by Thomas P. Healy
At the national, state, and local level, the data about COVID-19 infections is clear: The disease disproportionately affects communities of color.
A recent report by the Polis Center at IUPUI found that while 29% of Marion County residents are Black they represent 34% of coronavirus-related deaths. According to the Marion County Health Department, Blacks have tested positive for COVID-19 at nearly twice the rate of white residents.
The reasons why this is true are complex. Public health officials recognize that an interactive matrix of material circumstances, social situations, and economic causes called social determinants of health (SDOH) is responsible. Factors include economic stability, education, health and health care, neighborhood and the built environment, as well as social and community context.
According to Nir Menachemi, chair of the health policy and management department of the IU Richard M. Fairbanks School of Public Health, “Social determinant factors are far more predictive of health outcomes irrespective of the pandemic. In many ways, the pandemic has done nothing but highlight what we already know and bring it to the forefront.” He said racial and ethnic minorities are distinctly represented in essential jobs and therefore less able to social distance or shelter in place, and are less likely to have the luxury of a paid sick day off. He added that the larger family structure of many racial and ethnic minority households plays a role. “These folks are low income and living in smaller quarters,” he said. “When you have lots of people living in a small congregate setting and someone is disproportionately exposed, it makes the household more exposed.”
Carl Ellison, president and CEO of the Indiana Minority Health Coalition (IMHC), said the reality that people of color have worse health outcomes than whites is not new. “Alarm bells about health disparity have gone off back to the time of W. E. B. Du Bois,” he said, referring to the Black sociologist, historian, civil rights activist, and author who died in 1963. “COVID-19 is just a marker,” he continued. “It’s not the COVID as much as it is the growing underlying inequalities that are the root of the problem.” Ellison points to a 1985 report by U.S. Secretary of Health & Human Services Margaret Heckler, Report of the Secretary’s Task Force on Black and Minority Health. That study focused national attention on health disparities including reduced life expectancy and higher rates of chronic disease—co-morbidities that continue to plague communities of color today and contribute to COVID-19 infection rates.
Ellison defined social determinants as life factors that contribute to adverse health outcomes. “People of color are more likely to hold a minimum wage job and live in an environmentally challenged area or a neighborhood with greater density so there’s more possibility for exposure,” he said. Ellison said the determinants reflect the sad fact that it’s possible to predict health outcomes by virtue of a person’s ZIP code. “Indianapolis is reflective of the national profile of inequities that are crushing populations of color and precluding the health of the nation,” he said.
Material Factors Affect Health
The nation’s affordable housing crisis is resident in Indiana and the stress of housing insecurity contributes to poor health outcomes. The Hoosier Housing Needs Coalition (HHNC) tracks the growing number of Indiana renter households that are cost-burdened by housing, defined as paying more than 30% of their income for housing. Using U.S. Census data, HHNC estimates that 40.4% of white renter households, 44.5% of Latinx households, and 51.4% of Black households in Indiana are cost-burdened. This financial hardship means families have fewer financial resources for food, clothing, transportation, and medical care.
Despite the current rent moratorium, both city and state emergency rental assistance programs are oversubscribed. Based on data compiled in a national study of affordable housing costs, Prosperity Indiana, the statewide community development network, reports that a worker earning Indiana’s minimum wage of $7.25 must have 1.8 full-time jobs or work 73 hours per week to afford a one-bedroom apartment. To afford a two-bedroom apartment at fair market rent, that same Hoosier must have 2.3 full-time jobs or work 90 hours a week.
Feeding Indiana’s Hungry, the state association of Feeding America affiliate food banks, estimates food insecurity will rise 40% in Indiana this year as families struggle to make ends meet during the pandemic. Currently, 17% of Indiana adults who live with children report that their children don’t have enough to eat because they can’t afford it.
Resource Planning and Allocation
While the problem was identified long ago, the pandemic is a reminder that disparities still exist. “We have not been fundamentally successful in eliminating health disparities, period,” Carl Ellison said. Nevertheless, politicians and local officials persist in their efforts to address the situation.
At the national level, the Trump administration has proposed major changes to the National Environmental Policy Act (NEPA) to limit the scope of environmental impact assessments. Those changes will have disproportionate consequences for communities of color at a time when clean air and water are even more important to community health
A new report by the Shriver Center on Poverty and Law [PDF] found that 70% of the most hazardous, polluted sites in the country are located within 1 mile of federally assisted housing. The report calls for a comprehensive approach to providing housing assistance in a way that protects public health.
