Contributor: Maycie Elchoufi, MD
To learn more about Maycie, click here.
By the time you read this article, three months will have passed since I wrote it. Perhaps you’ll be gathering with friends and family for a summer picnic. Maybe you’ll notice 4th of July decorations on display and a festive vibe in the air. I hope that’s what things will look like for all of us.
However, at the moment it’s the last week of April 2020, and I am upstairs in my home office, hunched over my laptop. My thoughts filter through a lens of cabin fever and hay fever. My gaze wanders out the window and settles upon the house across the street. My neighbor is adjusting her mask as she stakes her row of Easter lilies, which are starting to bloom. A blanket of pollen coats my driveway – a golden path, interrupted only by a set of paw prints – evidence of my floppy-eared co-worker, softly snoring at my feet. All four legs are twitching in unison, likely in pursuit of a felonious squirrel.
From my perch the view is much like any other weekday morning in the middle of spring, except for my masked neighbor, my furry officemate, and the trending news content. There is no mention of pollen count or heat index, but the latest COVID-19 statistics show over 1 million confirmed cases of COVID-19 to date in the U.S., with over 60,000 deaths.
However, the heightened vigilance and sense of urgency we experienced back when the cherry trees first blossomed seem to have given way to “pandemic fatigue.” Many of us have settled into our “new normal” and have started embarking upon the “what happens next?” phase of our journey. Certain states and businesses have started to reopen, with some of us saying it’s too soon, and others protesting that we’re long overdue.
It was only three months ago, January 30th, that the World Health Organization declared the novel coronavirus a global public health emergency. One month prior to that date, many of us still had our 2019 holiday decorations up and had never heard of Wuhan. However, less than a month later, “COVID-19” had established itself in our country’s vernacular, and, in February 2020, the first COVID-related death in the U.S. was reported. Within a few short weeks, the number of confirmed cases in the U.S. exceeded 1,600 with over 40 deaths (although our ability to accurately measure prevalence was somewhat limited, at least in part due to logistical challenges around widespread screening and testing).
On March 13th, after conflicting narratives about the potential severity of risk posed to the American public by the pandemic, COVID-19 was declared a national emergency in the U.S., setting in motion a series of regulatory, operational, and fiscal changes in response to the threat. We were urged to stay at home. Various events would be cancelled across the country, travel bans enacted, schools closed, and toilet paper hoarded. An image of a bell-shaped curve was branded onto our collective consciousness. We were cautioned we must do our part to #flattenthecurve, lest the exponential surge in the number of people stricken by the illness potentially exceed our healthcare system’s capacity to care for them, thus placing us all in even greater jeopardy.
As I write this, only about 6 weeks have passed since the presidential declaration. We had already been practicing proper handwashing and trying to avoid touching our faces. We hunkered down and sheltered-in-place, as best we could. I tried new recipes, based on what was available in the supermarket at the time, observing an imaginary 6-foot bubble around myself and other shoppers. I baked – and ate – a lot of carbs. I even concocted home-made dog treats. We followed the news closely. We seemed more appreciative of frontline healthcare workers. We were also reminded of the importance of sanitation workers, postal workers, food service workers, and the multitude of shipping and distribution workers who package all the stuff we order online and deliver these items to our doorstep. We were more cognizant of the diverse range of people we depend on as a society, but whose contributions we often take for granted.
Facing uncertainty together seemed to augment our innate sense of connectedness and generosity of spirit. That’s a heart-warming thought to file in our memory banks. Some might even say the COVID-19 pandemic brought out the best in us. I believe it has – to an extent. The crisis also amplified the fact that, while we were all facing the same pandemic, we were by no means facing the same threat.
Even now, in late April, I cannot seem to equitably summon the range of thoughts and feelings I experienced a month ago. Some thoughts – even important ones – do not lend themselves to accurate recall as easily as others. But that’s how human memory manifests; it is not a fixed constant. A memory’s fidelity to the initial imprint is continuously shaped by our thoughts and feelings each time we try to retrieve the original “file.” Every time we remember an event or a moment in time, our brain’s neural circuitry reshapes that memory ever-so-slightly, bringing certain images into sharp relief and further reinforcing them with each iteration, like my dog’s pawprints in the pollen and my neighbor’s flowers. Meanwhile, the jagged edges of other memories start to recede, quietly blurring into the background static. For example, I prefer not to resurrect the nauseating heat rising from my chest and the churning in my stomach when I learned that my sister, a physician employed by a large hospital system, only had two N95 masks for the entire month of March.
I remember dining rooms and kitchen tables being converted into home offices, and many Americans, if they were fortunate enough to still have a paycheck, would find themselves working from home… unless they were “essential.” Essential workers did not have the luxury of being able to work from home, and often did not even have adequate PPE while they worked in settings where exposure risk was high. This group includes not only front-line healthcare workers, but a host of other individuals upon which our infrastructure depends, many of whom are employed in lower-paying jobs, such as those working in grocery stores, food services, sanitation services, manufacturing, and public transportation, to name just a few.
