The social determinants of health during the COVID-19 pandemic

As an academic internist, over the past five years, I’ve been hearing more and more about social determinants of health.  I have read countless journal articles comparing health outcomes; I’ve attended grand rounds on the subject; recently, our electronic medical record changed to incorporate a tab on social determinants of health into the patient’s chart.  As a course director in the medical school, I’ve incorporated this topic into our teaching cases.  The evidence continues to support what I have observed in practice over the past 18 years: that factors such as a stable home life and financial security impact health just as much if not more than our medical interventions and screening programs.  

Fast forward to 2020 and the global coronavirus pandemic.  I am seeing my patients virtually, by phone, or via video; I am abiding by social distancing rules; I wear a mask when out in public.  I venture out to the grocery store only once a week; I haven’t had my hair cut in months.  I can understand the reasons behind it, and we have seen the results of now five weeks of the stay at home order.  The peak originally predicted for April 14 has been extended to late May or early June, and the number of cases and deaths far fewer than expected.   The need for ICU beds and ventilators has been met, with excess capacity thus far.

But as I watch and observe, I can’t help but notice the other side of the equation.  As of May 2, there were 395 deaths in Minnesota from COVID-19.  To compare, there were over 450,000 new jobless claims as of April 15, and the number is still climbing. It’s an order of magnitude greater, 1000 times over; it’s as though the entire city of Minneapolis is now unemployed.  Thinking about the impact of that on our population, health should be a focus of ours, not just for politicians, but physicians and health care professionals as well.  I have not heard much, if anything, about social determinants of health throughout this discussion, whether it’s the news or social media or the academic literature.  It’s something we can no longer ignore.  

There is a reason that getting a paycheck is called “livelihood.”  It’s not about the tension between jobs vs. lives lost; it’s not placing the economy as a priority over health. I would argue that both are one and the same, according to the medical literature we’ve been reading in recent years.  As a society, we need to address both issues with the same sense of urgency, and not vilify those who question when to reopen as renegade lunatics with no regard for the health and welfare of others.  Where are the mathematical models of the impact of prolonged closure on small businesses?  Where is the detailed plan of how to test the population to identify who has already been exposed and can report back to work?  

I am in no way suggesting that our response to the virus should diminish; in fact, I am extremely proud of my home institution and the amazing work they are doing.  From remdesivir and hydroxychloroquine trials to new model ventilators to repurposing labs and reagents for testing, the rapid response and teamwork have been impressive.  If we can orchestrate these kinds of interventions in a short amount of time, the same could be done for the financial devastation that will almost certainly occur as a result of this pandemic.  Paying attention to both will ensure the health of our population can truly stay intact.  

We flattened the curve; now, let’s be sure we don’t flatline the economy.

Heather Thompson Buum is an internal medicine physician and author of With Mirth and Laughter: Finding Joy in Medicine After Cancer and Mirth is God’s Medicine: Coping with Cancer as a Physician. She can be reached at her self-titled site, Heather Thompson Buum.

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