The most vulnerable groups in the US, which have been least able to afford the lockdowns and school closures, have been devastated by unscientific ineffective policies and have been hardest hit by Covid-19. The health of a nation is directly tied to the socioeconomic health of the nation, and the socioeconomic drivers that played a role in Covid-19’s severity cannot be ignored, particularly for the future burden of disease outcomes. Focused protection would have performed far better than lockdowns, which have not only been a distraction but actually enhanced the unequal impacts of severe outcomes of the virus.
In May 2020 the prevailing winds presciently suggested that there was a significant care-burden on the families in the future. The socioeconomic status of a person can negatively impact their lifestyle choices that are often unhealthy in nature, and this is complicated by the reality that often, this is not by choice, and rather based on ‘need.’ Often there is no other option but maladaptive ones.
The ineptness of the government leaders, public health officials and some television medical experts who have shown gross academic sloppiness and a depth of cognitive dissonance to all views not aligned with their failed ones, in retrospect is available to all for review. The evidence of the segments of the populace at greater risk emerged several months ago, included risk factors such as being elderly, being obese, and having comorbid conditions and has remained firm as a precursor of acquiring the ravages of the SARS-CoV-2 infection.
The failure to adopt appropriate public health measures to prevent the catastrophic disaster on the vulnerable and those at risk is laid at the feet of those officials and experts who were involved in the policy making process. The responsibility of the “Task Force” was protection and the safeguarding of all the citizens and they failed in their efforts. Not only did these experts resort to using political import as their guidance on decision-making, they have now resorted to groupthink and we have entered the age of Lysenkoism science where contrarians, dissenters, skeptics, and people who question their motives and underlying evidence for their ineffective policies, are attacked, slandered, and smeared.
All politicization aside, Covid-19 exploits our risk factors and age is the principal risk factor among them. This is understandable given that as we all age, our immune systems become less durable and there is a gradual deterioration of the immune system, called immune senescence. A focus on the other risk factors that Covid-19 exploits will help us prepare for future coronaviruses and other pathogens that also will exploit such risk factors. Covid-19 is a condition of disparity given its unequal force of mortality on lower SES populations. Minority populations in the US have been hit harder by Covid-19 in terms of severe outcomes due to a multiplicity of factors. The worldwide data suggests that this harm has occurred elsewhere and is not unique to the US. As an example, we are willing to discuss the elevated risk due to excessive body weight (obesity, morbid obesity) and this is a very serious issue that must be debated as a society. We argue that for many impoverished persons with depressed SES status, obesity is tied to economics. We have seen that Covid-19 gives away age to obesity in younger persons. Recent British research in near 7 million persons has shown that a body-mass-index (BMI) of greater than “23 kg/m2 was associated with a linear increase in risk of severe Covid-19 leading to admission to hospital and death, and a linear increase in admission to an ICU across the whole BMI range, which is not attributable to excess risks of related diseases. The relative risk due to increasing BMI is particularly notable in people younger than 40 years and of Black ethnicity.”
In confronting this pandemic in March 2020 and certainly by the summer of 2020, we had in our arsenal (yet failed to capitalize upon) a combination of i) strongly protecting (double- and triple-down protection) the elderly high-risk persons in nursing homes and similar congregated settings ii) use of effective public service announcements on who is at risk and how to mitigate the risk iii) allowing the low-risk portion of the population to live daily lives with sensible reasonable precautions, allowing them to get infected naturally and harmlessly given their low risk of severe illness or death and iv) use of early outpatient drug treatment (sequenced antivirals, corticosteroids, and anti-clotting drugs) in high risk populations, younger persons with comorbid conditions, and obese persons.
Unfortunately, we chose to ignore the signals from the pandemic. The fact remains that age and excess body weight/obesity, have accounted for almost 80% of the hospitalizations, intubations/ventilation, severe sequelae and deaths in Covid-19. A large number of persons who have died in nations such as the US have been overweight with some level of obesity.
The importance of educating the public on the risk factors and the need for such protective efforts can be enhanced by the people themselves. Had public health leaders used their platforms optimally, the geared messaging would have helped reduce the damage significantly. We could have cut deaths significantly had the options described above been used, especially early outpatient treatment.
As an example, the various US health agencies and their leaders have failed the minority and higher-risk African-American communities by neglecting to message the need for vitamin D supplements in persons with darker skin color. Evidence suggests that Vitamin D has an important immune function role and is a means to mitigate acute respiratory distress due to Covid-19, with patients revealing improved clinical recovery (shorter lengths of stay), lower oxygen requirements, and a reduction in inflammatory marker status.
So why have the public health agencies not messaged this to the high-risk minority groups, especially African-American and Asian-Americans? Why have the public health agencies or the Surgeon General not focused on public service messaging on the risk of excess body weight in Covid-19, as the right messaging could have saved tens of thousands of lives? We could have saved tens of thousands of lives had public health not been so politicized and done its rightful job.
We are responding to these failures by calling for a ‘social determinants of health’ approach to Covid-19 (a strong focus on the social aspects) and we find it is unacceptable that the public health agencies and television medical experts continued to use the platform to create fear rather than use their daily podium to address the potentially correctable catastrophic linkages.
US public health agencies such as the CDC appear to be 9 months to one year behind the science, routinely. The messaging, even at this late stage, continues to confuse the public as it waffles regarding masking, social distancing and vaccination, thus squandering the opportunity to help mitigate the impact of Covid-19 in their public health roles.
