There is now well-established evidence on how long-standing systemic health and social inequities compound one’s risk of acquiring COVID-19. However, further research is needed to explore how disadvantaged social status(es) may interact with mandated or recommended social policies that aim to prevent COVID-19. One way to examine this topic is through a social determinants of health approach. The World Health Organization defines social determinants as circumstances that are based on the distribution of money, power, and other types of resources at various levels that impact opportunities to protect one’s health and effectively manage illness (WHO, 2020). It is understood that chronic health conditions increase COVID-19 risk, particularly among older adults and Black, Indigenous, and People of Color (BIPOC). Further investigation on how risks are compounded by social status and inequitable policies and practices can shed light on how various social groups are impacted differentially by COVID-19. Here, we aim to highlight the multilevel interplay of age and race as social factors contributing to the challenges that many aging BIPOC communities may be facing during this current pandemic.
Ageism and Racism
Ageism (“the stereotyping, prejudice, and discrimination against people on the basis of their age”) (WHO, 2020) encompasses social and institutional practices and policies that produce significant differences in access to care and treatment for older individuals. Ageism towards older adults also potentially contributes to isolation and loneliness, and this dynamic particularly affects BIPOC.
On the interpersonal level, ageism manifests as discriminatory behavior toward a person or group (Changing the Narrative Co, 2018; Achenbaum, 2015) including the tendency to view and treat older people as debilitated, unworthy of attention, or unsuitable for employment (Random House Webster’s Unabridged Dictionary, 2018). These stereotypical notions can contribute to disparities in the healthcare system and the services provided to older adults. One study found that provider bias in delivery of healthcare may contribute to mortality and use of fewer preventive health services, increasing the burden on health in older adults (Rogers, 2015). Internalized negative attitudes towards one’s own age also contribute to negative outcomes. For instance, one study found that internalizing the negative stereotypes about one’s older age peers and one’s self, decreased life expectancy by 7.6 years for those who endorsed such stereotypes, compared to those who held positive attitudes towards older age (Levy, Slade, Kunkel, & Kasl, 2002; Robertson, 2017).
On an institutional level, a recent systematic review by the Yale School of Public Health exposed adverse effects of ageism on older adults in 96% of 422 studies (Chang, 2020). In this study, ageism led to worse mental health outcomes and adversely affected whether older patients received appropriate and sufficient medical treatment (Chang, 2020). As such, ageism within this current pandemic may not only affect access to sufficient and necessary treatment, but it may also negatively affect older adults’ mental health as they manage anxiety, loneliness, and isolation.
Racism, the oppression of BIPOC communities based on the artificial assignment of “whiteness” that was socially constructed for the purpose of affording those belonging to this group with unearned social, political and economic privilege (Anti-Defamation League, 2020), also contributes to differences in access to care and treatment for older individuals. While racism has existed in the United States since its formation, the deleterious impact of racism on health, as is now more openly discussed. This is in part due to decades of health disparities research coupled with the epidemiology of the COVID-19 pandemic and the murder of Mr. George Floyd – a watershed moment that has elevated national and global consciousness of racial injustice and the significance of social unrest.
Racism underlies a multitude of health-related challenges for BIPOC communities such as, suboptimal access to primary care, a low number of referrals to specialists when medically indicated, and a lack of culturally humble providers (Ferdinand, 2017). The racial disparities highlighted by the COVID-19 pandemic reinforce the connections between racism, intergenerational trauma associated with racism, and social determinants that reproduce the racist social structure. While there is growing awareness and focus on the disproportionate impact of COVID-19 on BIPOC, the intersections of ageism and racism in the context of the pandemic and its psychosocial impact on this group, have received limited attention. As this intersection of age and race is dynamic, literature on the topic is sparse. Further research and data is needed to understand the relationship between access to quality healthcare and the role of differential experiences of ageism.
Social Isolation and Loneliness
Older adults in our society are at heightened risk for loneliness and social isolation. (Ducharme, 2020), chronic illness (Csesznek, 2020), injury (Chatters et al., 2020), mental illness (Achenbaum, 2015), and mortality (Achenbaum, 2013; Butler 2010; Whittington, 2014). Social isolation significantly increases a person’s risk of premature death from all causes, a risk that may rival those of smoking, obesity, and physical inactivity (National Academies of Sciences, Engineering, and Medicine, 2020). Further, social isolation has been associated with a 50% increased risk of dementia (National Academies of Sciences, Engineering, and Medicine, 2020). A common consequence of social isolation is loneliness – a painful, distressing feeling arising from the perception that one’s social connections are inadequate (Shiovitz-Ezra, 2017). Loneliness has been associated with adverse mental health outcomes, including higher rates of depression, anxiety, and even suicide (CDC, 2020). In fact, loneliness has been found to confer four times the risk of death and 68% increased risk of hospitalization (National Academies of Sciences, Engineering, and Medicine, 2020).
