Culture of Health Blog

New Jersey is ranked as one of the nation’s healthiest states—on average. But if you were to look more closely, you’d see the numbers mask significant differences in health across the state. For instance life expectancy in one Newark census tract is 75.6 years while just a few miles outside the city, it’s 87.7 years.

Race is a big factor contributing to this and other health disparities. For example, babies born into Black families in New Jersey are twice as likely to die before their first birthday in contrast to those born into white families.

Other factors contributing to health disparities include income, gender, and education. Some are less apparent, like the distance from people’s homes to parks and grocery stores or the availability of public transit. The point is that many things beyond what might immediately be thought of as health related do, in fact, play a major role in determining health. 

As COVID-19 swept our nation this year, the important influence utility services have on our health became clearer than ever. Running water is essential for washing hands to prevent infection. Electricity keeps individuals and families comfortable while they follow recommendations to stay home. And internet access allows employees to work from home, children to learn remotely while schools remain closed, patients to access needed health check-ups, and all of us to stay connected.

Conveniently powering up our laptops, logging onto the internet and turning on the faucet are things many of us take for granted. But the COVID-19 pandemic has also revealed fault lines in America’s aging infrastructure. These inequities especially impact people of color, rural and tribal communities, and low-income households. For them, energy, water, and broadband are often unavailable, unaffordable, unreliable—and even unsafe.

In the almost seven months since the novel coronavirus national emergency was declared, we’ve witnessed how it has magnified centuries-long inequities that have created deep-rooted barriers to health and opportunity in communities of color and tribal communities.

At the County Health Rankings & Roadmaps, my colleagues and I know the first step to action is knowledge. We cannot address the disparities the coronavirus has brought to light without first understanding the data, challenges, and historical context at play.

Through conversations with six leaders from Black, Latino, and tribal communities, we examined the inequities the pandemic has exacerbated and explored strategies and solutions for where we can go from here. Three lessons emerged from these conversations that can inform an equitable response and recovery.

A Personal Journey

It's hard to describe water to a fish while it’s swimming in it. I was that fish, growing up in a working-class, majority Black community in southwest Ohio. For instance, it hadn’t occurred to me to question why my school had metal detectors and armed police officers at every entrance yet so few textbooks that students had no choice but to share. Or why we had to travel to find affordable fresh vegetables while unhealthy food nearby was as easily accessible as  payday loans and other predatory financial products. Having unmet needs was normal in these waters.

I was in high school when I began wondering why there were so many of these unmet needs in my community. An invitation to a cancer research conference hosted at a neighboring public school was an eye-opening experience. The school was one of the top-ranked in the state, nestled in a wealthy neighborhood with a well-stocked grocery store and multiple banks within walking distance. 

These waters were different.

That sense of unfairness filtered into my own life from another angle. I attended a school with limited resources which meant that opportunities within the school were offered to only a few. Since my mother was a powerful advocate for my education, I had access to after-school activities and advanced placement classes while friends living on the same block did not. That bothered me too.

For tens of millions of children in the United States, school isn’t just a place to learn, but a place where they can depend on receiving healthy meals. In March 2020, according to the U.S. Department of Agriculture (USDA), more than 31 million children participated in the National School Lunch Program (NSLP) and more than 17 million participated in the School Breakfast Program (SBP); the vast majority of children receiving these school meals are from families with low incomes.

So when COVID-19 swept across the nation this spring and forced at least 124,000 schools in the United States serving 55 million students to close, a public health crisis quickly became an education crisis and a nutrition crisis.

School districts responded quickly, creatively, and heroically, implementing “Grab and Go” models allowing parents to pick up meals in school parking lots or other community hubs; loading up school buses with meals and dropping them off at stops along neighborhood routes; and delivering meals directly to students’ homes. USDA did its part by issuing a series of waivers granting more flexibility in how meals could be prepared, packaged, and served. Particularly for students living in poverty and areas where healthy foods are typically scarce, the heroism of school officials and volunteers was a lifeline.

Today, there are more questions than answers about the 2020–2021 school year, which may be unlike we’ve ever experienced. But the last thing school officials should be worrying about upon reopening is how to process meal applications and figuring out who qualifies for free or reduced-price categories; their mission of educating and feeding students as safely as possible should be their primary concern.

Among the many lessons emerging from the COVID-19 pandemic is the impact of obesity. People with obesity and associated diseases tend to become sicker and are more likely to die when COVID-19 strikes.

