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As the COVID-19 pandemic has made alarmingly clear, disease is contextualized by socioeconomic factors as much as biological factors. Our vulnerability to disease is determined by where we live and who we have access to, combined with the unique makeup of our physiology. As such, it is critical to consider the social background of patients and the values they bring to the healthcare sphere.

In her grand round on Thursday, March 4 2021, Dr. Adaora Adimora MD, MPH, discussed this idea in the context of HIV and COVID-19’s impacts on Black communities in the United States. Dr. Adimora is a Sarah Graham Kenan Distinguished Professor of Medicine and professor of epidemiology at the UNC School of Medicine. Her work has shed light on the importance of contextual factors like race and ethnicity in understanding sexual networks contributing to the spread of HIV. In the talk, Dr. Adimora focused on early research on racial inequities in HIV and illustrated the contextual features that help drive these inequities. She also highlighted how persistent inequities in the social epidemiology of HIV and COVID-19 can hinder public health from making progress in combating these illnesses through treatment and prevention.

Looking at HIV in particular, differences in high-risk behaviors could explain a portion of the racial distribution of the epidemic. But Dr. Adimora also emphasized that more than a quarter of the people had normative behavior—the common denominator, then, was that nearly all lived in poverty. From these observations, Dr. Adimora highlighted that individual-level behaviors do not sufficiently explain racial inequities in STI/HIV contraction and factors apart from individual risk behaviors and covariates appear to account for racial disparities. A particularly insightful study she conducted examining focus groups of black men and women found that extensive economic oppression and racial discrimination often restrict educational and employment opportunities. Further, institutional racism impedes black progress in school and the workplace, greatly slowing their social mobility. Coupled with these impediments, there is also a substantial disparity in the ratio of available black men to women due to male attrition accelerated by the mass incarceration of black men. Combined together, these factors create a profound male shortage and a socioeconomic plight that negatively impacts partner selection and the types of male behavior women tolerate.

Delving more deeply into the phenomenon of mass incarceration in the U.S., Dr. Adimora expanded on how incarceration, especially of racial minorities, directly impacts sexual networks. Specifically, incarceration leads to disrupted partnerships, lower employment prospects, a smaller pool of men in the community, and new long-term links among antisocial networks. With the U.S. as the only democracy that disenfranchises many convicted offenders who have served their sentences, incarceration has a detrimental impact not only on individuals, but also on the democratic process as a whole.

So how can we begin to mitigate the HIV epidemic? Dr. Adimora presented several strategic interventions. Reforming policing is a critical first, through which the numbers of people killed by law enforcement can be reliably documented. As part of the reformation, individual police and law enforcement agencies could be held accountable for police actions and misconduct. From the funds used for police militarization, the government could bolster social services and expansion of social safety nets.

Another intervention with the potential to bring transformative change is the implementation policies that promote decarceration. Currently, some states have made steps in this direction to decrease prison populations by eliminating some mandatory minimum sentences, specialty courts, decreasing reincarceration, and pursuing alternatives to incarceration. Although much more needs to be done, particularly with regards to decreasing racial inequities. Dr. Adimora further emphasized that unreasonable collateral consequences of criminal conviction must be eliminated as they erect social and economic barriers for people re-entering society. For example, the denial of professional licenses, felon disenfranchisement, and denial of access to government programs systemically prevent individuals from securing mobility.

As Dr. Adimora emphasized, all policy is health policy. We see that racial inequities in HIV and COVID-19 are driven primarily by the social, economic and political forces molding our lives. Among these forces, the criminal justice system, policing, incarceration, and health care coverage (or lack of) are the most prominent. Although the interventions Dr. Adimora outlined will not reverse centuries of oppression, they can begin to mitigate the fundamental drivers of the US HIV and COVID epidemics as well as improve life for all Americans.

Mili is a student with an interdisciplinary love for the hard sciences and humanities. She is particularly interested in pursuing trauma and critical care, and wants to deepen her understanding of individual patient experiences in the field of medicine.

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