in the greatest need. Otherwise, these technologies will simply reflect the biases that currently infect and infest our systems. We must prioritize developing tools in an anti-racist way.

COVID-19 is not, as some early commentators claimed: “the great equalizer.” Yes, we were all vulnerable to infection, but Black people and other marginalized groups were uniquely predisposed to carrying a greater burden of sickness and death. We must be intentional about targeting racism as the root cause of inequities across systems of power — including the medical industrial complex. We must mobilize our own resources to create the tools and resources that can protect us from a system designed to kill us.

[i] Centers for Disease Control and Prevention. “COVID-19 Hospitalization and Death by Race/Ethnicity.” National Center for Immunization and Respiratory Diseases. Last Modified 23 Apr 2021. Retrieved from: https://www.cdc.gov/coronavirus/2019-ncov/covid-data/investigations-discovery/hospitalization-death-by-race-ethnicity.html

[ii] Jones CP. Levels of Racism: American Journal of Public Health. 2000

Despite the wide-ranging devastation of the COVID-19 pandemic, particularly within communities of color, we feel a sense of optimism that we have not felt in over a year. Our new administration explicitly acknowledged the existence of systemic racism and white supremacy in American society and launched one of the most ambitious public health efforts of the last century: the emergency vaccination of more than 300 million U.S. citizens. Since January 2021, more than 139 million Americans have been vaccinated, and the American Rescue Plan has been passed. There is hope, finally, that Americans will be able to resume many of their pre-pandemic activities and that our entire society will begin to recover from the losses of the last year.

However, our hope is tempered.

Of the more than 598,000 COVID-19 deaths in the United States, a disproportionate number were Black, Native, Latino, and Pacific Islander Americans. And because vaccination strategies have lacked a specific focus on equity, COVID-19 disparities have now extended to vaccination rates. As of mid-May, Black Americans, who are 12.4% of the U.S. population, represent 8.5% of vaccinations; Latino Americans, who make up 17.4% of the population, represent 11.6% of vaccinations; and white Americans, who are 61.2% of the population, represent 65.1% of those fully vaccinated.

Following a year of excess pandemic deaths, job loss, residential evictions, food insecurity, police violence, and inequities in education and health care access due to the digital divide, Black Americans are experiencing “community bereavement.” We need a restorative justice plan that ensures access to COVID-19 vaccinations and overall health care and creates opportunities for improvements in education, employment, and living conditions.

Discussions regarding racial disparities in COVID-19 vaccine uptake have focused heavily on vaccine hesitancy and medical mistrust. Hesitancy and mistrust reflect lived experiences in health care settings and are rooted in structural racism, which is the totality of the systems, policies, and practices that have consistently placed white Americans in a position of advantage and people of color in positions of disadvantage. The same structural and systemic forces that put people of color at increased risk of COVID-19 infection and its complications also contributed to differences in health status and access to appropriate health care services generations before the pandemic began. Addressing inequities in negative social determinants and disease outcomes is why we and our community partner colleagues at the Johns Hopkins Center for Health Equity have directed critical research programs, developed innovative programs, trained future leaders, and advocated with policymakers for more than a decade.

Health equity leaders are changing the narrative regarding racial disparities in COVID-19 vaccine uptake. Attitudes toward COVID-19 vaccination have improved — and most dramatically among Black Americans. In January 2021, 34% of Black Americans and 20.1% of white Americans responding to the U.S. Census Household Pulse Survey reported that they would definitely or probably not get a COVID-19 vaccine. However, by the end of April 2021, those numbers decreased to 12.4% and 12%, respectively. Therefore, remaining disparities in COVID-19 vaccination rates cannot be attributed primarily to differences in vaccine acceptance; they indicate inequities in vaccine distribution and access — manifestations of structural racism.

We’re also changing the narrative regarding health disparities in general by ensuring that people understand that addressing these inequities isn’t solely an individual responsibility, but rather a societal one. The multi-faceted nature of health disparities requires cross-sector partnerships using restorative justice approaches to address the legacies of structural racism. Such partnerships must include trusted community and faith-based organizations and policymakers as well as the education, public health, health care, community development, and food sectors. These partnerships have served a vital role in meeting the needs of communities of color during the pandemic, from providing relevant COVID-19 information and advocating with policymakers to setting moratoriums on evictions and providing food, educational, and social support for older adults and families with children.

