The Role of the Social Determinants of Health in the Post COVID-19 World

By: Natasha Sunderji and Dea Biancarelli

As we near the end of 2020, many countries are amidst another surge of COVID-19. While there is much we still don’t know about COVID-19, one issue is clear - the impacts have not been felt evenly across different groups of people largely due to the social determinants of health (SDOH). Further, government responses to stem the spread of COVID-19 led to unintentional negative impacts on already vulnerable groups based on SDOH classifications. In many cases, community-based organizations (CBOs) stepped up to address critical social and economic needs and fill gaps.

As world leaders’ attention shifts to vaccine distribution, what can we learn from the world's response thus far in addressing the SDOH during the pandemic, and how can we apply these lessons in the post COVID-19 world? Utilizing the early COVID-19 pandemic response as a case study, we can build back better by integrating the SDOH into our collective efforts. Specifically, the SDOH must be prioritized in public health planning processes and community organizations need a seat at the table. Innovative partnerships are required to achieve this.

Social Determinants of Health and COVID-19

To date, hundreds of academic articles have been published exploring the connection between the SDOH and COVID-19. Social determinants of health, defined by WHO as “the conditions in which people are born, grow, live, work and age” [1], are influenced by the social and political context of communities. Though these factors are complex and interconnected, the main categories can be distilled into five key areas: education, healthcare access, environment, social, and economic.[2]  

Differential exposure, susceptibility, and consequences of COVID-19 for diverse groups of people can be mapped to each area of the SDOH.[3]

Variances in healthcare access and quality have resulted in large disparities in access to COVID-19 testing and timely treatment.

• Early in 2020, more COVID-19 tests were performed in New York City neighborhoods that were predominately White compared to Latinx, despite a higher proportion of Latinx testing positive.[4]
• Another U.S study found that while differences in testing between races was minimal, Black Americans were more likely to be tested in inpatient settings vs. outpatient than White Americans, indicating inequitable access to testing.[5]
• Other global reports show variances in health care quality of COVID-19 treatment provided to different races. In Brazil, only 21.6% of Padro Brazilians (mixed ethnicity) were admitted to the ICU compared to 69.4% of White Brazilians; a larger proportion of Padro Brazilians who did not access the ICU died compared to White Brazilians.[6]

The necessity of physical presence to work, which can lead to increased exposure to COVID-19, is more common for service jobs - many of which are linked to having less education.

• In Bangladesh, 80% of essential sanitation workers felt that they were at high risk of contracting COVID-19 due to their job; 40% reported not receiving necessary safety supplies as frequently as needed from their employer.[7]

The Role of Government Policy

Few experts believe that their country’s COVID-19 response adequately addresses the SDOH.[8] In fact, many government policies to address COVID-19 have had unintended consequences that have worsened some aspect of the SDOH and placed their most vulnerable citizens at even higher risk of negative health impact. A recently developed framework outlines how policy responses to the pandemic interact and can worsen existing inequities, driving further vulnerability of certain groups to COVID-19.[9] Many of these impacts are complex and multi-layered.

One clear example of government action that was necessary to prevent the spread of COVID-19 but led to negative consequences were government lockdowns. Though economic consequences were felt globally, they were especially felt by people already living in poverty and working in the informal job sector. Many people’s jobs disappeared altogether, threatening the economic stability and livelihoods of millions of people. Additionally, heavily crowded neighborhoods experienced increased susceptibility and spread of COVID-19.

• 1.2 billion people in the global informal economy were significantly impacted by the COVID-19 lockdowns, losing 60% of their income.[10] In low- and middle-income countries (LMICs), people in the informal economy lost more than 80% of their income.[10] Countries had various response mechanisms to the economic impacts, such as direct cash payments and wage subsidies.[11] However, as the crisis continues, some countries like the US, have failed to continue providing critical economic relief.[12]
• Crowded slums in India have resulted in high infection rates, with more than half of people who lived in the slums in Mumbai testing positive for COVID-19 in early July, compared to 16% of people who lived outside of the slums.[13]
• Similar policies in South Africa have led to violence between the military and poor South Africans constrained to slums.[14]
• Domestic abuse helplines in multiple countries have seen an increased volume of calls (between 40% and 400% according to a rapid assessment by UN Women);[15] police and healthcare centers have also received increased reports relating to domestic violence.[15]
• Isolation and loneliness resulting from community lockdowns, particularly among the elderly, reflect the serious consequences and tradeoffs of lockdown measures to our social and community health.[16]  

Some COVID-19 policies have less clear and measurable impacts, such as closing schools and the subsequent impact to education access and quality. School closures have left girls increasingly vulnerable to childhood marriage and can impact the educational achievements of an entire generation of poor students, who are unable to access remote education.

