The pandemic uncovered disparities in the care and health of people of color in the United States, but to health policy experts whose research is devoted to this field, COVID-19 exacerbated inequities that have long been baked into our public health system.
The key, they said, will be to sustain public awareness of these disparities after the pandemic subsides and take meaningful action to reduce inequities in our health-care delivery.
These were the overarching themes of the Department of Health Policy’s inaugural Health Equity Panel, moderated by Sherri Rose and Maya Rossin-Slater, Associate Professors of Health Policy and co-chairs of the Justice, Equity, Diversity and Inclusion Committee in the department.
The panelists were:
- Samantha Artiga, Director for Racial Equity and Health Policy at the Kaiser Family Foundation
- Kirstin Bibbins-Domingo, Chair and Professor of Epidemiology & Biostatistics; Vice Dean for Population Health and Health Equity at the UCSF School of Medicine
- Jeremy Goldhaber-Fiebert, Professor of Health Policy in the Stanford Department of Health Policy
- Petra Persson, Assistant Professor of Economics in the Stanford Department of Economics
"We certainly all know that one of the most widely recognized aspects of the COVID-19 pandemic is how uneven its impact has been,” Artiga told the panel. “We know that people of color, lower-income people and other historically underserved groups have really borne the brunt of the pandemic, and this is not only in terms of direct health impacts as measured by cases, hospitalizations and deaths, but also in terms of broader social and economic impacts.”
One of Artiga’s KFF studies shows that as of Oct. 5, Hispanic people represented a larger share of cases relative to their share of the total population (27% vs. 17%.) A joint study by Stanford Health Policy and KFF researchers in June found that Black and Hispanic people lagged behind in vaccination than those of white people, largely due to access and logistical barriers as well as concerns about safety and potential side effects.
Artiga acknowledged the pandemic has increased public awareness of these disparities.
“But for those of us working in the field of health equity, none of the pandemic’s disproportionate impacts are surprising or new,” she said. “The pandemic really just exposed and exploited inequities that have been baked into our system for decades.”
Artiga said the long-term lack of data to identify and address disparities is harming those who need help most.
“We simply cannot address what we cannot see,” she said.
The Government Accountability Office issued a report in September revealing that data on race and ethnicity collected by the Centers for Disease Control and Prevention (CDC) is woefully incomplete. By March of this year, the CDC lacked information on patients’ race and ethnicity for almost half of the reported COVID-19 cases and vaccinations — data that could have helped the government better understand the extent of disparities and take action, the report said.
Bibbins-Domingo also focused on the lack of data needed to diminish health disparities.
“If we’re going to achieve our goals, you need metrics and accountability that’s both regulatory and has the financial levers to do this,” she said.
Bibbins-Domingo presented her work on excess mortality in California during six months of the pandemic. She discovered that the highest excess mortality was among people 65 years and older, men, Black and Latino residents — and those without a college degree.
“So, while Latinos have had a disproportionately higher excess mortality rate during the pandemic, those who are working in food and agriculture have strikingly higher mortality,” she said. Her study showed those hit hardest were cooks and bakers, machine operators, agricultural workers and those in construction, maintenance work and shipping.
“Higher mortality and these aspects — education and occupation — are variables that we oftentimes don’t think about when we capture health data or think about the designs of our interventions.”
Health Equity and Families
Persson, a health economist, conducts research on heath equity and families, and collaborates with both Rossin-Slater and Maria Polyakova, an Assistant Professor of Health Policy.
Persson discussed two studies conducted jointly with Polyakova, for which they have linked tax and health records for the entire population of Sweden, which has free universal health care and allows the researchers to do in-depth modeling. In one study they found that Swedes with a doctor or nurse in the family are more likely to undertake important preventive health investments, such as getting vaccinated or quitting smoking in pregnancy.
“This suggests that families may serve as a nexus of informal transmission of health-related information that is essential for preventive health,” she said.
Persson said the finding underscored the importance of an equitable division of health-related information in society for health equity.
“Today, however, all available measures of health literacy suggests that there is more of it at the upper end of the income distribution. So, not everyone in society has an equal chance to rely on health-related knowledge that we know is so important for preventive health.”
In light of this policy implication, she said, it’s frustrating to see that, if anything, the medical profession — at least in the context they’re studying — is becoming less socioeconomically diverse over time. She shared another study that showed that more and more doctors are coming from families that already have a doctor. “This increased concentration of health-related expertise may perpetuate socioeconomic health inequities.”
Concentrations of Health Disparities
Goldhaber-Fiebert, who established a team of faculty and graduate students for his SC-COSMO consortium, has built mathematical models throughout the pandemic to help California state and correctional officials prepare for and mitigate COVID-19 outbreaks. They have published more than a dozen studies in the last year dealing with health inequities, including a recent one that found unequal vaccination rates emerging and persisting in racial/ethnic groups across the United States and pointed to approaches to address these disparities.
The team was one of the first to publish a study on how California’s largest ethnic group, Latinos, faced greater exposure to COVID-19 and contracted and died from the virus at higher rates than non-Hispanic whites in California.
He told the panel his focus of health disparities during the pandemic has highlighted how disadvantaged individuals who are at higher risk are often concentrated in communities, which in turn can concentrate risks experienced by the communities. Such communities are frequently overlooked and often underserved.
“People of color are more likely to be poor in the United States, more likely to work in jobs that require attendance outside the home, and are more likely to live in households with fewer rooms than people,” Goldhaber-Fiebert told the panel. Crowded households, in turn, are in neighborhoods with similar high concentrations of people facing socioeconomic barriers such as time off work and the cost of and access to health care.
“Those access barriers and challenges are very important when thinking about transmission risks from respiratory infectious diseases and about equitable service design,” he said.
Another highly concentrated population is comprised of people incarcerated in correctional facilities.
While African Americans comprise just under 6% of the California population, more than 28% of the people incarcerated in Californian correctional facilities are Black residents. And at the height of the pandemic, incarcerated people were infected by the coronavirus at a rate more than five times higher than the nation’s overall rate.