As COVID-19 spread across North America, our societies' weaknesses and vulnerabilities were exposed like fluorescein seeping through cracks in the cornea. Indeed, SARS CoV-2 threatens our lives and the systems, communities, and economies on which we rely.
The pandemic has brought the importance of societal health to the forefront. We are "all in this together," whether we choose to cooperate or not. One’s behavior influences another’s risk, and on it goes. Within the major health journals, there is outrage surrounding the evident inequalities of outcomes of COVID-19.
Societal health determinants have been well studied and include income, literacy and health literacy, language, affordability of care, medicine, food and housing, and the complexities of life and health.
As Dr. Linda Rae Murray, a public health physician in Chicago stated, “What we understand more and more is that the structural factors – how the country votes, whether or not people have medical insurance, whether or not people are able to get sick days– these are all things that influence individual health and health of populations in profound ways, certainly more than just their individual personal habits.” COVID-19 has exposed these inequalities. The pandemic has unequally affected those of lower income and those of color. Recently the Journal of the American Medical Association reported that, "In the US, black people account for 13% of the population, but 24% ofCOVID-19 deaths where race is known. And blacks, Latinos, American Indians and Asian Americans make up a disproportionate number of cases.” This disparity is also true in the two major cities of Canada, Montreal and Toronto.
The New England Journal of Medicine (NJEM) states that, “Black and Latino Americans often have less ability to socially distance because of crowded housing conditions and essential jobs requiring in-person interaction. They have higher baseline rates of chronic illness and worse disease outcomes. These factors put them at higher risk of contracting and dying from COVID-19.”
So here we are on the precipice, clearly viewing these health disparities. Will we slide back into the old ways? Can we hold on to our outrage? Can we contribute to a more equitable health future? The big picture may seem daunting, but there is much for us to do. “Baby steps,” my mother would have said.
Perhaps the first step is to accept the recent review of mask wearing in NEJM in which the analysis of several studies concluded that mask wearing reduces transmission. As representatives of the public health system, we can serve as leaders by wearing masks and teaching our patients the importance of this simple habit.
Next, we can influence health literacy. Educating our patients in words that they can understand is essential. When you say glaucoma, patients hear blindness. I am reminded of my time as a student in Boston when a gentleman sat in my chair with painless vision loss in his right eye. After my 60 minute examination, I was able to tell him that he had a cataract and that he could have a relatively simple surgery to restore his vision. I said, "Do you understand?" He said, "Yes, I have cancer." And so it goes. Communicating with patients is one of our excellent skills. We can get better at it.
The other area of immediate impact is dealing with each patient as a whole by understanding the complexity of body, mind, and life circumstances. Too often, hypertension, diabetes, morbid obesity, depression, cataracts, macular degeneration, and poverty exist in the same person. Imagine living with this formidable situation. We can take the time to help patients understand their circumstances. We can reinforce the importance of taking medications, exercising and eating healthy food, and losing weight. We can empower our patients to influence their health status.
And what about access to care? It is time-consuming and expensive for patients to attend our offices. Some are not allowed time off work. Some are afraid to use public transportation at this time. Most of us have dabbled in telemedicine during the pandemic. Soon, telemedicine, remote imaging, and artificial intelligence will allow us to service all of our citizens, from the long term care facility down the street to the remote communities of our states and provinces. This way, our skills can be utilized for the common good.
This pandemic is a crushing blow to our societies. It has revealed that societal factors are strong determinants of health outcomes. We can lead the way in mitigating these determinants through actions that are both simple and complex. Let us, as a profession, move forward to reduce inequalities in health care.