key: cord-0801856-bitexkrn
authors: Asfaw, Eliyas K.; Guo, Emily S.; Jang, Sarah S.; Komarivelli, Swathi R.; Lewis, Katherine A.; Sandler, Claire B.; Mehdipanah, Roshanak
title: Students’ Perspectives: How Will COVID-19 Shape the Social Determinants of Health and Our Future as Public Health Practitioners?
date: 2020-10-14
journal: Health Educ Behav
DOI: 10.1177/1090198120963117
sha: 07959b1e3b27b7d7654854e46ac8f93de0c266ee
doc_id: 801856
cord_uid: bitexkrn

We are the next generation of public health practitioners. As public health students, we acknowledge that the COVID-19 (coronavirus disease 2019) pandemic will continue to fundamentally alter the field that we are preparing to enter. We will be the first wave of public health professionals whose education is being shaped by this pandemic. For decades to come, we will be working to address the impacts of this pandemic. In this commentary, we are lending our voice to discuss and highlight the importance of considering the intersections of various determinants of health and COVID-19, including education, food insecurity, housing instability, and economic hardship. We provide a discussion on what is being done across the United States in attempts to reduce the growing health inequities. As the next generation of public health leaders, we believe that only by investing in these issues can we begin to address the social and economic impact of the COVID-19 pandemic.

The COVID-19 (coronavirus disease 2019) pandemic has ravaged U.S. cities, communities, and businesses, sending the economy into a free fall and killing more than 170,000 Americans so far (Centers for Disease Control and Prevention, 2020) . In the absence of a treatment, health agencies have relied on public health (PH) basics: hand washing and social distancing. Across the country, businesses were ordered to shut their doors, residents were told to stay home, and students were sent home. Such policies, while vitally important in the fight against COVID-19, have disrupted the lives of millions of Americans, who now face unemployment, financial stress, and housing instability in addition to fears about their health and safety. The pandemic has exposed preexisting inequities in the United States, resulting in hasty responses across all sectors to address the social determinants of health (SDOH) as they relate to Initially, COVID-19 was described as "the great equalizer," a force that would sweep across the country without regard for race, socioeconomic status (SES), gender, or sexuality (Jones & Jones, 2020) . However, it is clear that this is not the case, as disparities by race, age, and SES have become evident, with African Americans, low-income individuals, and/or seniors being disproportionately affected (Chowkwanyun & Reed, 2020; Schulz et al., 2020) . It is unclear how these disparities will affect the long-term health of marginalized populations, but it is overwhelmingly obvious that PH interventions addressing the SDOH are critical in fighting the pandemic's lasting impacts.

As undergraduate PH students and the first wave of PH professionals whose education is being shaped by this pandemic, we acknowledge that the COVID-19 pandemic will fundamentally alter the field. Even long after a vaccine or cure is developed, we will be addressing the lingering impacts of a pandemic that dramatically heightened social and health inequities. Although our training in PH is not complete, we have all reflected on the distinct differences between the education we have received and the real-world implications of this pandemic. While we have all studied diseases, inequities, and systemic challenges to societal health, we recognize that our traditional PH education has not adequately prepared us for a challenge of this scale. This is partly due to the unprecedented scale of this crisis, but it is also the result of an optimistic oversimplification of what it takes to protect the public's health. For example, while we have learned about the challenges faced by various programs, we are only now learning that even the best-intended PH programs will fail or be rejected at times. We also need to learn how to listen, communicate effectively, and collaborate with other fields like politics and economics to create PH solutions that address different values and beliefs. In the months to come, we will be learning alongside our teachers about the recovery process, which will include revisiting conversations on program planning and implementation to discuss the intersections of PH with differing views and values among political leaders as well as the public. On a personal level, for some, the pandemic has further validated efforts in working in a field that is becoming more widely recognized, while for others, the sociopolitical aspects of the pandemic have cast doubts about the decision-making abilities PH practitioners will have in the future. In this article, we aim to highlight our perspectives as students on the COVID-19 pandemic and provide a call to action for leaders in all fields, including PH, politics, economics, and education, to work together to address the ever-widening disparities worsened by the pandemic.

Research has shown that having an education can provide a person with opportunities for fulfilling, higher-income, fulltime work, with less economic hardship compared with those who do not have an education (Ross & Wu, 1995) , in turn resulting in positive health outcomes (Case et al., 2005; Jackson, 2009 ). COVID-19 has caused major disruptions in education attainment. The sudden shift to online learning has exposed even more educational inequities, including a technology divide as some students do not have reliable electronic devices and internet at home (Burgess & Sievertsen, 2020; Thomas, 2020) . Furthermore, the safe, engaging environment at school-which provided for the physical and social needs of some students who do not have adequate housing-was taken away. These barriers will disproportionately affect the education of students from lower-income families and those attending underresourced schools that are not able to make up for these shortcomings. Finally, the lack of quality education, in-person instruction, and socialization with peers affects the mental health and development of students-especially young children, who need in-person interaction in their critical periods of development-which can delay skill development (Heckman, 2006) .

