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As the St. Louis region and the state of Missouri confront the coronavirus challenge, it has posed a number of serious issues for health policy analysts and health economists.

“This is the most unprecedented challenge to the health system I have seen in my career,” said Tim McBride, Bernard Becker Professor and a leading health economist.  “Our public health systems in the region were already underfunded relative to most of the rest of the country, and people with low incomes were already facing challenges accessing medical care. This is only exacerbating the problems.”

McBride points to several challenges that have become acute in recent days because of the COVID-19 crisis:

Low-income persons have less access to health insurance in Missouri, one of 14 states that never expanded Medicare. “We have not expanded Medicaid, and the existing levels for Medicaid are among the lowest in the country,” McBride said. “Missouri has over 500,000 uninsured people. Uninsured persons will face significant challenges paying for medical care during this crisis, especially if they need to be tested or treated for coronavirus. The problem will only become worse if these low-income persons lose their jobs. And all this will challenge the finances of our health care systems.”

The public health systems in Missouri have long been underfunded. “Our public health system funding ranks near the bottom in the country; we rank 44th in the U.S.,” McBride said. “This means we do not have enough funding to do the significant surveillance, testing, communications and research needed in a situation like this. Our public health departments are doing great work despite these challenges and reaching out to universities and others for help, but our systems are stretched.”

Given that we have needed to suddenly and significantly move to social distancing and strongly encourage people to stay home, this is creating a monumental economic challenge. “We will not know until we see the numbers, but it seems certain that we will have a significant economic downturn, probably a recession, maybe a very large one in the second quarter,” McBride said. “The extent of the recession depends on how widespread the virus extends and how long policymakers continue policies to encourage social isolation. But certainly some sectors will be severely impacted: airlines, hotels, restaurants, retail, for example. And this will have a big ripple effect on the rest of the economy. We can recover from this, once people are allowed to leave home, but in the meantime, there will be losses in jobs, incomes. This only will make it more difficult to pay for medical care, especially for people who already had the biggest challenges paying for care: the uninsured, for example. What we worry about the most is that some people will forego medical care because they cannot pay, and that this will exacerbate the spread or depth of coronavirus.”

Numerous challenges to the health care workforce. “Health economists have been worried for a while about areas where we have shortages or challenges in what we call the health care workforce,” McBride said. “The biggest areas where there are significant shortages of health care providers are nurses, mental health providers, and providers to serve those in underserved communities — that is, central city and rural areas. Unfortunately, this COVID-19 outbreak will only exacerbate these challenges and may create a crisis in some areas. If some parts of the health care workforce get sick from coronavirus, especially nurses, that will be a huge problem. If the workforce is not well distributed across the state, region or country, then we will see big shortages. For example, the big outbreaks right now are in Washington and New York, and they likely are already experiencing shortages of providers. Missouri may experience this at some point.”

We must consider this coronavirus crisis as a wake-up call to prioritize equity and challenge ourselves to consider how to better serve historically underserved communities, says a public health expert at Washington University in St. Louis.

“In the middle of a pandemic, it is easy to overlook health equity,” said Darrell Hudson, associate professor at the Brown School.

Health equity, Hudson said, means that everyone — regardless of their identity, including race/ethnicity, gender and social class — has the opportunity to reach their optimal level of health.

Health equity for many was problematic before the pandemic.

“Health does not simply mean that people are not sick or have a disease. Health is comprehensive and encompasses so much,” Hudson said. “In fact, many patients seeking care do not actually care much about health. How can they when their bandwidths are exhausted? Most people are consumed with day-to-day functioning.

“They care about their jobs, providing for their families, paying bills, and other social and economic concerns. This is even more problematic right now for families that are struggling with sudden, drastic changes in employment and financial strain.”

What effect will the pandemic have on such families?

“There is often a misalignment between the messages that public health and medical professionals seek to deliver to the public, especially people who have been historically marginalized and who are most vulnerable,” Hudson said. “Presently, the public health message being disseminated across the country is to observe social distancing guidelines — to stay home and avoid contact with large groups of people. How does this messaging affect citizens who do not have adequate resources to purchase additional food and supplies, especially if they have growing children at home for three meals a day?

“Simultaneously, these families may have jobs in industries that are not shuttered or operating at barebones capacity to observe the social distancing guidelines. How will these families get the resources they need if they cannot work?”

Health inequity already has taken a toll, Hudson said.

“Racial and socioeconomic inequity in the social and built environment has already affected the health and well-being of marginalized communities,” he said. “For example, the risk factors associated with illness due to coronavirus include obesity ─ a whopping 76% of black Americans are overweight or obese. Another risk factor is chronic disease. Over 60% of black Americans age 50 and older have high blood pressure and 23% have diabetes.

“Black Americans experience chronic disease at earlier ages and are more likely to die prematurely compared to whites. Scholars have found that black Americans experience greater stress and trauma across the life course, compared to whites. Therefore, their immune systems may be functioning less effectively due to chronic stress, making them more susceptible to chronic disease as well as infections.

“The confluence of these factors is placing a tremendous burden on communities of color and people with low socioeconomic status. We have already failed these communities before COVID-19. What will happen if the highly contagious COVID-19 is widely transmitted in communities that do not have equitable access to healthcare services much less the social and economic resources that could help mitigate the spread of the virus in the first place?”

This outbreak, among other changes, may provide the “wake-up call” that there is a health gap based on income and privilege as well, Hudson noted.