At the Johns Hopkins Urban Health Institute, we focus on advancing health equity in Baltimore by facilitating partnerships. We recently held an online symposium, “Building and Restoring Health in Communities: Understanding and Leveraging Partnerships To Advance Health Equity,” convening faculty, students, community residents, and leaders all across Baltimore who are working to advance health equity in our community. We organized the symposium around the topics of employment, education, food, and housing as prerequisites for achieving optimal health. Many panelists highlighted that equitable access to these basic necessities is a fundamental human right. Here are some reminders and new lessons from our discussions.

1. Relationships in these partnerships must be built on mutual respect, trust, sharing of power, responsibility, and accountability.
2. People must be valued for their humanity, including their cultures and lived experiences.
3. Partnerships should amplify and advocate for the voices of marginalized groups.
4. Building agency and capacity from a foundation of existing strengths is paramount.
5. Data and evidence are critical to informing and evaluating programs and policies.
6. Solutions should focus on systems and root causes.
7. We must create supportive and nurturing environments at work, school, home, and in communities.
8. Health must be viewed holistically and as a life-long journey.
9. Whenever possible, our approaches should be proactive — not reactive — using what we know from research and past experiences to inform decisions, policies, and practices.
10. Achieving health equity is not a zero-sum game. Health equity efforts target those who need them most, but typically benefit many others.

Health care was discussed as a fundamental thread woven throughout all the other concerns, with the understanding that health care institutions must determine their role as cross-sector partners and become anchor institutions that promote health equity not only within their own walls but within their surrounding communities.

Dr. Lisa Cooper’s book, Why Are Health Disparities Everyone’s Problem? provides evidence-informed insights on how we can all be a part of the solution.  Events of the past year have brought greater public awareness of the impact of structural racism on health disparities, and we can leverage this awareness for greater action. Although more work is needed to restore our communities to health and wholeness, these solutions will come as we commit to working together toward a common vision of health equity — when every person in our nation and around the world has the opportunity to attain their full health potential.

To improve health equity for people of color, we need to address racism’s impact on health across medical and non-medical sectors. While it is important to explicitly highlight race/ethnicity and racism in the medical field and help health care professionals understand common mechanisms used to discriminate against people of color, it is also important for the medical field to contribute to efforts that highlight the health impacts of racism across non-medical sectors.

Studies show that non-medical socioeconomic, environmental, and behavioral factors account for a majority of health outcomes. Past and present discriminatory policies and practices that created inequities in social and environmental conditions are to blame for many poor outcomes experienced by Latinos and other populations of color today.

The pathway between inequities in social and environmental conditions and poor health outcomes are known as social risk factors, such as housing insecurity, income insecurity, and transportation insecurity. Because social risk factors are a consequence of racism and a contributor to health inequity, the medical sector plays an important role in educating the public about the effects of such inequities and supporting the non-medical sector in addressing the broader social determinants of health (SDOH) through upstream change (see Exhibit 1).

As communities across the country declare racism a public health crisis, the medical sector can contribute in three meaningful ways: focus on addressing the root causes of social risk factors while also addressing social and medical needs; establish and utilize tools to screen for the social risk factors that arise from systemic inequities that contribute to social need and poor health; and understand and overcome common mechanisms used to discriminate against people of color.

The idea that health is shaped by social and economic conditions is not new. However, the awareness that interventions are necessary to tackle social needs in patient care is only now entering mainstream health care. Finding solutions to deal with the root causes of those social needs is way behind. Addressing social needs in medical care is essential to improve health outcomes, but social needs are neither unique nor random. Systemic inequities rooted in a racist past result in the social risk factors that contribute to social needs, making it harder for Latinos, Blacks, and other people of color to stay healthy.

COVID-19 shined a harsh light on and further exacerbated systemic inequities, especially for Latinos. These inequities are particularly problematic because literature suggests there is a dose-response relationship between social risk factors and health; meaning, the more social needs a person faces, the higher their risk for worse health outcomes. For example, researchers assessed the rate of hospital readmission by the level of health-related social needs from ICD-10 Z codes (diagnosis codes for non-medical social needs that a patient may experience). The researchers found that among patients without codes in any of the five domains of health-related social need ─ including employment, family, housing, psychosocial, and socioeconomic status (SES) ─ 11.5% had a 30-day readmission. Among those with codes in one domain, 27% had a 30-day readmission, increasing to 63.5% for patients with codes in five domains. Of note, only 2.4% of the more than 13 million patients included in this study had at least one health-related social need.

