COVID-19 and the Impact of Social Determinants of Health

Executive Summary 

The coronavirus disease caused by SARS-COV-2 originated in Wuhan, China and has since spread to the rest of the world with devastating consequences. According to the Johns Hopkins Coronavirus Resource Center, over 4.3 million people were infected by May 14, 2020, with over 297,000 registered deaths (Abrams & Szefler, 2020). The novel disease, however, has the following challenges. First, in a large population of the patients, the disease's presentation ranges from mildly symptomatic to asymptomatic (Driggin et al., 2020). Secondly, complications, and often death, come long after the infection. In other words, the virus as a longer incubation period (2 to 3 weeks after infection), before it starts to present clinically. As a result, the infected individual could spread the virus to more people, thus limiting the effectiveness of any containment protocols. These individuals are most likely unaware that they are disease vectors because they are more likely to be asymptomatic or mildly symptomatic (Torales et al., 2020). In a clinical study of 16186 suspected cases and 10567 confirmed cases, 81.4% were mildly symptomatic while 13.9% were severe and the last 4.7% were in critical condition (Wu & McGoogan, 2020). Furthermore, the clinical presentation of the infection was similar to other viral infections while the severe cases presented as pneumonia and ARDS (Acute Respiratory Distress Syndrome; Huang et al., 2020; Li et al., 2020). Lastly, testing is a challenge for most jurisdictions, and geographic regions lack the equipment or infrastructural support (Abrams & Szefler, 2020). These factors combined make it a highly infectious and hard to diagnose the condition that has no cure yet. 

It is essential to address these contributing factors immediately if all efforts to stop the spread of the virus are to be effective. Specifically, three strategic populations need to be protected if there is to be some hope of containing the pandemic. First, infected individuals need to be isolated (quarantined). Furthermore, vulnerable populations, especially older adults in nursing homes and other health care institutions, need to be protected. These vulnerable populations, especially those with comorbidities like cardiovascular disease and respiratory system conditions, are like reservoirs for the infection (Murthy et al., 2020). If they are not protected from the pandemic, then the infection will continue returning in waves in the future. Secondly, health care practitioners currently providing care and testing services are vulnerable to contracting the infection. These individuals need to be protected for three reasons. First, it is human dignity and ethical to do everything possible to protect human life. Secondly, without the health care practitioners, the virus will spread more because their skill and experience are essential to providing quality care. Thirdly, if the patients and older adults in hospitals and care facilities are like reservoirs for the infection, then the practitioners are the link through which the virus would escape containment and start spreading to the entire population. Therefore, it is tactical and strategic to provide all protective measures to protect the health care practitioners from the pandemic. The last population that needs protection and regulation are the participating providers. Though their main function is information collection and running the care facilities, their continued operation would facilitate the collection and utilization of resources towards solving the challenges created by the pandemic. 

Fast Facts about COVID-19 

It has affected over 4.3 million people, with over 297,000 deaths by May 14, 2020 

81.4% of the cases are mildly symptomatic, 13.9% severe, and 4.7% critical 

Mild symptoms are virtually indistinguishable from the symptoms from common viruses 

Severe cases present with pneumonia and ARDS 

The virus takes about 2 to 3 weeks to become symptomatic, thus is very infectious 

There is no infrastructural support for testing and treating the virus 

Background and Significance 

Economic factors have been found to affect health and the prevalence of COVID-19 in a certain population. For instance, economically deprived individuals are more likely to live in poverty, live in low-income neighbourhoods, or be homeless. According to Tsai & Wilson (2020), homeless people are at a higher risk of infection due to close living quarters and lack of access to screening facilities. The health of the individual is another social determinant that impacts the severity of the virus. For instance, a study in Boston established that smokers are at a higher risk of developing adverse outcomes than non-smokers. These individuals are also more likely to be admitted to the intensive care unit, require ventilation for life support, and have a higher COVID-19 related mortality (Adams & Szefler, 2020; Yancy, 2020). Therefore, lifestyle choices, as well as economic factors, have a significant impact on the spread of the virus. 

