Dr Ana Caskin treats underserved populations in Washington DC, in parts of the city where life expectancy is 20 years lower than it is in places that are a 20-minute train ride away. The last thing she wants when the Covid-19 pandemic finally recedes is for things to go back to “normal”.
Because for the people she treats that would mean limited access to doctors and therapists, healthy food and affordable, safe housing – the type of things that are now proven to help protect people from Covid-19.
The virus has killed more than 619,000 people in the US and left millions more to deal with economic turmoil.
Despite the recent surges of the Delta variation in parts of the US, vaccinations are helping many Americans return to a life largely similar to pre-pandemic times as most of the economy has reopened, but Caskin has a warning about that. “It would be easy for more affluent parts of the population to say we’re back to normal now," lei disse. "OK, let’s move forward, just be mindful the gap has been widened.”
There was widespread relief recently when the Centers for Disease Control and Prevention (CDC) extended its moratorium on most evictions for people behind on rent, but perhaps few will have stopped to reflect on why it was the nation’s public health agency that was responsible for a homelessness-prevention order.
Another economic intervention, expanded unemployment benefits, has also been recognised for protecting health during one of the worst disease outbreaks in a century.
Caskin, deputy medical director of the Georgetown University Health Justice Alliance Law Clinic, said when she was first trained in medicine, doctors didn’t always think about what happens when a patient leaves the office, or what their lives were like before they arrived.
Adesso, at the clinic, they talk about what to do if a patient’s gas and electricity have been cut off or they can’t pay for food. This is a rare approach for health clinics, but Caskin thinks it should be more common for healthcare providers to include social determinants and legal partnerships in their work. “It turns out, the more you know about your patient, it helps you get the correct diagnosis and right treatment," lei disse.
Social determinants such as education, access to healthcare and the environment where people live are such important factors that the alliance bakes them into its care.
Yael Cannon, the director of the alliance, warned that without interventions like the expanded unemployment benefits, the toll on millions of people in the US could have been even more catastrophic. “If those things had not been in place we would have seen even worse disparities and outcomes," lei disse.
E adesso, they are due to expire. The expanded unemployment benefits end in early September, one month before the federal eviction moratorium is set to expire again. Some states chose to cut the benefits earlier this summer because they put pressure on business owners to raise wages.
This benefit – which was expanded to $600 a week for several months in 2020 and has since gone down to $300 – was associated with a 35% relative decline in food insecurity and a 48% relative decline in eating less due to financial constraints, according to a study by Boston University.
In Washington DC, where there were strong eviction protections in place in addition to the federal moratorium, there was a 19.9% drop in homelessness nel 2021. E several studies showed that when eviction moratoriums were temporarily lifted last year, Covid-19 infections increased.
“The pandemic really did bring to light that there are differences for families in terms of their vulnerability,” Caskin said.
When health officials in Michigan saw that Covid-19 cases were much higher among African Americans compared with their representation in the population, they were able to close the gap by investigating where people were getting exposed and why they weren’t sheltering in place.
Dr Debra Furr-Holden, who is part of a government taskforce to address Covid-19 health disparities, said they found this disparity was clearly about work: the people getting infected were grocery store workers, hospital staff and Uber drivers who didn’t have the option to work remotely on Zoom.
The findings were different from the common narrative at the time – that racial disparities in cases were tied to higher rates of pre-existing conditions in certain populations. While that could explain why hospitalisations and deaths were higher, it did not explain why infections were higher.
“We just are more comfortable putting the blame and burden on individuals than looking at our own systems, structures and cultural context which from their origin were inequitable,” said Furr-Holden, an epidemiologist and public health integration associate dean at Michigan State University.
Furr-Holden said state and federal interventions helped close the gap, Compreso expanded access to healthcare, more accessible testing and a federal paid sick leave requirement.
By September 2020, Michigan could officially declare that African Americans were no longer overrepresented in cases and that has stayed true to today, when they are underrepresented in both cases and deaths. Furr-Holden has had to explain to people that this isn’t because more white people are now dying. “Nobody had to get sicker. A group did get substantially better but it’s because that group was doing substantially worse and was at much higher risk for exposure," lei disse.
To get there, Michigan also had to prioritize collecting race and ethnicity data in Covid-19 cases, something that may seem obvious, but remains a major problem today. The CDC doesn’t have race and ethnicity data for about 39% of Covid-19 infections because several states are choosing to ignore a federal requirement to collect this information.
“Michigan is the only state that I know of that transparently reported the racial disparities in Covid early on and also closed the gap," Furr-Holden said.
Tia Marie Sanders has been an activist since she was a child fighting segregation at her middle school. Her community work continued even after a two-month hospitalisation for Covid-19 last March and ongoing treatment, including chemotherapy, for long Covid. In April, she gave moving testimony in Michigan’s House of Representatives about how unemployment benefits helped workers.
Sanders is part of the Mothering Justice activist network in Michigan, whose members are known as Mamavists. Well before the pandemic, the group campaigned for reforms including affordable childcare and paid leave. As people talk about returning to pre-pandemic life, Sanders said it was worth asking who benefits most from the return to “normal”.
