What lies beneath underlying health conditions… A look at the intersection of chronic medical conditions, health disparities, and COVID-19

Recently we’ve been hearing a lot about “underlying health issues”, “pre-existing conditions” and “chronic medical conditions” as a primary explanation for the disparate impact of COVID-19 on African American and other racial and ethnic communities. Chronic medical diseases are defined as medical conditions that persist over time (usually one year or more) and require ongoing medical treatment. Conditions such as high blood pressure, heart disease, diabetes, obesity, kidney disease, and lung diseases such as asthma, which are more prevalent in these communities, increase the risk for severe illness from COVID-19.

 Population differences in COVID-19

Recent data showed that African Americans and Latinx have been three times more likely to contract COVID-19 than Whites and nearly twice as likely to die from it. In some areas in the U.S., these differences between population groups have been even greater, such as New Mexico, where American Indians make up about 11 percent of the population, however, account for more than half of COVID-19 cases. American Indians also have the highest prevalence of Type 2 diabetes. Overall, people who have chronic medical conditions such as heart disease, diabetes, or lung disease who are diagnosed with COVID-19 are six times more likely to be admitted to the hospital and 12 times more likely to die compared to those with no underlying medical condition.

What had been missing from the broader conversation was the root cause of this. The pandemic forced society to face what researchers, public health officials, and those who prioritized these differences in health outcomes as important have known for years. The conversation has finally shifted from the what to the Why.   Why do certain population groups, such as African Americans or American Descendants of Slavery more specifically, have such a higher prevalence of chronic disease to begin with. These discussions have mostly been done on an academic level, however, I felt it vital for the community to be involved in this conversation.

Digging up Roots

For decades we have been inundated with statistics about how bad the health of Blacks is compared to Whites without little explanation concerning the root cause. The data was often presented in a way that placed blame on marginalized groups for their condition with little accountability for the role systems and institutions played in individuals having the opportunity to achieve their highest level of health. These racially biased epithets had become commonplace to explain away the unjustifiable differences in health outcomes in certain population groups versus others. These disparities are not random or by chance. They persist due to an expected outcome of a system working as designed.

 The soil of white privilege and supremacy was cultivated; seeds of racism were planted and watered with various forms of violence and oppression to produce crops of inequities and inequalities across multiple areas of life, including health. The roots of these crops, i.e. structural and institutional racism, run deep and are vast, creating intricate systems and networks for growth of desired fruit.

Historical trauma, discrimination, and medical experimentation fertilized distrust of systems that crossed generations. When we dig up what lies underneath these underlying health conditions, we find avoidable and unjust differences rooted in employment, income, housing, transportation, education, food security, incarceration, police violence, environmental conditions (i.e. pollution, crowded housing, segregation), healthcare access and quality. These conditions, also known as social determinants of health, play a key role in the health and resiliency of a community, especially during a pandemic.

When we consider the racial wealth gap alone, in the U.S. White households own 85% of the national wealth, Blacks 4%, and Hispanics 3%. In 2016, White households had a median wealth of $171,000, Blacks $17,600, and Hispanics $20,700. This gap is predicted to widen over the next 40 years driving the discussion for reparations not just for economic reasons, but because income and wealth is a predictor of health outcomes. Money means power and power means access and resources. However, even when we adjust for access and means, the differences in health outcomes in populations still exists. This underscores the importance of abolishing structural racism as a key determinant for health equity.  

From Post-traumatic Slave Syndrome to Toxic Stress

Living in an unjust and oppressive society has produced long-term consequences of chronic and toxic stress that negatively impacts mental, emotional, and physical health for communities of color. This started with chattel slavery, and extended through Jim Crow, redlining, mass incarceration, welfare rules, and police violence. This cumulative exposure to repeated socioeconomic disadvantage causes early deterioration of the body. The body’s stress response, also known as fight or flight, triggers the body’s brain, immune, and endocrine systems to respond to threats (i.e. discrimination, poverty, violence)  by releasing hormones and chemicals, mainly adrenaline and cortisol, which can cause inflammation and specific damage to organs when the exposure is ongoing. This is particularly important in childhood when the brain is still developing (Adverse Childhood Experiences/ACEs). Research has found that traumatic stress leaves a chemical mark on a person’s genes which can be passed down to future generations. The turning on or off of specific genes, known as gene expression, contributes to the development of chronic medical conditions. In addition, chronic stress and cortisol contributes to the breakdown of the protective casing at the end of DNA strands, known as telomeres, which contributes to early cell death and inflammation in the body. When you consider how prevalent conditions such as high blood pressure is in the African American community, understanding the roots of illness gives a deeper understanding of what needs to be done to make us whole.

 To heal, we must destroy it from the roots.

By: Tamiko Foster, MD, MPH 

Sources:

1. The Centers for Disease Control  

2. Federal Reserve Board, Survey of Consumer Finances and Financial Accounts of the United States.  

3. National Scientific Council on the Developing Child at Harvard University. www.developingchild.net