On the other hand, the question of the impact of the pandemic at a large scale is a concern to public health. Historically, the health care system has been designed in a manner that pandemics would disproportionately affect the disadvantaged and the poor. As a result, there is a higher risk of the infection returning in the future due to wintertime outbreaks. Winters are a public health concern because other social determinants, such as overcrowding, quality housing, and proper nutrition would either drive individuals out or put them in closed spaces for extended periods, thus increasing the rate of spread of the virus (Adams & Szefler, 2020). However, winters are not the only environmental risk that is being amplified by the pandemic. To limit the spread of the virus, government, local and national, have had to take specific measures in waste management. Medical, household and other waste have had to be handled carefully to minimize secondary impacts on the environment (Nishiura et al., 2020). Such strategies are also effective when preventing the spread of the virus through other vectors. 

It is clear that nurses and other health care practitioners have had a significant impact on controlling the spread of the virus. However, a survey conducted by the American Nurses Association with a sample size of 32,000 revealed that 87% of the nurses were afraid to go to work, 36% lacked the quality of adequate personal protective equipment (PPE) when they had to provide care for an infected patient, and 11% believe that they are prepared to care for patients with COVID-19 (Schulz & Shattell, 2020). According to McCauley & Hayes (2020), approximately 600 health care practitioners have died from the virus, thus raising several ethical concerns. It is part of the practitioner's ethical duty to provide the best care they can. However, is it ethical to expect them to do so considering the risks they expose themselves to? The situation is compounded further by the consideration that while the nurses and other health care practitioners have the right to protection, the patients also have the right to receive the best care available, infected or not. Therefore, the ethical dilemma lies in whose rights take priority and how the situation should be resolved. 

Social Determinants of Health 

Health 

The economy 

The health care system 

Nursing practice or advanced nursing practice 

The environment 

Human rights (e.g., ethical factors and theories) 

Position Statement 

In response to the pandemic, the government has taken several measures. Apart from closing institutions of learning and putting in place social distancing measures, the government, through the Federal Reserve has taken several measures to protect the economy, and the livelihoods of the Americans by extension. For instance, the Federal Reserve purchased $500 billion of treasury securities and over $200 billion mortgage-backed securities (Mizrach & Neely, 2020). Furthermore, the government released a $2 trillion federal stimulus package (the Coronavirus Aid, Relief and Economic Security Act (CARES)). These actions, according to Schulz & Shattell, 2020), were taken to ensure the economy responds to the crisis while helping to prepare hospital staff and health care practitioners in treating and providing care for patients with COVID-19. These legislative actions, however, are short term and would create more problems than they solve. For instance, they do not provide a regulatory framework and oversight for the preventative measures to stop the spread of the virus while protecting the vulnerable populations. Furthermore, the measures are designed from an economic standpoint, this would largely be incompatible with providing health care needs. 

The solution to these problems and concerns comes in the form of the US Congress House Bill 8114. The purpose of the bill is to ensure that different stakeholder, from personnel and residents of long-term care facilities to state survey agency personnel, with PPEs while they conduct their duties. The bill also ensures that residents of care facilities, their personnel, and participating providers regularly get tested for COVID-19 to prevent the spread of the virus, to or from the facilities. Finally, the bill requires that standards and frameworks for care be drafted, implemented, and complied with to control the virus. The bill is the most appropriate solution to the current problems because it resolves the issues raised by Abrams & Szefler, 2020, Driggin et al. (2020), and Torales et al. (2020). These issues were discussed and summarized in the executive summary section above. 

Evidence-based Strategies 

The strategies proposed by the Congress House Bill 8114 are effective because it ensures that all individuals caring for older adults and infected patients have adequate protection. As a result, private stakeholders can start addressing the critical supply shortages of the PPEs (Cook, 2020; Ranney et al., 2020). Besides, the bill addresses the regulatory changes, especially the creation of standards and compliance entity to help coordinate the efforts and implementation of the proposals. Therefore, the bill is efficient because it will ensure that all stakeholders implement its provisions at the same time. It is also equitable because all stakeholders will benefit without a chance for inequalities to occur. 

