The pandemic, health inequities, and an ‘opportunity for change’

Experts across the University weigh in on which lessons the pandemic drove home and what immediate measures are needed to prevent future loss.

mrna vaccine
As of this writing, more than 54% of Americans have received one dose of the vaccine, while almost 47% are fully vaccinated. Yet as the pandemic eases, the inequities it created persist.

With states dropping mask mandates, businesses opening up, and the U.S. vaccination rate approaching 50%, the “hot vax summer” is shaping up as planned, for some. But even as case rates slow and restrictions ease, there is no official end date for a pandemic that debilitated global economies and killed more than three million people worldwide. Meanwhile, many scientists believe that the spillover effect of wildlife disease transmission to humans means that the next pandemic is simply a matter of when, not if. 

COVID-19 was not an equal opportunity disease, writes political scientist Julia Lynch in her latest book, “The Unequal Pandemic: COVID-19 and Health Inequalities.” “These inequalities are a political choice,” she says. “With governments effectively choosing who lives and who dies, we need to learn from COVID-19 quickly to prevent growing inequality and to reduce health inequalities in the future.”

Penn Today spoke with experts across the University to determine which lessons the pandemic drove home and which measures need to be implemented immediately to prevent future loss. 

Julia Lynch, professor of Political Science in the School of Arts & Sciences and co-director of the Lauder Institute and the Penn-Temple European Studies Colloquium

The pandemic was an incredibly clear, robust validation of one of the central axioms of social epidemiology, which is that people who have higher socioeconomic position (meaning more money, social status, power in the workplace or in politics), almost always do better when there is a threat to health or well-being. This is because they’re able to use these resources that they have to protect themselves. 

Sociologists Jo Phelan and Bruce Link have shown that socioeconomic position is, in fact, a “fundamental cause” of inequalities in health. All of that is background to say that what we learned from the pandemic is nothing really new, but it is forcing us to take very seriously this idea of fundamental causation. If you want to reduce health inequalities going forward, then you have to address their fundamental causes, which are inequalities in power and resources. 

The pandemic made it really clear to a lot of people who hadn’t noticed before that two of the fundamental drivers of health inequalities in the U.S. were racism and conditions in the workplace—including income, but also workplace safety and the ability to say no to going to work if it’s not safe. And that, in turn, has made it clear that if we want to reduce inequalities in health, we really need to get serious about attacking the underlying social inequalities that are generating these inequalities, and we need to stop pretending that we can solve the problem by giving people slightly improved access to health care, or by making sure that people eat better, or drink a little bit less.

Political scientists typically have not thought a lot about health, and when they do, they tend to think much more about medicine and medical care than about health inequalities. But we know that medical care is really a minor contributor to health inequalities, compared to these bigger, underlying social inequalities. This presents an opportunity for additional research in political science into how the politics of social inequality affect population health. 

José Bauermeister, the Albert M. Greenfield Professor of Human Relations, professor in the School of Nursing and the Perelman School of Medicine, senior fellow at Penn’s Center for Public Health Initiatives and the Leonard Davis Institute of Health Economics

What COVID did for us as a society was to show us that health disparities exist, even when you least expect disparities in health. These end up having social and financial implications to our collective well-being. So, if we can take that understanding socially, that we’ve hopefully garnered through the pandemic, and then think about it for other health conditions where we know the disparities are continuing to increase or where we’re having a hard time making inroads to decreasing, I think we’ll be much better off as a public health community. It just comes at a very steep price, unfortunately.  

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Medical professionals worked to deliver clear messages to the public about how to protect themselves and their loved ones from COVID-19, including mask wearing and hand washing. (Image: Fran Jacquier)

To that end, it’s important that we don’t get complacent. Much work remains to remove the inequities around COVID, as well as the long-term ramifications that COVID will bring to our communities physically and socially and fiscally.  

To address this, we must reinvest in our public health infrastructure. Our collective trust in science and public health has been eroded by an increasingly politicized society. COVID-19 has taught us that community-academic partnerships are vital to renew the public’s trust in public health and ensure that new scientific discoveries are accessible and available to all members of our society.  

Rachel Werner, executive director of the Leonard Davis Institute of Health Economics, the Robert D. Eilers Professor of Health Care Management at the Wharton School, and professor of medicine at the Perelman School of Medicine

Black Americans are more likely to be hospitalized and die from COVID-19. The pandemic’s unequal burden on Black communities has placed a spotlight on the longstanding and ongoing impact of systemic racism on the health of Black Americans. 

A common explanation for these disparities is that Black individuals are more likely to have health conditions that put them at higher risk for having worse outcomes. This explanation is misleading. These health conditions may themselves result from discrimination in health care.

A more important explanation is segregation in health care. Black Americans tend to go to different hospitals than white Americans and those hospitals often have worse outcomes. We recently found that if we removed hospital segregation—if Black patients were instead hospitalized at the same hospitals where white patients go—their mortality would have been 10% lower.

black lives matter
George Floyd's death catalyzed social uprising in the U.S. Here, protestors wear masks while demonstrating in Brooklyn, New York, on June 7, 2020.

Many forces combine to create this situation. Decades of racial residential segregation have concentrated Black people in some areas and white people in others, accompanied by inequities in school funding, economic opportunities, and upward mobility. Hospital segregation follows residential segregation. People tend to seek out health care close to home and hospitals in poor neighborhoods typically have inadequate resources to provide optimal health care.

