How COVID-19 exposed Detroit’s public health inequities

Thomasenia Weston. Photo by Nick Hagen.

Thomasenia Weston and her two grandchildren don’t get much protection from the truck traffic and air pollution inundating her Detroit neighborhood at the intersection of West Vernor Highway and Livernois.

“My house does not feel like my home,” Weston told Planet Detroit. “My house feels like I’m on the freeway.”

Weston points to the Marathon Refinery, the U.S. Steel facilities on Zug Island and the Great Lakes Water Authority’s Southwest Water Facility as additional sources of stress, emitting foul odors and pollutants that she believes have contributed to asthma that she and her grandchildren endure. She also suspects these sources contribute to her migraine headaches, high blood pressure and high blood sugar. And a University of Michigan study published this month demonstrates that noise levels in the area regularly exceed guidelines designed to protect public health.

But problems come from inside her home as well. Like many Detroiters, Weston deals with frequent sewer backups and basement flooding that have caused mold and mildew, adding to her respiratory issues.

“I keep the upstairs windows in a hallway cracked because you want to have ventilation,” she said. “But at the same time, I feel that when I crack them, more stuff is coming in.”

While truck traffic is her most constant cause of distress, she can’t identify any single thing as the source of her health problems.

“I feel like I’m being poisoned, and I can’t even point a finger to who’s poisoning me,” she said.

Weston’s situation illustrates the tangled web of indoor and outdoor environmental stressors impacting many Detroit residents. Collectively, non-medical factors influencing health outcomes are often referred to as social determinants of health. 

Dr. Ijeoma Nnodim Opara, an internal medicine pediatric physician serving a predominantly African American population in Detroit, defines these determinants as “the conditions in which we live, work, play, raise our families, go to school, worship and die.” 

Social determinants of health link strongly to housing conditions in Detroit. And those conditions have been shaped by a history of redlining â€” the practice begun by the federal Home Owners’ Loan Corp in the 1930s where many low-income and minority neighborhoods were shaded red on maps and marked as “hazardous.” Redlining added to a legacy of discrimination, making it even more difficult for minorities to obtain loans to buy and repair homes.

Across the country, research shows that poor health outcomes are often associated with previously redlined neighborhoods and the associated inferior housing quality. A recent study from the National Community Reinvestment Coalition found that the average life expectancy in formerly redlined areas was 3.6 years lower than in neighborhoods that had been graded as “best” on the HOLC maps. 

“We know places that were redlined are exposed to higher levels of pollution, in air, water and soil,” Nnodim Opara said. She describes the conditions in Detroit as “not terribly unique” relative to redlined communities in other cities. A study in the journal Environmental Justice on the health impacts of redlining showed that residents of redlined areas of cities like Atlanta, Cleveland, Miami and San Francisco-Oakland “were nearly twice as likely to have poor health than non-redlined areas.”

Correcting these systemic problems will requiring addressing what Opara refers to as the “causes of the causes” or the “policies, laws and resource allocation processes that determine who gets to live where… and who gets what kind of early childhood experience.” Factors like access to quality housing and education, clinical care, healthy food and exposure to environmental contaminants dictate the underpinnings of public health.

“We can’t just focus on individuals and their immediate environment,” Nnodim Opara said. 

More time indoors: The impact of an aging housing stock

Housing has also had a massive impact on resident health in Detroit, on account of structures that often not only fail to protect residents from environmental threats but can be a source of contamination themselves. And during the pandemic, people spent more time inside their homes, increasing their exposure to health hazards like indoor air pollution.

Home repair — whether for lead or mold abatement or to protect residents from air pollution — is crucial for mitigating environmental health threats. But with roughly 51% of Detroiters renting, housing values in Detroit at 23% of the national median and median household incomes at 49% of the national average, home repair is a significant economic challenge.

Detroit has some of the oldest housing in the country, with 80.4% of homes dating from before 1960. That means many were built before modern lead regulations and are often in need of repair. 

In Detroit, lead from these household sources is the primary source of exposure affecting children. And in some neighborhoods, including southwest Detroit and parts of the east side, a concentration of toxic release sites tracked by the Environmental Protection Agency contaminate low-income areas where residents may have trouble affording new windows or other upgrades to keep out polluted air. 

“With these older housing stocks, they’re often very difficult to maintain and repair,” said Roshanak Mehdipanah, an assistant professor of health behavior and health education at the University of Michigan’s School of Public Health. “And some of the interventions of preventing air pollution from entering the home like filter systems, but also improving windows, are way too expensive for low-income homeowners.”

