Utibe R Essien, MD, MPH

In 2016, a study was published that continues to shock observers today.¹ Examining 200 medical trainees, researchers reported that an alarming percentage of these individuals held false beliefs about Black bodies, including 22% believing that nerve endings in Black persons are less sensitive than nerve endings in White persons and 63% believing that Black skin is thicker than White skin. Furthermore, the study found that those who held these false beliefs about biological differences between Black and White individuals were also less likely to recommend pain treatment to Black patients in a follow-up case vignette. Two years later, in an evaluation of racial differences in opioid prescribing in the United States published in Epidemiology, one of the authors suggested, “It’s an extremely rare case where racial biases actually protected the population [Black individuals] being discriminated against.”²

These studies provide the background for the analysis by Rambachan et al³ published in this issue of the Journal of Hospital Medicine. The authors examined a diverse cohort of more than 10,000 patients hospitalized on a general medicine service at an academic medical center in San Francisco from 2012 to 2018. Black patients were significantly less likely to receive an opioid prescription at discharge, and when they did, were discharged on opioids for fewer days than White patients. No other racial group experienced such a disparity, with Asian patients more likely to receive opioids at discharge. Whereas these findings align with myriad studies demonstrating racial disparities in opioid prescribing,⁴ the authors focus on patients admitted to a general medicine service, where most hospitalized patients receive medical care daily.

The authors concede that determining the etiology of these disparities was beyond the scope of their study, yet this is the exact question we must answer today. Why should the color of a patient’s skin continue to determine the type, and duration, of care they receive, especially when treating pain? The authors hypothesize that individual factors such as provider bias and systemic factors, including limited guidelines on pain management, may drive the observed racial inequities. This progression from individual- and institutional- to community- and policy-level determinants offers a useful framework for understanding the drivers of disparities in opioid prescribing. It also provides an agenda for future research that can guide us from simply detecting disparities to understanding and eliminating them. Furthermore, it is important to examine care team provider characteristics, including race/ethnicity, years in practice, education level (eg, resident vs attending),⁵ experience with implicit bias training, and differential referral to specialists, such as pain, palliative care, and addiction providers. Factors associated with the facility where a patient is hospitalized also warrant further exploration, including the diversity of medical and nonmedical staff as well as patients.⁶ Examining these factors will allow us to move closer toward implementing effective interventions that eliminate disparities in pain treatment.

The authors begin to provide us with possible levers to pull to address the inequities in opioid prescribing. They suggest provider-level bias training, improved institutional tracking of disparities, and policy-level solutions to address the persistent dearth of diversity in the healthcare workforce. While these broad solutions may address health disparities across the medical field, targeted solutions are needed to directly address inequities in pain treatment. First, we must explore the reasons for disparities in the prevalence, presentation, and management of pain in Black populations. These reasons may include occupational exposures or injuries, psychological stress (often associated with racism), and a disproportionate presence of chronic medical comorbidities. Second, health systems can implement a standardized system for opioid prescribing, supported by pharmacy expertise and considering clinical diagnoses, to reduce subjectivity associated with determining the appropriateness of an opioid prescription. Third, health systems must improve access to addiction, harm reduction, and pain specialty services to effectively manage comorbid conditions in at-risk patients.⁷ Furthermore, we must look beyond traditional measures of healthcare access, such as insurance coverage, to address social determinants of health, such as distance to pharmacy, housing security, employment status, and experience with the criminal justice system, which may influence a patient’s receipt of a prescription. Finally, as a society, we must prioritize early training of healthcare providers, long before the undergraduate and graduate medical education level, to practice medicine without stigmatizing biases and stereotypes related to drug use in communities of color.⁸

The pattern of racial and ethnic disparities in healthcare has been documented for decades, with an ever-increasing depth of the different ways in which minoritized patients are undertreated. Despite this breadth of research, our understanding of the etiology of these inequities and development and implementation of interventions to reduce them remain limited. Rambachan et al³ do a commendable job highlighting further racial disparities in opioid prescribing in hospitalized patients and provide another opportunity to answer the important questions plaguing health care today: Why do these disparities exist and what can be done to address them? The urgency we take towards answering these questions will confirm our commitment to achieving antiracism in medicine and prioritizing health equity. Black lives are depending on it.