If the approach is mainly a therapeutic biomedical one to deal with Covid-19 (only to treat the disease or mitigate the epidemic/transmission), then this will end in failure each and every time. We must consider the socioeconomic ‘upstream’ fundaments of Covid-19 (and similar illnesses) and in an integrated manner. There is a certain level of personal responsibility in the decision-making on the part of the individual, as part of this discussion that must not be overlooked, but we would be ignorant to not recognize the direct association between poverty and health and the seemingly strong role that Covid-19 has in exploiting this link. Failure to understand this link between the SARS-CoV-2 virus and the SES of an individual thus fails to address an addressable and treatable issue.
In other words, had the US been a healthier population with a lower burden of noncommunicable chronic type diseases (diabetes, renal disease, hypertension, cardiovascular disease, respiratory illnesses etc.) and had the population been composed of less overweight and obese persons, then the force of severe morbidity and mortality would have been far lower from Covid-19.
If Covid-19 entered a population of 10,000 persons as an example, with a mean age of 40 (eldest being 60) and where all 10,000 persons were healthy, no underlying conditions, and a respectable health care system that could respond if there is need, then Covid-19 will likely (more certainly) severely impact no one and kill no one. At least the impact will be minimal. A strong argument could be made here and this is the approach we are taking. We make this clarion call not only for ‘Western’ richer nations plagued by these chronic conditions and risk factors, but also for poorer developing nations also struggling with these chronic conditions. Covid-19 has shown us that as a society, we must urgently heighten our resolve to combat hypertension, obesity, diabetes, cardiovascular, renal, and respiratory diseases, as well as cancer.
In addition, ‘stopping Covid at all costs’ (zero-Covid) has been a critically flawed approach that has proven to be harmful. The mindset of lockdowns continues unabated although the data suggests otherwise and some epidemiologists are voicing contrary opinions. This was indeed understandable in the first month (March/April 2020), but this may come back to haunt us as we have prolonged the fixation on Covid-19 at the loss of other equally and even more dangerous illnesses.
We already see warning signs of dramatic declines in vaccine-preventable disease vaccinations for children (declines in pediatric vaccine ordering and doses administered), and as such, anticipate a surge in such illnesses we usually control with vaccine programs. Yet we continue to fixate on Covid-19, ignoring other pressing conditions, when we know who the at-risk group is, and we know much better how to treat. Covid-19 in April/May 2021 is not Covid-19 in February and March 2020. Covid-19 is not a death sentence for we can manage and treat it and we do have early outpatient treatment that has proven effective, once given early in the sequelae when the patient has not yet worsened.
We continue to caution against the exploits of the politicians and their strong and deliberate inroads into the scientific community. This egregious intrusion is causing a grave harm on science itself. This includes the medical research community and the academic journal publishing and editors (peer-review process) whose roles have been politicized, and have contributed to the current failures. Covid-19 has revealed the political and corrupted underbelly of academic and medical scientific research and journal manuscript publishing with its steep conflicts of interest that will require many years if not decades to recover its reputation (if at all).
Understanding Covid-19 must therefore not involve the traditional unidimensional, dogmatic orthodoxy whereby we simply wish to control the spread of the pathogen or eradicate it. It remains an impossibility to eradicate a viral pathogen, especially if it is highly mutable like the flu virus. We as humanity have learned to live with such viruses. There is a greater severity and adverse sequelae in lower SES populations (socioeconomically disadvantaged populations), so we have to look at this and consider what is happening and focus here with a more nuanced finessed approach to pathology, as we address targeting the pathogen. This approach will help us now as well as in the future, as we deal with existing, emerging, and reemerging pathogens.
Importantly, (and a potential reason for the excessive burden of death in obese persons we have found this to be the case in African-American, minorities etc.), is the heightened expression of the ACE2 receptor in adipose tissue fat cells in obese persons (expression is higher in visceral and subcutaneous adipose tissue than that in lung tissue). A poor diet dominated by high-sugar, high-starch foods (predominantly rice, potatoes etc.) driven by affordability and the drive for satiety, contributes to obesity and the associated health conditions such as diabetes. The seeds of this are often planted in childhood. Is one at-risk group more differentially impacted and can obesity explain a substantial proportion of the severe sequelae? Do these social and economic factors (socioeconomic inequality) affect the severity sequelae differentially based on type of background condition e.g. will a socially disadvantaged person fare worse with diabetes or kidney disease versus cardiovascular illness?
The answers to some of these questions have been answered by the science community. The CDC posits a similar opinion that health disparities among minorities are real and related to the Covid illness. We applaud the CDC for this position. Yet even with a plethora of information available our policy makers still continue to punt on the issues that remain unaddressed and continue to harm people unnecessarily.
To end, we are arguing that the SES status with the social factors work to drive, perpetuate, prolong, and potentially worsen the emergence and clustering of pathogens and diseases. The above-mentioned comorbidities that exist in the vast majority of SARS-CoV-2 severe illness outcomes and death with Covid-19 especially among the poorer minority communities seem to drive Covid-19 and dramatically compromise a person’s ability to ward off the disease and escalate an infected individual’s susceptibility and vulnerability to harm or worsen their health outcomes. We need to study and understand this if we are to effectively shape prognosis and treatments. Good public health policy must reflect this interwoven relationship between pathogen, pathology, and social and economic equality, not merely impose the blunt and devastating “nonpharmaceutical interventions” indiscriminately on the whole of the population.
- Paul E Alexander MSc PhD, McMaster University and GUIDE Research Methods Group, Hamilton, Ontario, Canada [email protected]
- Howard C. Tenenbaum DDS, Dip. Perio., PhD, FRCD(C) Centre for Advanced Dental Research and Care, Mount Sinai Hospital, and Faculties of Medicine and Dentistry, University of Toronto, Toronto, ON, Canada [email protected]
- Dr. Parvez Dara, MD, MBA, [email protected]