BACKGROUND

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In a matter of weeks, COVID-19 altered all aspects of daily life worldwide—disrupting the global economy and testing the capacity of each country's healthcare infrastructure. Reported cases elevated it to the most common daily cause of death in the United States.^1,2 The virus threatens the health and safety of everyone and puts the most vulnerable at risk of physical, social, and financial harm. Within the United States, public health containment measures taken to minimize the spread of COVID-19 may have significant implications when considering the social determinants of health (SDH). The SDH reflect the context in which an individual is born and lives. Studies have demonstrated that SDH, which include factors such as economic stability, neighborhood and physical environment, housing, education, food, and access to quality health care, are fundamental to determining individuals' opportunities to experience optimal health outcomes.³ As others have commented, although COVID-19 does not discriminate whom it infects and kills, we find that certain racial/ethnic minority and low socioeconomic status (SES) groups are disproportionately impacted, because of SDH.^4,5 As we mitigate and address the COVID-19 outbreak, it is important that we consider policies that recognize the critical importance of the SDH and the ways in which they exacerbate health disparities among vulnerable populations, such as individuals with a cancer diagnosis. Here, we outline the pillars of an SDH framework as it relates to COVID-19 and highlight the influences on patients with a cancer diagnosis.

SDH FRAMEWORK AND COVID-19

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In Table 1, SDH are described using a Kaiser Family Foundation Framework with a list of the relevant changes borne out of the COVID-19 pandemic.⁶ These determinants include economic stability, neighborhood and physical environment, education, food, community and social context, and healthcare system. These factors are known to have dramatic effects on one's health and well-being. For vulnerable patients, such as those with cancer, the risk of adverse outcomes from COVID-19 can be even more pronounced when examining outcomes through the lens of SDH. We have an urgent need to consider what policies and safety nets need to be put into place now to mitigate adverse outcomes.

TABLE 1. COVID-19 Impact on SDH (Kaiser Family Foundation Framework22,23)

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ECONOMIC STABILITY

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The pandemic has had an unprecedented impact on the nation's economy affecting every sector.

As of April 25, 2020, more than 30 million workers have filed for unemployment.⁷ This employment loss is mostly concentrated among older and less educated workers⁸ and will likely result in exacerbation of existing economic and health disparities. In patients with serious chronic comorbidities, such as cancer, economic destabilization as a result of the COVID-19 pandemic may have more devastating effects, particularly in the era of rapidly rising cost of health care. Given that most health insurance is linked to employment in the United States, the sweeping job loss across the country will also result in millions of patients potentially losing their healthcare coverage. Several studies have demonstrated that financial distress and financial toxicity are already prevalent in patients with cancer.^9,10 For patients already under heavy financial burden, the impact of COVID-19–related economic losses may lead to further consequences, including cessation of life-saving/prolonging therapies, eviction, and even homelessness. Policies that protect individuals who are most financially vulnerable are critically important now more than ever.

NEIGHBORHOOD AND THE PHYSICAL ENVIRONMENT

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With mandatory social distancing requirements across the United States, the physical environment of many has also been affected by the COVID-19 outbreak. Particularly for those with cancer, fears of contagion have pushed many indoors. Several studies out of China,¹¹ Italy,¹² and the United States¹³ have suggested an increased COVID-19 infection fatality rate in patients with cancer, partly because of their underlying malignancy, treatment-related immunosuppression, or increased comorbidities. Patients with cancer who have the means to self-quarantine have been doing so. Isolation resulting from the home-based quarantine and the reduced contact with co-workers and family members creates feelings of loneliness, which can be associated with anxiety and depression.^14-16 Several studies have demonstrated that higher levels of depressive symptoms are associated with increased mortality in patients with cancer.^17,18 Moreover, social isolation and self-quarantine may mean limited opportunity to engage in physical activity for some which, in turn, may lead to an increase in depressive symptoms and increased mortality,¹⁹ in addition to worse cancer survivorship outcomes. On the other hand, for those living in densely populated urban areas, self-isolating may not always be feasible and can potentially put them at risk for more viral exposures.