In 2016, a study was published that continues to shock observers today.¹ Examining 200 medical trainees, researchers reported that an alarming percentage of these individuals held false beliefs about Black bodies, including 22% believing that nerve endings in Black persons are less sensitive than nerve endings in White persons and 63% believing that Black skin is thicker than White skin. Furthermore, the study found that those who held these false beliefs about biological differences between Black and White individuals were also less likely to recommend pain treatment to Black patients in a follow-up case vignette. Two years later, in an evaluation of racial differences in opioid prescribing in the United States published in Epidemiology, one of the authors suggested, “It’s an extremely rare case where racial biases actually protected the population [Black individuals] being discriminated against.”²

These studies provide the background for the analysis by Rambachan et al³ published in this issue of the Journal of Hospital Medicine. The authors examined a diverse cohort of more than 10,000 patients hospitalized on a general medicine service at an academic medical center in San Francisco from 2012 to 2018. Black patients were significantly less likely to receive an opioid prescription at discharge, and when they did, were discharged on opioids for fewer days than White patients. No other racial group experienced such a disparity, with Asian patients more likely to receive opioids at discharge. Whereas these findings align with myriad studies demonstrating racial disparities in opioid prescribing,⁴ the authors focus on patients admitted to a general medicine service, where most hospitalized patients receive medical care daily.

The authors concede that determining the etiology of these disparities was beyond the scope of their study, yet this is the exact question we must answer today. Why should the color of a patient’s skin continue to determine the type, and duration, of care they receive, especially when treating pain? The authors hypothesize that individual factors such as provider bias and systemic factors, including limited guidelines on pain management, may drive the observed racial inequities. This progression from individual- and institutional- to community- and policy-level determinants offers a useful framework for understanding the drivers of disparities in opioid prescribing. It also provides an agenda for future research that can guide us from simply detecting disparities to understanding and eliminating them. Furthermore, it is important to examine care team provider characteristics, including race/ethnicity, years in practice, education level (eg, resident vs attending),⁵ experience with implicit bias training, and differential referral to specialists, such as pain, palliative care, and addiction providers. Factors associated with the facility where a patient is hospitalized also warrant further exploration, including the diversity of medical and nonmedical staff as well as patients.⁶ Examining these factors will allow us to move closer toward implementing effective interventions that eliminate disparities in pain treatment.

The authors begin to provide us with possible levers to pull to address the inequities in opioid prescribing. They suggest provider-level bias training, improved institutional tracking of disparities, and policy-level solutions to address the persistent dearth of diversity in the healthcare workforce. While these broad solutions may address health disparities across the medical field, targeted solutions are needed to directly address inequities in pain treatment. First, we must explore the reasons for disparities in the prevalence, presentation, and management of pain in Black populations. These reasons may include occupational exposures or injuries, psychological stress (often associated with racism), and a disproportionate presence of chronic medical comorbidities. Second, health systems can implement a standardized system for opioid prescribing, supported by pharmacy expertise and considering clinical diagnoses, to reduce subjectivity associated with determining the appropriateness of an opioid prescription. Third, health systems must improve access to addiction, harm reduction, and pain specialty services to effectively manage comorbid conditions in at-risk patients.⁷ Furthermore, we must look beyond traditional measures of healthcare access, such as insurance coverage, to address social determinants of health, such as distance to pharmacy, housing security, employment status, and experience with the criminal justice system, which may influence a patient’s receipt of a prescription. Finally, as a society, we must prioritize early training of healthcare providers, long before the undergraduate and graduate medical education level, to practice medicine without stigmatizing biases and stereotypes related to drug use in communities of color.⁸

The pattern of racial and ethnic disparities in healthcare has been documented for decades, with an ever-increasing depth of the different ways in which minoritized patients are undertreated. Despite this breadth of research, our understanding of the etiology of these inequities and development and implementation of interventions to reduce them remain limited. Rambachan et al³ do a commendable job highlighting further racial disparities in opioid prescribing in hospitalized patients and provide another opportunity to answer the important questions plaguing health care today: Why do these disparities exist and what can be done to address them? The urgency we take towards answering these questions will confirm our commitment to achieving antiracism in medicine and prioritizing health equity. Black lives are depending on it.