It would be still be another three weeks, April 8, 2020, before the CDC would release a report summarizing hospital data from 14 states, tracking not only disease prevalence and severity, but also describing characteristics of individuals hospitalized with COVID-19, including age, gender, medical co-morbidities and ethnographic data. Although the data set was limited, the report would serve to rip the Band-Aid from our collective conscience. We would be reminded, yet again, of our societal inequities and the fundamental importance of social determinants of health (SDOH), which are described by Healthy People 2020 as “conditions in the environments in which people live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.”
The CDC report showed that hospitalizations were highest among people 65 and older. African Americans made up about 18% of those studied yet accounted for about one-third of all severe cases. Data collected throughout our country echoed disturbing patterns related to COVID-19, for example:
- In Louisiana, African Americans comprise about a third of the population but account for 70% of deaths.
- In Michigan, African Americans account for about 14% of the population but 40% of deaths.
- In Wisconsin, African Americans represent about 7% of the population but 33% of deaths.
- In New York, African Americans were twice as likely to die as whites.
About 90% percent of people hospitalized with COVID-19 had at least one underlying health condition, such as high blood pressure, obesity, chronic lung disease, diabetes, and heart disease – diseases which disproportionately affect minority and lower socioeconomic groups – again underscoring the importance of SDOH.
Notwithstanding the confounding variables that one might invoke to moderate the significance of societal inequities on the prevalence and severity of COVID in certain groups (e.g., population density, personal choice, heterogeneity of gene expression, such as the ACE receptor on lung cells, etc.), the fact remains that none of these variables negate the fact that the scaffolding upon which good health is built is far more attainable for some groups relative to others. Healthy food, clean air, safe outdoor space, access to quality education, healthcare, housing, employment opportunities, and meaningful inclusion – these are foundational to our overall health and well-being.
In addition to shouldering a disproportionate degree of chronic disease burden, members of certain groups are also subject to greater risk of exposure to the virus for several reasons, such as being more likely to have jobs which are both essential and lower-paying. They are often reliant on public transportation to travel to work, which introduces recurring risk of exposure and infection. Members of these communities, in which we have historically failed to equitably invest resources, are also less likely to be able to access healthcare if they do become ill. They are less likely to have adequate health insurance or sick leave to recuperate.
Systemic inequities impairing one’s opportunity to attain optimal health affects many groups, including individuals with disabilities, our elderly, people living in multifamily and multigenerational housing, our homeless population, the African American, Latino, Native American, immigrant, and LGBTQ communities, and others. The list seems endless and overwhelming.
However, as overwhelming as it may be to think about, I can only imagine what it might feel like to experience some of these inequities first-hand. It’s easier to not imagine it at all. It’s easier to sympathize rather than empathize. I am not certain who to credit for this version of the following quote, but I think it captures the essence of our COVID-19 era: “We are all in the same storm, but we are not all in the same boat.”
The coronavirus pandemic has unmasked and amplified our nation’s glaring health inequities and its deep-rooted disparities, as have other health crises before it. The pandemic presents us with a reminder that we’re all in this together, and gives us a chance to do better. But we have been presented with this opportunity countless times previously: H1N1, hurricane Katrina, AIDS, etc.
What lessons do we remember from the past? More importantly, what do we choose to remember? And what memories do we choose to “flatten”? What values do we choose to act upon in a meaningful and consistent manner? Will the COVID-19 pandemic be our galvanizing moment? Or will our most prominent memory be the day we learned that toilet paper was more valuable than crude oil?
For now, I am encouraged to see that many of us – including individual citizens, governing bodies, community agencies and various businesses – are actively working together on relief and recovery efforts related to COVID-19. Pharmaceutical companies, medical researchers, the biotech industry, and other groups are collaborating to develop vaccines and treatments. I am genuinely heartened that social determinants of health are increasingly recognized as foundational to these efforts and to the well-being of our society as a whole.
However, by the time anyone reads this, three months will have passed. The explosion of springtime allergens will have been replaced by fireworks in celebration of our nation’s independence. We have indeed come a long way in acknowledging some of the inequities which have been unmasked by COVID-19, but we have a great deal of work left to do. This work will be difficult and unsettling at times. We cannot predict what might happen in the future, but we can choose to be informed by patterns we have previously experienced. Unanticipated challenges arise. Priorities get reshuffled. Life happens. The world moves on. Memories are remodeled, and the mind tries to tweak uncomfortable truths into more palatable options. Commitment sometimes yields to convenience. This is to be expected. But we always have a choice.
I am writing this account to serve as a reminder to myself as much as a message to anyone who may be reading this in the future. Let us hold the lessons we’ve learned and the commitments we’ve made close to heart and clear in sight. Let’s be intentional about what we choose to remember, and let’s make it matter. Too many lives have been lost for us to accept selective amnesia.
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