Overview of health disparities in the US including context-specific insights for understanding COVID-19 disparities

1. What Can the COVID-19 Pandemic
Tell Us About Health Disparities in
the United States?
Debra Furr-Holden, PhD
Associate Dean for Public Health Integration
C.S. Mott Endowed Professor of Public Health
Director, NIMHD-funded Flint Center for Health
Equity Solutions
Michigan State University, College of Human
Medicine, Division of Public Health

2. Student Learning Objectives
Students will be able to
distinguish between health
disparities and health
inequities
01
Students will be able to
distinguish between
upstream, midstream, and
downstream determinants
of health
02
Students will understand
current disparities in
COVID-19 cases, deaths,
and testing
03
Students will learn about
innovative strategies to
reduce COVID-19
disparities, as well as
health disparities and
inequities beyond COVID-
19
04

3. Background Definitions: Health
Disparity
• Healthy People 2020 defines a health disparity as “a
particular type of health difference that is closely linked
with social, economic, and/or environmental disadvantage.
• Camara Jones said health disparities are the differences in
outcomes; when health disparities are
eliminated, health equity will be achieved.

4. Background Definitions: Health
Equity
• Health equity, as defined by Healthy People 2020
definition, is the attainment of the highest level
of health for all people.
• Health equity, as defined by Camara Jones, Morehouse
School of Medicine, is the assurance of the condition of
optimal health for all people.
• By the end of this conversation, you can create your own
definition of health disparities and health equity.

5. Background Definitions: Social
Determinants of Health
• As defined by Healthy People 2020, the social
determinants of health are conditions in the environments
in which people are born, live, learn, work, play, worship,
and age that affect a wide range of health, functioning, and
quality-of-life outcomes and risks.
• Conditions (e.g., social, economic, and physical) in these
various environments and settings (e.g., school, church,
workplace, and neighborhood) have been referred to as
“place.”
• In addition to the more material attributes of “place,” the
patterns of social engagement and sense of security and
well-being are also affected by where people live.

6. FRAMEWORK MATTERS
Equality Equity
Social
Determinants

7. Disparities
versus
Inequities
7
Disparities
Differences
Person-centered
Downstream
Inequities
Unfairness
Systems-, structures,
intervention-centered
Upstream

8. Upstream versus Downstream Defined
• The term upriver (or
upstream) refers to the
direction towards the source
of the river, i.e. against the
direction of flow.
• The term downriver (or
downstream) describes the
direction towards the mouth
of the river, in which the
current flows.
Source: thechartroom.com

9. A Few Examples from the
Field
Upstream vs. Downstream in a Health Equity Framework

10. Source: https://hqc.sk.ca
Obtained from: https://twitter.com/hqcsask/status/1106604911091990528/photo/1

11. Obtained from: https://www.slideshare.net/NCCMT/methods-and-tools-for-integrating-health-equity-into-
public-health-program-planning-and-implementation

12. Upstream versus Downstream in Health Equity
Upstream  The source of the
river/disparities
• What are these factors?
Downstream  The mouth of
the river/the disparities
• What are these factors?
Source: thechartroom.com

13. Gaps in the Field of Health Equity
Health equity literature, leaders, and initiatives typically focus on
what health equity is…..
• …and (mostly) intervenes on (downstream) disparities.
• …but not how we got here, i.e., how did we get to be such an
inequitable society (in general and relative to health).
• …but not how how we can achieve health equity (attainment versus
assurance).
• …but not the causes of the causes of health inequity (and in our
society at large). Dare I start naming the ‘…isms’.

14. Disparities Facing Us during
COVID-19

15. COVID-19 is
disproportionately
affecting African
Americans 15%
33%
14%
42%
70%
41%
0%
10%
20%
30%
40%
50%
60%
70%
80%
Illinois Louisana Michigan
% Population % COVID-19 Deaths

18. Tremendous Racial Disparities in COVID-19
• Confirmed racial disparities in cases and deaths in
multiple states and cities across the country….
…and a lack of data continues to fuel the debate
• Confirmed racial disparities in cases and deaths in
Michigan…
…and at least we have shared the data/facts
• Emerging racial disparities in Texas and many
other places
…and likely in many other cities and many for many
other population subgroups

19. Why?
Pre-existing health conditions
Increased exposure
Medical mistrust
Misinformation and/or misunderstanding
Social determinants of health
The Usual
Suspects…

20. Explanations
versus
Algorithms
• We have accepted these usual
suspects/explanations
• The explanations so far are not
actionable
• These explanations have influenced
algorithms for who gets what
• Screening
• Mobile testing
• Hospital admissions
• DNRs
• The algorithms are (I believe)
attributable to excess morbidity and
mortality  literally killing people!