In 2016, a study was published that continues to shock observers today.¹ Examining 200 medical trainees, researchers reported that an alarming percentage of these individuals held false beliefs about Black bodies, including 22% believing that nerve endings in Black persons are less sensitive than nerve endings in White persons and 63% believing that Black skin is thicker than White skin. Furthermore, the study found that those who held these false beliefs about biological differences between Black and White individuals were also less likely to recommend pain treatment to Black patients in a follow-up case vignette. Two years later, in an evaluation of racial differences in opioid prescribing in the United States published in Epidemiology, one of the authors suggested, “It’s an extremely rare case where racial biases actually protected the population [Black individuals] being discriminated against.”²

These studies provide the background for the analysis by Rambachan et al³ published in this issue of the Journal of Hospital Medicine. The authors examined a diverse cohort of more than 10,000 patients hospitalized on a general medicine service at an academic medical center in San Francisco from 2012 to 2018. Black patients were significantly less likely to receive an opioid prescription at discharge, and when they did, were discharged on opioids for fewer days than White patients. No other racial group experienced such a disparity, with Asian patients more likely to receive opioids at discharge. Whereas these findings align with myriad studies demonstrating racial disparities in opioid prescribing,⁴ the authors focus on patients admitted to a general medicine service, where most hospitalized patients receive medical care daily.

The authors concede that determining the etiology of these disparities was beyond the scope of their study, yet this is the exact question we must answer today. Why should the color of a patient’s skin continue to determine the type, and duration, of care they receive, especially when treating pain? The authors hypothesize that individual factors such as provider bias and systemic factors, including limited guidelines on pain management, may drive the observed racial inequities. This progression from individual- and institutional- to community- and policy-level determinants offers a useful framework for understanding the drivers of disparities in opioid prescribing. It also provides an agenda for future research that can guide us from simply detecting disparities to understanding and eliminating them. Furthermore, it is important to examine care team provider characteristics, including race/ethnicity, years in practice, education level (eg, resident vs attending),⁵ experience with implicit bias training, and differential referral to specialists, such as pain, palliative care, and addiction providers. Factors associated with the facility where a patient is hospitalized also warrant further exploration, including the diversity of medical and nonmedical staff as well as patients.⁶ Examining these factors will allow us to move closer toward implementing effective interventions that eliminate disparities in pain treatment.

The authors begin to provide us with possible levers to pull to address the inequities in opioid prescribing. They suggest provider-level bias training, improved institutional tracking of disparities, and policy-level solutions to address the persistent dearth of diversity in the healthcare workforce. While these broad solutions may address health disparities across the medical field, targeted solutions are needed to directly address inequities in pain treatment. First, we must explore the reasons for disparities in the prevalence, presentation, and management of pain in Black populations. These reasons may include occupational exposures or injuries, psychological stress (often associated with racism), and a disproportionate presence of chronic medical comorbidities. Second, health systems can implement a standardized system for opioid prescribing, supported by pharmacy expertise and considering clinical diagnoses, to reduce subjectivity associated with determining the appropriateness of an opioid prescription. Third, health systems must improve access to addiction, harm reduction, and pain specialty services to effectively manage comorbid conditions in at-risk patients.⁷ Furthermore, we must look beyond traditional measures of healthcare access, such as insurance coverage, to address social determinants of health, such as distance to pharmacy, housing security, employment status, and experience with the criminal justice system, which may influence a patient’s receipt of a prescription. Finally, as a society, we must prioritize early training of healthcare providers, long before the undergraduate and graduate medical education level, to practice medicine without stigmatizing biases and stereotypes related to drug use in communities of color.⁸

The pattern of racial and ethnic disparities in healthcare has been documented for decades, with an ever-increasing depth of the different ways in which minoritized patients are undertreated. Despite this breadth of research, our understanding of the etiology of these inequities and development and implementation of interventions to reduce them remain limited. Rambachan et al³ do a commendable job highlighting further racial disparities in opioid prescribing in hospitalized patients and provide another opportunity to answer the important questions plaguing health care today: Why do these disparities exist and what can be done to address them? The urgency we take towards answering these questions will confirm our commitment to achieving antiracism in medicine and prioritizing health equity. Black lives are depending on it.

The novel coronavirus disease of 2019 (COVID-19), caused by the SARS-CoV-2 pathogen, has resulted in a health crisis unlike any other experienced in the past century, with millions of people infected and over one million people dying from COVID-19 worldwide. The pandemic has disproportionately impacted historically marginalized groups, resulting in higher rates of infection, hospitalization, and death in racial/ethnic minority populations, including Black, Hispanic/Latinx, and Native American populations, compared with the White population.¹ Statistics suggest that it is not just socioeconomic differences but also structural racism that has played a role in worse health outcomes in minority populations. However, the health inequities uncovered by the pandemic represent an opportunity—a “plastic hour” in which improvements at the population level may be uniquely possible.² As healthcare providers, we must take advantage of this moment and work toward improving healthcare and increasing health equity in the post–COVID-19 era. We highlight three strategies to guide us toward achieving this goal: (1) prioritizing health system equity and government improvements to population health, (2) fostering community resilience, and (3) promoting equity in economic sustainability.

