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How should historically segregated cities, such as Los Angeles, respond to the widening inequities in access to healthcare perpetuated by the outbreak of COVID-19?


Introduction

After spending the majority of my summer examining the relationship between public health and community development in Northern India and Nepal, I came to the realization that although the conditions in India and The United States are immensely different, the systems used to oppress people and their respective access to healthcare contain some similarities. Traveling through rural Himalayan villages and vibrant, yet over-populated, cities stood out to me as a grand metaphor for how zip code is a determinant of access to healthcare in my hometown, Los Angeles. While traveling in a developing country, it is hard to not find issues and feel compelled to change them, however, the professors and public health officials that I met with taught me that the most impactful change is made within one’s own respective community. When given the option to research any topic that is connected to bioethics for our final project, I instantly thought about creating a project that explored inequities in healthcare when it comes to already segregated cities such as my hometown, Los Angeles. 

Interestingly enough, right as the planning phase of this project began the world was taken by storm as coronavirus spread to cities and populations throughout the world. As the pandemic began to affect my own community, I started to see how the already prevalent inequities in access to healthcare throughout Los Angeles were being perpetuated by the conditions of this virus. The perspectives on this topic are often influenced by income, politics, and race as it is true that in Los Angeles socioeconomic status is often an indicator of access to healthcare.  The objective of this project will be to explore and answer the question of how historically segregated cities, such as Los Angeles, should respond to the widening inequities in healthcare perpetuated by the outbreak of COVID-19?

The Problem

Before COVID-19 reached Los Angeles, the segregation and inequality throughout the city left us in a vulnerable position to the widening inequality gaps heightened by an outbreak. Health equity is not just limited to access to healthcare but is defined by everyone having access to goods, services, resources, and the power needed to advocate for optimal health and well-being.

Goals of health equity:

Source: http://publichealth.lacounty.gov/CenterForHealthEquity/Equity.html

As stated by the LA County Center for Health Equity, “In LA County, we continue to see stark differences in health outcomes across LA County, largely based on geography (place) and race and ethnicity. Depending on where we live and the color of our skin, we are more or less likely to have access to resources and opportunities that allow us to grow healthy and thrive. These differences are a result of past and present policies and practices influenced by prejudice, discrimination and systemic racism.” 

The following graphs illustrate the segregation in access determined by neighborhoods in Los Angeles:

Source: https://map.healthyplacesindex.org/

When looking at the data for Insured Adults, Income, homeowner status, and access to parks you can see how access to resources that often determine the quality of health in Los Angeles is very segregated by neighborhood and zip code. We can see how in each of the maps the distinct neighborhoods stay consistent in their quality of access, which illustrates a serious problem of geographic segregation and inequality throughout the County of Los Angeles.

Even when looking at which populations are affected most by the healthcare cost crisis we see how these determining factors of privilege dictate one’s ability to receive medical treatment in Los Angeles.

Furthermore, in the Los Angeles County Human Development Report from 2017- 2018, These divisions are categorized.

In this table Los Angeles is divided in the “Five LA Counties” which are defined as follows: 

The clear inequities in access to Healthcare in Los Angeles connect in a multitude of different ways to the fundamental principles of bioethics that I studied this semester. In the bioethics course that I took we focussed on four main principles of bioethics:

1) Principle of respect for autonomy,
2) Principle of nonmaleficence,
3) Principle of beneficence, and
4) Principle of justice.

excerpted from Beauchamp and Childress (2008)

I see this question of healthcare inequality connecting to bioethics through the principle of justice. The principle of justice in healthcare is often defined as fairness. The UW Department of bioethics and humanities states that this principle ” implies the fair distribution of goods in society and requires that we look at the role of entitlement. The question of distributive justice also seems to hinge on the fact that some goods and services are in short supply, there is not enough to go around, thus some fair means of allocating scarce resources must be determined (adapted from Beauchamp & Childress, 1994, p. 330). ” The way that we as a society dictate how scarce resources are distributed during times of crisis will dictate how much we chose to value the principle of justice.

When data about COVID-19 in Los Angeles was first released, researchers found “that many of L.A. County’s whitest and wealthiest enclaves were reporting far higher rates of infection than poorer neighborhoods of color. However, public health officials said those disparities did not necessarily mean the virus was spreading more widely through rich neighborhoods than in poorer ones. Instead, the reporting was likely skewed by uneven access to testing and, in some instances, by wealthy residents who traveled internationally and had some of the earliest confirmed infections”(LA is missing racial data for many coronavirus deaths). This finding demonstrates a serious ethical concern in regards to how the principle of justice is being upheld during this pandemic.

 The intersection of bioethics and public health is defined by Nancy E. Kass, Johns Hopkins School of Public Health, as having the goal “To advance traditional public health goals while maximizing individual liberties and furthering social justice, public health interventions should reduce morbidity or mortality; data must substantiate that a program (or the series of programs of which a program is a part) will reduce morbidity or mortality; burdens of the program must be identified and minimized; the program must be implemented fairly and must, at times, minimize preexisting social injustices; and fair procedures must be used to determine which burdens are acceptable to a community”(Kass, N E. “An ethics framework for public health.” American journal of public health vol. 91,11 (2001): 1776-82. doi:10.2105/ajph.91.11.1776). 

