Opinion | Healthcare

Failing public health is killing Americans, unequally

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Geography tells us important stories. The states that have suffered the most cases of COVID-19 (mostly in the Southeast and Southwest) also have the highest rates of food insecurity, meaning that people can't always afford sufficient food, according to data recently released by USDA. These same states also have the highest rates of obesity.

Why?

It's not an issue of climate or soil or mere coincidence.

It's about failed public policies.  

The top reasons for disproportionate COVID-19 cases in these regions are pretty obvious: resistance to mask mandates, low rates of vaccination and little promotion of social distancing throughout the pandemic.   

Their reasons for high levels of hunger and diet-related chronic diseases should be equally obvious: public policies that ensure low wages, high taxes on food, inadequate government safety nets and widespread food deserts (where healthier food is scarce). These states also have the country's highest rates of poverty. And - while systemic racism is still a serious problem in every state - it's likely no coincidence that the three maps also overlap heavily with many states in the former southern Confederacy, where racial disparities in all these maladies remain particularly pronounced.

These drivers of poor health are deeply interconnected, and each makes the other worse. Humans who are malnourished are more likely to have compromised immune systems and poor metabolic health, making them more likely to contract and transmit diseases such as COVID-19. Indeed, nearly two-thirds of COVID-19 hospitalizations may be related to common diet-related conditions. In communities with more COVID-19 cases, businesses (where workers earn money to purchase food), schools, senior centers and food charities (where people obtain free meals) have been more likely to be closed. The nutrition insecurity crisis fuels the pandemic, and vice versa.

Take Mississippi, for example. Per 100,000 people, Mississippi ranks in the top 10 states for COVID-19 cases endured since the onset of the pandemic. It also has the nation's single highest rates of food insecurity, poverty, obesity, and (just behind West Virginia) diabetes. It is a grim irony that Mississippi also has the steepest sales tax on groceries, 7 percent.

While obesity rates are high among Americans of all incomes due to complex physiological, emotional, genetic and cultural causes, people suffering from nutrition insecurity and poverty have even higher rates. Since healthier food is often more expensive, more time consuming to prepare and harder to find in low-income communities than junk food, hunger and obesity are flip sides of the same malnutrition coin. When low-income humans are forced to skip meals, they are more likely to overeat when they do eat again. 

Obesity - as well as other diet-related diseases such as diabetes, hypertension, and heart disease - also make it more likely for people who get COVID-19 to die from it. Even before the pandemic, diet-related diseases were the top reason why this generation is the first in U.S. history to die earlier of natural causes than their parents.

While these problems are most pronounced in certain regions, nutrition insecurity, poverty and diet-caused diseases are a serious problem in every state - significantly harming wide swaths of suburban, rural and urban America across every racial, ethnic, education, political and income subgroup. 

Almost half the entire adult population - more than 100 million adults - have pre-diabetes or diabetes. Fully 122 million Americans have cardiovascular disease, resulting in roughly 840,000 deaths each year. 

Not only are the human costs devastating, but so too are the economic losses. The total cost to the U.S. of obesity is estimated at $1.72 trillion per year, or 9.3 percent of gross domestic product. As a nation, we spend about $1.1 trillion on direct costs for food - and another $2.1 trillion on additional, external costs of food from poor health, wasted natural resources and lost livelihoods. In other words, for every $1 we spend on food, our nation and economy lose an additional $2. 

House Rules Committee Chairman Rep. Jim McGovern (D-Mass.) and many other public and private food leaders are right to be calling on the White House to convene a 2022 Conference on Food, Nutrition, Hunger and Health to draw together all key stakeholders (including federal, state and local officials and the food industry) to comprehensively address these grave threats.

But states, cities, counties and the private sector should also take concrete, meaningful actions now on all these fronts. They should immediately increase vaccination campaigns and encourage mask-wearing and social distancing in indoor public spaces.

They should ensure that all jobs pay a living wage so that families can afford to buy the healthiest food - and when wages aren't enough to do so, they need to help as many eligible families as possible obtain healthy foods through federally-funded nutrition programs such as SNAP, WIC and school meals. 

States and cities should also incentivize farmers markets and grocery stores to deliver to food deserts, build healthier foods into their administration of Medicaid, and promote community gardens, urban farms and food entrepreneurship.  

The intertwined challenges of COVID-19, hunger, and obesity graphically demonstrate our national geography of failed public health. Smart public policies can move American states and communities from the bottom to the top of key national rankings. Geography doesn't need to equal destiny.

Dr. Dariush Mozaffarian is a cardiologist and dean of the Tufts University Friedman School of Nutrition Science and Policy. Follow him on Twitter: @Dmozaffarian

Joel Berg is CEO of Hunger Free America, a national direct service and advocacy nonprofit group. Follow him on Twitter: @Joelsberg

This piece has been updated.

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