“Normal has never been normal for everyone,” Sanders, 47, disse, adding that inequities would persist unless white supremacy was dismantled. Durante la pandemia, she challenged government unemployment training programs that treated groups of mostly Black jobseekers differently from white ones and fought for doctors to recognise her Covid-19 infection.
Presto 2020, doctors dismissed her symptoms until she was too sick to turn away. Once she was admitted to the hospital, they told her she probably had an autoimmune disease because they are common in African American women. Doctors finally acknowledged she had Covid-19 in June 2020.
Another Mothering Justice activist, Marna Muhammad, has also confronted racism while seeking treatment for long Covid, with doctors disregarding her pain and ignoring requests for drugs stronger than over-the-counter ibuprofen.
Muhammad, who lives just outside Detroit, probably caught Covid-19 from a colleague in March 2020, just before her office switched to remote work. Her infection was so severe she could barely get out of bed for two months and would lie down in the dark because the light made her excruciating headaches even worse. But she worked through the pain.
“Our biggest thing was, if I don’t keep working, and they let me go, then everything falls apart,” Muhammad, 53, disse. “So then my health is bad and we lose the house and we lose the car.”
This battle continues today. Muhammad has 10 vacation days a year and no sick days as a salaried employee, far less than what she needs to be able to treat her long Covid symptoms, including uncontrollable blood pressure. The frequent appointments and emergency room visits produce a constant stream of medical bills, forcing her to choose which life essentials or medicines to buy.
“For years, I’ve worked my way all the way up into management while struggling to get there,” Muhammad said. “To fall off of that ladder during the pandemic because I got sick is disappointing. America’s lack of equitable policies to support its citizens during this pandemic is unacceptable. I believe we all would appreciate better support from our leaders.”
In rural Georgia and South Carolina, a network of food banks has found one way to respond to low vaccination rates in rural areas.
Il Golden Harvest Food Bank partnered with a local health system to have medical workers and vaccines available at mobile food pantries, a surprise to some of the people who attend.
Golden Harvest’s executive director, Amy Breitmann, said an elderly woman waiting with her husband in their car for food in McCormick, South Carolina, said she had been vaccinated but her husband had not because of mobility problems. When Breitmann explained he could get the shot then and there, he told her it was an answer to a prayer.
“I heard story after story from people that were impacted not just by the food we put in their trunks but also by the vaccine,” Breitmann said.
Breitmann knew immediately that the families the food bank helps would struggle to get vaccines because of barriers including lack of access to a doctor or even to the internet to book appointments, and limited ability to travel because of caregiving and work comitments. .
Access problems are also a barrier in the crowded streets of New York City, where community health centers are seeing a different set of concerns stop people from getting vaccinated.
Free vaccines are available at government-run vaccination sites and pharmacies, but the population of mostly immigrants who trust the African Services Committee for healthcare have been waiting months for the community center to administer vaccines.
Amanda Lugg, ASC’s director of advocacy and LGBTQ programming, said the group was granted a licence to administer vaccinations in February but was still waiting for them in early August. Theorganization is seeking outside funding to pay for people to administer the vaccines.
“There are grants left right and center for outreach and Covid education, but until we get the vaccines into community-based organizations and provide opportunities for those organizations to serve their communities, then we won’t see any further movement in vaccination uptake,” Lugg said.
To assume immigrants would be comfortable getting vaccinated at a clinic or agency run by the government or a corporation ignores the country’s systemic targeting of immigrants.
Under Donald Trump’s administration, there was a years-long campaign to penalize immigrants for using public benefits under the “public charge” rule, which threatened to bar people from getting green cards if they or a family member used programs like food stamps. Though it was rescinded, throughout the pandemic, groups that advocate for immigrants warned it was having a damaging effect, e reports show immigrants avoided seeking government assistance because of immigration-related concerns.
“All of this, New York strong, we’re all in this together, but when the pedal hits the metal, we’re not,” Lugg said.
From the earliest days of epidemiological research there have been strong associations between race, ethnicity, poverty and disease.
When the Black Death traveled across Europe in the 1300s, the people at greatest risk were the already marginalized. Once sanitation was identified as critical to curbing infectious disease in the mid-1800s, it was urban working-class areas in New York and London where illnesses like smallpox, cholera and tuberculosis became rampant.
Nel 2020, this pattern remained even with the enormous advancements in modern medicine, technology and knowledge.
The dozen people the Guardian spoke to for this story are just a sliver of those who have ideas for how to make the world safer and healthier for those most vulnerable to the health and economic inequities Covid-19 brought to the surface. They’ve had these ideas for years.
But it would require a structural change to how healthcare works in the US and a response, not just acknowledgment, to the notion that income, race and ethnicity and education have a substantial effect on one’s health.
Dr Furr-Holden, of Michigan, disse: “We’ve learned a lot in this pandemic. The question is: are we now going to re-organise our systems of care to ensure those most at risk are fairly and equally protected?"