Why COVID-19 Hits Some People and Places Differently

By Allen S. Weiss, MD, FACP, FACR, MBA, and Chief Medical Officer for the Blue Zones Project

COVID-19 strikes with alarming inconsistency. Most recover quickly while others die. The disease devastates some communities and spares others. Understanding why and how COVID-19 preys on some and not others is essential to limiting its spread and mitigating its impact.

Prevention, averting, detecting, and restricting disease, is always better than even the most effective treatment. We need answers. Let’s go find them.

Contagion Exploration

Although uneven in prevalence across communities, public health history shows that diseases typically spread by travel between population centers. Take a look at “The Ten Deadliest Epidemics Throughout History.” COVID-19 is closely tracking this historic pattern with a modern twist: science, intervention, and technology can decrease morbidity and mortality.

Postulating genetic susceptibility in the article “COVID-19 Susceptibility: Why Do Some Become So Ill?” in MedPage Today, Dr. Mark Zucker observes the virulence of the Coronavirus is patient-dependent and might be genetically determined. Italy has tragically experienced a fatality rate seven to ten times that of Germany and the United States.

Anecdotally, an ill-fated Italian-American family of eleven members experienced four COVID-19 deaths and two more critical care hospitalizations. Many variables, including random bad luck, could be causing these dreadful and variable statistics. Nonetheless, researching genetic susceptibility might reveal actionable insights.

In addition to genetic susceptibility, social determinants of health (SDOH) are key identifiers of vulnerable populations. The often-used warning in prevention literature, “Your ZIP code is more important than your genetic code,” suggests genetics are not primarily responsible for COVID-19 susceptibility.

'Your ZIP code is more important than your genetic code,' suggests genetics are not primarily responsible for COVID-19 susceptibility. — @AllenWeissMD Click To Tweet

In an important 2002 paper entitled “The Case for More Active Attention to Health Promotion,” Dr. Michael McGinnis defined the SDOH. After years of research, he believed that genetics account for 30% of health and wellness, with the SDOH responsible for 70%.

That 70% further divides into four subcategories: 15% for social circumstances such as income and education; 5% for environment, 10% for medical care, and 40% for lifestyle choices. By addressing the 70% non-genetic factors for health and wellness, communities and individuals can improve their health status.

Chronic Failure

Individuals with chronic disease disproportionately die from COVID-19. In a March 2020 article, “Americans Unfit to Fight a Pandemic—Epidemics of Obesity, Sedentary Habits, and Chronic Stress Leave Nation With Poor Baseline Health” in Medpage Today, author Rami Bailony asserts that addressing personal or community SDOH will reduce pandemic mortality.

Bailony starts with a snapshot of shoppers in a national, big-box grocery store. Packages of chips, candy bars, soda, frozen chicken wings, and other unhealthy foods overflow from the carts of overweight or obese purchasers. This creates a powerful visual for COVID-19’s top three co-morbidities: COPD; heart disease and diabetes.

COVID-19 kills by overwhelming the pulmonary system. Three prevalent lifestyle issues in American society compromise individuals’ pulmonary systems. They are obesity, tobacco use, and sedentary behavior. Let’s examine each.

Excess weight makes breathing more difficult. During the outbreak of H1N1 (i.e. bird flu) in 2009, 61% of people who died were obese with a body mass index (BMI) greater than 30. Obesity is a risk factor for all pulmonary diseases.

Cigarettes, e-cigarettes, and smokeless tobacco products stack up behind the counters of large chain pharmacies and convenience stores. Although the national smoking rate has decreased substantially, vaping has increased exponentially since 2007. This exposes a new population, largely young, to future pulmonary disease. Smoking doubles the chance of most infections and increases by 2.4 times the chance of severe illness—ICU admission, ventilator need, and possible death.

Sedentary behavior increases influenza-related hospitalization by up to 7%. Only 35% of people over age 65 are physically active. Moderate exercise increases immune function and strengthens the cardiovascular and pulmonary systems. A randomized study of people over age 50 enrolled in an exercise program had 35% fewer cold and flu episodes, and 47% fewer sick days.

Poverty’s Mark

Shocking anecdotal evidence indicates an intense connection between the worst of COVID-19 and ethnicity and poverty. “Early Data Shows African Americans Have Contracted and Died of Coronavirus at an Alarming Rate” argues that SDOH is the critical risk factor in COVID-19’s spread and virulence.

Authors Akilah Johnson and Talia Buford in ProPublica discuss that COVID-19 entered Milwaukee from a white, affluent suburb and subsequently erupted within the city’s low-income, black community. Clearly, economic stress, high population density, excess obesity, smoking rates, drug abuse, and lack of access to healthcare contribute to COVID-19’s rapid transmission, high prevalence, and increased mortality in marginalized communities.

...economic stress, high population density, excess obesity, smoking rates, drug abuse, and lack of access to healthcare contribute to COVID-19's rapid transmission, high prevalence, and increased mortality in marginalized communities. Click To Tweet

As in Milwaukee, African American neighborhoods in Detroit and New Orleans, are disproportionately experiencing COVID-19’s lethal impact. Initially, governmental statistics on COVID-19 prevalence and mortality included age and location demographics, but not race. Beginning in April, Illinois and North Carolina began detailing COVID-19 cases by race. The evidence is incontrovertible. COVID-19 poses a grave threat to low-income communities afflicted with poor SDOH. The challenge is to increase preventive measures, as Chicago is doing, to limit disease spread to these vulnerable populations.

Now and Forever

It is self-evident that a community of healthy, economically stable, and happy people can withstand the onslaught of a pandemic better than a group of sick and sad people. Successful communities achieve longer life expectancy and a lower all-cause mortality by pursuing healthier lifestyles together. Improving SDOH may be the single best strategy for pandemic threat mitigation.

It is self-evident that a community of healthy, economically stable, and happy people can withstand the onslaught of a pandemic better than a group of sick and sad people.

Preventing obesity, ceasing tobacco products, and boosting physical activity are all positive individual and community goals even in normal times. These are not normal times. COVID-19 should motivate America to embrace health and wellness broadly. Decreasing disease burden now increases our collective ability to repel the next pandemic.

Key Takeaways

“Your ZIP code is more important than your genetic code,” suggests genetics are not primarily responsible for COVID-19 susceptibility.
By addressing the 70% non-genetic factors for health and wellness, communities and individuals can improve their health status.
COVID-19 kills by overwhelming the pulmonary system. Three prevalent lifestyle issues in American society compromise individuals’ pulmonary systems. They are obesity, tobacco use and sedentary behavior.
Economic stress, high population density, excess obesity, smoking rates, drug abuse, and lack of access to healthcare contribute to COVID-19’s rapid transmission, high prevalence, and increased mortality in marginalized communities.
COVID-19 poses a grave threat to low-income communities afflicted with poor SDOH.
COVID-19 should motivate America to embrace health and wellness broadly. Decreasing disease burden now increases our collective ability to repel the next pandemic.

This article was originally published on 4sight Health.

Dr. Allen Weiss is Chief Medical Officer for the national Blue Zones Project. Having practiced rheumatology, internal medicine, and geriatrics for 23 years and been President and CEO for 18 years of a 716-bed, two-hospital integrated system, Dr. Weiss now has a national scope focused on prevention.