Abstract
As I write this editorial from my hometown of Philadelphia, our city has endured yet another population health-related tragedy, namely the death of 12 people, including 9 children, in an apartment building fire. Our daily newspaper, The Philadelphia Inquirer, has appropriately carried reports and editorials with headlines such as “Deadly Blaze Must Be a Wake-Up Call: The real cause of Philadelphia's rowhouse fire is our unequal society.” 1
We remain in the throes of the omicron variant-related surge. In our own Jefferson delivery system consisting of 18 hospitals, we still have >1000 COVID-related hospitalizations with scores of patients in our intensive care units across the enterprise.
We are also at the 2 year mark for dealing with the pandemic in a city where nearly one quarter of the population lives in poverty and where public schools remain a political battleground with regard to lack of testing, quarantining teachers, disparate access to remote learning, and all of the other ills that highlight the health inequities in our society. Our research colleagues at the University of Pennsylvania have noted that, “It is one of the most robust findings in all of social science, that there is an incredibly strong association between socioeconomic status and health status. So this (the pandemic) is not a test case, but rather this is a demonstration case.” 2
Given the so-called patchwork quilt of our United States public health system, 3 it is no surprise to informed readers of this journal that our crumbling public health infrastructure could not withstand the epidemiological tsunami presented by COVID-19, and the attendant variants. Every system is perfectly designed to achieve exactly the results it gets.
It is with this backdrop that my coeditors and I, along with our publisher, Mary Ann Liebert, are so proud to present this second special issue of our journal devoted to the sequelae of the pandemic. This issue will highlight aspects of those aforementioned health inequities in our society.
Our previous dedicated issue in October of 2020 was entitled Population Health and the Pandemic: Early Lessons. We were gratified by the response to that dedicated issue. In addition, we published a supplement to the journal in February 2021, entitled, COVID-19 Pandemic Insights from a Diagnostic Services Provider. The supplement highlighted the national research agenda of our colleagues at Quest Laboratories.
I would first like to give context and definitions for this special issue and then I will describe some of the emerging themes we learned from our colleagues. I will briefly share with you some of the challenges we see in the world of research on inequities and end with some pragmatic approaches to the future.
First some context and definitions. I have previously written about a fascinating report from our colleagues at the Institute for Healthcare Improvement in Boston, Massachusetts, entitled, “Achieving Health Equity: A Guide for Healthcare Organizations.” 4 In that report, and in my accompanying editorial, 5 I noted the following: health disparity is defined as the difference in health outcomes between groups within a population. Although the terms may seem interchangeable, health disparity is different from health inequity. Health disparity denotes differences, whether unjust or not; health inequity, in contrast, denotes differences in health outcomes that are systematic, avoidable, and unjust. Hence, we will use the term health inequity to describe this special issue of our journal.
Inequity in our society is deeply rooted and creates the foundation for what others have called structural racism. Structural racism promotes poor health and the pandemic has made all of this axiomatic.
What have we learned from our colleagues across the nation who have shared their research findings with us as it relates to health inequities in our society currently? I believe several major themes have emerged from reviewing all of the submissions, both those we chose to publish here, and the scores of submissions that were not included in this special issue.
Effectively screening for the social determinants of health (SDOH) and getting this data into the everyday workflow for clinicians is a major challenge. For now, the SDOH remain an important part of the medical history. But we cannot yet say that we have carefully operationalized this information and the measures of its impact on the clinical outcome remain scarce.
Managing chronic illness for persons in poverty is a challenge, which touches upon issues such as mental health, lack of transportation, lack of childcare coverage, lack of paid days off, and related structural challenges in the way the poor attempt to work each day. Even the wealthy have challenges in managing chronic illness in our society!
The role of transportation in health inequities is underappreciated and articles in this special issue give research evidence to support changes in how delivery systems decide to staff off-site clinics, urgent care centers, and the like. Putting a new clinic with a freshly paved parking lot in an area unreachable by public transportation contributes to structural racism and, therefore, health inequities.
Mental health, for both adults and children, is also deeply underappreciated. Kudos to our contributors who bring this front and center and make specific evidence-based recommendations to tackle the epidemic of depression and anxiety especially prevalent during the pandemic.
The diffusion of new or existing technology such as telehealth and low-dose CT scanning for lung cancer, although impressive, creates challenges as it relates to reducing disparities in access to this technology. In a word, a telehealth program that only keeps the wealthy healthy does nothing to reduce health inequities.
Our contributors make it crystal clear that expanding access to insurance, whether through the Affordable Care Act, Medicaid, Federally Qualified Health Centers and the like, makes a difference. Access to care improves health.
Rural America faces all of these aforementioned problems and additional ones such as access to the internet and long distances to reach care that might not be readily available locally. Rural America suffers disproportionate health inequities that often go unnoticed or at least underreported.
I remain very interested in the rise of the for-profit SDOH industry. 6 Although we cannot paint all of those current companies with the same brush, clearly we need better research evidence about the contribution these firms make to actually improving health.
Fortunately, colleagues elsewhere in our industry are making an important contribution such as the Vizient Vulnerability Index, and related work coming from major national health care systems such as Mass General Brigham and the University of Chicago. 7 These yet to be published presentations will find their way into the peer-reviewed literature as the entire SDOH investigative field continues to mature.
Health inequities, similar to other components of structural racism, will not simply disappear once we reach the endemic stage of the COVID pandemic. Indeed, we will need to continue to build what the Pew Charitable Trusts 8 called resiliency, most especially in our great city of Philadelphia. This resiliency will mean many things, including easing of the housing problem, contending with a crushing opioid epidemic, modernizing our civil court system, and of course, improving the city's overall fiscal health, just to name a few.
We will also need more pragmatic approaches to counter health inequities. One approach might be new partnerships, especially with organizations across the spectrum of health care, including, surprisingly, major global pharmaceutical companies. As in our work with Closing the Gap 9 and related work elsewhere in the nation, sometimes new partnerships generate more solutions.
Finally, it is too early to ascertain the impact of the American Rescue Plan but I am confident that the Plan will at least continue to call attention to health inequity, especially as it relates to our most vulnerable citizens, our children. 10,11
I want to personally thank all of the contributors for their important dedication to the field of health inequities and for their doggedness in getting their articles to us on time. I would also like to thank the myriad peer reviewers who provided very helpful comments to the authors, and thereby invariably strengthened each article. I want to give special thanks to our incredible managing editor, Ms. Virginia Hawkins, whose tenacity, attention to detail, and professionalism helped make our journal essential reading during this tumultuous time in our history.
Finally, I owe a real debt of gratitude to 2 of our associate editors who went above and beyond the call of duty in helping us to craft this special issue: Doctors Shiva Chandrasekaran at Einstein Healthcare Network, now a part of the Jefferson system, and Jewel Mullen at the Dell Medical School in Austin, Texas. Hats off to Shiva and Jewel for their amazing help and for carving out precious time during a critical moment in health care.
Shining the light on health inequities has never been more important than now. On behalf of the entire editorial board, our authors, the myriad peer reviewers, and our publisher, my heartfelt thanks go to all of you, our readers. Your feedback on any aspect of this dedicated issue is most welcome. It is a privilege for me to be a part of this important and ongoing national dialogue. I am proud that our journal is a central component of the conversation.