While social isolation and loneliness may be contributing factors to poor health outcomes over the long-run, social distancing and remote lifestyle as a result of COVID-19, may further compound mental and physical health challenges. Practicing social distancing is an effective means of curtailing the COVID-19 pandemic, as it has the potential to increase loneliness and social isolation, especially for those older adults who may already have risk factors for COVID-19, namely underlying chronic disease conditions (Ducharme, 2020). When exploring this phenomena from a disparities lens, Pew Research indicates that Black Americans are significantly less likely to have home broadband services (66%) compared with non-Hispanic white adults (79%) which prevents opportunities for virtual social contact (Chatters, 2020). This dangerous confluence of the COVID-19 pandemic and the social isolation epidemic has significantly amplified the risk of loneliness and associated mental illnesses among older adults and is potentially exacerbated among Black Americans.
Underlying Role of Social Determinants
The negative health outcomes for older BIPOC are not only attributable to experiences of ageism and racism, but also to other key social determinants, such economic instability, housing instability, and food insecurity. Many health disparities are due to factors external to the individual, such as poverty and different forms of social exclusion (such as residential and educational discrimination) that limit access to life opportunities (such as employment and housing) and adequate medical care. Lack of opportunities over the lifecourse can also contribute to behaviors that undermine health (Bach, Pham, Schrag, Tate, & Hargraves, 2004). The differential access to, and allocation of resources due to socially constructed race-, class- and age-related hierarchies has led to unfair and preventable disparities in health outcomes experienced by many communities of color. Institutional and interpersonal experiences of discrimination in employment practices, access to quality housing, availability of healthy food options and quality health care, occurring across the lifespan are the products of an unjust social system, driving health outcomes that are ‘socially determined.’
If we are to solve the public health problem of disparities driven by social determinants, we must develop and implement policies and programs across the life trajectory to ensure adequate life opportunities before BIPOC become older adults. A call to action for a life-course remedy is in order and should include actions that move beyond a deficit model, emphasizing protective factors serving as a source of interventions. Through a social determinants and life course perspective, we can better understand how income and wealth differences, rooted in a lifetime of inequitable opportunities from education to employment to housing, affect an individual’s health.
The Way Forward
COVID-19 has presented us with an opportunity to act against inequities by enacting solutions, many of which are readily available and/or require minimal investment. A multi-level approach that focuses on governmental policies and programs at the state, municipal, community, and individual levels is essential to optimize impact.
At the state and municipal level, it is important that policymakers and providers continue to support programs such as supplemental benefits and food vouchers to meet the needs of those with food insecurity. Ongoing emergency rental assistance provides direct aid for low-income older adults who slipped into unstable housing situations due to COVID-19. Extending the COVID-19 rental moratorium to prevent evictions until March 2021 is an example of policies focusing on equity.
At the community-level, the use of tools, such as health impact assessments to identify proposed, and assess existing social policies to address the needs of this population could result in promptly and efficiently allocating appropriate resources to those most vulnerable while also closing health gaps. Partnerships between local government and community are foundational to ensure the necessary resources are available, properly allocated, and sustained. For instance, services such as telehealth and mental health support continue to be in great need. Fear, stress, and worry are normal responses to threats and during times of uncertainty and change. Initiatives by New York State’s Office of Mental Health (OMH) to establish, and now routinize telehealth and telephonic mental health support for individuals feeling, anxious, depressed or stressed constitutes an example of efforts to address long standing mental health disparities experienced by older BIPOC that can be sustained over time.
As many older adults participate in activities within the community and as social distancing guidance remains in effect, it will be important to ensure those without access to or knowledge of resources are able to stay connected. Ensuring access to phone, Wi-Fi and mobile technologies is critically important. Continuing food distribution, automatic delivery of medications, and access to telemedicine post COVID pandemic may ameliorate challenges due to low economic support, housing instability, and access to health care.
As providers, we are tasked to effectively support and care for the vulnerable during this current pandemic. Through cultural humility, and a keen awareness of how the interplay of ageism and racism operates through exclusion from life opportunities and manifests as explicit and implicit discrimination, distrust of health care providers, and historical and racial trauma, we can promote socio-culturally responsive treatment and support.
To this end, two Centers of Excellence for Cultural Competence in New York State have developed projects that are highly translatable for addressing disparities among aging BIPOC. The Center for Research on Cultural and Structural Equity in Behavioral Health (C-CASE) has developed a novel training in cultural humility and social determinants of health for the workforce serving diverse families with children and youth with high emotional and behavioral health needs. This training can be seamlessly adapted for providers serving the aging BIPOC communities. Also, the New York State Center of Excellence for Cultural Competence has developed innovative efforts to counteract economic vulnerability of BIPOC with mental illness that focuses on increasing financial empowerment in communities living in poor socioeconomic conditions. This project is also applicable and adaptable to aging BIPOC communities. These innovations are examples of how we can leverage our on-going efforts and policy commitments to creating equity during a time when need has reached a historical high point. Anything less may likely result in further entrenchment of health inequities experienced by BIPOC, and particularly our ageing communities.
For more information, visit www.nki.rfmh.org.