In May, the Indiana Health Disparities Task Force convened with the mission of providing a report with an action plan for addressing health disparities in Black and Latinx communities, and to address COVID-19 response in the state’s jails, prisons, and juvenile detention centers. A collaboration between the Indiana Black Legislative Caucus, the Interagency Council on Black and Minority Health, the Indiana State Department of Health Office of Minority Health, and the IMHC, the Task Force submitted its report on June 30. [PDF]
IMHC’s Ellison served on the task force. “What we’re finding in Indiana and in the United States is the absence of precise data. It’s hard for us to profile what’s happening to these populations if we don’t collect data in a systematic manner.” While acknowledging the Indiana State Department of Health’s efforts, Ellison said the task force recommendations would reset the guidelines for future planning and resource allocation. “This should allow our state to be able to know in a real-time basis the status of populations of color with respect to COVID,” he said. “My dream is that there would be a dashboard to display aggregate info.”
Among the report’s many recommendations are those specifically targeting social, economic and environmental conditions at work:
- Ensure that employers provide safe work environments that are clean, maintain physical distancing, isolation, and quarantine spaces;
- Educate employees and employers on rights of workers;
- Increase hourly minimum wage;
- Provide hazard pay to frontline workers;
- Expand insurance eligibility and coverage; and
- Provide financial assistance for medical debt, rent, utilities, medication, childcare, and other important needs.
The task force further called for increased funding of public health infrastructure, and a requirement that policies and procedures place inclusion, diversity, equity, anti-racism, and implicit bias into practice in government agencies.
On June 8, the City-County Council passed a resolution, [PDF] introduced by Council President Vop Osili, declaring racism a public health crisis. The n0n-binding resolution highlights the importance of addressing the SDOH, and calls for City and County departments, “to eliminate disparities based on race, place, or identity across key indicators of success including health, education, criminal justice, the environment, employment, and the economy.”
Mayor Joe Hogsett’s office is also taking steps to eliminate disparities. During a virtual media briefing, Paul Babcock, director of the Office of Public Health and Safety, said that his office continues to focus on SDOH. “These objective measures are designed to provide equitable access to education, healthcare, and environmental remediation. Our COVID-19 policies try to get masks and testing into hardest-hit neighborhoods and improve access to transport to make sure COVID-19 testing is free. We’re trying to make sure the barriers are as minimal as possible.”
Jeff Bennett, deputy mayor for community development, said health data has guided his office in determining the deployment of resources for the City’s rental assistance program. “We’ve been looking at eviction data over time, and [affected neighborhoods] are sometimes impacted by a number of factors including coronavirus,” he said during the briefing. Bennett is in charge of the City’s comprehensive community development program, LIFT Indy. “We’re looking at ways to evolve it during the current crisis to think of it as more of a potential COVID recovery or relief program—as much a targeted investment program rather than a market-based one.” The recently-released 2021 Lift Indy application states, “this year’s application process will be focused on investing in neighborhoods disproportionately impacted by the COVID-19 crisis.”
IMHC’s Ellison said it makes no business sense to continue to suppress wages, and recommends raising the minimum wage, increasing education funding, and increasing the level of home ownership. “It’s simple. If you invest in the economic capacity of minority populations and take action to make sure communities of color thrive, that, in and of itself, will go a long way to reducing health disparities.”
IUPUI’s Menachemi said combatting an infectious disease that is targeting society’s most vulnerable proves we’re only as strong as the most vulnerable among us. “We can improve the healthcare system by making those who are best off better off, or by making the people who are worse off significantly better off. It’s significantly easier and cost-effective to help folks at the bottom of the health distribution system.” In light of the pandemic, he said, the country should revisit paid sick leave. “We should reinvestigate it and talk about a lot of things that are inadvertently creating a more difficult situation.”
In a statement, Prosperity Indiana’s executive director, Jessica Love, urged proactively tackling the housing affordability issue: “This pandemic has certainly highlighted the very harsh reality of living at the edge of housing stability—often just one paycheck away from homelessness.” She and her HHNC allies want to make housing stability a priority and are calling for better coordination between state and local rental assistance programs and the establishment of a statewide Housing Security Task Force.
In one of her regular COVID-19 virtual briefings, Dr. Virginia Caine, director of the Marion County Health Department, said her team is working diligently to distribute masks to Black and Latinx communities as well as to all older residents. “We recently distributed 1,200 masks to seniors, 90% of whom were African American,” she said. “The week prior, we distributed almost 1,000 masks to the homeless population at all of the shelters. We continue to have activities trying to reach different racial and ethnic populations,” she added. This includes providing bilingual information online and in handouts.
IMHC’s Ellison said populations of color cannot solve the health disparities problem by themselves. “Our organization has a saying,” he said. “Minority health is everybody’s business.”
