Dr. Jaime Imitola said he believes COVID is “fueled” by people who “live at the edges of poverty.”
Imitola, a neuroscientist, neurologist and immunologist, is director of the Division of Multiple Sclerosis and Translational Neuroimmunology at the University of Connecticut. People who live in poverty are at greater risk for the comorbidities that continue to make COVID deadly, even as disease rates decrease statewide, he said.
Poverty is indicated with a higher risk for obesity, hypertension and for autoimmune diseases like asthma, he said. Those who are poor are less likely to have access to high-quality medical care or good health insurance, he pointed out.
“This is a historical thing,” Imitola said. “Every single pandemic, always, is permeated by poverty.”
Imitola believes that poorer communities, with less access to health care and higher rates of comorbidities will continue to see higher rates of death and hospitalizations.
Researchers and public health experts began commenting on the inequitable outcomes in both poorer communities and among racial and ethnic minorities at the start of the pandemic.
Now two years after COVID first appeared in Connecticut, what has been done to address those health disparities?
The answer is complicated, and Tiffany Donelson, president and CEO of the Connecticut Health Foundation, said it’s first important to understand the difference between equality and equity.
“Equality is treating everyone the same; equity is meeting the differing needs people have,” she said.
Donelson said the difference between the two was exposed throughout the pandemic.
“An equality approach would be to open online slots for vaccine clinic appointments to everyone at the same time,” she said. “An equity approach would be to offer vaccines at locations you know people can access whether they have a car or not, that don’t require booking online, that are designed to address the barriers people face.”
“The pandemic really illustrated why an approach centered on equity, not just equality, is so important,” she said.
‘Social determinants’
Mark Masselli, president and CEO of Community Health Center Inc., said access to health care and health insurance are downstream effects of larger issues, which he referred to as “social determinants of health.”
Food insecurity, housing insecurity, education and transportation, for example, are all important factors in a patient’s health care profile.
“I don’t know if there’s a plan for that. But I think more people understand this,” Masselli said. “The current health system is set up to address all the problems that we created by not addressing determinants. The question is can we, in fact, pivot from where we are, take what we’ve learned, and move forward?”
The pandemic has put a brighter spotlight on the issues that have led to health inequities, which have long been ignored, according to Sara LeMaster, manager of government relations and public policy for the Community Health Center Association.
“In Connecticut, at least, there has been a more intense focus on addressing the social determinants of health and health inequities,” she said. “I think that one of the struggles for us has been that health centers have been doing that work for a long time.”
Ken Lalime, CEO of Community Health Center Association, called it “an awakening.”
“All of a sudden, there’s a bit of an awakening that the underlying issues of the Black and brown communities not getting access to the same level of service that others get is something that continuously needs to be worked on,” he said.
The future
The key, Lalime said, is making better use of technology, to provide a greater level of access to health care, but also to track the social determinants of health patient by patient, community by community.
“Health care is 20 percent of health,” he said. “The bigger piece of health is behavioral, it’s social. It’s where you live, where you breathe.”
Dealing with those large and long-standing issues “starts with technology,” Lalime said.
“It starts, actually, with defining what social determinants of health we’re talking about, what issues are we talking about, finding a way to identify those issues,” he said. Then, it’s possible to “find a way to get, from a technology point of view, those issues into an electronic health record, so that you can start looking at codifying those patients.”
Then advocates can ask: “What types of services do we need to provide to certain groups of patients that are in need, that can change their pattern of health the most,” Lalime said.
Public Act 21-35, signed into law last year, began that process, Donelson said. She said it “contains a number of provisions focused on advancing equity,” including the creation of a commission on racism and public health.
“Public Act 21-35 requires health care providers to collect race, ethnicity, and language preference data from patients — having them self-report it (or opt out), rather than guessing or not collecting it,” she said. “This data allowed state leaders to see who was getting COVID and who was — and wasn’t — getting vaccinated, and to better focus on reaching those who were being left behind.”
Removing barriers
Adjusting for age, Black and Hispanic patients were far likelier to have caught COVID in June 2020, when the pandemic was new, with case rates three times higher than among white residents.
Though case rates have since leveled out somewhat, Black and Hispanic people in Connecticut are still far more likely to have contracted COVID than their white neighbors.
That disparity is even more stark when looking at COVID death rates. Data from the state Department of Health suggests that Black people are twice as likely to die from COVID than white Connecticut residents.
Adjusting for age, the COVID death rate in Connecticut is 180 for every 100,000 white residents, compared with 313 for every 100,000 Hispanic residents and 359 for every 100,000 Black residents in Connecticut.
Vaccination rates have also lagged among communities of color in the state.
Only 57.77 percent of Connecticut residents who identify as Black are fully vaccinated, according to data maintained by the state. In comparison, 66.31 percent of the state’s Hispanic residents and 73.04 percent of residents who identify as white are fully vaccinated.
There have been some concrete steps taken to improve outcomes for at-risk communities like Public Act 21-35, according to Donelson.
It’s also important, Donelson said, to meet people where they live and work, “whether that means providing testing and vaccine clinics in communities where people live or going door-to-door to offer appointments to vaccine clinics and information about COVID.”
“We learned to approach access with an equity lens,” she said. “Health systems and other providers can learn from this going forward.”
Masselli said disparities in vaccination and COVID testing between ethnic groups in Connecticut demonstrated that “we did not have a public health structure in place.”
“We realized, and still we fell short, that if you remove the economic and structural barriers to care, then you can focus on the work of where people live, work, play and pray,” he said.
That has meant both physical shifts — a movement from mass vaccination sites to smaller, community-centered approaches — and digital efforts.
“At the beginning of the pandemic, all health center patients had to see a provider in person, LeMaster said. “Through telehealth, we’ve been able to reach a lot more patients, but there are still technology issues and access issues that exist.”
“It’s not the perfect thing,” she said. “But I think that it has helped a lot more people continue to access care when they couldn’t before.”