During my residency in public health 35 years ago I first heard about the Oregon Health Plan. We learned about then Oregon state senator John Kitzhaber’s vision of creating a health plan that would serve the working poor, while rationing some benefits. This put Oregon in the 1990s on the map as an international leader in health care reform. The idea of limiting reimbursable services to the most frequent ones which would benefit the largest number of people, was innovative and radical. It symbolized the values of public and population health, serving the greater good by sacrificing some individual privileges.
Later, I learned about the Whitehall study of British civil servants that showed for the first time the link between social status and health outcomes. Then came the results of the Kaiser Permanente Adverse Childhood Events (ACE) report that made the connection between historical abuse and trauma and health. These Social Determinants of Health (SDH) that result in excess morbidity and premature death for the marginalized and poor members of our communities are now integral parts of any health care reform plans such as universal healthcare or Medicare for all. They require us to put aside our individual health lenses and don our population and public health eyeglasses.
The current Covid-19 pandemic amplifies the impact of SDHs. In most environments the poor, marginalized, and elderly are getting sick and dying in much greater numbers than the more privileged. While the virus itself does not discriminate, the social conditions create more or less fertile grounds for contagion and the severity of the illness itself.
The now commonly heard catchphrase we are all in this together captures our shared humanity and existence on the planet and the indiscriminate nature of the virus. Only, we are not. We are all experiencing the same storm, the pandemic. And yes, we are all afloat in a great vast sea of uncertainty, trying to weather the storm. The issue is that some of us are dealing with simultaneous ongoing downpours of poverty, racism, sexism, homophobia, and other discriminations. For others, their immune systems are weakened as they cope with the wounds of historical abuse and trauma. This results in some of us barely hanging on to a pool noodle and being at the mercy of the next big wave. Others are surviving in a dingy with no motor, in a fishing boat or even a luxurious cruise ship.
For those who have lost their jobs and other social supports and who do not have access to resources and benefits, the virus puts them at the greatest risk of going under the next time a wave crests. For those who are subjected to adverse community environments and experiences, live on the wrong side of the city, have the wrong skin color, gender, sexual orientation, speak the wrong language, life under Covid-19 adds to the chance of getting sick and dying prematurely. For those on the cruise ship, the privileges of having access to food, health care, remote work makes the storm a mere inconvenience.
Concrete examples of issues that contribute and make us all complicit to health injustices are: refugee youth with limited English proficiency are being abandoned in the current distance learning environment. Many of them have no computer hardware, no access to the internet, and no interpreters to help them do their schoolwork. Although the enforcement of privacy regulations has been waived by the federal government, many provider agencies and organizations restrict the use of available communication platforms for tele-health and create access barriers for community members with limited options. Frontline staff who strongly advocate for more equitable policies and workflows might experience consequences from power sensitivities akin to white fragility such as corrective human resource measures. In some countries raising your voice for the most vulnerable can lead to more serious silencing actions for instance imprisonment and death.
We have a genuine opportunity to examine the broken community arrangements that continue to perpetuate inequality and health disparities. As the pandemic is exposing our racial and other divides, we need to take the risk and advocate for the most vulnerable in our communities.