• Save the Children estimates that “up to an additional 2.5 million more girls around the world are at risk of marriage in the next 5 years because of the COVID-19 pandemic”[17]
• UNICEF estimated that globally 31% of children are unable to access remote education during school shutdowns.[18]

Communities Fill the Gaps to Address SDOH

Like in previous health emergencies, communities have come together during COVID-19 to address the gaps in government response. In many geographies, CBOs that existed pre-COVID shifted their missions to provide critically needed support.

India: Women’s Self-Help Groups

Women’s self-help groups (SHG) in India have become an incredible vehicle for addressing the economic impact of the COVID-19 pandemic through the provision of food and financial relief. SHG in India were formed in the 1980s by NGOs as a strategy to support rural micro-finance programs.[19] The success of the programs in increasing women’s income led to many partnerships with the Indian government to address broader needs.[20]

During India’s lock down, women’s SHG provided food rations door to door, in addition to opening over 10,000 community kitchens to serve low-income families.[21-22] While the Government of India supported an economic stimulus package of 1.7 trillion rupees to provide financial relief, many of its poorest citizens were unable to receive funds due to a lack of bank accounts. Women’s SHGs have enabled the delivery of COVID financial relief to the rural poor, who otherwise would be unable to access these critically needed funds.[22-24]

Brazil:  The Landless Workers Movement

In Brazil, the Landless Workers Movement - an activist organization that supports Brazilian farmers -  quickly shifted from its mission of supporting land reform and social justice for rural workers, to providing broader economic and education support for local community members.[25]  Similar to the women’s SHG in India, the Landless Workers Movement also established communal kitchens and necessity drop-offs for families and hospitals.[26] With students unable to attend traditional schooling, the Landless Workers Movement also helped teachers provide virtual learning opportunities for students so that education did not come to a halt during the pandemic.[26]

Kenya: Shining Hope for Communities

Lastly in Kenya, a Kiberian CBO called “Shining Hope for Communities” has assisted over 2.4 million people across Kenya since the beginning of the pandemic. One of their initiatives includes assisting low-income families through direct cash transfers - distributing almost $2.9 million USD to ~34,000 individuals in need.[27] Like the prior examples in India and Brazil, Shining Hope for Communities addressed urgent food needs with food parcels.[27] The organization also set up over 350 sanitation stations in 17 different settlements for people who did not have access to running soap and water in their homes.  Finally, Shining Hope for Communities engaged with local community and religious leaders to form partnerships to protect people from misinformation and increased gender-based violence during lock downs, responding to more than 2,000 cases of gender-based violence.[27]

Lessons Learned

As we look towards 2021, governments and communities are starting to tackle the next challenge of the pandemic - vaccine distribution.

The majority of the discourse on equity is focused on persuading policy makers to approach the vaccine supply with a global vs. nationalist viewpoint. [28-29] However, the overall supply of vaccines is not the only challenge in equitable vaccine distribution. Research shows that immunization rates for other diseases in low, middle, and high-income countries are impacted by the SDOH.[30] Thus, vaccine distribution and implementation strategies require a clear SDOH lens with a focus on multi-stakeholder engagement.

Three key takeaways from the response to the COVID-19 pandemic can help us face the challenges ahead - from COVID-19 vaccine distribution to the health issues of the post COVID-19 world.

1.      Increase Focus on the SDOH in Public Health Strategy and Planning

Early responses to the pandemic were primarily focused on urgent PPE needs and government action to stop the spread, with measures like lock downs. Focus on the unequal impacts of COVID-19 and the SDOH largely occurred after disparities were highlighted by community members themselves. The SDOH must be a key consideration in any public health planning effort, even when action is urgently needed. A lack of consideration of the SDOH in planning results in gaps in health outcomes and resolving disparities post policy implementation, which can be increasingly difficult. With vaccine distribution as the next major hurdle of the COVID-19 response effort, public health strategies should proactively incorporate SDOH thinking. Policy makers should proactively integrate the SDOH framework into vaccine prioritization strategies. For example, the WHO SAGE Allocation and Prioritization Framework for the COVID-19 Vaccine includes socio-demographics groups at higher risk of severe disease or death in Priority Two.[31] However the WHO indicates that it is up to each country to determine who those groups will be. Bringing an SDOH lens to the identification of such groups will be critical to ensuring vulnerable populations are appropriately identified and prioritized. In addition, countries will need to develop appropriate plans to ensure identified socio-demographic groups are willing and able to receive the vaccine, considering known healthcare access and quality challenges.