The COVID-19 pandemic has revealed deep-seated structural and medical vulnerabilities in the US healthcare system, with distressing racial/ethnic differences in COVID-19 infection continuing to emerge.³ Despite variation in the availability and quality of these data, disparities observed in COVID-19 have tracked closely with historical inequities in access to healthcare and discrimination within the healthcare system.⁴ Any approach to addressing these inequities must appreciate the intersection between social and medical vulnerabilities.

It is notable that healthcare systems serving the most vulnerable populations have borne the brunt of the economic toll of COVID-19. Hospitals in socioeconomically challenged areas lost millions of dollars due to the postponement of elective procedures and reallocation of most resources to COVID-related hospital admissions. Many community-based practices, already stretched in caring for medically and socially complex patients, had to shut their doors. These losses have left patients without the support of their network of healthcare and community service organizations—at the same time that many of them have also lost support for food and housing, employer-based health insurance, and in-person schooling and childcare.

The current circumstances due to the COVID-19 pandemic, therefore, require us to reconsider many aspects of both healthcare and the social safety net, including the reliance on financial penalties as a strategy to improve health quality, which ultimately has a disproportionate impact on communities of color.⁵ The present situation may also allow for the federal, state, and local governments, as well as health systems and payers, to make targeted investments in healthcare, public health, and community programs. For example, an increased healthcare system investment on preventive and primary care will be essential to reducing the chronic risk factors that underlie COVID-19 infection and death. Efforts by payers to reduce economic incentives for unnecessary elective procedures, while simultaneously providing incentives to increase the focus on preventive care, would further stimulate this effort. Although there is controversy over the inclusion of social risk in financial and value-based health system payment models, novel approaches to this problem (eg, consideration of improvement over achievement of static targets) may provide an opportunity for struggling health systems to invest in new strategies for underserved populations. Additionally, investing in a care system that allows racial, language, and cultural concordance between clinicians and patients would both promote a diverse workforce and improve quality of care. Health system equity will also depend upon bold policy advances such as expansion of Medicaid to all states, separation of health insurance from employment, and targeted government and health system investments around social risk (eg, food and housing insecurity). These programs will help vulnerable communities close the gap on disparities in health outcomes that have been so persistent.

Some of these specific concerns were addressed by the Coronavirus Aid, Relief, and Economic Security (CARES) Act that was implemented by the US Congress to address the broad needs of Americans during the acute crisis.⁶ The CARES Act provided supplementary funding to community health centers and healthcare systems caring for the uninsured. Cash assistance was provided to most US taxpayers along with financial support to those experiencing unemployment through July 31, 2020, measures that have yet to be extended. In addition to the CARES Act, policymakers proposed establishing a COVID-19 Racial and Ethnic Disparities Task Force Act to drive equitable recommendations and provide oversight to the nation’s response to COVID-19.⁷

While these measures were critical to the immediate pandemic response, future US congressional relief plans are needed to ensure equity remains a tenet of state and federal policy post COVID-19, particularly with respect to social determinants of health. Additional recommendations for federal relief include rent assistance for low-income families, eviction stoppages, and increased funding for short-term food insecurity. With respect to long-term goals, this is the time to address broader injustices, such as lack of affordable housing, lack of a sensible national strategy around food security, and a lack of equitable educational and justice systems. This moment also offers an opportunity to consider the best way to address the impact of centuries of structural racism. If we place equity at the center of policy implementation, we will certainly see downstream health consequences—ones that would begin to address the health disparities present long before the current pandemic.

While national, state, and local responses to COVID-19 are required to bolster population health when we emerge from the COVID-19 crisis, a focus on community resilience is also needed. Community resilience, or the ability to prevent, withstand, and mitigate the stress of a disaster like COVID-19, requires integration of emergency preparedness practices into community disaster programs, with ongoing efforts to mitigate disparities in chronic disease management. A framework for community resilience includes (1) engaging with communities in planning, response, and post–COVID-19 recovery, (2) ensuring communities have access to high quality, culturally concordant health and social services, and (3) developing robust community networks to mobilize individuals, community services, and public health infrastructure in times of emergency.⁸

After seeing the devastating effects of Hurricane Katrina in 2005, researchers, public health officials, and community leaders founded the Los Angeles County Community Disaster Resilience (LACCDR) project. Through this collaborative effort, the LACCDR established partnerships across 16 communities to foster community resilience during health emergencies against the backdrop of daily chronic stressors such as violence, segregation, poverty, and homelessness.⁸ A model such as this to improve health systems and public health integration post-COVID will support health provisions and help build trust in communities wherein there is a high distrust of the healthcare system. Engaging with community partners early to ensure that its members have access to basic needs (eg, food, water, shelter), public health needs (eg, timely information, personal protective equipment such as face coverings and cleaning supplies), and affordable testing and vaccination will help prevent disparities that could affect the most vulnerable in future phases of the COVID-19 crisis.