“Dr. Martin Luther King Jr. once stated that it seems like a cruel jest to tell a bootless man to pull himself up by his bootstraps. We must be mindful of our public health and medical messaging and whether people can comply with what we are asking,” he said. “And if they are not able to adhere to guidelines, we should interpret that as a societal failure to ensure that everyone has equitable opportunities to achieve their highest level of health.

“To be frank, we are a long way off from health equity in our society, much less our region. And we have yet to see what the effects of COVID-19 transmission could be on historically marginalized communities. We must consider this crisis as a wake-up call to privilege equity and challenge ourselves to consider how to better serve historically underserved communities.”

Across the U.S., requests to 2-1-1 from Americans seeking help getting food and paying rent rose sharply and instantly in the days following the start of the COVID-19 pandemic, according to a Brown School researcher who tracks calls to 2-1-1 help lines. Matthew Kreuter, the Kahn Family Professor of Public Health at Washington University in St. Louis, and his team are tracking requests for hundreds of needs, as captured by 2-1-1 help lines across the country. They have established a web presence, FOCUS-19, to report new findings daily.

The most recent analyses examined cities and states nationwide since the beginning of 2020. For each week, they charted the total number of requests to 2-1-1 for food pantries, home-delivered meals, and rent assistance. Many states saw 2-1-1 calls top 1 million by the last week of April.

An earlier analysis found that in the first week since COVID-19 was designated a pandemic, requests for food pantries skyrocketed across the United States. Requests for home-delivered meals more than tripled in the same time period.

“In all locations, requests for food pantries were much higher, often 2-4 times higher than the same week last year,” Kreuter said. “Requests for home-delivered meals were higher in all but one location.”

Kreuter is senior scientist at the Brown School’s Health Communication Research Laboratory, which developed 2-1-1 Counts, the first tool to provide real-time, searchable and visual presentations of data from 2-1-1 call centers across the country

Other insights revealed in the ongoing analyses by Kreuter and his team:

“The size and suddenness of these increases is striking,” he said. “People need help feeding and supporting their families, and local agencies need help keeping pace with the higher demand.”

2-1-1 is a free and confidential service that helps people across North America find the local resources they need 24 hours a day, 7 days a week, in most communities. Each year, 2-1-1s receive 16 million requests, not only seeking emergency services, but also basic needs such as food, shelter and clothing.

Data tracked by 2-1-1 Counts can be searched and displayed by date, county, congressional district and more.

Upcoming analyses will examine income, employment, transportation, health care and other social needs; mapping where the increases in local needs are greatest; and reporting calls specific to COVID-19.

This research is conducted in partnership with Health Communication Impact LLC, United Way and 2-1-1 help lines. The team’s recent work has been featured in news outlets across the country: 

(This article will be updated as new features emerge.)

As schools and entertainment venues close due to the coronavirus outbreak, many of us are seeing our social circles reduced quite significantly. An expert on social support at Washington University in St. Louis offers a few evidence-based suggestions for thriving during household isolation.

“We don’t know for sure what the long-term health outcomes of widespread forced social isolation will be, but given what we know about the effects of social isolation and stress on physical and mental health, there is reason to be concerned,” said Tess Thompson, research assistant professor at the Brown School and author of a recent study on social isolation and health.

To help alleviate some of the stress inherent in social isolation, Thompson offers these tips:

“Pull yourself up by the bootstraps.” It’s an old adage about American resilience. But how does it impact poverty?

A new book by a professor at the Brown School at Washington University in St. Louis explores and critiques the widespread perception in the United States that one’s success or failure in life is largely the result of personal choices and individual characteristics.

“Rugged Individualism and the Misunderstanding of American Inequality,” co-authored by Mark Rank, the Herbert S. Hadley Professor of Social Welfare, is published by Lehigh University Press.

“From its beginnings, America has emphasized and celebrated the idea of rugged individualism,” said Rank, a noted expert on income inequality. “The notion of breaking the frontier, or the rags to riches stories, celebrate this ideal. The problem is that while individual effort is important for getting ahead in life, it is often not enough.”

We might think of it as a necessary but insufficient condition, he said. “Many other factors beyond an individual’s control come into play in affecting how well one does in life. For example, I’m currently working on a book that focuses on the importance of chance and luck in profoundly shaping the course of our lives.”

In “Rugged Individualism,” Rank and his co-authors show that the distinctively individualist ideology of American politics and culture shapes attitudes toward poverty and economic inequality in profound ways, fostering social policies that de-emphasize structural remedies.

A new book by Jenine Harris, associate professor at the Brown School, introduces students to statistics using a narrative approach that makes the sometimes daunting subject approachable and useful.

“Statistics with R – Solving Problems Using Real-World Data” (Sage Publishing) draws on the open source R programming language and uses examples from the social and behavioral sciences to explain statistics concepts. The book follows three women characters, two data scientists and a student, who meet at the community group “R-Ladies” and decide to work together to master the skills of statistical analysis and data visualization. In each chapter, the three characters meet and work through analyzing a real-world, publicly-available data set about a  contemporary issue like marijuana legislation, voter registration, or the opioid epidemic.

“The main goal of this book is to prepare students and other readers for the messy and exciting reality of working with data,” Harris writes in the preface. “The book aims to encourage women and other underrepresented groups to consider data science careers, and aims to improve the quality of social science through the promotion of reproducible research practices.”

The book has received positive reviews, including one from David A.M. Peterson of Iowa State University, who called it “easily the most accessible and almost fun introduction to statistics and R that I have read.”

Harris has expertise in social network analysis, public health systems, and reproducible research. She is the co-founder and organizer of R-Ladies St. Louis which is the local chapter of R-Ladies Global, an organization that focuses on improving gender diversity in the R community.