STRUCTURAL BARRIERS: THE ROLE OF SYSTEMS AND INSTITUTIONS

For some Americans, protecting themselves or their family during the pandemic means for example forgoing Covid-19 vaccination to ensure a paycheck rather than risk taking unpaid time off because of side effects. Communications campaigns or behavioral interventions can’t adequately address such a barrier – it requires direct financial support in case work days are missed due to side effects, or a policy change mandating paid sick time (which then needs to be effectively communicated and enforced.)

The hidden cost of getting vaccinated – such as taking time off, paying for childcare, and having transportation to a vaccination site – are just one of many structural factors that impact vaccine demand.

Failures to understand and address such structural barriers have led to misguided interventions and contributed to significant inequities and vaccination struggles in this pandemic. When vaccination efforts include consideration of structural factors alongside information and social/behavioral factors, however, they often lead to improved outcomes.

Structural barriers don’t affect all Americans equally

In the U.S., structural racism and economic discrimination have enabled systems that determine who is most affected by structural barriers: People of color and low-income people.

The data on this has been unequivocal for decades – people of color and poor people have consistently lived sicker and shorter lives than white or wealthy Americans. According to the most recent data, white Americans on average live almost four years longer than Black people and close to six years longer than Indigenous people. This pattern is also reflected in the gaps between income groups – today, the richest American men live 15 years longer than the poorest men, while the richest American women live 10 years longer than the poorest women.

Notably, this data reflects the period immediately preceding the Covid-19 pandemic; disparities will now likely be larger as the same communities that have had worse health outcomes before the pandemic have endured higher rates of infection, hospitalization, and death in this pandemic. While life expectancy dropped for all races in 2020, for example, it dropped by 1.2 years to 77.6 years for whites but by 3.0 years to 78.8 years for Hispanic/ Latinx and by 2.9 to 71.8 years for Black people.

This is because of the impact of what experts call the Social Determinants of Health: “The conditions where people live, learn, work, and play affect a wide range of health and quality-of-life risks and outcomes,” states the CDC.

In a nutshell, the concept of Social Determinants of Health (SDoH) acknowledges that promoting health equity and wellness for all requires more than medical care – it requires providing economic stability, education, safe neighborhoods, food security and other enablers.

Some of these SDoH are well understood, particularly those tied to economic poverty. Others — such as access to and quality of information — are only partially understood.

In the United States, structural racism and economic discrimination are intersecting drivers of negative health outcomes due to social determinants.

Let’s take a closer look at how these structural factors have played out in the pandemic and continue to influence vaccine demand.

Structural Factors: from vaccine supply to social determinants of health

There are two types of structural factors that influence vaccine demand:

Direct structural factors, such as how vaccines are developed, produced, distributed and administered. These are usually considered in vaccine demand efforts, and addressed to varying degrees. They are initiated and executed by authorities and institutions during a pandemic, and often fall into the category of Vaccine Supply.

Indirect structural factors, such as how housing, jobs, healthcare systems, food security, safe neighborhoods and the effects of structural racism impact people’s health. These are often overlooked or considered too complex to address through a single measure such as a vaccination campaign. They are shaped by policies and actions taken by authorities and institutions since long before the pandemic, and are often described as the Social Determinants of Health.

Direct structural factors play out in ways that
are deeply shaped by indirect structural factors. Immediate needs for physical safety and daily meals, for example, often supersede needs such as safety from a novel disease; to reach people who live with food or housing insecurities, vaccination efforts need to provide support with such essentials first.

Why economic opportunity & stability matter

Grocery store clerks, bus drivers, teachers, nurses, farm workers – these are just a few of the positions that make up the fifty million US workers deemed “essential” and “frontline” who have shouldered the pandemic’s greatest burdens. Often paid low wages but required to stay on the job, they face significantly increased risk of infection, little support if they or a family member gets sick, and the greatest chance of losing their job

Low wages are a risk factor for Covid-19. Low-income workers often have little financial cushion, making it challenging to take time off work and thus forcing people and by extension their families to risk workplace exposure. Only 35% of low-wage workers have paid sick leave, while 95% of high-wage workers do. Moreover, the national increase in unemployment during the pandemic has overwhelmingly affected low-wage workers. In 2020, low-wage jobs were lost at about eight times the rate of high-wage ones.

Denied paid time off to cope with potential side effects, health insurance to protect against surprise bills, or ability to pay for child care or transportation, people in these positions have been left behind in the vaccine rollout. By June 2022, only 37.5% of  workers ages 18 and older making $25,000 dollars or less had received two doses of two-shot series or a single dose vaccine.