Over 40 million Americans were seeking unemployment benefits at the peak of the economic repercussions of the COVID-19 pandemic. Unfortunately, low-income, rural, and minority communities disproportionately experienced this economic shock. Given the relationship between wealth and health, successfully achieving equity post-COVID-19 will require deeper financial investments in underserved communities.⁹ Healthcare organizations, which represent 18% of the United States gross domestic product and employ nearly 9% of all working individuals, are uniquely positioned to have a direct influence on this strategy.

One equity-based strategy is for healthcare institutions to pursue an anchor mission. Anchor missions have increased a health system’s investment in social services, including providing housing and food resources.¹⁰ Additionally, hospitals such as Brigham and Women’s, Boston Children’s Hospital, and Bon Secours Health System, are working with a diverse group of entrepreneurs to create jobs and build wealth in underserved communities by employing local and minority-owned businesses to support critical supply chain purchasing decisions regarding food, maintenance, and construction projects.¹¹ These local and inclusive hiring and procurement measures can be bolstered by continued place-based investments by all health system leaders in vulnerable communities.

Since the first enslaved Africans were brought to America over 400 years ago, racial and ethnic minorities have experienced struggle and triumph, sadness and joy. The bonds of a long legacy of discrimination are so deep that we must be intentional in our pursuit of equity—during and beyond the COVID-19 pandemic. Placing equity at the center of healthcare system practice and policy implementation, fostering community resilience and emergency preparedness, and prioritizing equity in economic strategic planning are key steps toward addressing the population-level inequities exposed by the COVID-19 pandemic. As the once touted “great equalizer” rages on, we must remember that we are all jointly affected by the distress caused by the novel coronavirus and we also must be more aware than ever of our interconnectedness. We can use this time of pandemic to fight more than ever to ensure that all populations can enjoy just and optimal health.

The authors would like to thank Dr Denise Polit for her review of this manuscript.

The novel coronavirus disease of 2019 (COVID-19), caused by the SARS-CoV-2 pathogen, has resulted in a health crisis unlike any other experienced in the past century, with millions of people infected and over one million people dying from COVID-19 worldwide. The pandemic has disproportionately impacted historically marginalized groups, resulting in higher rates of infection, hospitalization, and death in racial/ethnic minority populations, including Black, Hispanic/Latinx, and Native American populations, compared with the White population.¹ Statistics suggest that it is not just socioeconomic differences but also structural racism that has played a role in worse health outcomes in minority populations. However, the health inequities uncovered by the pandemic represent an opportunity—a “plastic hour” in which improvements at the population level may be uniquely possible.² As healthcare providers, we must take advantage of this moment and work toward improving healthcare and increasing health equity in the post–COVID-19 era. We highlight three strategies to guide us toward achieving this goal: (1) prioritizing health system equity and government improvements to population health, (2) fostering community resilience, and (3) promoting equity in economic sustainability.

The COVID-19 pandemic has revealed deep-seated structural and medical vulnerabilities in the US healthcare system, with distressing racial/ethnic differences in COVID-19 infection continuing to emerge.³ Despite variation in the availability and quality of these data, disparities observed in COVID-19 have tracked closely with historical inequities in access to healthcare and discrimination within the healthcare system.⁴ Any approach to addressing these inequities must appreciate the intersection between social and medical vulnerabilities.

It is notable that healthcare systems serving the most vulnerable populations have borne the brunt of the economic toll of COVID-19. Hospitals in socioeconomically challenged areas lost millions of dollars due to the postponement of elective procedures and reallocation of most resources to COVID-related hospital admissions. Many community-based practices, already stretched in caring for medically and socially complex patients, had to shut their doors. These losses have left patients without the support of their network of healthcare and community service organizations—at the same time that many of them have also lost support for food and housing, employer-based health insurance, and in-person schooling and childcare.