As future PH practitioners, we highlight the importance of addressing the rising mental health issues and the need for access to programs and strategies to address trauma, including the death of loved ones, the experience of confinement, child abuse and neglect, economic uncertainty, and the pandemic itself.

Food insecurity plagued the United States even before the pandemic. In 2018, approximately 11.1% of households were food insecure, with households headed by single parents and Black and Hispanic households being 21.85% and 18.7% food insecure, respectively (Economic Research Service, U.S. Department of Agriculture, 2020). However, the current pandemic exacerbates the difficulties in access to food-including a widespread reduction in income and children who rely on meals provided by schools not currently attending (Casselman et al., 2020) . Even access to food in grocery stores is limited as stores could be a high-risk contact point for susceptible groups, and food banks have been drained because of high demand.

While interventions such as continuing to provide school lunches despite schools being closed and increasing access to food banks have helped millions of families, food insecurity will remain an important issue for a long time. As future PH practitioners, we are concerned about households making decisions to forgo food in order to pay for other necessities like rent and medications. The physical and mental repercussions of such decisions will remain for generations if this issue is not addressed. We urge the concerned public officials to consider expanding national programs such as SNAP (Supplemental Nutrition Assistance Program) and NSLP (National School Lunch Program) to account for the drastic decrease in income and reduce the harm faced by vulnerable populations. With the uncertainty surrounding the duration of COVID-19 economic relief and aid, it is imperative to implement sustainable food programs.

The COVID-19 pandemic has revealed the inequities within the housing system. Homeless populations are at higher risk of contracting communicable diseases, including tuberculosis, hepatitis, and influenza (Badiaga et al., 2008) . Now, COVID-19 is added to this list (Tsai & Wilson, 2020) . Before the pandemic and the consequent closure of many public areas, those experiencing homelessness spent time in places like libraries and fast-food restaurants (Ellis, 2020) . These places also provided facilities for sanitary needs. With the closures, such facilities to maintain basic hygiene are scarcer. For those not experiencing homelessness, their housing situation may not be any better. The United States was already experiencing a dire housing situation even before the pandemic. For millions, paying rent was difficult, and the cost burden continued to increase (Charette et al., 2015) . In 2018, an estimated 2 million evictions were filed across the country (Eviction Lab, n.d.) . During the COVID-19 pandemic, the situation has worsened, with one of three adults unable to pay rent in April, while 50% reported difficulty paying rent or for utilities (Adamczyk, 2020) .

Interventions such as California's redirecting the use of hotel rooms and deployment of travel trailers to house the homeless (California All, 2020) and the moratorium on evictions in several states have helped (Choi et al., 2020) . However, these are temporary at best and will soon end. We urge the implementation of long-term solutions to replace these Band-Aid measures, as emphasized in our education. As students and neighbors, we are worried about unstable housing conditions, especially during a time when people have myriad other things to worry about.

Employment and SES correlate directly with health and affect essential services such as child care, education, food, housing, and health care. Prior to the pandemic, in February 2020, the U.S. unemployment rate was around 4%. However, by May, the rate was estimated to be between 13% and 16% (Kochhar, 2020) . While many companies adapted to social distancing by using online platforms, stay-at-home orders took a huge toll on some businesses and their employees. Some of the racial inequities in the economic toll of the pandemic are attributed to more people of color working in the service industry and other essential positions (Rho et al., 2020) . Less than 15% of minority-owned businesses received the Paycheck Protection Program loans (Flitter, 2020) . Furthermore, existing inequities in education, food insecurity, and health care have disproportionately affected people of color during the pandemic. More than 60% of Hispanics experienced wage losses (Lopez et al., 2020) , while Black or African Americans have had the greatest number of infections and double the death rates compared with Whites (Chowkwanyun & Reed, 2020) .

For one of us, my African American identity combined with a low SES have shown me the various disadvantages people of color face every day. When I came to the University of Michigan, I learned how the inequities I saw in my community translated to worse health. Hence, I wanted to study PH to make changes that could lead to equity in health and other areas. The current pandemic has shown me that the strides needed to be made to achieve equity are more daunting and more needed than ever. Hence, PH has a fiduciary duty to do more in sharing these disparities with the public, along with their causes and real-life implications, as well as to be a leader in drafting policies that address these disparities. For this to happen, future PH trainees should have an interdisciplinary focus in the fields of economics and education. The field should use the pandemic as a wake-up call and intensify efforts toward a path to equity.