Although we are still in the height of this pandemic, it is important to try to gain insight into how the social outcomes of this time will affect our world and communities forever.  A recent Atlantic article titled The Coronavirus Will Be a Catastrophe for the Poor analyses ways that the novel virus can and will affect cities and towns all over the world. By looking at the inequality that resulted from the 1918 influenza pandemic we can predict similar trends in a widening inequality gap as it appears that in some senses history is repeating itself.  The populations hit the hardest by the 1918 influenza outbreak were lower-income workers who lived in close quarters when compared to the wealthier populations. As a result of the vast inequalities from the 1918 pandemic, a lot of social movements took place that are still alive today working to better conditions for underpaid industrial workers. The work of these progressive groups, however, will be severely halted by the current coronavirus pandemic. Similarly to the influenza outbreak, we can already see how coronavirus will and is disproportionately affecting lower-income individuals. As stated by Mark Muro, Senior Fellow and Policy Director of Metropolitan Policy Program, “One month could wipe out 10 years of progress… A huge service-sector recession is coming, and we’re talking about more than 10 million jobs at risk that are often low-wage, low-benefit, or tip-based.” 

This information articulates that the effects of the pandemic that we are currently living in will last for generations to come. Thus, the question then becomes: what do we need to do the lower the inequality gap and lasting effects of COVID-19?

Response

Before COVID-19 reached Los Angeles there were plans in place to work on reducing inequalities in access to healthcare, however, now it is very clear that any solution to this problem would have to be much more aggressive. 

The LA County Government Center for Health Equities strategic priorities to reducing healthcare inequality are stated as follows:

Los Angeles County Department of Public Health Center for Health Equity

Although the strategic priorities are strong, they are no solution to the inequalities that will rise as a result of the pandemic. As stated in Shuja Haider’s article titled Covid-19 Shows America’s Class Divide Is Untenable, “In order for a society to function under capitalism, the circuits of the market have to remain unbroken. But the inability of this system to weather the threat of a pandemic makes the terms of survival clear: The prerogative of certain members of society to secure their own safety at the expense of others will doom us all. The refrain of the moment has been ‘We’re all in this together.’ But unless the divisions among the living are dismantled, we are not. Without universal health care, housing, and a living wage, the nation will remain collectively at risk from disasters both natural and economic.” I believe that this statement articulates exactly the level of response that needs to be implemented as a result of this pandemic. We can see now more than ever how necessary universal healthcare and housing is, and it is now the responsibility of the people to respond in such a way. The pandemic needs to come as a reminder and warning of the division experienced by countries such as the United States who do not have universal healthcare. One $1,200 check is NOT healthcare and surely is NOT enough to fight the effects of this pandemic. After reflecting on what I have learned, I strongly believe that any response needs to go further than the end of the pandemic. After the AIDS epidemic, the field of bioethics became “more aware of the values at stake when individual rights and the public good come in conflict,” however, we need to respond in ways that address the ethical conflicts at hand in a context greater than just a singular event (Levin, Betty Wolder, and Alan R Fleischman. “Public health and bioethics: the benefits of collaboration.” American journal of public health vol. 92,2 (2002): 165-7. doi:10.2105/ajph.92.2.165). Bioethics needs to be used as a tool for evaluating the fundamental concerns with the healthcare system and specifically the way that resources are allocated during times of crisis. As stated by Annette Dula and Sarah Goering in “it’s just ain’t fair: The ethics of Health Care for African Americans,” they state “The reasons for a lack of access to health care vary considerably among different groups, and may include poverty, discrimination, the decline in availability of employment-based health insurance, closed and distant facilities, and the unavailability of particular services such as obstetrics and other reproductive health services. These distinct factors warrant distinct assessments and normative recommendations, both ethical and programmatic”(quote found in: Galarneau, Charlene A. “The Ethics of Access to Health Care.” The Annual of the Society of Christian Ethics, vol. 18, 1998, pp. 305–314., www.jstor.org/stable/23561093. Accessed 14 2020.).   As someone mainly focussing on public health responses, I believe that an appropriate response to this needs to be something as groundbreaking and effective as universal healthcare in America. Not only does a response need to focus on an economic issue, but more importantly on a moral assessment. At this time in America, many politicians thrive on the suppression of the voice of the people, and thus, in order for a response to this crisis to address the inequities in access to healthcare voices need to be amplified from people who are directly affected, healthcare policymakers, and finding from health policy analysts. Although seemingly outdated, Charlene Galarneau’s Ethics of Access to Healthcare frames this problem and resolution clearly: “ Understanding access as context-specific means that access involves the relationship between individual health care needs and the social-economic-political and institutional situations within which those needs exist” (Galarneau, Charlene A. “The Ethics of Access to Health Care.” The Annual of the Society of Christian Ethics, vol. 18, 1998, pp. 305–314., www.jstor.org/stable/23561093. Accessed 14 2020.).

For sources consulted and cited:

https://docs.google.com/document/d/1Y2UmBAp4iBljJVNtl6oan-LAUf6UI50Y5-phgOxfTcM/edit?usp=sharing

Feedback

Thank you so much for checking out my project. I am conducting a survey to hear your feedback and perspective: https://www.surveymonkey.com/r/9NHJDQT

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COMMENTS: 2
  1. April 25, 2020 by Eric Hudson

    Cleo, I really appreciate the depth of research here as well as the clear connection you draw between inequality you witnessed in South Asia and in your own city, Los Angeles. Thanks, I learned a lot.

    • April 27, 2020 by Cleo

      Thank you so much, Eric! I am so glad that you enjoyed checking out my page. Being able to research this topic was so informative and inspiring for me.

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