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Published in NEJM, this perspective article co-authored by UNC School of Medicine’s Seth Berkowitz, MD, MPH, and Crystal Wiley Cené, MD, MPH, and Boston University’s Avik Chatterjee, MD, MPH, recognizes that social policy solutions are needed to advance health equity, along with health policy and individual-level efforts.

Seth A. Berkowitz, MD, MPH, and Crystal Wiley Cené, MD, MPH, from the division of general medicine and clinical epidemiology at the UNC School of Medicine and the Cecil G. Sheps Center for Health Services Research, are authors of a new perspective on health inequities, published today in the New England Journal of Medicine with Avik Chatterjee, MD, MPH, from the division of general medicine at Boston Medical Center, Boston University School of Medicine, and Boston Health Care for the Homeless Program.

The article recognizes that, in addition to health policy and individual-level efforts, social policy solutions are needed to advance health equity.

“There have been terrible racial/ethnic and socioeconomic disparities in outcomes related to COVID-19,” Berkowitz said. “While much discussion rightfully focused on how clinical care might improve these outcomes, we think it is also important to study and improve the forces that shape who is most vulnerable to COVID-19. This perspective is important because it focuses on public policy changes that could both improve COVID-19 outcomes and advance health equity.”

The authors emphasize how the pandemic has exposed structural racism, the social context (institution, practices, mores, and policies) that influence actions that result in different allocations of resources that increase inequities across racial groups. They identify two key lessons from the pandemic: public policy enables public health and health equity requires big investments in public policy.

“To address the 400+ years of structural racism in the US, we must move beyond implicit bias and cultural competency trainings to address the structures, policies, and practices that drive disparities,” Cené said.

The authors advocate for thinking big, to reach beyond healthcare systems, and they suggest three policy targets to help advance health equity and the response to COVID-19.

First, food insecurity is known to be a health equity issue that disproportionately affects racial/ethnic minorities and those with lower incomes and rural communities. Berkowitz has conducted a number of studies on health-related social needs and their effect on health outcomes, published in JAMA Internal Medicine, the Washington Post, and the New York Times.

Second, working conditions are patterned by race/ethnicity, and precarious employment, low wages and lack of benefits undermine efforts to control the pandemic. The CARES Act (Coronavirus Aid, Relief, and Economic Security) has helped many of these issues; however, unemployment insurance expires at the end of July 2020.

Third, community development is needed to provide quality affordable housing and advance health equity long-term by improving living conditions. The authors identify the Low-Income Housing Tax Credit and Community Reinvestment Act as key pieces of legislation that can address these issues.

“COVID-19 has exposed the failures in our healthcare system, but also in our approach to public policy, in a tragic way,” said Chatterjee. “But, we hope this tragedy provides an opportunity to reflect on our values as a society and to re-envision public policy such that we can support resilience and promote equity even among the most marginalized communities in America.”