As the public health and economic toll of the coronavirus spreads across the country, many health foundations are focused on mitigating the economic impact, which has caused unprecedented levels of unemployment. Examples include expanding responsive grantmaking, establishing or contributing to community emergency funds, increasing flexibility to existing grantees, and responding quickly to new needs that arise in the community.
But as our co-CEO, Lauren Smith, MD, notes, public health crises take a significantly increased toll on groups who were marginalized before the crisis. Due to social factors such as structural racism, the health and wellbeing of these individuals were already compromised by housing insecurity, disconnected transportation, unsafe neighborhoods, and inadequate education. Seniors with fixed income often have to choose between paying for food or medication to manage their chronic illnesses. Families have to choose between paying their utility bills or their rent.
These complex circumstances in which people live, work, and raise their families are called the social determinants of health. Now, given the number of people who have already lost their jobs, especially in frontline service sector jobs with low wages and no sick time, this public health crisis is precipitating a devastating economic crisis for the many who were perched on the precipice of financial ruin. We are already witnessing how the pandemic is increasing economic and social inequality. And there is early evidence that people of color are disproportionately harmed by COVID-19. ProPublica reports that in Wisconsin “African Americans made up almost half of Milwaukee County’s 945 cases and 81% of its 27 deaths in a county whose population is 26% black.”
Based on predictions we can make about the continued and worsening impact on the social determinants of health, here are a number of ways health foundations can deepen and lengthen their impact by leveraging their staff, their voice, credibility, social capital, and financial resources to improve them.
- An increased proportion of individuals will have unmet social needs: Foundations can work with health care providers to increase the capacity for comprehensive and uniform screening for social determinants. Many health care settings are incorporating such screening into their electronic medical records and their workflows. The California Health Care Foundation Health Innovation team has challenged entrepreneurs to address the needs of safety net providers in bridging the gap between the patients they serve and the services and resources they need to address social determinants of health. Technological investments in screening tools and processes require an investment of time and resources over the medium and longer-term. However, in the shorter-term, foundations could assist health care providers to increase their cadre of community health workers to do outreach to those that are isolated or unable to come into the clinical setting. Foundations can use their policy skills and influence to move health insurers to cover this kind of preventative outreach.
- Low-income and working poor individuals will lose valuable income: Despite state, federal, and local relief available, the complicated and lengthy process to access these funds will provide an additional barrier. Place-based foundations are well-positioned to help translate the legislation into action. The existing structures used to assess community health needs and develop solutions can be put into action to address the longer-term impacts of this crisis. Health foundations can serve as a credible “information hub” by engaging community partners to understand what is happening on the ground, while simultaneously translating the implications of federal and state policy changes for the community. Some individuals may be navigating safety net services for the first time and will need support. They can use their local community context knowledge and their convening power to build on existing platforms such as 211 or create new resources as needed. For example, the Medical Legal Partnership of Boston created a “Digital Digest” of resources for both individuals and community-based organizations. Foundations could tap into their trusted relationships with partners to ensure that often excluded communities, such as English language learners, individuals with disabilities, the LGBTQ population, or those with behavioral health conditions, are aware of and can access these resources. The pandemic has also highlighted the stark need for paid sick and family medical leave– priorities that should not be forgotten after the initial crisis subsides. The president of the Robert Wood Johnson Foundation has also used this crisis to point out the importance of health equity promoting policies, including paid family medical leave.
- Food insecurity is going to increase: Foundations who have already been focusing on food security, can build on their work and others who have worked in adjacent issues, such as healthy aging, can bring their expertise and networks to the effort. For example, in the shorter term, the Harvard Pilgrim Healthcare Foundation is building on its focus on food security by engaging restaurants throughout the region to provide and deliver take-out meals to families in need and helping to put people back to work. Other foundations are expanding meal delivery for seniors or others who are isolated. Still others are partnering with local school districts to provide meals to students who rely on school breakfast and lunch as an essential source of food. In the longer term, foundations can consider working with partners, including community-based organizations that work with families to connect them to state and federal nutrition benefits, like SNAP and WIC. Foundations can use their balance sheet to help grantees weather the short-term impact of COVID-19 on their operations. This will be especially true for organizations such as community health centers, food banks, and other basic services that will see a surge in demand without additional funding to support their operations.
- There will be a predictable increase in people suffering from mental health and substance use disorders: It is well documented that those who experience financial, housing and employment hardship related to an economic downturn experience increased symptoms of depression, anxiety and substance use. Unfortunately, this increased symptom burden will come at a time when health care systems are overburdened with caring for those ill with COVID 19 and at a time when more people will be uninsured because they have lost their jobs. RIZE Foundation, focused on substance use in MA, is supporting policy changes to ensure individuals seeking substance use treatment can still access it during this time when the healthcare system is under pressure. This could be an important opportunity for foundations to partner with insurers and others to promote the adoption of telemedicine, which will be increasingly useful as healthcare providers seek to reduce the number of patients who come into their clinical settings.
- Housing insecurity and instability is going to increase: For issues like housing insecurity, foundations can catalyze collaboration by leveraging investments in cross-sector initiatives. Instead of cancelling or postponing meetings, consider ways to repurpose them to coordinate a community-wide response. For instance, use an upcoming meeting on healthy aging to jointly better understand emerging housing and other challenges for seniors, and share what different organizations are offering and what they need. Coalitions could advocate for a temporary moratorium on evictions while assisting landlords in obtaining economic relief while their tenants face difficulties in paying their rent. Boston-based CHAPA is hosting weekly Affordable Housing Coronavirus Response virtual meetings to help coordinate its coalition members’ work on housing. In a related effort, coalitions focused on equitable economic development can work together to increase banking options for individuals and small businesses so fees and other predatory practices do not have an outsized impact during this time.
Children will experience increased trauma related to family stress and will have their educational progress upended by prolonged school closures and associated “learning loss.” The data on the impact of toxic stress and adverse childhood experiences on children is compelling. The educational impact of millions of school children being out of school for 6 months is likely to be staggering. Our colleague, Ursula Wright, in her recent blog Quakes and Tremors: What Foundations Can Do to Safeguard Childhood Wellbeing in the Wake of a Pandemic writes “foundations are well-positioned to take the lead in forging cross-sector action that prevents escalating pressure on the system.” The California Children’s Trust initiative is organizing a group of funders to work together to ensure that organizations that provide mental health services to children can quickly adopt tech-enabled modalities in response to the COVID-19 pandemic, and families are connected to these services.
Health foundations have been investing in and championing the social determinants of health for years. Now is the time for the field to step in to ensure that the COVID-19 crisis does not exacerbate social determinant of health inequities that already existed in our communities. Please contact Abigail Ridgway with other actions you think health foundations can take to address the social determinants of health during this time, or topics you would like to see us explore more in future posts.