There are ways to address these inequities in payment and segregation. We can improve equity in hospital funding by expanding health insurance to everyone and also ensuring parity in payment rates across insurers. We can increase our investment in the health care safety net. We must also invest in communities. Decades of research demonstrate the link between poverty and poor health. The spotlight on health inequities during the COVID-19 pandemic has provided an opportunity for change that shouldn’t be wasted.

Sharon Wolf, assistant professor, Human Development and Quantitative Methods Division, Graduate School of Education 

The pandemic exacerbated existing inequalities in children’s health, education, and well-being. We saw vast differences in the types of opportunities and resources children had access to while schools were closed. This was true within the United States, and it was true globally: Children in low- and middle-income countries were much less likely to have access to any remote learning opportunities. While these inequalities existed before, they accelerated during the pandemic in an unprecedented fashion. What happened points to the urgency in insuring that all children—regardless of their backgrounds or the countries in which they live—have access to quality education.

This is a historic moment where the central role of education in the economic, social, and political prosperity of countries is so clear and understood by the public. We can learn from this time and chart a vision for stronger education systems globally. Teachers and schools were forced to innovate during the pandemic to reach their students, and there is an opportunity to identify successful strategies that, if sustained, can help young people get an education that prepares them for our changing times.

Strong and inclusive public education systems are essential to the short- and long-term recovery of society. There is an opportunity to re-think our public schools to leverage the most effective partnerships and help students grow and develop holistic skills and competencies that will serve them in and out of school. We can move schools to be the center of a broader community that strengthens student learning and development using every path possible.

Jennifer Prah Ruger, the Amartya Sen Professor of Health Equity, Economics, and Policy in the School of Social Policy & Practice, founder and director of the Health Equity and Policy Lab, and faculty chair at the Center for High Impact Philanthropy

COVID-19 has affected practically every area of life, including individuals’ and communities’ abilities to exercise their faith, vote, and exercise their civil and political rights. These cascading effects provide evidence that being healthy is essential to human flourishing. The ability to work during the pandemic—a critical dimension of human flourishing—both contracted considerably for, and fell disproportionately on, persons of color. This has resulted in economic and financial insecurity. The insecurity in individuals’ and households’ income triggered by this crisis is massive, and the impacts are felt by our local, state, national, and global economies. 

While the U.S. $2 trillion coronavirus stimulus package offered relief in terms of unemployment benefits, aid to industries and hospitals, loans and loan-payment suspension, protections against foreclosures and evictions, one-time checks to Americans, as well as food stamps, it was too little, too late. 

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Essential workers were praised as heroes during the pandemic, taking additional risks in order to deliver service. (Image: Mika Baumeister)

To learn from the pandemic, governments must institute morally responsible leadership in building and operating a resilient systematic prevention effort, which would prevent further inequities stemming from future pandemics. During a disease outbreak, everyone is at risk. Partitioning off and privileging the wealthy and well-connected is impossible. Yet despite the high cost/benefit ratio, governments continue to disregard preparation as a moral imperative. 

The current approach to pandemic preparedness is broken; it is a morally deficient mindset that requires a transformation to correct the injustices our world has exposed and experienced from COVID-19. It is time to reconsider what we value and create a stronger and sounder version of ourselves and our communities. Positive public health ethics has the potential to lead us to a more just and sustainable world.

Eileen Lake, the Jessie M. Scott Endowed Term Chair in Nursing and Health Policy and Associate Director of the Center for Health Outcomes and Policy Research in the School of Nursing (written in collaboration with postdoctoral fellow Rebecca Clark and predoctoral fellow Kathleen Rosenbaum)

The pandemic occurred in the context of longstanding health inequities, raising the question of how clinicians and hospitals could respond effectively to prevent these inequalities from growing. In hospitals, registered nurses are the frontline caregivers. Research has shown that having better hospital nursing resources ameliorates health disparities in elderly Black patients, suggesting there is potential for these nursing resources to narrow the gap. By nursing resources, we mean the ratio of nurses to patients, a work environment supportive of professional practice, and the nurses’ educational level.    

In a hospital context, we propose that these nursing resources provide a foundation for organizational resilience, something we think is needed not only to manage COVID-19 and future large-scale disasters but to manage the everyday battle against health inequities. Resilience in organizations occurs at several levels—personal, team, organizational—and entails foresight, coping, and recovery, something nurses can support.   

Foresight, for example, would be a nurse manager anticipating resource needs and staff preparedness in the event of a patient surge, such as with a disaster like the one COVID-19 presented in many places. Coping and recovery may thrive through a supportive work environment, including collegial teamwork between doctors and nurses, a nurse manager who advocates for nurses, and nurses contributing to decisions about clinical care protocols. Better educated nurses may enhance a hospital’s coping and recovery through nurses’ enhanced care coordination skills, decision-making skills, and knowledge of and desire for evidence-based practice.   

The pandemic brought to the light the inequities that have been simmering in our health care system for a long time. One way to potentially decrease them is to provide better nursing resources. 

covid global map
As a global pandemic, COVID-19 spread across the world. But it didn’t hit everyone equally. “Being healthy is essential to human flourishing,” says Jennifer Prah Ruger, who advocates for shared norms in health governance to address global inequalities. (Image: Martin Sanchez, also featured on homepage)