 2.      Engage Community Based Organizations  

The examples above demonstrate the critical role that CBOs play to address not only the gaps in government aid, but also the unintended negative consequences of government policy decisions. Governments should recognize the power of CBOs and leverage them as a tool to address the goals of improving the SDOH in both times of crises and stability. It is important to proactively build relationships with CBOs by investing in communities through capacity building and funding. By building relationships with CBOs, governments can support communities to be “owners” in building programs that are acceptable and relevant for local needs. Pre-existing relationships will also allow them to quickly collaborate when urgent response efforts are needed.  Engagement of communities in building government programs is a principle of human centered design (HCD) - a private sector strategy that global health organizations have increasingly embraced in development efforts.[32] A key element of HCD is a strong focus on empathy and engaging end users in the design process.[33] As a result, designs tend to have greater uptake and acceptance by end users, who feel they have shared ownership in the design and results. A rapid assessment of the COVID-19 response in Mumbai supports this idea, finding that “communities are keen to script their own development, even in crisis.”[34] The medical community’s past violations of trust with vulnerable communities, specifically communities of color, has led to distrust and hesitancy of intention to take the COVID-19 vaccine, demonstrated through protests,[35] low participation in vaccine trials,[36] and surveys on intention to vaccinate.[37-38] Stronger engagement of community members and trusted community leaders may be an effective tactic to ease some of these concerns. In a recent study by the COVID Collaborative in the US, Black adults who had family and friends planning to get the COVID vaccine were more likely to plan on getting the vaccine themselves, compared to Black adults with few family and friends intending to vaccinate.[39]

3.      Develop Cross Sectoral Partnerships to Address the Complex Nature of the SDOH

Ensuring health and wellbeing for all can only occur with careful consideration of the SDOH, which extends beyond the narrow silo of traditional healthcare. Greater collaboration is needed between leaders in health, economic planning, housing, city planning, and the education sectors. In addition, policy makers need to work even more closely with cross-sectoral actors including CBOs, academia, and the private sector. Diverse perspectives are critical to ensuring we are aware of and addressing the complex nature of the SDOH through our collective efforts. While the urgency of COVID-19 led to innovative partnerships, those partnerships tended to focus on the immediate needs of COVID-19 and not the broader community impact. Fewer partnerships formed to support livelihoods compared to vaccine development, treatment, PPE and other direct COVID response related needs.[40] Governments should explore how to create pathways for more innovative partnerships to support policy development and implementation activities within communities.

The SDOH are not a new concept in public health and neither are the actions needed to mitigate their impact. Though attempting to reduce the burden of complex issues like poverty, education, and racism can be difficult to actualize, that does not mean they cannot be meaningfully integrated in public health strategies and actions. Appropriate strategic planning, inclusion of communities, and working together across silos will help alleviate the wide disparities in the pandemic as the world moves towards the next phase of COVID-19 response and the health challenges of the post COVID-19 world.

References

[1] Solar O, Irwin A. A Conceptual Framework for Action on the Social Determinants of Health. Social Determinants of Health Discussion Paper 2 (Policy and Practice). Published 2010. Accessed November 6, 2020.

[2] Healthy People 2030. U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Accessed November 6, 2020.

[3] Burstrom B, Tao W. Social determinants of health and inequalities in COVID-19. Eur J Public Health. 2020;30(4):617-618. doi:10.1093/eurpub/ckaa095

[4] Campbell C. Hundreds are still being turned away for coronavirus tests at a predominantly Latino church in Baltimore. Baltimore Sun. https://www.baltimoresun.com/coronavirus/bs-md-build-covid-testing-20200606-ubyqfzc5dra5hbj5zkcho3ir34-story.html. Published June 6, 2020. Accessed November 6, 2020.

[5] Lieberman-Cribbin W, Tuminello S, Flores RM, Taioli E. Disparities in COVID-19 Testing and Positivity in New York City. Am J Prev Med. 2020;59(3):326-332. doi:10.1016/j.amepre.2020.06.005

[6] Baqui P, Bica I, Marra V, Ercole A, van der Schaar M. Ethnic and regional variations in hospital mortality from COVID-19 in Brazil: a cross-sectional observational study. Lancet Glob Heal. 2020;8(8):e1018-e1026. doi:10.1016/S2214-109X(20)30285-0

