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"It’s up to each one of us to make decisions and take actions that will determine whether our 'new normal' is more just and more equitable than the old one."
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COVID-19 and Equity: Tragedy and Opportunity

By Derek Feeley | Tuesday, May 5, 2020

Line of Sight

It’s tempting to think of a pandemic as a “great equalizer.” It’s not.

The impact of the virus that causes COVID-19 could hardly be more disparate. While billions are stuck at home and restricted by social-distancing guidelines, millions of people must still put themselves and their families at risk by continuing to go to work. Millions are coping with the requirement of effectively working from home, but millions more have lost their jobs and don’t know how they will pay for housing or food. And for those who contract the virus, its effects span from nothing at all to death.

These inequities aren’t a matter of chance. They are, far too often, the direct result of unacceptable injustice.

I’m encouraged that some of the inequities of COVID-19 are front-page news. The first step to solving a problem is acknowledging and naming it.

The statistics are alarming and heartbreaking. When Louisiana released its COVID-19 data stratified by race in early April, we learned that African Americans accounted for 70 percent of deaths while only making up 33 percent of the population. In Chicago, about 30 percent of the population is Black, yet more than half of the people known to have COVID-19 and more than 70 percent of those who have died from it are Black. From Michigan to Mississippi to New York, Black people are more likely to get sick and die from this disease.

The media has focused much less attention on indigenous communities in the US (including American Indians, Alaska Natives, and Native Hawaiians). They also face a disproportionate burden from the coronavirus due to structural inequities. The Navajo Nation is behind only New York and New Jersey in rates of COVID-19. A new study reports that the highest rate of COVID-19 cases in five US states are among Native Hawaiians and Pacific Islanders. In these states — Hawaiʻi, California, Oregon, Utah, and Washington — the rates of COVID-19 cases are greater than those reported for African Americans and American Indians.

Some will point out that the conditions known to exacerbate COVID-19 disproportionately afflict some populations and are, therefore, the drivers of these disparities. Some might even suggest that these conditions are the product of life choices. Yet, the reality is that these conditions — e.g., diabetes, hypertension, cardiovascular disease — are themselves the products of generations of inequities.

Centuries of scientific and medical achievements have made us more prepared than ever to understand and combat a pandemic. Tragically, those same centuries have seen the implementation and entrenchment of structures and systems that bestow advantage and disadvantage to different populations. Structural racism has produced inequities in health for all of modernity, and dismantling it is a moral and ethical imperative.

I know I have colleagues in the world who wonder what we in health care can do in the face of such vast and intractable problems. The answer is quite a lot. By some measures, health care is the largest industry in the US and one of the largest in the world. Its institutions are landmarks, sources of civic pride, and examples of international collaboration. Health professionals number in the tens of millions.

COVID-19 did not create health inequities, but it has certainly exacerbated them. It has also cast a bright spotlight on glaring injustices. If there is a silver lining in the pandemic, it may be the opportunities this unprecedented challenge has presented to us. In every decision and action to prepare and respond more effectively to the new realities facing us, there is opportunity to build new systems and structures with equity as a crucial component.

Now we must see. Now we must listen. We cannot let this opportunity pass.

There will be no “return to normalcy” and there shouldn’t be. Pre-2020 health care left too many behind. We need health systems that acknowledge how racism and implicit bias compromise both the quality of care, and health. We need leaders who understand that racism is more than the rantings of bigots and bullies, but also the pervasive and pernicious design feature of systems that touch nearly every aspect of our lives, including within our own organizations. We need the communities we serve to be represented and heard throughout our health systems, including as part of efforts to design crisis standards of care. We need to treat staff who serve in every part of our organizations with respect and dignity as they have yet again proven themselves to be essential in ways we may not have fully acknowledged before.

The awe-inspiring efforts of health professionals on display right now demonstrate what is possible in the face of huge challenges. We all recognize that we need to draw lessons from this current pandemic to respond more effectively to the next major crisis, but we must also acknowledge that this extends to building equitable health systems.

We at IHI don’t have all the answers to these formidable challenges. We do, however, have the beginnings of an approach. Last year, we published a series of Improving Health Equity guides that offered lessons learned from the first phase of IHI’s Pursuing Equity initiative that started in 2017. Later this year, we will launch the Pursuing Equity Learning and Action Network, the second iteration of this effort.

Those of us who survive this pandemic will be living in a changed world. It’s up to each one of us to make decisions and take actions that will determine whether our “new normal” is more just and more equitable than the old one. If health care moves to right past wrongs, perhaps other parts of society will follow.

Editor’s note: Look for more from IHI President and CEO Derek Feeley (@DerekFeeleyIHI) on leadership, innovation, and improvement in health and health care in the “Line of Sight” series on IHI.org.

You may also be interested in:

IHI Virtual Learning Hour — Centering Equity in the Response to COVID-19

When Talking about Race and Racism, Don’t Wait to Feel Comfortable

Community Engagement Is Essential for Developing COVID-19 Crisis Standards of Care

More COVID-19 Guidance and Resources

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