COVID-19, health disparities and the US election

The recent Coronavirus Disease 2019 (COVID-19) pandemic has been distinguished by its disproportionate high rates of infection, hospitalization, and mortality in oppressed and disenfranchised communities [1Nguyen L. H. Drew D. A. Graham M. S. et al. Risk of COVID-19 among front-line health-care workers and the general community: a prospective cohort study. Lancet Publ Health. 2020; 5 (Sep): e475-e483https: //doi. org/10. 1016/s2468-2667 (20) 30164-xSummary Full Text Full Text PDF PubMed Google Scholar, 2Golestaneh L, Neugarten J, Fisher M, et al. The association of race and COVID-19 mortality. EClin Med 2020/07/15/ 2020: 100455. doi: https: //doi. org/10. 1016/j. eclinm. 2020. 100455Google Scholar]. These disparities have drawn great global attention to inequities in social determinants of health (SDOH) such as education, employment, housing, and access to affordable health care, which often increase risk for contracting and dying from COVID-19 in Black, Indigenous, and People of Color (BIPOC) communities [3Egede L. E. Walker R. J Structural racism, social risk factors, and Covid-19 — a dangerous convergence for black Americans. N Engl J Med. 2020; 383 (2020/09/17): e77https: //doi. org/10. 1056/NEJMp2023616Crossref PubMed Scopus (329) Google Scholar]. In most instances, inequities in SDOH are independent of the level of national wealth, as exemplified in Canada, the United States (US) and the United Kingdom (UK), by their translation into disparities. However, among wealthy nations the US is an outlier in not having universal health coverage, despite the 2010 Affordable Care Act, which was a major step in providing a broader safety net of care [4Blumenthal D. Abrams M. Nuzum R The affordable care act at 5 years. N Engl J Med. 2015; 372 (2015/06/18): 2451-2458https: //doi. org/10. 1056/NEJMhpr1503614Crossref PubMed Scopus (175) Google Scholar]. The US also stands out, among wealthy nations in having by far the highest level of income inequality and the worse index of health in almost every health outcome and social dynamic [5Wilkinson R. Pickett K. The spirit level: why greater equality makes societies stronger. Bloomsbury Publishing USA, 2011Google Scholar], levied most heavily upon BIPOC in the US. Since the founding of the US, oppressive dichotomies against BIPOC have existed and, over the last fifty years, have had pressing and visible impacts in the US. This divide has never been so dramatic and visible to the entire world as it is today when examining health through the lens of COVID-19 [3Egede L. E. Walker R. J Structural racism, social risk factors, and Covid-19 — a dangerous convergence for black Americans. N Engl J Med. 2020; 383 (2020/09/17): e77https: //doi. org/10. 1056/NEJMp2023616Crossref PubMed Scopus (329) Google Scholar]. This does not mean the US is not a great nation in many respects. As nations celebrate accomplishments, they must also recognize when its people have been wronged and seek opportunities to correct the wrong. The COVID-19 pandemic has not only exposed the stark and ever present structural racism in the US [3Egede L. E. Walker R. J Structural racism, social risk factors, and Covid-19 — a dangerous convergence for black Americans. N Engl J Med. 2020; 383 (2020/09/17): e77https: //doi. org/10. 1056/NEJMp2023616Crossref PubMed Scopus (329) Google Scholar, 6Bailey Z. D. Krieger N. Agenor M. Graves J. Linos N. Bassett M. T Structural racism and health inequities in the USA: evidence and interventions. Lancet. 2017; 389 (Apr 8): 1453-1463https: //doi. org/10. 1016/s0140-6736 (17) 30569-xSummary Full Text Full Text PDF PubMed Scopus (0) Google Scholar], but has amplified racial/ethnic tensions leading to national protests for racial and social justice, all in the midst of a presidential election year. As always there are many factors that influence voting decisions: abortion rights, women's rights, tax cuts, environmental justice, and, now more than ever in the last 50 years, racial and social justice along with health care for all. The COVID-19 pandemic has influenced the 2020 US elections and its respective campaigns in numerous ways, including but not limited to highlighting structural racism embedded in the US election process. Not only has the pandemic limited the gathering of groups that are a core aspect of traditional campaigning for the presidency, but the actual proposed management of the COVID-19 pandemic by the presidential candidates has become an important campaign issue, especially for communities it impacts most: BIPOC and essential workers. However, COVID-19 presents a contradictory dynamic: it is an important issue to voters, but a decline in new voter registrations due to