“I look at my medications: take with food, don’t take on an empty stomach … I never have money. I never have food … Sometimes I go to the churches, but a lot of the food is canned goods stuff … It contributes a whole lot [to] not eating healthy and poor diet.”

The man quoted above has a car, which he sleeps in, but no money for gas. He has no phone and no one to help care for him as his daughter lives far away.

He was telling his story for a University of Hawaii study several years ago about why his heart disease got so bad that he was hospitalized. Even in the best of times, it can be hard to eat healthy, exercise, take medications on schedule, and follow doctor’s recommendations to prevent and manage chronic diseases like diabetes or heart disease.

For people with limited funds, unstable housing, and no social support, as another woman with diabetes and heart disease said in the UH study: “It’s a day-to-day struggle. It’s stressful because the cost of keeping healthy is expensive and I have no money.”

These challenges lead to deep inequalities in our communities and in our health care systems around the burden and consequences of chronic disease. In the necessary but massive disruption of daily life around the COVID-19 pandemic, there are now even more competing priorities in staying safe while maintaining physical distancing — stresses from urgent alerts, store closures, confusions around changing guidance, medication shortages, loss of health insurance coverage due to job loss, extreme caution around health system use.

Crane Park in Kaimuki was the site of a homeless encampment earlier this month. Homeless people are especially at risk of falling ill with COVID-19. Cory Lum/Civil Beat/2020

Even those rich with resources are struggling as stores run out of rice, pasta, beans and spinach, along with toilet paper. Those who relied on community resources and food banks may be in deeper need. Many who were living paycheck to paycheck have lost their jobs and are newly reaching out for basic necessities.

We will continue to hear a loud, important, and steady drumbeat of messages around the risk and consequences from COVID-19, a highly contagious disease, in order to keep our communities safe. The quiet symphony of synergistic recommendations for chronic disease prevention and management must not be lost.

To Prevent Future Morbidity

This is necessary to prevent future morbidity and mortality for chronic conditions, the most prevalent conditions in the world, and also because 1) those with chronic disease, especially uncontrolled chronic disease, appear to be more susceptible to hospitalization and death from COVID-19; and 2) uncontrolled chronic disease can lead to urgent health crises that will strain fragile health systems now as well as long into the future.

Preliminary evidence from the United States highlights that most COVID-19 deaths have had an underlying condition, with diabetes, chronic lung disease, and cardiovascular disease figuring prominently. Smoking/vaping are also risk factors, putting young people at surprising risk, especially in a state like Hawaii where over a third of youth report vaping.

Public health draws upon a framework called the social ecological model to understand the levels of influence that help to keep a person healthy. The model starts with an individual in the center and around this puts layers of influence starting with interpersonal factors (families, relationships) then organizational factors (health care, schools) then community (neighborhoods, culture, social networks) and finally policy (laws).

Each of these layers have been disrupted by the COVID-19 pandemic.

Individuals are experiencing stress and worry, even depression, around health, job loss, and futures for themselves and their families. With 37% of Hawaii’s labor force filing unemployment claims and many others facing cuts to already low wages, more of our community will be pushed into homelessness and poverty.

Families may be too far apart, or too close together for too many days in a row, to provide full support. Neighborhoods are disrupted and cultural fabrics have been challenged. Schools, pharmacies, and primary care providers may be closed. Laws are changing and uncertainty exists around what is yet to come.

Deep Health Inequalities

Innovative solutions to help prevent and manage chronic disease are available across the levels of the social ecological model even in this time of crisis. Numerous health and social agencies, businesses, and individuals have stepped up across our state in support of our communities.

Options include individual-level considerations (e.g., how to exercise during social distancing; tobacco quit lines available virtually); interpersonal-level efforts (e.g., intimate partner and family supports); organizational-level responses (e.g., online diabetes prevention programs; school lunch pick-ups), community-level responses (e.g., mutual aid efforts; funds to share with communities in need, cultural practice adaptations), and policy-level changes (e.g., households scheduled to renew food stamp benefits may receive a six-month extension).

Effort and solutions must be distributed across our communities so that certain groups who already have deep health inequities are not put even deeper at risk. The UH study found many hospitalized with heart failure or uncontrolled diabetes had extreme social vulnerability (e.g., homeless, poverty, no social support).

Other challenges to managing chronic conditions included difficulty interacting with the health system or providers, or limited access to care because of transportation or insurance barriers, limited health-related knowledge, and behavioral health issues (e.g., substance abuse, mental illness). All of these issues still exist, and may be exacerbated, in the time of COVID-19.

These issues will likely have deep impacts in vulnerable communities, including non-English speakers who already struggle to find understandable guidance with culturally-relevant information, or those who live in rural communities with insufficient primary care providers. Though we currently lack the data specificity to investigate these concerns, Native Hawaiians and Pacific Islanders may be at higher risk due to greater socioeconomic vulnerability and high rates of chronic conditions.

COVID-19 has acutely highlighted all of the weaknesses in our economic, societal, and health systems. In order to be more resilient in the future, we have to address those weaknesses, starting with assuring a living wage, adequate social safety nets, resources for the most vulnerable in our communities, equity in education, and integrated health systems.

The noise of an outbreak can easily drown out other but equally important health messages. But infectious diseases are not delinked from chronic diseases. Let go of one, and other will worsen. Turn our backs on prevention and management of chronic diseases and more of our community will be at risk of having negative outcomes from a COVID-19 infection.

The noise of an outbreak can drown out other equally important health messages.

The tools for fighting this pandemic are not limited to just social distancing — they also include the arsenal of innovative approaches for preventing and managing chronic conditions.

These can build a new symphony, which like Andrea Bocelli’s Easter Sunday Concert may be unexpectedly virtual but still powerful, able to uplift and support wellness and chronic disease management.

Public health recognizes that everyone from the community member to the policy maker is required to create resilient communities. Walkable neighborhoods, grocery stores with healthy affordable foods, tobacco-free norms, living wage, are necessities. The inclusive music must continue to be written so everyone can enjoy the melody of health.

Editor’s note: Dr. Catherine Pirkle (academic) and Dr. Lance Ching (epidemiologist) of HHIET are co-authors.

Community Voices aims to encourage broad discussion on many topics of community interest. It’s kind of a cross between Letters to the Editor and op-eds. This is your space to talk about important issues or interesting people who are making a difference in our world. Column lengths should be no more than 800 words and we need a current photo of the author and a bio. We welcome video commentary and other multimedia formats. Send to news@civilbeat.org. The opinions and information expressed in Community Voices are solely those of the authors and not Civil Beat.

About the Authors

  • Tetine Sentell
    Tetine Sentell is the director/chair of the Office of Public Health Studies at UH Manoa and a professor in Health Policy and Management. She is currently co-lead of the Healthy Hawaii Initiative Evaluation Team, which evaluates chronic disease prevention efforts for the Hawaii Department of Health.
  • Lola Irvin
    Lola Irvin is the administrator of the Chronic Disease Prevention and Health Promotion Division at the Hawaii Department of Health, which has categorical program areas in tobacco, nutrition, physical activity, obesity prevention, asthma, cancer, diabetes, heart disease and stroke. The CDPHPD employs systems, policies, and environmental change strategies to support the prevention and management of chronic disease.