Tackling poverty in a coronavirus-induced economic downturn: Is it too risky or the right thing to do?

RALEIGH, N.C. – Jeremiah Newson, 25, moved here from Chicago last year to be closer to his girlfriend and baby. He found a homeless shelter that helped him get three meals, transportation and medical care. 

When COVID-19 hit and he wasn't allowed to leave the shelter, Newson started sleeping on the streets where he thinks he's less likely to catch the coronavirus that causes the disease. But the poverty and homelessness he's faced since high school puts him and his immune system at high risk of other chronic health conditions that make him more vulnerable wherever he goes. 

The social problems borne of poverty – unstable housing, food insecurity, lack of transportation and the trauma caused by them – are a key reason health experts say people of color like Newson, who are far more likely to be poor, are being disproportionately sickened and killed. Public health advocates hope the virus, which has put everyone and the economy at grave risk, will lead to funding boosts for proven ways to tackle poverty and improve health.

"COVID-19 is shining a bright light on this. There is an opportunity here," said Dr. Brian Klausner, chief medical officer at WakeMed Key Community Care, which works with Oak City Cares, where Newson was a client. "Healthy patients cost less than sick patients, so we should do everything can to be efficient and prevent expensive, and avoidable, human suffering."

Early childhood development programs and services like those Newson received through the shelter, addressing "social determinants of health," are proven to reduce poverty and health care disparities, said David Williams, a Harvard professor who chairs the T.H. Chan School of Public Health's department of social and behavioral sciences.

A 2017 Federal Reserve Board report found the median and mean net worth of black families was less than 15% that of white families. African Americans also develop far more of chronic health conditions that increase their susceptibility to COVID-19, he said, and they get them earlier than other races. 

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That causes African Americans to "experience higher levels of stresses and a greater clustering of stresses," said Williams.  

Black people's share of COVID-19 deaths was at least twice as high as their share of the total population in 11 of 35 states reporting racial breakdowns, according to data out Saturday from the Kaiser Family Foundation. In Wisconsin and Kansas, it was five times greater. 

The Coronavirus Aid, Relief, and Economic Security Act enacted last month included $5 billion in community development block grants and $4 billion in assistance to prevent homelessness resulting from the impact of coronavirus. 

A 2018 survey of more than 8,500 doctors by the Physicians Foundation found nearly 90% said their patients had a serious health problem linked to poverty or other social conditions. Just 10% of health problems are addressed by medical care; the rest relate to people's environment and the way they respond to it. 

"We know from a scientific point of view what can be done, we know that those programs will work and we know those programs will save society money," Williams said. "The question is how do we generate the political will to do those things that would work and would create a more productive workforce for the American economy?" 

Poverty and health disparities linked

If socioeconomic status is the key factor that determines an individual's health, solutions might seem out of reach in an economic downturn. But just as the coronavirus highlights stark health disparities, it's also changing medicine in a way that should help close the gap, Klausner said.

Widespread use of video visits, new ways of paying health care providers and "innovative technologies" may be a way to better address health care disparities, he said.

Any new approaches that help reduce the stigma and distrust in the Latino community towards health care, especially mental health, are sorely needed, said Margarita Alegria, a psychologist and Harvard University professor who is chief of the disparity research unit at Massachusetts General Hospital in Boston. 

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Latino people, particularly the undocumented, are fearful of seeking coronavirus testing, medical treatment and care for the mental health or abuse problems that arise from the social isolation and unemployment spawned by the pandemic. 

"We may not have been prepared for COVID-19, but we should be prepared for the post-coronavirus after effects," Williams said. 

Addressing poverty will help reduce racial and ethnic disparities, Williams and Alegria agreed.

Williams cited randomized control studies of early childhood development programs, including the Chapel Hill, North Carolina-based Abecedarian Project, as the best evidence investment would reduce poverty and improve health.

A 2014 follow up study in the journal Science reported infants born between 1972 and 1977 in the Abecedarian Project's child care and education program had much lower risk factors for heart disease and hypertension in their mid-30s than peers who did not attend the child care program. Taxpayers also saved money because participants had higher incomes and less need for educational and government services including for health care.  

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Since the Affordable Care Act passed in 2010, the health care system has slowly moved toward giving incentives to doctors and hospitals to keep people healthy. Many of the states that expanded Medicaid under the ACA to all of its lowest income residents have used managed care organizations to bring down costs by covering and connecting patients to social service organizations. 

When North Carolina passed a law to convert its Medicaid program to managed care in 2015, the North Carolina Medical Society, which represents the state's doctors, became part of a joint venture to make Medicaid more focused on social determinants of health.

Robert Seligson, the medical society's CEO, said the group wanted to help connect patients to services "so people could have their basic needs met."

"If you look at the epidemiological map of our state, the people that are usually lower socioeconomic status are more apt to be in a situation where they have health problems," said Seligson. "When the virus hits, it has a very draconian impact."

COVID-19 compounds stress of survival 

People who are chronically homeless see their life expectancy shorten by about 20 to 25 years, said Klausner. While Jeremian Newson hasn't gotten sick, Klausner said people who are homeless have a five to seven times greater risk of catching the traditional flu. 

Coronavirus has affected Newson in other ways. A well paying door-to-door charity fundraising job disappeared when pandemic restrictions started. Now, he makes a few hundred dollars a month selling his plasma, which helps pay for cheap hotel rooms when it's cold out. 

"I try to mediate, keep myself calm and keep myself positive but, man, it’s like at times, I will be ready to breakdown," he said. "I think I’m at the bottom. I hope I am. I don’t want to fall no more."

It's a life that former Illinois health commissioner, Dr. Lamar Hasbrouck, knew well growing up in a tough urban neighborhood in southern California and treating the poor as a resident at a Los Angeles safety net hospital after medical school. The challenges of poverty make low income people of color "a more vulnerable host" to coronavirus. 

"When you’re stressed and malnourished, those are linked to your immune system," said Hasbrouck. "When 90% of your time is spent on survival, like air, food and housing, healthy behaviors are a luxury you can't afford."

At Children's National Hospital in Washington, D.C., child and adolescent psychiatrist Dr. Bhavin Dave sees firsthand the effect of trauma linked to poverty. While some stress "helps build immune response," Dave said higher levels associated with trauma lead to abnormal brain development, immune dysfunction and cardiovascular disease. It's also associated with a much higher risk of viral hepatitis, cancer, chronic obstructive pulmonary disorder and several autoimmune diseases.

Repeated emotional and physical trauma, including homelessness, exposure to domestic violence, neglect and hunger, can lead to "chronic inflammation that is exhausting to your body."

"The body just gets worn out because it is constantly bombarded with inflammatory reactions," he said. "The biological outcomes of psychological stress – the whole brain/body connection – can't be undersold."  

Contributing: Claire Thornton