This low number suggests inadequate screening practices because the unemployment rate was 4.4% the year the study was conducted, and the poverty rate was 12.3%, with drastic disparities by race/ethnicity for each measure. In 2017, the unemployment rate was 7.5% for Black people and 5.1% for Latinos compared to 4.2% for white people; and the poverty rate was 21.2% for Black people and 17.2% for Latinos, compared to 9% for white people.

Although ICD-10 Z codes are the primary tool for the medical field to standardize screening for documenting and coding social needs, adoption has been slow. In a cross-sectional study of U.S. hospitals and physician practices, only 24% of hospitals and 16% of physician practices reported having a system in place to screen for the following five social needs: food insecurity, housing instability, utility needs, transportation needs, and interpersonal violence. Of course, having a system is a far cry from using the system. In addition to concerns about low screening practices are concerns that ICD-10 Z codes are not granular enough. That’s why, in December 2020, after years of consensus building, The Gravity Project and several other organizations developed and submitted a proposal to the CDC National Center for Health Statistics ICD-10-CM Coordination and Maintenance Committee to replace the Z codes with 10 domains of social risk codes.

Without addressing the systemic inequities that cause the social risk factors that contribute to social needs, social needs will continue to arise in populations of color; and social needs will continue to return in patients who are the sickest, and as a result, require the most expensive care.

Efforts to address the impact of racism on health must be informed by a better understanding of the “causes of the causes” of health inequities, particularly a better understanding of how toxic stress undermines health and how inaccessible, inadequate, unaffordable, unreliable, and unsafe transportation undermines health. Additionally, efforts to address the impact of racism on health must focus on Latino families’ strengths and Latino contributions to urban space.  

Another important target for the medical sector is implicit bias. Many studies show that physicians — especially white physicians — have implicit, subconscious preferences for white patients over patients of color. Implicit bias can lead to false assumptions and adverse health outcomes. For example, Latino men are less likely to get treatment for high-risk prostate cancer than white men, and white male doctors are less likely to prescribe pain medications to Black patients than their white counterparts. We must find new ways for health care providers to understand and overcome implicit bias as well as other mechanisms they use to discriminate against people of color.

Everyone has the capacity to try to uncover their own implicit biases. The national Salud America! program has a toolkit that guides people to reflect on their own implicit bias and learn from others who have overcome theirs. And we need health care providers to take the lead to educate their peers, like Dr. Jabraan Pasha, who created a training workshop to spread awareness of implicit bias in health care; and Dr. Chiquita Collins, who helped launch a new diversity training to empower UT Health San Antonio faculty members to recognize and speak out against acts of racism and discrimination.

The United States should have a goal to achieve health equity, where everyone has an equal opportunity to be their healthiest. That means we must address racism across medical and non-medical sectors. We need cities to declare racism a public health and safety crisis and commit to systemic change. Without a better understanding of the prevalence of social risk factors and recognition of the role discriminatory practices have played and contributed to social risk factors, health policies or initiatives may not be as effective as intended.

Therefore, we need health care leaders to play a role in screening for social risk factors, promoting awareness of the mechanisms behind discrimination of people of color and advocating for upstream solutions to address inequities in social and environmental conditions that contribute to social risk factors, particularly as we recover and rebuild from COVID-19.

Exhibit 1: Examples of transportation interventions across the continuum of social determinants of health (SDOH), social risk factors, and social needs in medical and non-medical settings. Although often overlooked, transportation issues are particularly important because so many families are transportation cost-burdened, especially those of color. These families forego other essentials like food and health care, which further threatens health, or are at risk of employment insecurity because they are dependent on others or unreliable mass transit to get to work.

Our country is facing a health care crisis. During the COVID-19 pandemic, we watched as some communities experienced skyrocketing COVID-19 cases, complications, and deaths while others had ample supplies of personal protective equipment and mass testing sites. Many of those same communities where cases climbed had little access to testing or treatment and faced serious challenges in accessing the life-saving vaccine. The pandemic certainly tested the limits of our health care system, but these inequities existed long before the COVID-19 crisis.

Communities of color, rural communities, and communities below the poverty line are among the most underserved when it comes to health care access. Financial constraints, limited access to transportation, and the inability to take time off to see a health care provider can all impede a person’s ability to access care.

Take, for example, the maternal health desert in South Side Chicago. Years of closing obstetrics and gynecology departments and entire hospitals have resulted in limited access for expectant and new mothers. This means that pregnant women must figure out where or how to get care somewhere else; and, unfortunately, too many women simply go without adequate care. Just last month, the Illinois Department of Public Health released a report illustrating the disproportionately higher rate of maternal mortality and morbidity for Black women. The review committee offered one recommendation: Increase telehealth coverage on health insurance plans.