The current circumstances due to the COVID-19 pandemic, therefore, require us to reconsider many aspects of both healthcare and the social safety net, including the reliance on financial penalties as a strategy to improve health quality, which ultimately has a disproportionate impact on communities of color.⁵ The present situation may also allow for the federal, state, and local governments, as well as health systems and payers, to make targeted investments in healthcare, public health, and community programs. For example, an increased healthcare system investment on preventive and primary care will be essential to reducing the chronic risk factors that underlie COVID-19 infection and death. Efforts by payers to reduce economic incentives for unnecessary elective procedures, while simultaneously providing incentives to increase the focus on preventive care, would further stimulate this effort. Although there is controversy over the inclusion of social risk in financial and value-based health system payment models, novel approaches to this problem (eg, consideration of improvement over achievement of static targets) may provide an opportunity for struggling health systems to invest in new strategies for underserved populations. Additionally, investing in a care system that allows racial, language, and cultural concordance between clinicians and patients would both promote a diverse workforce and improve quality of care. Health system equity will also depend upon bold policy advances such as expansion of Medicaid to all states, separation of health insurance from employment, and targeted government and health system investments around social risk (eg, food and housing insecurity). These programs will help vulnerable communities close the gap on disparities in health outcomes that have been so persistent.

Some of these specific concerns were addressed by the Coronavirus Aid, Relief, and Economic Security (CARES) Act that was implemented by the US Congress to address the broad needs of Americans during the acute crisis.⁶ The CARES Act provided supplementary funding to community health centers and healthcare systems caring for the uninsured. Cash assistance was provided to most US taxpayers along with financial support to those experiencing unemployment through July 31, 2020, measures that have yet to be extended. In addition to the CARES Act, policymakers proposed establishing a COVID-19 Racial and Ethnic Disparities Task Force Act to drive equitable recommendations and provide oversight to the nation’s response to COVID-19.⁷

While these measures were critical to the immediate pandemic response, future US congressional relief plans are needed to ensure equity remains a tenet of state and federal policy post COVID-19, particularly with respect to social determinants of health. Additional recommendations for federal relief include rent assistance for low-income families, eviction stoppages, and increased funding for short-term food insecurity. With respect to long-term goals, this is the time to address broader injustices, such as lack of affordable housing, lack of a sensible national strategy around food security, and a lack of equitable educational and justice systems. This moment also offers an opportunity to consider the best way to address the impact of centuries of structural racism. If we place equity at the center of policy implementation, we will certainly see downstream health consequences—ones that would begin to address the health disparities present long before the current pandemic.

While national, state, and local responses to COVID-19 are required to bolster population health when we emerge from the COVID-19 crisis, a focus on community resilience is also needed. Community resilience, or the ability to prevent, withstand, and mitigate the stress of a disaster like COVID-19, requires integration of emergency preparedness practices into community disaster programs, with ongoing efforts to mitigate disparities in chronic disease management. A framework for community resilience includes (1) engaging with communities in planning, response, and post–COVID-19 recovery, (2) ensuring communities have access to high quality, culturally concordant health and social services, and (3) developing robust community networks to mobilize individuals, community services, and public health infrastructure in times of emergency.⁸

After seeing the devastating effects of Hurricane Katrina in 2005, researchers, public health officials, and community leaders founded the Los Angeles County Community Disaster Resilience (LACCDR) project. Through this collaborative effort, the LACCDR established partnerships across 16 communities to foster community resilience during health emergencies against the backdrop of daily chronic stressors such as violence, segregation, poverty, and homelessness.⁸ A model such as this to improve health systems and public health integration post-COVID will support health provisions and help build trust in communities wherein there is a high distrust of the healthcare system. Engaging with community partners early to ensure that its members have access to basic needs (eg, food, water, shelter), public health needs (eg, timely information, personal protective equipment such as face coverings and cleaning supplies), and affordable testing and vaccination will help prevent disparities that could affect the most vulnerable in future phases of the COVID-19 crisis.

Over 40 million Americans were seeking unemployment benefits at the peak of the economic repercussions of the COVID-19 pandemic. Unfortunately, low-income, rural, and minority communities disproportionately experienced this economic shock. Given the relationship between wealth and health, successfully achieving equity post-COVID-19 will require deeper financial investments in underserved communities.⁹ Healthcare organizations, which represent 18% of the United States gross domestic product and employ nearly 9% of all working individuals, are uniquely positioned to have a direct influence on this strategy.