21. Solutions……???
1. Pre-existing health
conditions
2. Increased exposure 3. Medical mistrust 4. Misinformation
and/or
misunderstanding
5. Social determinants
of health
…Reorder the Algorithm!!!

22. Turn risk into priority for continuum of care
3. Pre-existing health
conditions
2. Increased exposure
4. Medical
mistrust/race
5. Access to Primary
Care
1. Social determinants
of health

23. Take Aways
STOP DESCRIBING THE
PROBLEM AND START
IMPLEMENTING
SOLUTIONS
MAP SOLUTIONS ONTO
PRIORITIES (VS VARIATION
IN CARE BASED ON RISK)
FOCUS ON FACTORS WE
CAN CONTROL/IMPACT.
STOP BLAMING THE
DISPARATE
BRING A HEALTH EQUITY
LENS
USE DATA TO INFORM
ACTIONS/INTERVENTIONS
STRENGTHEN PUBLIC-
PRIVATE PARTNERSHIPS

24. Other likely disparate populations
OTHER RACIAL/ETHNIC
MINORITIES
PRISONERS OTHER INSTITUTIONALIZED
POPULATIONS
POOR SEXUAL MINORITIES
UNINSURED ELDERLY UNDOCUMENTED
RESIDENTS & NON-NATIVE
ENGLISH SPEAKERS

25. Policy
Initiatives
Needed
1. Equity-Driven Access
• Testing
• Hospital admissions
• Critical care (e.g., DNRs)
2. Equity-Driven Protections
• E.g., Off label medications testing in prisoners and
other institutionalized populations
3. Equity in Resource Allocation
• Even if inequity is not built in, it’s the natural drift
• Funding must require equity
4. Proactive (versus Reactive or Post-Hoc)
Intervention

26. Student Learning Objectives Met?
Students will be able to
distinguish between health
disparities and health
inequities
01
Students will be able to
distinguish between
upstream, midstream, and
downstream determinants
of health
02
Students will understand
current disparities in
COVID-19 cases, deaths,
and testing
03
Students will learn about
innovative strategies to
reduce COVID-19
disparities, as well as
health disparities and
inequities beyond COVID-
19
04

27. Bonus Discussions

28. Secondary Impacts of COVID-19
that We Are NOT Talking About
A bonus session if we have time

29. COVID-19
Secondary
Impacts that
We Are NOT
Talking About
Management of pre-existing and new
health conditions  the impact of
fear
1. People waiting longer than
normal/suffering at home from non-
COVID related illness == excess
morbidity/worse outcomes
2. People dying at home from non-
COVID related illness == excess
mortality

30. COVID-19
Secondary
Impacts that
We Are NOT
Talking About
Lapses in primary care and preventive care
1. Primary Care visits are at an all time low
2. Vaccination rates are at an all time low
3. Potential for unusual disease outbreaks
following COVID-19 (e.g., measles)
4. A less health nation possibly emerging
following COVID-19

31. COVID-19
Secondary
Impacts that
We Are NOT
Talking About
Mental Health
1. Mental Health Care was already
lacking
2. People are under tremendous COVID-
related stress
3. How we manage death and dying has
changed

32. COVID-19
Secondary
Impacts that
We Are NOT
Talking About
Behavioral Health
1. Care was already lacking
2. People are under tremendous COVID-
related stress
3. Many Inpatient and Intensive
Outpatient Programs had to ‘kick
people out’
• Many were sent home with
‘bottles’ and no other care
• Opioid overdose death is spiking in
many places

33. How Are We Doing in
Michigan with COVID-19?
A bonus session if we have time

34. from bridgemi.com

35. from bridgemi.com

36. from bridgemi.com

37. from bridgemi.com

38. from bridgemi.com

39. from bridgemi.com

40. What’s
happening at
the local level
COUNTIES ARE STANDING UP
LOCAL TASK FORCES
ADDRESSING GAPS IN
TESTING AND DOING
CONTACT TRACING
ADDRESSING
DISPARITIES/INEQUITIES

41. Bottom Line
THINGS ARE MOVING IN THE RIGHT
DIRECTION
STILL TOO EARLY TO TELL, CAUTIOUSLY
OPTIMISTIC
BEST STRATEGY IS TO CONTINUE TO
PRACTICE GOOD PUBLIC HEALTH (I.E.,
PROTOCOLS, TESTING, CONTACT
TRACING)

42. The Cliff of Good Health
By Camara Jones
https://www.youtube.com/watch?v=to7Yrl50iHI