[7] Risk and Vulnerability of sanitation and waste workers during Covid-19 pandemic in five major cities of Bangladesh. WaterAid. Published 2020. Accessed November 13, 2020. https://reliefweb.int/sites/reliefweb.int/files/resources/Risk and vulnerability of waste workers during COVID-19 pandemic in five major cities of Bangladesh_V4_16.08.2020 %281%29 %281%29.pdf

[8] Shadmi E, Chen Y, Dourado I, et al. Health equity and COVID-19: Global perspectives. Int J Equity Health. 2020;19(1). doi:10.1186/s12939-020-01218-z

[9] Glover RE, van Schalkwyk MCI, Akl EA, et al. A framework for identifying and mitigating the equity harms of COVID-19 policy interventions. J Clin Epidemiol. 2020;128:35-48. doi:10.1016/j.jclinepi.2020.06.004

[10] Impact of lockdown measures on the informal economy. International Labour Organisation. Published 2020. Accessed December 6, 2020. https://www.ilo.org/wcmsp5/groups/public/---ed_protect/---protrav/---travail/documents/briefingnote/wcms_743523.pdf

[11] Coronavirus bailouts: Which country has the most generous deal? BBC News. Published 2020. Accessed December 13, 2020. https://www.bbc.com/news/business-52450958

[12] Sarlin B, Ruhle S. As coronavirus surges, countries spend more on economic aid. But not the U.S. NBC News. Accessed December 13, 2020. https://www.nbcnews.com/politics/politics-news/coronavirus-surges-countries-spend-more-economic-aid-not-u-s-n1250411

[13] Biswas S. India coronavirus: “More than half of Mumbai slum-dwellers had Covid-19.” BBC News. https://www.bbc.com/news/world-asia-india-53576653. Published July . Accessed November 6, 2020.

[14] Trippe K. Pandemic policing: South Africa’s most vulnerable face a sharp increase in police-related brutality. Atlantic Council. Published 2020. Accessed November 13, 2020. https://www.atlanticcouncil.org/blogs/africasource/pandemic-policing-south-africas-most-vulnerable-face-a-sharp-increase-in-police-related-brutality/

[15] Impact of COVID-19 on violence against women and girls and service provision. United Nations Entity for Gender Equality and the Empowerment of Women. Published 2020. Accessed December 13, 2020. https://www.unwomen.org/-/media/headquarters/attachments/sections/library/publications/2020/impact-of-covid-19-on-violence-against-women-and-girls-and-service-provision-en.pdf?la=en&vs=0

[16] Koma W, True S, Biniek JF, Cubanski J, Orgera K, Garfield R. One in Four Older Adults Report Anxiety or Depression Amid the COVID-19 Pandemic. KFF. Published 2020. Accessed December 2, 2020. https://www.kff.org/medicare/issue-brief/one-in-four-older-adults-report-anxiety-or-depression-amid-the-covid-19-pandemic/

[17] Cousins S. 2·5 million more child marriages due to COVID-19 pandemic. Lancet (London, England). 2020;396(10257):1059. doi:10.1016/S0140-6736(20)32112-7

[18] COVID-19 and School Closures: Are children able to continue learning . UNICEF. Accessed December 6, 2020. https://data.unicef.org/resources/remote-learning-reachability-factsheet/

[19] Kaur P, Kaur R. Empowering Rural Women through Self- Help Groups in India. Gian Jyoti E-Journal. 2015;5(1). Accessed December 6, 2020. https://www.gjimt.ac.in/gianjyoti-e-journal/39

[20] National Rural Livelihoods Project. World Bank. Accessed December 6, 2020. https://projects.worldbank.org/en/projects-operations/project-detail/P104164

[21] Community Kitchens run by SHG Women provide food to the most poor and vulnerable in Rural Areas during the COVID-19 lockdown. Ministry of Rural Development. Published 2020. Accessed December 6, 2020. https://rural.nic.in/press-release/community-kitchens-run-shg-women-provide-food-most-poor-and-vulnerable-rural-areas

[22] In India, women’s self-help groups combat the COVID-19 (Coronavirus) pandemic. World Bank. Published 2020. Accessed December 6, 2020. https://www.worldbank.org/en/news/feature/2020/04/11/women-self-help-groups-combat-covid19-coronavirus-pandemic-india

[23] NRLM Self Help Group network rises to the challenge of COVID-19 situation in the country. Ministry of Rural Development. Published April 12, 2020. Accessed December 6, 2020. https://pib.gov.in/PressReleaseIframePage.aspx?PRID=1613605

[24] Jain R. In India’s Villages Women SHG members provide vital banking services during the COVID-19 crisis. World Bank. Published 2020. Accessed December 6, 2020. https://www.worldbank.org/en/news/feature/2020/07/22/in-indias-villages-women-shg-members-provide-vital-banking-services-during-the-covid-19-crisis

