Written by Cecilia Rogers

One year ago, the United States began to implement lockdown measurements to prevent the spread of COVID-19. During this past year, everyone across the United States has experienced the hardships of living through this global pandemic; however, certain populations have been disproportionately affected by this disease. But, what has led to the rise of these vulnerable populations? High risk populations are often generated by a variety of social factors. “Structural vulnerability” was coined to describe how existing hierarchies within social life reinforce the likelihood of negative health outcomes for individuals or populations. Factors such as race, gender identity, and socioeconomic status, can often be neglected in healthcare because social forces can seem more abstract than overt health conditions. However, acknowledging structural vulnerability is important for developing a comprehensive understanding of the risks faced by minority groups. 

The United States healthcare system has historically been wrought with discriminatory practices which have disadvantaged minority groups. A major barrier to equitable healthcare is socioeconomic status. The United States’ refusal to operate via a universal healthcare system, coupled with the high costs of private health insurance companies results in low income individuals not being able to afford necessary procedures or treatments for health conditions. This issue of class disparity is also inflated by other social factors such as race–– David R. Williams states that “compared with White persons, Black persons and other minorities have lower levels of access to medical care in the United States due to their higher rates of unemployment and under-representation in good-paying jobs that include health insurance as part of the benefit package.” This example demonstrates how an intersectional approach to analyzing healthcare inequities reveals the role of the relationship between race and economic status in affecting an individual’s barrier to healthcare. 

Not only is race a determinant of access to healthcare, but also quality of care.  Studies have shown that many White medical students hold the belief that Black people have a higher pain tolerance than White people. This false notion can lead to an inadequate administration of medication to Black patients. Another social construct contributing to structural vulnerability is gender identity. In particular, transgender and non-binary (TGNB) individuals face strong barriers to healthcare. Again, this factor is amplified by its intersection with socioeconomic status as individuals who hold TGNB gender identities face high rates of employment discrimination and economic instability. Consequently, TGNB individuals are uninsured at higher rates than cis-gender individuals. These deep-rooted power dynamics within society continue to create a hierarchical structure that places minority groups at risk for negative health outcomes.

The COVID-19 crisis has illuminated how social hierarchies affecting healthcare persist in the United States. The first wave of  the coronavirus hit the elderly population the hardest,making its way through nursing homes and assisted living facilities. This group was immediately deemed the most vulnerable due to their reduced physical capacity to fight this disease. However, as a second wave claimed more victims, vulnerable populations were more socially than physically disadvantaged. The American Journal of Tropical Medicine and Hygiene reports that “the novel coronavirus disproportionally affected African Americans, undocumented and documented Hispanic immigrants, and members of the Native American Navajo Nation”. A study conducted in May 2020 reveals that Black people were 3.57 times more likely to die from COVID-19 than White people, and a shocking statistic shows that 70% of deaths due to the coronavirus in Louisiana are African Americans. Moreover, Dr. Denise Herd, a professor of behavioral sciences at UC Berkeley, states that “even though people of color are two to three times more likely to get infected or die, they’re two to three times less likely to get vaccinated”. 

“The COVID-19 crisis illuminates how social hierarchies affecting healthcare persist in the United States.”

Minority groups in America were made most vulnerable to coronavirus due to their spatial and societal position. Dr. Herd discusses how “the health system itself is segregated. […] medical facilities are less likely to be located in areas where vulnerable populations live.” Another major factor affecting minority groups’ exposure to this virus is the poverty cycle for minorities in America. For example, almost half of the low-wage workforce is made up of women of color. These working-class individuals cannot afford to remain at home; instead, they are forced to report to work in order to receive a paycheck to support themselves and/or their families. Remote work not being an option for many of these individuals, they are greatly exposed to the public and at greater risk of contracting COVID-19. Reliance on public transportation and crowded public housing situations also increase the likelihood of contracting Coronavirus for these populations. These same mechanisms work against transgender individuals who have reported “high rates of poverty, unemployment, food insecurity, homelessness, and sex work”.  This pandemic has also led to more recent job loss for transgender individuals which has exacerbated employment disparities. These vulnerable groups demonstrate how structural vulnerability has played out in a predictable manner during this pandemic, with the most marginalized of society at the highest risk of negative health outcomes.

“Another major factor affecting minority groups’ exposure to this virus is the poverty cycle for minorities in America. For example, almost half of the low-wage workforce is made up of women of color.”

A third wave brought to light another structurally vulnerable population: imprisoned persons and individuals held in detainment centers. Statistics show that 1 in 5 prisoners has had COVID-19. Furthermore, “ICE reports 19,092 tests since February – amounting to a 20% average test positivity rate across all detention centers. This is nearly three times the current positivity rate across the US”. These populations are subject to overcrowding and poor living conditions creating a perfect storm for disease outbreak. Lack of healthcare providers for these groups also contributes to the high rates of covid cases. 

So, how can structural vulnerability be addressed? A study done in March 2017 outlines steps which can be taken to mitigate the effects of structural vulnerability on healthcare. Initial screening questions can be used to flag patients who are subject to traditional social and institutional barriers to healthcare. Structural vulnerability should also be taken into account during diagnosis and determination of a treatment plan; patients should be asked how their social factors may have affected their symptoms. Another important step is raising awareness of a practitioner’s surrounding because interaction between healthcare providers and their community is crucial to understanding how to best serve the surrounding populations.  However, more immediate solutions rely on policy response. Dr. Herd states how in “California the governor announced that 40% of the vaccine allocation is going to now go to lower income zip codes.” Policies geared toward protecting vulnerable groups by making the vaccine available to them are necessary to combat the inequities minorities are facing during the pandemic.

“Another important step is raising awareness of a practitioner’s surrounding community and what needs they face. Interaction between healthcare providers and their community is crucial to understanding how to best serve the surrounding populations.”

Overall, this pandemic has exemplified the social hierarchies which affect our healthcare system and disadvantage minority groups. Following the trends of other healthcare crises in America, coronavirus has disproportionately affected individuals who face discrimination based on social factors such as race or gender identity. Hope for immediate relief for these groups comes from policy makers as covid relief bills and vaccine distribution can serve to help the most at risk populations. Long-term, structural vulnerability needs to continue to be at the forefront of medical care and education so these devastating trends become a less foreseeable outcome. 

Edited by Priya Mahableshwarkar