People of color account for 24% of the US population but represent the majority of low-wage,“essential” workers, increasing their risk of Covid-19 infection. For instance meat processing plants are disproportionately staffed by workers of color, who  made up 87% of Covid-19 cases in these sites.

The pandemic’s disproportionate damage to workers of color continues the nation’s legacy of racialized exploitation, occupational segregation, and racial economic inequity. Black and Hispanic/ Latinx people are concentrated in low wage positions because of systemic factors including racial discrimination in hiring, unstable employment and community disinvestment.

As a result, there are significant racial economic disparities. For instance, the typical white family has eight times the wealth of the typical Black family and five times the wealth of the typical Latinx or Hispanic family.

By shaping the resources at our disposal, the disease risks we are exposed to, and our ability to mitigate these risks, economic instability simultaneously shapes health as an independent variable and through other SDoH that are described below. Unpredictable employment and work schedules, little or no benefits, and wages too low to achieve financial security lead to the greater likelihood of disease and premature death. The most recent research indicates that the gap in life expectancy between the richest 1% and poorest 1% of Americans is 14.6 years.

These underlying structural factors explain how economic instability and inequity undermine vaccination efforts. Nationwide, by October 2021, counties with lower vaccination rates had lower  median annual household incomes, one study found. In 8 of the 10 largest cities in the U.S., undervaccination was associated with poverty, enrollment in Medicaid, or being uninsured.

The role of neighborhoods in wellbeing

The neighborhoods we live in have been a central  marker for Covid infection and vaccination rates. At the pandemic’s start, poor urban areas saw the majority of infections and death but by fall of 2020, rural poor counties led the nation in cases. In particular, it is highly diverse counties and highly segregated rural counties that have struggled most. A February 2021 analysis for example showed that by that time, highly rural diverse counties had experienced a 60% higher death rate than less diverse counties.

Vaccine distribution has been just as unequal. The initial rollout focused on urban areas and hospitals, academic medical centers and later expanded to clinics and pharmacies, which are less accessible to poor rural communities, creating “vaccine deserts”. Close to 9 million Americans live further than 10 miles from the closest vaccination site

Poverty is greater in rural areas (14%) compared to urban areas (10%) and poor rural Americans face numerous economic barriers to vaccination as explained in the previous section. There is also a severe shortage of hospitals, clinics, and health care  providers in rural areas and large chain pharmacies  have fewer locations in rural areas. People of color are the most economically marginalized in rural areas. More than 30% of Black people, 29.6% of Indigenous people and 21.7% of Hispanic/Latinx people who live in rural areas live at or below the federal poverty line ($27,750 for a family/household  of 4) compared to 13.3% of rural white Americans.

These place based disparities in Covid risk, infection, death, and vaccination follow a dependable link between neighborhoods and health outcomes. Your neighborhood determines the economic opportunity available to you, the quality of your housing, access to healthcare and a safe and strong social network, which all shape health. Health may also be adversely affected by neighborhood characteristics such as poor air and water quality, proximity to hazardous substances, substandard housing, and lack of access to nutritious foods and safe places to exercise or play.

A long history of racist strategic disinvestment in minority neighborhoods determines why some places are worse for health than others; and who lives there. This history includes segregationist policies like discriminatory zoning rules, redlining, and land dispossession of Indigenous people. As a result, people of color are more likely to live in areas of concentrated poverty, while whites are more likely to live in areas of concentrated wealth.

The importance of housing

For millions of Americans, home is a place shared with more than immediate family. The number of Americans who are sharing homes and living in congregate spaces to deal with growing economic pressure and housing insecurity is increasing, data shows. Currently, approximately 20% of U.S. households are shared housing (using the most expansive definition of shared housing), 7% of households are shared by more than 1 family, and 20% of households are multigenerational. However, with more people in one house, it is harder to socially distance or isolate someone who is infected, increasing the risk of spreading Covid. For example, in 2019, before the pandemic, 31% of multiperson  homes with an individual 65 years or older did not  have at least two full bathrooms.

People without homes or stable housing face a significant risk for Covid infection, hospitalization and death. People living on the streets, in their cars, or in shelters are more likely to have a compromised immune system, suffer from chronic, underlying physical and mental conditions, and have trouble maintaining personal hygiene without access to a restroom or laundry facilities. People experiencing homelessness who have work (as many do) are often in low-wage jobs, facing the challenges described previously.

