The Intersection of Societal Inequalities and Health Care: Lessons Learned From the COVID-19 Pandemic | Health Disparities | JAMA Oncology | JAMA Network
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Invited Commentary
July 22, 2021

The Intersection of Societal Inequalities and Health Care: Lessons Learned From the COVID-19 Pandemic

Author Affiliations
  • 1Department of Urology, University of Michigan, Ann Arbor
JAMA Oncol. Published online July 22, 2021. doi:10.1001/jamaoncol.2021.2750

It has been extensively documented and widely reported that Black, Hispanic, and Indigenous individuals are more likely to contract and die of COVID-19.1 However, the ultimate effect of this disparity on receipt of cancer care is not as well known. The racial disparities seen in prostate cancer outcomes are well described, and in this issue of JAMA Oncology, Bernstein and colleagues2 assess the prostate cancer delivery for Black and White men during the first wave of the COVID-19 pandemic. Although prepandemic prostatectomy rates were similar between Black and White patients, the prostatectomy rate during the COVID-19 lockdown among Black men was 1.3% compared with 25.9% among White men. The authors also found that these differences in prostatectomy rates were not simply associated with the increased use of radiotherapy for Black men. Correspondingly, they found that hospitals serving predominantly minority communities were more likely to have large-scale shutdowns for elective surgical procedures. These data are consistent with other research demonstrating how the COVID-19 pandemic disproportionately affects poor Black, Indigenous, and Hispanic communities.1 So, what exactly do these data tell us?

Unequivocally, the differential burden of the COVID-19 pandemic extends beyond the illness caused by contracting this virus. Although these disparities did not start with, nor will they end with, the COVID-19 pandemic, Zellner eloquently described this pandemic as a “litmus test for inequality.”3 In other words, the existing pandemic highlights many of the inequities in our society rooted in a history of systemic racism and oppression.

Just as it was a century ago during the 1918 influenza pandemic, the risk of dying of COVID-19 is twice as high for Black individuals compared with White individuals.4,5 During the current pandemic, Hispanic and Indigenous patients have similar mortality risk.1 As members of the medical profession, how do we physicians confront these disparities to progress toward equity?

Although we have acknowledged a decrease in interpersonal racism and blatantly racist policies, as a country and profession, we have yet to examine the impact of structural racism in its totality. It is essential to recognize how policies that do not use racist terminology often still have racist implications, particularly in health care. To date, we have made little to no progress in closing the wealth gap, resulting in higher poverty rates among the country’s most oppressed racial/ethnic groups.6 It would be a mistake to assume that these disparities have nothing to do with the racial/ethnic disparities seen in our medical system.

People who live in high-poverty neighborhoods are more likely to live in multigenerational housing. They are also more likely to work in low-wage jobs that have been termed essential during the pandemic. In addition, many patients from impoverished communities are underinsured or uninsured, limiting access to health care.7 All of these issues are now incorporated in the discussion about social determinants of health. While we can give new titles to centuries-old problems, we will not make progress unless we take the time to acknowledge our country’s foundation—a foundation that, throughout history, has promoted one group of people as superior to others through its laws and policies.

To acknowledge this history requires us as individuals and health care professionals to be open to listening to the experiences of members of oppressed communities. This process requires listening without prejudice. Only after recognizing and acknowledging how structural racism has affected our institutions and policies can we move forward in making change. Without reconciliation, we will continue to find ourselves in a brutal cycle, yielding intergenerational poverty and trauma, which have substantial ramifications on our patients’ health.

Although this important work from the Pennsylvania Urologic Regional Collaborative has uncovered data showing that the odds of prostate cancer surgery were lower among Black patients compared with White patients during the initial wave of the COVID-19 pandemic,2 similar unintended consequences appear to surface in government relief efforts. In an analysis of Coronavirus Aid, Relief, and Economic Security (CARES) Act funding conducted by the Kaiser Family Foundation, hospitals receiving the top 10% of private insurance funding received more than double the relief funds per patient bed than hospitals receiving the lowest 10% of private insurance revenue.8 This is just 1 example of how policies may exacerbate the disparities that extend past those uncovered in the article by Bernstein and colleagues.2 As members of a profession, we physicians have tremendous social and political capital; it is time for us to leverage this capital to make the changes needed to promote equity. So, I ask again—if now is not the time for change, when is?

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Article Information

Corresponding Author: Randy A. Vince Jr, Department of Urology, University of Michigan, 1500 E Medical Center Dr, TC 3875 SPC 5330, Ann Arbor, MI 48109 (virandy@med.umich.edu).

Published Online: July 22, 2021. doi:10.1001/jamaoncol.2021.2750

Conflict of Interest Disclosures: None reported.

References
1.
Centers for Disease Control and Prevention. Risk for COVID-19 infection, hospitalization, and death by race/ethnicity. Accessed May 26, 2021. https://www.cdc.gov/coronavirus/2019-ncov/covid-data/investigations-discovery/hospitalization-death-by-race-ethnicity.html.
2.
Bernstein  AN, Talwar  R, Handorf  E,  et al.  Assessment of prostate cancer treatment among Black and White patients during the COVID-19 pandemic.   JAMA Oncol. Published online July 22, 2021 doi:10.1001/jamaoncol.2021.2755Google Scholar
3.
Rutkin  AH.  Why some people are more vulnerable to catching coronavirus.   National Geographic. March 13, 2020. Accessed May 27, 2021. https://www.nationalgeographic.com/science/article/why-some-people-are-more-vulnerable-to-catching-coronavirus.Google Scholar
4.
Brooks  RA. Why African Americans were more likely to die during the 1918 flu pandemic. Accessed May 27, 2021. https://www.history.com/news/1918-flu-pandemic-african-americans-healthcare-black-nurses
5.
Krishnan  L, Ogunwole  SM, Cooper  LA.  Historical insights on coronavirus disease 2019 (COVID-19), the 1918 influenza pandemic, and racial disparities: illuminating a path forward.   Ann Intern Med. 2020;173(6):474-481. doi:10.7326/M20-2223 PubMedGoogle ScholarCrossref
6.
Pfeffer  FT, Killewald  A.  Intergenerational wealth mobility and racial inequality.   Socius. 2019;5:237802311983179. doi:10.1177/2378023119831799 PubMedGoogle Scholar
7.
Cohen  RA, Terlizzi  EP, Cha  AE, Martinez  ME. Health insurance coverage: early release of estimates from the National Health Interview Survey, January–June 2020. National Center for Health Statistics. Accessed May 26, 2021. https://www.cdc.gov/nchs/data/nhis/earlyrelease/insur202102-508.pdf
8.
Schwartz  K, Damico  A. Distribution of CARES Act funding among hospitals. Kaiser Family Foundation. Accessed May 27, 2021. https://www.kff.org/coronavirus-covid-19/issue-brief/distribution-of-cares-act-funding-among-hospitals/
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