Column: Socioeconomic Impacts On Health Care

[Column written by Dr. Annabel Fountain]

In the Journal of the American Medical Association last week, Dr. Clyde Lancy reported that in Chicago, more than 50% of COVID-19 cases and nearly 70% of COVID-19 deaths involve black individuals. This is particularly notable because black people make up only 30% of the population there.

This pattern is repeated in Louisiana, where 70.5% of deaths have occurred among black persons, who represent 32.2% of that state’s population.

In the UK, of the first 2,249 patients with confirmed Covid-19, 35% were not white. This is much higher than the proportion of non-white people in England and Wales which was 14%, according to the most recent census. Even medical staff are vulnerable to these disparities. The first 10 doctors in the UK reported to have died from Covid-19 were all from black, Asian or other ethnic minorities [BAME].

Johns Hopkins reports that the COVID-19 infection rate in US counties populated predominantly by people of African heritage is more than three-fold higher than that in predominantly white counties. The death rate for predominantly black counties is six times higher than in predominantly white counties.

You can see where I’m going with this. I’m worried about Bermuda, where most of our population is black. As of 14 April 2020, only 22% of Covid-19 cases reported in the US specified the race of the patient. Bermuda’s Ministry of Health has started to report the race of the COVID-19 cases in Bermuda.

52% of COVID-19 cases in Bermuda reported have been black. The racial composition of Bermuda, according to the 2010 census, was estimated at: 54% black, 31% white, and 8% multiracial. Most of the cases reported so far have either been from nursing homes or from repatriated residents on the flights from the US and UK. I wonder if this has skewed our statistics so far.

We have been asked to shield those in our population who are at increased risk of death from COVID-19. We’ve been advised to be extra careful with our elderly, and for those with chronic diseases, but our two largest employers – the hospital and the Government – are responsible for most essential workers, who cannot work from home.

And the majority of these workers are black. We can ask those who fit the highest risk profile to be extra-vigilant with hand-hygiene, face masks and social-distancing/self-isolation, but if they’re essential workers…

In the United States, and in Bermuda where we have a similar healthcare system, it seems easier to explain why this group might have worse outcomes. Black people tend to be poorer, have less comprehensive health insurance, and have worse statistics for pretty much all conditions from stillbirths to cancers.

However, even in countries where there is a national health service with universal healthcare free at the point of service, Black, Asian, and minority ethnic groups still have disproportionately poor outcomes.

They have a significantly increased risk of chronic metabolic disease. People of African heritage living in the UK are three times more likely to have type 2 diabetes in comparison to Caucasians.

A recent article in ‘Nature’ states that “patients with type 2 diabetes and metabolic syndrome might have up to 10 times greater risk of death when they contract COVID-19”. The author called for mandatory glucose and metabolic control of type 2 diabetes patients to improve outcomes.

The increased incidence of severe COVID-19 illness in black populations is not just about pre-existing disease. Social determinants of health must also be considered. Low socioeconomic status is a risk factor for mortality even before you add other factors. The communities where many black people reside are often in poor areas with higher population density, and poor access to healthy foods.

In many majority-white countries like the US [as well as some minority-white countries like South Africa], people from BAME groups have more limited economic resources. In the US, black households in 2018 were two times as likely to be food insecure as the national average.

And this was before the COVID-19 pandemic. In South Africa, development economists at the University of Witwatersrand, Imraan Valodia forecast that their lockdown would lead to a 45% loss of income for the poorest 10% of households, affecting informal workers without a safety net even more significantly.

Without savings, being out of work will have an impact on the ability of an individual or family to choose nutrient-rich fresh foods which are essential for maintaining healthy immune system. “For the upper classes who can continue to earn an income and who have wealth to fall back on, the lockdown is easy to manage. For the lower classes, this is not the case,” Valodia says.

Social distancing is the most effective strategy to reduce COVID-19 transmission within a community. However, for individuals and families who live in close quarters, multiple generations living together with many sharing beds and bedrooms, six-foot distancing, let alone isolation of an individual who is unwell, is impossible.

Being able to maintain social distancing while working from home or furloughed from work is a privilege and is simply not accessible for many in Bermuda. With elderly members of a family sharing living quarters with those who are out working, shielding of our vulnerable becomes more difficult.

Given the long history of unequal health outcomes, what we are seeing in other jurisdictions is not surprising. We have yet to see if our COVID-19 outcomes in Bermuda reflect the same. The COVID-19 pandemic did not create the inequities that we are seeing but it is making us focus more on them.

When COVID-19 is under control and we have understood what interventions are most effective for prevention and treatment, these health disparities will still exist unless we work to change them.

My hope is that, through our experiences of this pandemic, legislation is introduced that targets social, political and economic structures that perpetuate disparities in healthcare and health outcomes so that, in the future, a person’s socioeconomic status will not be a risk factor for their untimely demise.

- Dr Annabel Fountain is a Bermudian physician who is board certified in Endocrinology, Diabetes and Internal Medicine. She is the Owner/Medical Director of Fountain Medical Group. Dr Fountain offers the following Endocrinology services: Diabetes Prevention, Education and Management, Thyroid Disease – Hypothyroidism, Hyperthyroidism, Nodules and Cancer, Obesity and Weight management, Disorders of Calcium and Bone including Osteoporosis, Hypertension and Cholesterol disorders, Adrenal and Pituitary Disease, Infertility and Menopause, Other glandular disorders. Dr Fountain is available for telemedicine appointments during the Covid-19 isolation recommendations. Please call your primary care physician for a referral or 232-2027 to make an appointment.

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As the island and world deals with the Covid-19 pandemic, we are doing our best to provide timely and accurate information, and you can find more information on the links below.

• Live: Our continuously updated live blog here
• All: Our coverage of the Covid-19 pandemic here
• Official: The Bermuda Government website here
• World Stats: Live graph of all cases worldwide here
• Bermuda Stats: Chart of the Bermuda stats here
• Timeline: Visual look at the timeline here
• Comprehensive: Our new Covid-19 website here

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