One equity-based strategy is for healthcare institutions to pursue an anchor mission. Anchor missions have increased a health system’s investment in social services, including providing housing and food resources.¹⁰ Additionally, hospitals such as Brigham and Women’s, Boston Children’s Hospital, and Bon Secours Health System, are working with a diverse group of entrepreneurs to create jobs and build wealth in underserved communities by employing local and minority-owned businesses to support critical supply chain purchasing decisions regarding food, maintenance, and construction projects.¹¹ These local and inclusive hiring and procurement measures can be bolstered by continued place-based investments by all health system leaders in vulnerable communities.

Since the first enslaved Africans were brought to America over 400 years ago, racial and ethnic minorities have experienced struggle and triumph, sadness and joy. The bonds of a long legacy of discrimination are so deep that we must be intentional in our pursuit of equity—during and beyond the COVID-19 pandemic. Placing equity at the center of healthcare system practice and policy implementation, fostering community resilience and emergency preparedness, and prioritizing equity in economic strategic planning are key steps toward addressing the population-level inequities exposed by the COVID-19 pandemic. As the once touted “great equalizer” rages on, we must remember that we are all jointly affected by the distress caused by the novel coronavirus and we also must be more aware than ever of our interconnectedness. We can use this time of pandemic to fight more than ever to ensure that all populations can enjoy just and optimal health.

The authors would like to thank Dr Denise Polit for her review of this manuscript.

The novel coronavirus disease of 2019 (COVID-19), caused by the SARS-CoV-2 pathogen, has resulted in a health crisis unlike any other experienced in the past century, with millions of people infected and over one million people dying from COVID-19 worldwide. The pandemic has disproportionately impacted historically marginalized groups, resulting in higher rates of infection, hospitalization, and death in racial/ethnic minority populations, including Black, Hispanic/Latinx, and Native American populations, compared with the White population.¹ Statistics suggest that it is not just socioeconomic differences but also structural racism that has played a role in worse health outcomes in minority populations. However, the health inequities uncovered by the pandemic represent an opportunity—a “plastic hour” in which improvements at the population level may be uniquely possible.² As healthcare providers, we must take advantage of this moment and work toward improving healthcare and increasing health equity in the post–COVID-19 era. We highlight three strategies to guide us toward achieving this goal: (1) prioritizing health system equity and government improvements to population health, (2) fostering community resilience, and (3) promoting equity in economic sustainability.

The COVID-19 pandemic has revealed deep-seated structural and medical vulnerabilities in the US healthcare system, with distressing racial/ethnic differences in COVID-19 infection continuing to emerge.³ Despite variation in the availability and quality of these data, disparities observed in COVID-19 have tracked closely with historical inequities in access to healthcare and discrimination within the healthcare system.⁴ Any approach to addressing these inequities must appreciate the intersection between social and medical vulnerabilities.

It is notable that healthcare systems serving the most vulnerable populations have borne the brunt of the economic toll of COVID-19. Hospitals in socioeconomically challenged areas lost millions of dollars due to the postponement of elective procedures and reallocation of most resources to COVID-related hospital admissions. Many community-based practices, already stretched in caring for medically and socially complex patients, had to shut their doors. These losses have left patients without the support of their network of healthcare and community service organizations—at the same time that many of them have also lost support for food and housing, employer-based health insurance, and in-person schooling and childcare.

The current circumstances due to the COVID-19 pandemic, therefore, require us to reconsider many aspects of both healthcare and the social safety net, including the reliance on financial penalties as a strategy to improve health quality, which ultimately has a disproportionate impact on communities of color.⁵ The present situation may also allow for the federal, state, and local governments, as well as health systems and payers, to make targeted investments in healthcare, public health, and community programs. For example, an increased healthcare system investment on preventive and primary care will be essential to reducing the chronic risk factors that underlie COVID-19 infection and death. Efforts by payers to reduce economic incentives for unnecessary elective procedures, while simultaneously providing incentives to increase the focus on preventive care, would further stimulate this effort. Although there is controversy over the inclusion of social risk in financial and value-based health system payment models, novel approaches to this problem (eg, consideration of improvement over achievement of static targets) may provide an opportunity for struggling health systems to invest in new strategies for underserved populations. Additionally, investing in a care system that allows racial, language, and cultural concordance between clinicians and patients would both promote a diverse workforce and improve quality of care. Health system equity will also depend upon bold policy advances such as expansion of Medicaid to all states, separation of health insurance from employment, and targeted government and health system investments around social risk (eg, food and housing insecurity). These programs will help vulnerable communities close the gap on disparities in health outcomes that have been so persistent.