We know childhood obesity is a powerful predictor of obesity in adulthood. It puts children at increased risk for developing numerous health problems later in life, including diabetes and heart disease. In addition to these chronic diseases, early research suggests that obesity may also increase their susceptibility as adults to serious illness like COVID-19.

Imagine what it’s like to live on a block where elderly neighbors are bolted behind their front doors for fear of venturing out. Where parents worry daily about safety, so they resist letting children play in the neighborhood. Where more than half of the houses lie empty.

These images are not consequences of life under a pandemic. This was life pre-COVID-19 for the Baltimore neighborhood where I grew up and now work as a nurse researcher.  

For the past year, my research team at the University of Maryland, the Black Mental Health Alliance, the PATIENTS program, and B’more for Healthy Babies at Promise Heights, with support from the Robert Wood Johnson Foundation, has been listening to residents of two disadvantaged neighborhoods in West Baltimore. Residents told us they were “self-isolating” from family, neighbors and the community to cope with living in a neighborhood where they don’t feel supported, safe, or connected.

As one resident put it: “A lot of things scare us...it makes us not want to allow our kids to go to the recs that open because we fear that a drive by [shooting] or...standing in the doorway you can get shot.”

Editor's Note: The health impacts of our rapidly changing work environment are often overlooked. Since 2018, when this post was first published, we reported on the health equity implications of unstable incomes, unpredictable schedules, and lack of access to paid sick leave. In the wake of COVID-19, these questions about health equity are more important than ever. See what we’ve learned, and apply for funding to explore what the next five to 15 years may hold for workers.

When her regular job hours were cut, Lulu, who is in her 30s and lives in New York, couldn’t find a new full-time job. Instead she now has to contend with unsteady income and an erratic schedule juggling five jobs from different online apps to make ends meet. Cole, in his first week as a rideshare driver in Atlanta, had to learn how to contend with intoxicated and belligerent passengers threatening his safety. Diana signed up to help with what had been described as a “moving job” on an app that links workers with gigs. When she arrived, she had to decide whether it was safe for her to clean up what looked to her like medical waste.

Work is a powerful determinant of health. As these stories about taxi, care, and cleaning work from a 2018 report show, it is a central organizing feature of our lives, our families, our neighborhoods, and our cities. And work—its schedules, demands, benefits, and pay—all formally and informally shape our opportunities to be healthy.

But the world of work is rapidly changing. Job instability and unpredictable earnings are a fact of life for millions. Regular schedules are disappearing. With “predictive scheduling,” a retail worker today is essentially on call, making everything from booking child care to getting a haircut impossible until the work schedule arrives. Health and other fringe benefits are less often tied to the job. Nearly six in ten low-wage workers today have no paid sick leave. Two-thirds lack access to employer-based health care benefits.

One of the most troubling aspects of the COVID-19 pandemic is how it is exacerbating long-standing and deeply rooted inequities in communities of color. Health disparities stemming from structural racism have contributed to COVID-19’s devastating toll on blacks and Latinos in America. Often overlooked is how heightened stress from this heavy burden is impacting mental health.

Yolo Akili Robinson, a recipient of the RWJF Award for Health Equity, is swiftly responding to this new reality the pandemic has created. As the executive director and founder of Black Emotional and Mental Health Collective (BEAM), he leads his colleagues in training health care providers and community activists, as well as non-mental health professionals (family members, peers, etc.) to address mental health needs in communities of color. Robinson is witnessing firsthand how lack of access to testing and fear of profiling while wearing face masks, among other issues are increasing toxic stress and straining mental health.

In the following Q&A, Robinson shares insights about the impact and implications of COVID-19 on mental health within communities of color.

In the Robert Wood Johnson Foundation's (RWJF) first-ever book of fiction, Take Us to a Better Place, published earlier this year, Dr. Karen Lord and nine other writers use the power of fiction to help us imagine paths that may lead to a healthier, better place for all--and those that may lead us astray.  

In her short story The Plague Doctors, Dr. Lord envisioned what life on a small island during a pandemic might look like. Now, she reflects on foreseeing some of today’s challenges and solutions in her latest blog post.

Note: The following post originally appeared on the William Temple Foundation Blog and has been republished with permission. 

Last year, I was asked to write a story about the future of health. Speculating about the future is my job, but for something this specific and important, I asked Dr. Adrian Charles to be my advisor for all things medical. We chose that perennial favourite of history and fiction—a pandemic—never guessing that within weeks of the story’s publication, history would become present, and fiction real life.