The shortage of affordable, safe housing limits the choices people have about where they live, and can force lower-income families into overcrowded neighborhoods that may be unsafe due to higher rates of poverty and fewer resources for health promotion (e.g., parks). The quality or condition of a home affects health: a home can be cold or hard to heat, contain hazards such as fall risks or faulty wiring, be damp and moldy, or be overcrowded. Unsafe and low quality housing conditions contribute to infectious and chronic diseases, injuries, poor childhood development and mental  and psychological challenges.

The effects of housing on Covid-19 risk and outcomes are disproportionately shouldered by people of color.

Requiring early in the pandemic that most Americans “stay at home, work and learn from home” – initially without instructions for those in congregate living settings – also revealed how much authorities and some experts were out of touch with the lived realities of many Americans, including those who chose to live in shared or multigenerational housing. Shared housing isn’t the same as overcrowded housing and sharing a home has social and other advantages; for some, especially in communities of color, it is an essential way of life. Trust was lost as these communities needed additional guidance on how to protect themselves at home but struggled to find it.

The consequences of healthcare inequities

For millions of Americans, healthcare is neither accessible nor affordable. In a pandemic, lack of healthcare for example means:

• People do not have an existing, trusted physician or healthcare worker to ask for advice about vaccines or when they fall ill.
• People are likely to have encountered high healthcare costs when they needed treatment, and may have been subject to surprise billing, factors that can increase distrust that vaccines, treatments or tests can truly be free.
• People haven’t been able to do routine visits and preventive care, which puts them at higher risk for negative outcomes should they get Covid-19.

One of the most central factors in inequitable access to care is health insurance inequities. The latest data shows that 9.7% of Americans  are uninsured and an additional 21.3% were underinsured. People who are “underinsured” have high health plan deductibles and out-of-pocket medical expenses relative to their income and are more likely to struggle paying medical bills.

People can be uninsured because their employer does not provide coverage, they can’t afford private insurance, they live in a state that did not expand Medicaid or they remain ineligible for financial assistance for coverage. Additionally, undocumented immigrants are ineligible for Medicaid or Marketplace coverage. Being uninsured or underinsured often leads to negative and upsetting interactions with the healthcare system or in many instances, no interaction at all. Without adequate insurance, many people delay seeking  care, or forgo it entirely.

The same people who are most likely to be underinsured or uninsured also shoulder the largest burden of low-quality health care. Decades of  research have shown that Black, Latinx/Hispanic, Asian, and Indigenous people receive lower-quality care than the majority white population. Some of this can be explained by disparities in insurance coverage and hospital segregation but disparities still exist when controlling for economic factors.

Shortages of primary care physicians are 67%  more likely in majority Black zip codes, and more  is spent on healthcare for white Americans than Black Americans, particularly outpatient care, which includes vaccination.

Studies have generally found that when compared  with white people, people of color report lower- quality interactions with their physicians. This is particularly true when people of color are seen by white providers.

The consequences of a racially biased patient provider interaction can be fateful. For example, under the care of white physicians, Black newborns experience triple the in-hospital mortality rate of white infants and when under the care of Black physicians rather than white physicians, the mortality rate for Black infants is 58% lower.

The damage of racially biased care is compounded by the significant lack of diversity in the healthcare workforce. Today, 56% of physicians are white while 5.8% are Latinx/Hispanic and 5.0% are Black.

Generations of economically marginalized people and Black, Indigenous, Latinx/Hispanic and other people of color have had their trust and faith eroded by a system that is persistently unreliable and exclusionary. Medical mistrust is associated with underutilization of health care, particularly for Black  people, and with lack of vaccine confidence.

To mitigate the effect that insurance status has on vaccination and to maximize engagement with communities, vaccination distribution efforts  around the country are integrating health insurance enrollment into their outreach. For example, Washtenaw County Health Department in Michigan focused on supporting the area’s Latinx community and worked with Mexiquenses en Michigan and other community partners to host Latinx- targeted pop-up clinics where community members could get vaccinated and enroll in health insurance.

People-led mutual aid efforts have also played  a major role in successfully mitigating some of the inequities described in this section – from lack of access to healthcare to food and housing insecurities. Started at a grassroots level in a crisis to connect those in need with resources, funds and services, organizers activate solidarity and collective support from within the community to meet community members’ needs while opening pathways for autonomy and for people to support each other.

How education impacts health

The link between education and health has been studied for decades but the Covid-19 pandemic has shed new light on how complex and pervasive the relationship is.

Just like income and household size, lower levels of education are associated with increased case and death rates. An analysis of demographic county data found that Americans with a high school diploma or less are substantially more likely to be  infected and die from Covid-19.

Similarly, a cohort study including 25 million working-age Californians found that compared with the general population, Covid-19 deaths were higher among those with lower education – individuals with a high school education or less composed 36% of the study population but 69% of Covid-19 deaths.