We have been increasingly using telehealth services during the pandemic to limit doctor and patient exposure. However, as we begin to move past the pandemic and social distancing restrictions become more relaxed, we should capitalize on the momentum of telehealth technology and continue utilizing this tool to bring health care to underserved communities.

Access to quality health care services is a complex problem comprised of geographic, socio-economic, and historic factors. But as we witnessed in 2020, patients began connecting with health care providers via their laptops and cellphones with the increased expansion of telehealth, bypassing so many of the physical barriers that prevented them from managing chronic conditions and accessing preventative health services.

Telemedicine was already revolutionizing health care delivery before COVID-19, but the necessity for social distancing has only pressed the accelerator. More practitioners now offer virtual appointments, and file sharing technology is expanding. Telemedicine has the potential to fundamentally change the delivery of health care services and break down barriers to care. Telemedicine can be the great health care equalizer; but only if it is implemented equitably.

According to a 2019 Pew report, 82% of white Americans reported owning a laptop or desktop computer compared to 57% of Hispanic Americans and 58% of African Americans. Additionally, when comparing rates of broadband adoption, Black and Hispanic adults also lag behind in access to internet connection. However, when comparing the usage of mobile devices and smartphones, Black and Hispanic Americans own and use these devices at the same rate as white Americans, at around 97%. Additionally, these groups are more likely to rely on their smartphones for myriad activities, including seeking health information.[1] If we ensure that all Americans can have access to broadband internet and the technological devices needed to access telehealth, we can integrate their doctor and entire health care team into that device to help manage chronic conditions and address health inequities.

Telehealth has the potential to move us toward a preventative health model rather than a treatment-based health care system. Let’s envision a world where prevention is the norm rather than the exception. For example, congestive heart failure patients could receive a scale that sends their weight to their primary care team every morning, allowing their providers to track a patient’s progress with diet, medication, and exercise. If the patient began to show daily signs of fluid overload with increasing weight gain, the health care team could set a telehealth visit to determine whether the patient requires further intervention.

Anecdotally, I often hear stories of how telehealth is beginning to close the gaps. In fact, one story that has stuck with me during the recent public health emergency is that of a young constituent who met with me last year. This child uses a wheelchair and lives with her mother in a walk-up apartment building. Before the expansion of telehealth during COVID, she had to miss days from school; and her mother had to take time off from work to get her down the stairs, into their vehicle, and to the doctor’s office. Then, they would drive back and repeat the whole process again and again. During my visit with them, they shared what a gift the expansion of coverage of telehealth had been to them. This young lady was no longer missing substantial time from school, and her mother was able to save all the time and prep work required to get her daughter to the physician’s office. It was also easier for her to get an appointment and not have to wait for in-person availability to see a health care professional. 

I am also hearing from many health care providers that there has been an increase in the number of patients who are able to keep their appointments and that patients are adhering to recommended treatment plans. I have spoken to mental health providers who rejoiced in being able to increase the number of patients that they are able to see through telehealth.

If there is a silver lining in the dark cloud of the pandemic, it is that COVID-19 has demonstrated how vital telemedicine and telehealth technologies are — especially during a public health crisis. We know that telehealth cannot replace all in-person visits. There will always be a need for face-to-face interaction with providers, but the good news is that the quality of care has not been compromised during this time of increased virtual health care, and telehealth has been proven effective.

In the 116th Congress, I introduced the Evaluating Disparities and Outcomes of Telehealth During the COVID-19 Emergency Act. Many patients and providers have benefited from the Centers for Medicare & Medicaid Services’ (CMS) relaxed regulations and report positive experiences with the technology. Telehealth also raises questions regarding utilization, cost, fraud, security, privacy, and equitable access for those left behind by the digital divide, including rural citizens, the elderly, and minority communities. It is critical that, post-pandemic, Congress and CMS develop data-driven telehealth policies that benefits all communities.

Today, we have the capacity to knock down barriers, close the health care access gap, and bring health care into people’s homes, especially folks in places that have been locked out of the system for too long. We must use this moment to build needed investments and structures so everyone can access broadband internet and the digital technologies needed for telehealth services. Let’s move forward and create a system that allows equitable health care access to all in need. We can do it — and telehealth is the tool to get us there.

[1] https://www.pewresearch.org/internet/fact-sheet/internet-broadband/?menu...