Year in review: COVID continues to unveil the many faces of health inequity

Nearly two years into the coronavirus pandemic, there are still a lot of unanswered questions and uncertainty about what the future holds. But along the way, COVID has handed society the biggest natural experiment in health and economic equity – and social scientists say the scorecard is far from stellar.

“This was completely foreseeable,” said Tess Weathers, research associate at the Indiana University Richard M. Fairbanks School of Public Health. “We have seen many examples in the past where crises bring to the surface unfairness in the structuring of society.”

Weathers said COVID, like Hurricane Katrina, has highlighted long-standing inequities. During such crises, socially disadvantaged groups – African Americans in particular – bear the brunt of the suffering.

The disparities are seen around the globe. Racial minorities and lower-income communities – in the U.S. and abroad – have been hit the hardest

A look back at 2021 offers insight into why that’s the case and what can be done about it.

January 2021: Vaccination is bittersweet for those with family overseas

One-third of all U.S. doctors are foreign-born and many of them are recent immigrants. Those on the frontlines fighting COVID since the start of the pandemic in the U.S. were also at the front of the line for vaccines when they became available in late 2020.

“I got my vaccine even before the president of the United States,” said Dr. Wassim Abdallah, a Lebanese physician at Indiana University School of Medicine, who was an internal medicine resident at the time.

All of Abdallah’s family and friends are still back home in Lebanon. His feelings of pride and gratitude for getting the vaccine so early were tainted by the fact that back home in Lebanon there were no vaccines in sight. His 102-year-old grandfather was not yet vaccinated, and neither were his parents.

Abdallah's co-resident Dr. Samuel Urrutia, originally from Honduras, shared the same sentiment. For him, it felt like his life mattered more just because he is in the U.S. serving Americans. His father, a physician in his fifties in a rural Hounduran village, was not vaccinated and had no idea when a vaccine would be available for him. Orrutia lost some of his medical school friends who were still back home fighting the pandemic.

“It feels like their lives did not matter,” he said. “You are made to feel like you are expendable.”

In many of these immigrant doctors’ minds, the pandemic has made it clear that where people are born affects the value ascribed to their lives – and only the “lucky ones” in higher-income countries like the U.S. get a fighting chance during a global health crisis.

But as physicians, Abdallah said, the pandemic also made clear that even within the U.S. not all Americans are on the same footing or have an equal chance at a good quality of life.

June 2021: Vaccines are in, masks are off

Despite a rocky rollout, many Americans were able to get the COVID-19 vaccine by mid-2021. But across the U.S., White and affluent Americans got vaccinated at higher rates compared to Black Americans. Public health experts pointed to barriers, including lack of access to transportation and technology to sign up for the shot, inability to take time off work to get the vaccine, misinformation regarding the safety and efficacy of vaccines and lack of trust in medical institutions.

Not too long after, mask mandates were lifted in many states, including Indiana, for people who were fully vaccinated. The altered policies, which were supported by public health guidance at the time and were based on the honor system, were a reason to celebrate for many who had grown tired of masking up everywhere they went.

But 25-year-old Torian Jones was not celebrating. Torian works at Cleo’s Bodega – a local non-profit grocery store in Indianapolis’ Near Northside neighborhood. He said he was terrified, since grocery store workers cannot do their jobs from home and deal with hundreds of unmasked shoppers indoors everyday. Jones said many of his colleagues shared his concerns.

“And with everything I hear about mutations and variants, it’s scary,” he said.

Until June, Jones was still unvaccinated despite being eligible. He said he barely had time to go get the shot. At that time, no clinics were within walking distance from where he works and lives. He felt he was constantly in “survival mode.”

Since Jones has severe asthma, he is at higher risk of complications from COVID-19. His job at the grocery store is crucial to pay the bills, he said, but it barely covers his needs. To earn extra money, he also designs jewelry and works as a DJ. Still, he said money’s so tight he can’t pay for the health insurance benefits offered at his grocery store job.

"It will take about $140 dollars out of my paycheck,” he said. “I can’t afford that. It will come out of the budget I use to get food or pay rent.”

Jones said sometimes he would have to borrow asthma inhalers from friends and neighbors because he couldn’t afford to buy his own.

Employment situations like Jones’ — that do not offer adequate pay and benefits and that may put the employee’s health at risk — put people in a difficult situation, said Emily Ahonen, an assistant professor at IU’s School of Public Health. COVID made it clear that people’s jobs have a direct impact on their health, she said.

For example, while grocery store workers have been at the frontlines of the pandemic and regarded as essential workers, they were largely not prioritized in vaccination efforts. They are also at a disadvantage because they have fewer options to work remotely or take time off.