COMMUNITY AND SOCIAL CONTEXT

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Home-based isolation is not an option for all patients, for example, if a patient's employment is designated as essential and does not provide options for remote work. However, these challenges can be mitigated for those who have strong social support/community. For others, crowded living situations, especially if they live in residencies with multiple occupants, are unhoused, living in homeless shelters, or single room occupancy (SRO) facilities can make it difficult to quarantine appropriately. For example, in April 2020, the largest homeless shelter in San Francisco suffered an outbreak resulting in > 90 residents and 10 staff members testing positive for COVID-19.²⁰ Another SRO in the Mission District, Casa Quezada, also had an outbreak resulting in 22 residents testing positive for COVID-19.²¹ Patients with cancer who suffer from homelessness or lack stable housing are even more at risk for adverse health outcomes as a result of inability to self-quarantine. For those who find ways to isolate themselves in those situations, they may have difficulty accessing food, medical care, and lose their support networks.

EDUCATION

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Another effect of COVID-19 on SDH has been on the education system at every level. While universities across the country are announcing that they are transitioning to a distance learning model, public school systems are closing typically without much guidance on how to continue to enrich children while at home. As schools institute online learning for their students, those who lack access to a computer/Internet may fall behind. Moreover, parents with school-age children are grappling with the realities of a work from home model while also caring for their children who are at home. Others, especially low-wage workers who are unable to work from home, are struggling to find caretakers for their children while they work.

For medically vulnerable patients, the level of education also affects the extent to which they are able to access and process reliable information about COVID-19. For some patients, this may result in not having all the information they need regarding special precautions they may need to take to protect themselves from various infections. In addition, one's level of education can also affect health literacy and ways in which one interacts with the healthcare system, including the ability to take advantage of telehealth options.

FOOD

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Schools serve as the only meal source for many children from low-income households. Approximately 20.2 million free and 1.8 million reduced-cost lunches are dispensed every day for school-age children across 100,000 schools in the United States.²² In the context of COVID-19, children may have inconsistent access to food. Families who are food insecure are unlikely to afford to stock up on nonperishable foods, which may worsen their food insecurity. Across many cities in the United States, the demand at food pantries has risen at an extraordinary rate, as food banks are struggling with decreased donation and volunteer workers.²³ For patients who are medically vulnerable, including those with cancer, this may result in lack of access to healthy food options that help them manage chronic illnesses.

HEALTHCARE SYSTEM

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Finally, the healthcare system is most obviously strained by a surging demand for care and the stress of being unable to meet that demand because of unavailability of tests and, in some parts of the country, constraints on the availability of intensive care and other life-saving treatments. Several studies have now shown that patients with cancer are vulnerable to having severe illness and high mortality rates from COVID-19 infection. In cohorts from China and Italy, patients with active cancer had a higher risk of severe illness and death from COVID-19.^11,12 Similarly, in New York, the case fatality rate of COVID-19 in patients with cancer was as high as 28%.¹³ The pandemic has disrupted routine care for many patients with cancer, of which the effects on overall cancer-related outcomes are not yet known. Preventative screening such as mammograms, colonoscopies, and pap smears has also been reduced in an attempt to curb the spread of the virus and redirect resources. This may lead to an influx of new cancer diagnoses and with possible presentations at later stages of disease as only symptomatic patients present to the medical system. With the rise of telehealth services, patients with low English proficiency, those with decreased health literacy, or those who lack access to computer/Internet are likely to be disproportionately affected. Unfortunately, this may potentially widen the racial/ethnic disparities that already exist in cancer diagnosis.²⁴

POLICY IMPLICATIONS

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COVID-19 has affected the SDH in many ways and has highlighted the inequities within the US healthcare system. These SDH are the same fundamental influences that play distinct roles in leading to health disparities across the United States for decades. More recent data suggest that socially marginalized populations are suffering disproportionately from COVID-19 infections and mortality. In places such as Chicago, Milwaukee, New Orleans, New York, and many more, populations of color make up the majority of COVID-19 deaths.²⁵ It is important to highlight that these racial and ethnic disparities are unlikely to be the result of biological or behavioral difference but more likely the result of upstream forces such as economic inequality, food deserts, crowded living conditions, uneven geographic distribution of preventive care services leading to uncontrolled chronic diseases, limited COVID-19 testing, concentration of respiratory hazards and toxic sites in low SES or minority heavy areas, and weathering or chronic stress brought on by racial discrimination.^26-28 Thus, policies to address the COVID-19 outbreak must take these upstream factors into account to decrease exposure and susceptibility to COVID-19. Resources must focus on communities that are hardest hit by COVID-19.^4,5 Recognizing the role of SDH as we mitigate and address the COVID-19 outbreak is essential ensuring equitable outcomes for vulnerable populations in the United States.