[25] History of the MST. Friends of MST. Accessed December 6, 2020. https://www.mstbrazil.org/content/history-mst

[26] Tarlau R. Activist farmers in Brazil feed the hungry and aid the sick as president downplays coronavirus crisis. The Conversation. Published 2020. Accessed December 6, 2020. https://theconversation.com/activist-farmers-in-brazil-feed-the-hungry-and-aid-the-sick-as-president-downplays-coronavirus-crisis-136914

[27] SHOFCO’s COVID-19 Response. Shining Hope For Communities. Published 2020. Accessed December 6, 2020. https://www.shofco.org/covid-19/

[28] Gonzalez, L L. Coronavirus vaccine: How will poorer countries get a fair shot? Al Jazeera. Published 2020. Accessed December 6, 2020. https://www.aljazeera.com/features/2020/11/17/coronavirus-vaccine-how-will-poorer-countries-get-a-fair

[29] Kupferschmidt K. WHO unveils global plan to fairly distribute COVID-19 vaccine, but challenges await. Sci Mag. Published online September 2020. Accessed December 6, 2020. https://www.sciencemag.org/news/2020/09/who-unveils-global-plan-fairly-distribute-covid-19-vaccine-challenges-await

[30] Glatman-Freedman A, Nichols K, Nichols KA. The effect of social determinants on immunization programs. Hum Vaccin Immunother. 2012;8(3):293-301. doi:10.4161/hv.19003

[31] SAGE Working Group on COVID-19 Vaccines. Roadmap for Prioritizing Uses of Covid-19 Vaccines in the Context of Limited Supply. WHO. Published November 20, 2020. Accessed December 15, 2020. https://www.who.int/publications/m/item/who-sage-roadmap-for-prioritizing-uses-of-covid-19-vaccines-in-the-context-of-limited-supply

[32] SAGE Working Group on COVID-19 Vaccines. Roadmap for Prioritizing Uses of Covid-19 Vaccines in the Context of Limited Supply. WHO. Published November 20, 2020. Accessed December 15, 2020. https://www.who.int/publications/m/item/who-sage-roadmap-for-prioritizing-uses-of-covid-19-vaccines-in-the-context-of-limited-supply

[33] Crandall M. Human-Centered Design and Community Engagement. National Civic League. Accessed December 11, 2020. https://www.nationalcivicleague.org/ncr-article/human-centered-design-and-community-engagement/

[34] Venkatachalam P, Memon N. Community Engagement to Tackle COVID-19 in the Slums of Mumbai. The Bridgespan Group. Published 2020. Accessed December 2, 2020. https://www.bridgespan.org/insights/library/global-development/community-engagement-tackle-covid-19-mumbai-slums

[35] Anna C. Protest against Africa’s 1st COVID-19 vaccine test shows fear. PBS News Hour. https://www.pbs.org/newshour/world/protest-against-africas-1st-covid-19-vaccine-test-shows-fear. Published July 1, 2020. Accessed December 13, 2020.

[36] Hoffman J. “I Won’t Be Used as a Guinea Pig for White People.” The New York Times. https://www.nytimes.com/2020/10/07/health/coronavirus-vaccine-trials-african-americans.html. Published October 7, 2020. Accessed December 13, 2020.

[37] Markovitz G. Fewer people say they would take a COVID-19 vaccine now than 3 months ago. World Economic Forum. Published 2020. Accessed December 13, 2020. https://www.weforum.org/agenda/2020/11/fewer-people-say-they-would-take-a-covid-19-vaccine-now-than-3-months-ago/

[38] Tyson A, Johnson C, Funk C. U.S. Public Now Divided Over Whether To Get COVID-19 Vaccine. PEW Research Center: Science and Society. Published 2020. Accessed December 6, 2020. https://www.pewresearch.org/science/2020/09/17/u-s-public-now-divided-over-whether-to-get-covid-19-vaccine/

[39] Williams MA, Rice VM. COVID vaccine won’t undo decades of vaccine hesitancy in Black community | Expert Opinion. The Philadelphia Inquirer. https://www.inquirer.com/opinion/commentary/covid-coronavirus-vaccine-pfizer-moderna-black-hesitancy-20201202.html. Published December 2, 2020. Accessed December 13, 2020.

[40] Tewes-Gradl C, Stibbe D, Prescott D. Rapid Innovation Through Partnerships. Accessed December 13, 2020. https://snipbfp.org/C19_ResponseCentre