Another study of the 413,196 Covid-19 deaths between January 1, 2020 and January 31, 2021 found that people with less than a high school education were more than five times more likely to die from  Covid than those with a college or post graduate degree.

People with lower levels of education make up the majority of low-wage but “essential” workers. Research shows that only 22% of workers with a high school diploma or less were able to transition to telework compared to almost 65% of workers with a bachelor’s degree or higher, placing them at a disproportionately high risk for Covid infection and death, as discussed in the section above.

Simultaneously, people with lower levels of education have been excessively vulnerable to the serious economic consequences of the pandemic.

Education is a fundamental factor in health and well-being because it determines access to a multitude of material and non-material resources such as economic stability, safe neighborhoods, social connections or health care. Unemployment rates decrease with greater educational attainment and study after study has found workers with postsecondary degrees earn more than those without. Access to quality education in early childhood, adolescence, and early adulthood helps secure higher paying work with fewer safety risks, better employer-offered insurance, and financial resources to access care.

Thus, education is strongly associated with life expectancy, morbidity, and health behaviors. Adults with higher educational attainment live healthier and longer lives compared to their less educated peers. Less educated adults report worse general health, more chronic conditions and more functional limitations and disability.

Today, more than 20 million people in the U.S. have less than a high school education. Another 62 million have just their high school diploma, meaning that almost 20 percent, or every fifth American is affected by these disparities. Again, however, this burden is not equally shared across groups: Black, Indigenous, and Hispanic/Latinx people experience worse academic outcomes compared to whites and some Asian American groups.

Racial gaps in academic achievements emerge as the U.S. education system too often deprives students of color of educational resources, ignores culturally relevant curriculum and pedagogies, and criminalizes students through exclusionary discipline practices. Schools that predominantly serve students of color have been found to have drastically poorer resources (such as textbooks or computers), more unqualified teachers, and less adequate facilities than majority white schools.

Expectedly, vaccination rates follow the education gradient – folks with the least education are less likely to be vaccinated compared to those with college or graduate degrees. One study of vaccination coverage for more than 49.2 million Americans in 49 states found that disparities in coverage were largest by education level.

Information as a social determinant of health

The original framework for the social determinants of health was developed in 1991, before the world wide web, the global expansion of internet access and the widespread use of personal computers. Alongside other public health experts, we think it is time to update the SDoH framework for the current information age, and include information as a social determinant. The quality of health information available, how we access that information, and how we make sense of it, are central to health and well-being. Researchers and practitioners can work together to better understand and document how information ecosystems, mis- and disinformation, information voids and other factors central to information impact people’s health.

(See also Section 3: Information Challenges)

By triggering widespread, extended social isolation, for example, the pandemic heightened a profound reliance on digital communication and the broadband internet access it requires. Americans’ access to broadband internet is extremely uneven, however – a digital divide impacts both rural communities and neglected urban neighborhoods. Today, it is estimated that 42 million Americans live in areas without access to high-speed internet and those least likely to have high-speed internet are households of color, rural households, and low- income households.

Without good internet access, community members cannot access telehealth or use digital  resources to learn how to protect themselves, and connect their children to continued learning as schools operate remotely. For people in households and communities without consistent internet access it is also often harder to find and reserve scarce vaccination appointments, access vaccine information or follow up on a rumor they heard, particularly when digital obstacles are compounded by language barriers. Research by the FCC found in 2017 that preventable hospitalizations were 1.5 times higher in the least connected counties compared to other counties.

This and other factors described in section 3.a can leave individuals in a particularly disorientating information void. As they lack accessible, tailored, quality information, people have to navigate the pandemic without answers to questions that are personal and socially relevant to them, such as: “What is the actual risk for other young Hispanic men, like me?” “How many people in my community are vaccinated?”

Information voids often become an ideal space for mis- and disinformation to spread. Early in the pandemic, for example, Black leaders found themselves responding to false narratives that ‘Black people can’t get it’ [where the ‘it’ is Covid] – a recycled false trope that was also heavily used in the early days of the HIV/AIDS crisis.

The pandemic has also revealed how significant gaps in Covid-19 data about and for communities of color can prevent visibility into the burden carried by these populations, and subsequent allocation of resources. Almost three years into the pandemic, crucial data on the racial and ethnic distribution of cases, hospitalizations, deaths and vaccinations remains missing, and so is racial/ethnic disaggregation of this data by age or sex/gender.

This is called data invisibility. In many analyses of Covid-19 infection and mortality rates, for example, Indigenous Peoples (CDC uses ‘AI/AN’) are labeled an asterisk, lumped into the “other” category or are  racially misclassified and recorded incorrectly as part of another non-white racial classification. This erases and excludes Indigenous people from Covid- 19 data.