Recommendations for Action 

It is, therefore, recommended that the bill be passed and signed into law as soon as possible. However, the bill needs one major ratification. So far, it has been focused on protecting long-term care facilities, its personnel and residents. However, the provisions proposed could also be effective in addressing the current issues in the entire health care industry. Therefore, the bill needs to be changed to expand its influence to other health care providers and patients. After all, they too could contribute to stopping the spread of the pandemic. 

Opposition 

Though the bill has yet to pass and there are no literature sources published to oppose it, critics could claim that the changes introduced by the bill could be difficult to implement and monitor. However, this form of opposition is not critical because the value of the bill outweighs the argument. On the other hand, a critic could oppose the bill on the grounds that it would provide unequal protection to older adults and the person caring for them while other health care practitioners are risking their lives. The answer to this argument is that the bill's focus is strategic because long-term care facilities are one of the potential virus reservoirs that need to be resolved to prevent future reoccurrences. 

References 

Abrams, E. M., & Szefler, S. J. (2020). COVID-19 and the impact of social determinants of health.  The Lancet. Respiratory Medicine . 

Cook, T. M. (2020). Personal protective equipment during the coronavirus disease (COVID) 2019 pandemic–a narrative review.  Anaesthesia . 

Driggin, E., Madhavan, M. V., Bikdeli, B., Chuich, T., Laracy, J., Biondi-Zoccai, G., ... & Brodie, D. (2020). Cardiovascular considerations for patients, health care workers, and health systems during the COVID-19 pandemic.  Journal of the American College of Cardiology ,  75 (18), 2352-2371. 

Huang, C., Wang, Y., Li, X., Ren, L., Zhao, J., Hu, Y., ... & Cheng, Z. (2020). Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China.  The lancet ,  395 (10223), 497-506. 

Li, L. Q., Huang, T., Wang, Y. Q., Wang, Z. P., Liang, Y., Huang, T. B., ... & Wang, Y. (2020). COVID‐19 patients' clinical characteristics, discharge rate, and fatality rate of meta‐analysis.  Journal of medical virology ,  92 (6), 577-583. 

McCauley, L., & Hayes, R. (2020). Taking responsibility for front-line health-care workers.  The Lancet Public Health ,  5 (9), e461-e462. 

Mizrach, B., & Neely, C. J. (2020). Fed Intervention in the To-Be-Announced Market for Mortgage-Backed Securities.  Economic Synopses , (19). 

Murthy, S., Gomersall, C. D., & Fowler, R. A. (2020). Care for critically ill patients with COVID-19.  Jama ,  323 (15), 1499-1500. 

Nishiura, H., Oshitani, H., Kobayashi, T., Saito, T., Sunagawa, T., Matsui, T., ... & Suzuki, M. (2020). Closed environments facilitate secondary transmission of coronavirus disease 2019 (COVID-19).  MedRxiv . 

Ranney, M. L., Griffeth, V., & Jha, A. K. (2020). Critical supply shortages—the need for ventilators and personal protective equipment during the Covid-19 pandemic.  New England Journal of Medicine ,  382 (18), e41. 

Schutz, V., & Shattell, M. (2020). Impact of COVID-19: What Does It Mean For Nurses and Health Systems?.  Journal of Psychosocial Nursing and Mental Health Services ,  58 (8), 2-3. 

Torales, J., O'Higgins, M., Castaldelli-Maia, J. M., & Ventriglio, A. (2020). The outbreak of COVID-19 coronavirus and its impact on global mental health.  International Journal of Social Psychiatry , 0020764020915212. 

Tsai, J., & Wilson, M. (2020). COVID-19: a potential public health problem for homeless populations.  The Lancet Public Health ,  5 (4), e186-e187. 

Wu, Z., & McGoogan, J. M. (2020). Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72 314 cases from the Chinese Center for Disease Control and Prevention.  Jama ,  323 (13), 1239-1242. 

Yancy, C. W. (2020). COVID-19 and African Americans.  Jama .