Some of these specific concerns were addressed by the Coronavirus Aid, Relief, and Economic Security (CARES) Act that was implemented by the US Congress to address the broad needs of Americans during the acute crisis.⁶ The CARES Act provided supplementary funding to community health centers and healthcare systems caring for the uninsured. Cash assistance was provided to most US taxpayers along with financial support to those experiencing unemployment through July 31, 2020, measures that have yet to be extended. In addition to the CARES Act, policymakers proposed establishing a COVID-19 Racial and Ethnic Disparities Task Force Act to drive equitable recommendations and provide oversight to the nation’s response to COVID-19.⁷

While these measures were critical to the immediate pandemic response, future US congressional relief plans are needed to ensure equity remains a tenet of state and federal policy post COVID-19, particularly with respect to social determinants of health. Additional recommendations for federal relief include rent assistance for low-income families, eviction stoppages, and increased funding for short-term food insecurity. With respect to long-term goals, this is the time to address broader injustices, such as lack of affordable housing, lack of a sensible national strategy around food security, and a lack of equitable educational and justice systems. This moment also offers an opportunity to consider the best way to address the impact of centuries of structural racism. If we place equity at the center of policy implementation, we will certainly see downstream health consequences—ones that would begin to address the health disparities present long before the current pandemic.

While national, state, and local responses to COVID-19 are required to bolster population health when we emerge from the COVID-19 crisis, a focus on community resilience is also needed. Community resilience, or the ability to prevent, withstand, and mitigate the stress of a disaster like COVID-19, requires integration of emergency preparedness practices into community disaster programs, with ongoing efforts to mitigate disparities in chronic disease management. A framework for community resilience includes (1) engaging with communities in planning, response, and post–COVID-19 recovery, (2) ensuring communities have access to high quality, culturally concordant health and social services, and (3) developing robust community networks to mobilize individuals, community services, and public health infrastructure in times of emergency.⁸

After seeing the devastating effects of Hurricane Katrina in 2005, researchers, public health officials, and community leaders founded the Los Angeles County Community Disaster Resilience (LACCDR) project. Through this collaborative effort, the LACCDR established partnerships across 16 communities to foster community resilience during health emergencies against the backdrop of daily chronic stressors such as violence, segregation, poverty, and homelessness.⁸ A model such as this to improve health systems and public health integration post-COVID will support health provisions and help build trust in communities wherein there is a high distrust of the healthcare system. Engaging with community partners early to ensure that its members have access to basic needs (eg, food, water, shelter), public health needs (eg, timely information, personal protective equipment such as face coverings and cleaning supplies), and affordable testing and vaccination will help prevent disparities that could affect the most vulnerable in future phases of the COVID-19 crisis.

Over 40 million Americans were seeking unemployment benefits at the peak of the economic repercussions of the COVID-19 pandemic. Unfortunately, low-income, rural, and minority communities disproportionately experienced this economic shock. Given the relationship between wealth and health, successfully achieving equity post-COVID-19 will require deeper financial investments in underserved communities.⁹ Healthcare organizations, which represent 18% of the United States gross domestic product and employ nearly 9% of all working individuals, are uniquely positioned to have a direct influence on this strategy.

One equity-based strategy is for healthcare institutions to pursue an anchor mission. Anchor missions have increased a health system’s investment in social services, including providing housing and food resources.¹⁰ Additionally, hospitals such as Brigham and Women’s, Boston Children’s Hospital, and Bon Secours Health System, are working with a diverse group of entrepreneurs to create jobs and build wealth in underserved communities by employing local and minority-owned businesses to support critical supply chain purchasing decisions regarding food, maintenance, and construction projects.¹¹ These local and inclusive hiring and procurement measures can be bolstered by continued place-based investments by all health system leaders in vulnerable communities.

Since the first enslaved Africans were brought to America over 400 years ago, racial and ethnic minorities have experienced struggle and triumph, sadness and joy. The bonds of a long legacy of discrimination are so deep that we must be intentional in our pursuit of equity—during and beyond the COVID-19 pandemic. Placing equity at the center of healthcare system practice and policy implementation, fostering community resilience and emergency preparedness, and prioritizing equity in economic strategic planning are key steps toward addressing the population-level inequities exposed by the COVID-19 pandemic. As the once touted “great equalizer” rages on, we must remember that we are all jointly affected by the distress caused by the novel coronavirus and we also must be more aware than ever of our interconnectedness. We can use this time of pandemic to fight more than ever to ensure that all populations can enjoy just and optimal health.

The authors would like to thank Dr Denise Polit for her review of this manuscript.