The omission of Indigenous people has a long  history, and one recent study found for example that hospital inpatient discharge records have a nearly 50% rate of racial misclassification for Indigenous individuals.

Data brings crucial evidence to decisions about resource allocations and priorities in a crisis. In the absence of this information, these groups are further marginalized, their experiences are flattened, and diverse groups are treated as monoliths, inhibiting a meaningful understanding of their concerns and needs and making them invisible in public health dialogue.

How policing & incarceration practices affect health

The criminal justice system is a significant but often overlooked driver of negative health outcomes, including education as well as pandemic and vaccination inequities – for those who are incarcerated as well as their families and communities.

People who are incarcerated in jails, prisons, immigration centers, and other places of detention are at significantly higher risk for Covid infection and death while violent policing practices erode the trust and relationship central to vaccinating marginalized communities.

The United States has the highest incarceration in the world, with 5% of the world’s population but 25% of the world’s prisoners. More than half of the people in the nation’s prisons are serving time for drug offenses, and most of them are not high-level actors in the drug-trade and many have no prior criminal record. Since 1980, the number of people in prison for drug offenses has almost tripled.

About every fourth inmate is presumptively innocent, awaiting trial or confined solely because they can’t afford to buy their release.  In addition to the 2 million Americans currently incarcerated, another 4.5 million are under government control through probation and parole “supervision”.

A majority of the largest, single-site outbreaks since the beginning of the pandemic have been in jails and prisons. As a result, people who are incarcerated are five times more likely to be infected and are three times more likely to die from Covid compared to the general population.

Vaccination efforts in prisons and jails have been slow and inadequate.

Prisons and jails increase the spread of infectious diseases like Covid because of overcrowding and unsanitary living conditions. Incarcerated people do not have the agency to protect themselves with precautions like social distancing. Because of harsh sentencing practices the prison population is aging, with 11% of the population ages 55 and older, and age is another risk factor for Covid-19. People in jails and prisons generally are of poorer health, have higher rates of medical conditions that make them more vulnerable to severe illness and death, and if they do get sick, they don’t have the same access to prompt, effective medical care as people outside of prison do.

Once released, tens of millions of Americans are dealing with the comprehensive consequences of incarceration – many of which directly harm health and well-being, put them at greater risk for Covid-19, and make it more difficult to access vaccines. Former inmates often have no housing, employment, and family support, and face discrimination in finding jobs and housing.

The nation’s system of punishment is deeply racialized. Black men are six times as likely to be incarcerated as white men and Latinos are 2.5 times as likely. For Black men in their thirties, about 1 in every 12 is in prison or jail on any given day.

From historical slave patrols and the enforcement of Black Codes and Jim Crow laws to the more recent War on Drugs and “tough on crime” policies, it is clear that structural racism is embedded in “law enforcement” and that explicit and implicit racial bias is widespread in the public safety workforce such as police officers. Black people are 2.9 times more likely than white people to be killed by police. Police violence can also affect health through acute injury, effects on mental health, and as a contributing factor to chronic conditions. One study found that Black female youth in California between the ages of 10 and 14 were 6.7 more likely to sustain injuries from law enforcement compared to their white peers.

People of color, particularly Black people, regularly experience violence and brutality at the hands of the organizations allegedly entrusted with public safety and justice. These real-life experiences are a key driver of the Black public’s reluctance to trust  public officials on questions such as “Is the Covid-19 vaccine safe?”

Research has found racism in the criminal justice system can drive mistrust in medicine and vaccines (especially given the U.S. government role in the Covid-19 vaccine’s development). One study found “that individuals who had negative encounters with the police, even if they perceived these encounters to be necessary, had higher levels of medical mistrust compared to those with no negative police encounters.”

Chicago, one of the EVI’s five pilot cities, embodies this. The Chicago Police Department (CPD) is the second largest police force in the United States with a history of racial bias and police brutality. 47.7% of the city is white and 29.2% are Black yet are Black people are disproportionately stopped by CPD and more likely to face a use of force. Between 2010 and 2015, about four out of every five people shot by police in the city were Black males. Unsurprisingly, only 61% of Black Chicagoans have received at least one dose of the vaccine compared to 75% of white Chicagoans.

Acknowledging and working to mitigate structural barriers is a key element of making vaccination efforts both effective and equitable. While not all systemic challenges can be solved at once, it is essential to acknowledge and address these intersecting challenges alongside information and social/behavioral barriers. The next chapter explains how to do so.