As most of our readers have undoubtedly heard, President Trump and Melania have tested positive for the Coronavirus. While this comes as little surprise for most of us in the medical community, I want to take the conversation away from the irony of President Trump being infected and focus on what this infection really means and what it will likely show us.
When we look at the spread of Coronavirus here in the US, we see a stark difference in patient outcomes. Most of these outcomes have been attributed to what the medical system refers to as co-morbidities, or co-morbid factors (factors which contribute to the risk of morbidity/death). Co-morbidities are a non-racial, non-partisan way of looking at factors which contribute to an individual’s risk of death, and are a way that we can statically measure the quality of care an institution provides to their patients. We do this by looking at the likelihood an individual would have died based on the co-morbidities present with the patient. There are a number of calculators which are used in the medical community. Examples would be the Charlson Comorbidity Index and it’s derivitives (http://www.charlsoncomorbidity.com/), Elixhauser Comorbidity Model (https://www.hcup-us.ahrq.gov/toolssoftware/comorbidity/comorbidity.jsp), Kaplan-Feistein Index, and others.
While Co-morbidities allow us to compare the risk of death without consideration of race and other socioeconomic factors (Socioeconomic status [SES]/Social Determinants of Health [SDOH]), they are a disingenuous method of evaluating the risk of death. Most co-morbidities exist at a higher rate when an individual has lower socioeconomic status and their environmental factors also contribute to decreased access to care, increased risks for obesity, etc. These differences also exist as social determinants of health, as poor access, lack of care, poor diet, hunger, housing insecurities, and the many other SDOH factors increase an individuals stress level and risk of co-morbidities. So while Co-morbidities follow SDOH/SES’s fairly well, co-morbidities fail to factor in the underlying causes of the co-morbidities and hence can be prone to over-predicting risk for those who do not have poor SES/SDOH, and under-predicting the risk of death in those who have poor SES/SDOH.
Thus Social Determinants of Health can and do play a significant role in an individual’s quality of life, the presence of co-morbid factors, and the individual’s survival when diseases are present.
So how does this pertain to the conversation about President Trump and Melania testing positive for the Coronavirus? President Trump and Melania both have several co-morbid factors however they do not have poor socioeconomic circumstances or poor social determinants of health. Obesity, Age, Gender, etcetera have all been associated with an increased risk of mortality, and the first couple has some of these factors (age, gender, obesity) but their risk factors are not compounded by the additional risk associated with poor SES/SDOH. The risk factors President Trump and Melania have are under the close supervision of a personal physician with adequate access to services that decrease morbidity and mortality. Without poor SDOHs, without being a person of color, and with having a personal physician; President Trump and his wife both have a considerably better chance of surviving Coronavirus than a person with the same risk factors who also has poor SES/SDOH.
When we look at NYC, Texas, Florida, and Arizona, we have huge populations of marginalized races, poor or limited access to healthcare, and the presence of a high rate of co-morbid factors, what we see is a higher mortality rate. This combination undoubtedly contributes to a significantly higher mortality rate, and seems to be reflected in the reported data from these states (many of the states do not report specific SDOH/SES when reporting COVID-19 testing/positivity rates, so these are estimates based on the area SDOH factors and the known increased mortality rates for those who are black and Latinx.
This is also important when we look at our healthcare system and how it is currently structured. The presence of the Affordable Care Act, while imperfect, required individuals to have healthcare insurance or be penalized (all while supplementing the cost of this coverage based on the individuals income). While there is debate about whether this requirement is constitutional, the intention behind requiring healthcare coverage was to increase the availability and access to healthcare for marginalized groups and to minimize the cost of this coverage to those with poor SES’s. It is concerning as healthcare providers, that our current president (and others) are seeking to dismantle and remove these protections and provisions prior to showing even a shred of a proposed replacement for these extremely important healthcare coverage. Even before and continuing through the pandemic, there are individuals actively working to dismantle this safety-net system while a replacement hasn’t even been iterated.
It is extremely important that we understand that while coronavirus may not be a death sentence to ourselves, we can and should do our part to decrease the spread of this disease and it’s impact on those who have increased risks of death. It is our societal responsibility.
So while Trump has, and likely will continue to downplay the significance and impact of the coronavirus pandemic, continue to ignore and repudiate respected scientists who contradict him, and likely will continue to work against public health individuals who are trying to decrease the spread and impact of COVID-19 on the population, we as healthcare providers (specifically nurses), would never wish ill or death on an individual, and as we covered with the earlier death of Herman Cain, we sympathize with all families who have lost loved ones because of the pandemic.
For more information on how your state and county performs with social determinants of health, see this website