Although we have witnessed a variety of interventions, the impact of these programs pales in comparison to the daunting task of rebuilding lives and comforting a traumatized nation. The COVID-19 pandemic has exposed and exacerbated existing inequities across the country, emphasizing the need for continued work in the field of PH to address these issues. The pandemic has highlighted the dangers of disparities that we, as a nation, have normalized and attempted to address with a patchwork system of interventions, which under normal circumstances function well enough to avoid a national outcry. For example, while we accept that some Americans live paycheck to paycheck, the delicate balance of paying for housing, food, and other needs with the help of nonprofits and government assistance has crumbled during this pandemic. In 2018, a Federal Reserve report showed that if faced with a $400 unexpected expense, 40% of U.S. adults either would not be able to pay for it or would do so only by borrowing money or selling something (Federal Reserve System, 2018) . Postpandemic, we can only speculate what the setback will be for millions of Americans. This phenomenon calls attention to the fragility of our system and highlights the need to address disparities before, during, and after a pandemic.

As future PH practitioners, we acknowledge that our careers will be fundamentally shaped by the nation's response to this pandemic. While COVID-19 may eventually be treated, the socioeconomic toll of the pandemic will remain ours to address in the decades to come. As we complete our education and enter the workforce, we are witnessing a transformation of our field and the emergence of problems we will dedicate our careers to solving. We have a unique perspective in that our foundational PH education is being shaped by a pandemic reminding us every day of the importance of our field, but also the perilously high stakes of our work, serving as a constant reminder of the monumental changes needed to spearhead an equitable and healthy society. Some of us may become PH practitioners, while others may go into different fields. The pandemic may be a deciding factor.

Regardless of what we decide, we hope to address the challenges our society is experiencing by building a system that can weather future pandemics and disasters, by supporting vulnerable populations in a way that our current system has not. While many of us feel despair due to the widespread rejection of and disrespect for PH leaders and policies, some of us see this as a turning point that has the potential to fuel long-lasting change by strengthening our PH infrastructure. We expect that the increased global attention on PH will provide an opportunity to illuminate the importance of the field and a chance to create a more just, equitable, and healthy society. However, despite these expectations, we recognize that tragedy does not inherently lead to change. Rather than the current temporary patchwork of solutions we have described, the long-lasting, impactful change that we envision can only be achieved through sustained attention, funding, compassion, effective communication, and hard work by current and future PH practitioners. Additionally, we are aware that these perspectives may not include those of traditionally excluded students, further contributing to this problem. Given this difficulty, we urge current and future PH officials to go beyond discussing the intersectionality of the SDOH and intervene with proper methods of inclusion. We must not see this time as yet another social justice wave but use this momentum to create change through legislative actions and by holding failed programs accountable.

We emphasize that the invisibility of PH successes should not be mistaken for the lack of importance of the field itself. While PH failures (e.g., the spread of COVID-19) inspire global attention and panic, PH successes (e.g., the containment of global spread of Ebola) do not achieve the same level of attention. As such, it is all too easy to dismiss safety, equity, and health as the norm, when they are actually the result of sustained hard work and investment in PH. This phenomenon is also reflected at the individual level when adhering to PH guidelines. It is easy for an individual in a neighborhood where everyone stays home and wears a mask to complain about overbearing and unnecessary policies if they themselves do not become infected. However, even the maintenance of the status quo, being healthy and avoiding infection, is not a passive event but rather a PH success that requires the support, cooperation, and respect of citizens as well as political and community leaders. We have also seen how citizens' attitudes are very important, as many other countries with similar stay-at-home orders have residents who are more willing to cooperate than those in the United States.

We believe that it is crucial to address the systemic flaws that have placed millions of Americans in unsustainably vulnerable positions. Rather than addressing housing insecurity, food access, educational disparities, and racial inequities as isolated problems, we call on the PH community to address these issues as intersectional phenomena that interact with one another and other factors including ageism, sexism, and homophobia. As the next generation of PH leaders, we believe that only by investing in multifaceted approaches can we address the social and economic impact of the COVID-19 pandemic and create a society that is better prepared for the next disaster.

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We would like to thank Izza Ahmed-Ghani and Haley Rau for their contributions at the planning stages of this process.

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The authors received no financial support for the research, authorship, and/or publication of this article.

Roshanak Mehdipanah https://orcid.org/0000-0001-6821-0715