“When our systems are shaken and disrupted as they have been by the pandemic, those people whose employment was most precarious to begin with are the first ones to suffer,” Ahonen said.

Black and Brown Americans are more likely to be “precariously employed” than White Americans, Ahonen said. And COVID made the impact of that very clear.

The U.S. has seen nearly half a million extra deaths compared to before the pandemic, but not all of these deaths were due to COVID. Researchers at the University of Notre Dame analyzed data from the U.S. Centers for Disease Control and Prevention and found that while Americans overall have lost a year and a half of life during 2020, Black and Brown Americans have lost the most years — a drop of 2.8 years for Black Americans and 3.7 for Hispanic Americans.

“We're finding that 70 percent of the non-COVID excess deaths are among Black and Brown people. So it's a really, really striking figure,” said Christopher Cronin, assistant professor of economics at Notre Dame and co-author of the study.

“Folks who were dying for non-COVID reasons, they're dying at younger ages, and so we're losing a lot more life years.”

December 2021: Rural vaccination rates lag while the health toll remains high

Data released in 2021 show that geography – in addition to race – affected health outcomes in the first year of the pandemic.

According to a large study by the Regenstrief Institute that looked at data from the past year, Indiana residents living in rural communities were more likely to die from COVID compared to residents in urban settings.

In the beginning of 2020, rural communities were not as severely affected by COVID. But as the virus spread across the U.S., infection, hospitalization and death rates surpassed urban communities and rose higher than even some of the hardest hit racial groups.

Brian Dixon, the lead author of the study and the director of health informatics at the Regenstrief Institute, said the reasons for geographic disparities include the politicization of public health issues, misinformation and a persistent shortage of health care providers per capita.

Rural communities also have higher rates of health conditions like diabetes, obesity, heart disease and hypertension – which put people who contract the coronavirus at greater risk of hospitalization and death. Dixon said this is a matter of equity in access to health care.

“[Rural] populations generally lack access to primary care,” Dixon said. “And so, many of them have chronic conditions that might not be managed very well. Then when those people get sick, they often end up in the hospital and they're sicker.”

According to projections by the U.S. Department of Health and Human Services, in 2025, Indiana could be dealing with the eighth worst primary care provider shortage in the nation – with a shortage of 23% compared to the demand. Other states projected to have the biggest shortfalls include Alabama, Kentucky, Arkansas, Ohio, Missouri, Mississippi and New Jersey.

As of late 2021, the vaccine supply is outpacing the demand.

Even though all health authorities say vaccines are the best way to protect people from the virus, especially those with chronic health conditions, vaccination rates in rural areas across the U.S. lag behind the national average. In Indiana, the latest data released by state health officials shows vaccination rates are behind the national rate of 62 percent. Overall, 52 percent of Indiana residents are vaccinated. But some rural zip codes have vaccination rates below 30 percent.

These rural communities are heavily Republican and overwhelmingly voted for former President Donald Trump during the last two presidential elections. Since public health guidance has been highly politicized throughout the pandemic, the political divide comes with public health consequences.

For example, in August when the Delta variant surged across the country, parents in New Albany, Indiana, strongly opposed mask mandates in K-12 schools. Many had not been vaccinated and would not get their kids vaccinated either. Some say they do not trust health authorities, citing Trump-era political conspiracy theories.

Sociologists say this heightened politicization of science and public health is not a new problem created by the pandemic. It’s a culmination of pre-existing social and political issues that have been brewing under the surface for many years.

“Claims only make sense because they resonate against things that are already happening,” such as rising mistrust of experts and the increased emphasis on personal choice when it comes to health, said Jennifer Reich, a sociologist at the University of Colorado Denver.

She said much of the politically divisive rhetoric came from the Trump administration – especially the questioning of public health experts who’ve worked for the government for a long time. The result: The health crisis was made worse, especially in rural communities.

With 2021 ending on a not-so-cheery note – a super contagious variant and Indiana’s biggest hospital asking for help from the U.S. Navy – it's likely many of these long-standing health inequities will persist into the New Year and beyond. That is, unless underlying causes are addressed.

“At this point in the pandemic, you can't go back and fix what happened last year. You can't fix really what's happening right now, where we see these same communities being hit hard again by COVID-19,” Dixon said. “But what you can do is work on recovery.”

This story comes from a reporting collaboration that includes the Indianapolis Recorder and Side Effects Public Media — a public health news initiative based at WFYI. Follow Farah on Twitter: @Farah_Yousrym.

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