closure of government offices like departments of motor vehicles and increased risk for infection in persons voting using the more traditional approach (e. g. at polling stations in their local communities), presents a challenge. For those who opt to vote in person, the increased physical distancing at the polls with the longer wait times is particularly difficult for parents, elders, and frontline workers, whose jobs don't allow time off to vote. To reduce the risk of getting infected more people than usually are opting to vote by mail, an especially important strategy for many members of communities who are at higher risk for COVID-19 infection and complications. Unfortunately, anticipated changes in COVID-19 on voting patterns has led to the promotion of voter suppression strategies. More specifically, the current US administration has promoted gross misinformation about the magnitude of possible irregularities in voting by mail despite it being successfully used in the US since the American Civil War, over 150 years ago. In addition, the number of polling stations have been reduced in many communities where BIPOC and low-income populations reside, and senior elected officials have prompted local militia groups to oversee polling stations as part of a longstanding set of varying practices of voter suppression. Together these factors could further limit the ability of oppressed communities to participate in a formal approach to help reduce structural racism and eliminate the persisting structural inequities in SDOH that underlie the COVID-19 health disparities. Thus, the COVID-19 pandemic that has highlighted the plight of many BIPOC communities in the US may also influence the election and reduce the participation of those most affected and wanting to make positive changes with a vision of one day eliminating the US’ enduring caste system [7Bonilla-Silva E. Racism without racists: color-blind racism and the persistence of racial inequality in the united states. Rowman & Littlefield Publishers, 2006Google Scholar]. So, what then is the way forward? In regards to achieving health equity, the World Health Organization (WHO) has identified three major principles of action to address the systemic injustices that can arise with unequal distribution of the social determinants of health [8Organization W. H. Closing the gap in a generation: health equity through action on the social determinants of health. World Health Organization, 2008Google Scholar]. First, improve people's living and working conditions to allow them to achieve their full health potential. Second, re-organize the distribution of power, resources and money in a more equitable manner. Third, educate health-care workers and the broader society on how inequities in the social determinants of health that drive the disparities we profess to want to eliminate. Each of these three principles are highly relevant for the US and the many marginalized and under resourced American communities. Importantly, the first two are highly dependent upon a functional and equitable voting system in a democratic society. The COVID-19 pandemic threatens the sanctity of the 2020 US election. Ideally the US could benefit from input from the International Foundation for Electoral Systems (IFES) [9Shein E. Ellena K. Barnes C. Szilagyi H Leadership in crisis: ensuring independence, ethics and resilience in the electoral process. 2020https: //www. ifes. org/sites/default/files/leadershipᵢncrisisₑnsuringᵢndependenceₑthicsₐndᵣesilienceᵢnₜheₑlectoralₚrocess. pdfGoogle Scholar], but it would require bipartisan support for agreeing to and enforcing their recommendations. Until then a few suggestions around voting include increasing the number of polling stations especially in marginalized communities, making the day to vote for the presidential election a national holiday, removing the limits to the right to vote for formerly incarcerated people who by definition have paid their debt to society, and a broad condemnation and harsh legal penalties to prevent the new and continuing voter suppression practices which represent the legacy of structural racism embedded in the 150 year history of voter suppression tactics mostly targeting BIPOC voters [10Anderson C. One person, no vote: how voter suppression is destroying our democracy. Bloomsbury Publishing USA, 2018Google Scholar]. In the words of Sir Winston Churchill – “You can always count on the Americans to do the right thing after they have tried everything else”. We have been trying for nearly 250 years, the question is how much longer will it take until we do the right thing? KN is supported in part by NIH research grants UL1TR001881 and P30AG021684, and CG is supported by CTSI S00702B0.