Alex B. Hill, an adjunct professor of urban studies and public health at Wayne State University, said that services to help finance home rehabs and lead abatement are often underfunded. This is backed up by a 2020 University of Michigan Poverty Solutions study, which concludes,”the repair needs in Detroit are significant” and “current resources devoted to home repair don’t come close to meeting the need.” 

Mehdipanah said that renters may have even less ability to make home repairs or demand them from a landlord, especially when affordable housing is at such a premium. The median housing cost equals a staggering 48% of median income in Detroit; housing is considered affordable when it requires 30% of household income or less.

“Detroit has a history of large investors coming in, purchasing houses by the bulk and renting them out with very minimal changes done to them,” she said. “And so what you end up getting is these really kind of dire housing conditions.”

Another housing issue highlighted by the pandemic was Detroit’s ongoing crisis with water shutoffs. Since 2014, the city shut off water service to 141,000 residential accounts, and the cost of water in the city has nearly doubled since 2007. As the pandemic began to take hold in the state, the city suspended water shutoffs and began reconnecting service. But while Detroiters were asked to shelter in place–some of them without the ability to wash their hands or flush their toilets–reconnections were often slow in coming. Ultimately, Detroit Mayor Mike Duggan announced that the city would suspend shutoffs through 2022. However, activists have noted his previous reversal on drainage fees, which he suspended before the 2017 election, only to reinstate them later. 

The lessons of COVID-19 and access to quality clinical care

Sandra Turner-Handy, engagement director for the Michigan Environmental Council and a resident of Detroit’s east side, said that a lack of access to quality clinical care was a major factor that contributed to the toll that COVID-19 took on the city. “We were ripe for it,” she said. In the U.S., African Americans are nearly twice as likely to die from the COVID-19 than white Americans. 

In particular, Turner-Handy is concerned about the quality of care at hospitals like Detroit’s Sinai Grace, which along with Detroit Receiving Hospital is listed as having a one-star rating on the Medicare website — the lowest possible score. The rating accounts for factors like readmissions, mortality and effectiveness of care. 

And for many Detroiters, the only health care they receive happens in emergency rooms. The Detroit Metro Area Communities Study (DMACS) reported that in 2018, roughly one in five Detroiters used the emergency room for primary care. Of those lacking health insurance, 41.9% report using the ER for primary care. 

Even many Detroiters who have health insurance can’t afford care or medication. Although DMACS found that only 8.7% of residents lacked health insurance, nearly 10% experienced affordability issues. Health care coverage rates likely fell in 2020 as unemployment rose dramatically. A report from the health advocacy organization Families USA estimated that the number of uninsured adults in Michigan increased by 46% between February and May of 2020.

The ability to afford healthcare is ultimately tied to housing. “You definitely see hits on medication adherence where people forego taking certain treatments or medications because they don’t want to lose their home,” Mehdipanah said.

While the DMACS report listed affordability as the greatest barrier to healthcare for Detroiters, there were a number of other factors, including lack of transportation and discrimination. “We still have folks that are not believed when they talk about their symptoms, especially when it comes to pain,” Nnodim Opara said. “We have folks that feel they’re not respected and their dignity is not upheld by providers.”

Weston said she has often felt that clinical care providers ignored her concerns. “They may look at a Black woman as not being credible,” she said. She shared a recent situation where she complained to clinical care providers about chest discomfort and an earache, only to have her concerns ignored. Soon after, she wound up in the hospital, requiring defibrillation for her heart and treatment for an ear infection.

Nnodim Opara emphasized that access to health care entails addressing issues like implicit bias from healthcare providers, a lack of African American doctors and a digital divide that can limit Detroiters’ ability to obtain services.

The Association of American Medical Colleges reported that in 2018, African Americans represented 5% of doctors in the U.S., while Black people make up 13.4% of the overall population.

Meanwhile, recent estimates have shown that around 40% of Detroiters lack broadband access, something that almost certainly qualifies as a social determinant of health in a year when so much of life has moved online.

Food insecurity, COVID-19 and public health

The pandemic also demonstrated how food access impacts health outcomes in the city. The 2017 Detroit Food Metrics Report found that 30,000 Detroiters do not have access to a full-line grocer, 48% of WIC stores are liquor stores and 48% of residents in the city experience food insecurity. Poor access to restaurants and full-service grocery stores has been found to coincide with higher obesity rates, and scientists have identified obesity and its related maladies — diabetes and hypertension — as the most important risk factors for COVID-19 mortality.

The report also said 37% of Detroiters are obese and 14% have been told they have diabetes, compared to national averages of 31% and 11% respectively.

And COVID-19 has exacerbated food insecurity. According to a recent survey from DMACS, unemployment in Detroit reached 48% in the spring of 2020, more than four times higher than the rate from March. Nearly three-quarters of unemployed Detroiters responding to the survey said they were uncertain if they could afford food in the coming months. 

A few areas of the city hit hard by the pandemic demonstrate the ongoing struggle to access healthy food. Early on, the 48219 and 48235 ZIP codes in the city’s northwest corner listed food assistance as their top need according to Michigan 211, a free service that helps connect Michigan residents to health and social service agencies. 

These ZIP codes — which encompass many areas listed as having higher rates of “diet-related mortality” in the Detroit Food Metrics Report — have continued to see some of the city’s highest COVID-19 case numbers. 

Local food assistance providers, restaurant owners and food distributors have found new ways to work together to try and meet this growing need amid the pandemic. The Detroit Public Schools Community District expanded their food assistance beyond just children and their families to anyone in the community. The city’s Parks and Recreation Department began distributing more food and increased its offerings of pre-cooked meals with funding from the United States Department of Agriculture. 

But demand for food assistance remained high throughout 2020, with food making up 39% of total requests for assistance from Michigan 211. The Biden administration’s move to expand the Supplemental Nutrition Assistance Program could provide some relief by sending additional food assistance to an estimated 25 million people in low-income households. 

Finding solutions through ‘valuing residents’

Mehdipanah stresses that the city benefits from a long history of community organizing to address its heavy burden of health inequities, including efforts to improve air quality, increase access to healthy foods and repair homes. 

Local activists have achieved public health victories in recent years by helping to stop water shutoffs, forcing the closure of the city’s trash incinerator and pushing for the city’s Community Benefits Ordinance. 

“I think in terms of resilience and community mobilization, Detroit is a national example,” Mehdipanah said.

More investments to boost public health infrastructure may be coming from the new Biden administration. The American Rescue Plan is being hailed by some as the “greatest investment in public health in a generation.” The plan aims to increase the public health workforce and expand access to health insurance by increasing subsidies for low- and middle-income people who buy insurance through government exchanges over the next two years.

Mehdipanah emphasized that any public health solution should involve integrating health care systems with local economic development. Detroit’s Henry Ford Health System, for example, is part of the Anchor Network, which seeks to address racial and economic disparities by hiring, purchasing and investing in the community.

The hope is to bolster local economics so more residents will be able to afford high-quality food, access clinical care and make home repairs. The American Rescue Plan may help by offering direct payments, tax relief and other benefits that could reduce the annual poverty rate by roughly one-third. 

City government efforts to address broader systemic environmental health issues beyond the pandemic have included programs to address Detroit’s environmental health problems, including programs for lead abatement, tree planting and expanded bus service. But one major city-led initiative focused on improving environmental health, the city’s Sustainability Action Agenda, published in 2019, was deprioritized during the pandemic.

The agenda addresses public health issues like healthy food access, housing safety, air quality monitoring, reducing inequitable energy burdens and more. But the Office of Sustainability had its staff reduced to just one person, Director of Sustainability Joel Howrani Heeres, who now reports to the General Services Department rather than directly to the mayor, as he had previously. 

City spokeswoman Tracy Lynn Pearson confirmed the reorganization of the Office of Sustainability, but said that it isn’t “completely accurate” to say the staff has been reduced to just one because Heeres “has access to numerous project managers and the full support of GSD to aid him with projects.”

One example of the disconnect between those concerned about environmental quality and city government was Duggan’s decision to deliver his 2021 State of the City address from the FCA Assembly Plant, which he touted as a symbol of the city’s economic comeback on account of the thousands of jobs it’s scheduled to bring.

Yet activist Eden Kasmala-Bloom has referred to the company’s plans to reduce emissions at a plant in predominantly white Warren while increasing them in Detroit as “textbook environmental racism.” The plant — which received city and state tax incentives that could total more than $400 million — is likely to increase air pollution in ZIP codes that have some of the highest asthma hospitalization rates in the city. (Fiat Chrysler recently changed its name to Stellantis.)

Turner-Handy points to the city’s history of subsidizing industry at the expense of public health. Foremost in her mind is the $175 million in tax breaks the city gave to polluter Marathon Petroleum in 2007. For things to change, she said the city needs to begin “prioritizing residents as its most valuable asset.”

“The city doesn’t have any kind of organized government response” to public health, said Hill. “I think the Sustainability Action Agenda was the first step to try to move in that direction, but that seems to have fallen off the city’s priority list.”

That lack of a coordinated city response is felt by residents like Weston, who wonders why no one is stepping in to fix the problems in her neighborhood. 

“It has taken a big toll on my mental health,” Weston said of the truck traffic, noise, mold and flooding that she deals with on a daily basis. “It just runs through my mind constantly.”