The social determinants of health during the COVID-19 pandemic

COVID-19 didn’t just spread through coughs and sneezes. It spread through schedules, paychecks, crowded apartments, unreliable Wi-Fi, and the simple fact that
some jobs can be done in pajama pants while others require you to show up in personduring a pandemicnext to strangers who also had rent due.

In public health, we call those real-life conditions the social determinants of health (SDOH): the non-medical factors that shape whether people
can stay healthy in the first place. During the COVID-19 pandemic, SDOH acted like the world’s least fun “choose your own adventure” bookexcept nobody chose
the options, and the consequences were measured in infections, missed school, lost wages, and avoidable deaths.

This article breaks down how the pandemic collided with the five big SDOH domains (economic stability; education; health care access and quality; neighborhood
and built environment; and social and community context). We’ll also look at what worked, what didn’t, and what “health equity” actually means when your zip
code can predict your risk.

What are social determinants of health (and why did COVID-19 make them impossible to ignore)?

Think of SDOH as the “invisible infrastructure” of everyday lifemoney, time, safety, transportation, education, and social support. They influence exposure
to disease (Can you work from home? Do you live in a crowded household?), vulnerability to severe illness (Do you have stable access to preventive care?), and
recovery (Can you take time off? Do you have childcare?).

During COVID-19, the virus hit a population already shaped by long-standing inequities. That meant the pandemic didn’t create health disparities from scratch;
it amplified themlike turning up the volume on problems that were already playing in the background.

Economic stability: when “stay home” was advice some people couldn’t afford

Essential work, unequal risk

Early pandemic messaging often sounded simple: “Avoid contact. Stay home. Limit exposure.” But many workers didn’t have that option. Hospitals, grocery stores,
warehouses, farms, public transit, home health, sanitation, and childcare still needed people physically present. These roles are often lower-wage, less likely
to come with paid sick leave, and more likely to require close contact with coworkers and the public.

Meanwhile, people in many professional jobs shifted to remote work relatively quickly. That splitremote versus on-sitebecame one of the clearest ways that
income and occupation shaped COVID-19 exposure. If your job required face-to-face contact, your “risk budget” was spent the moment you clocked in.

Income shocks and the health domino effect

Layoffs, reduced hours, and unstable gig work didn’t just threaten financial security. They set off a chain reaction:
less money for food, rent, medications, utilities, and transportationplus more stress, which affects sleep, mental health, and chronic disease management.
In other words, a paycheck problem quickly became a health problem.

Safety-net policies (expanded unemployment benefits, stimulus payments, temporary changes to nutrition assistance, and other supports) helped many households
stay afloat, but the need was uneven, and gaps remainedespecially for people with barriers such as language access issues, limited internet access, complex
paperwork requirements, or immigration-related fears.

Housing: where the pandemic turned “home” into either a fortress or a fault line

Crowding, multigenerational households, and isolation that wasn’t possible

Public health guidance often assumed people had extra rooms, flexible space, and the ability to isolate. But housing reality in many communities looked more like:
shared bedrooms, multigenerational households, roommates, and limited ventilation.

In a crowded home, one infection can quickly become a household outbreak. And if one person is an on-site worker, the whole home shares the exposure.
That’s not a “bad decision”; it’s an SDOH reality.

Housing insecurity and eviction pressure

Housing instability also surged as income dropped. Eviction risk is a health risk: it forces people into doubled-up living arrangements, shelters, or frequent moves,
which can increase exposure to respiratory viruses and make it harder to quarantine, recover, or keep up with medical care.

Pandemic-era eviction protections and rental assistance were public health tools as much as housing tools. They didn’t solve structural housing shortages,
but they reduced immediate harms when millions of households were living one missed paycheck away from a crisis.

Food access: when the “next meal” became another pandemic uncertainty

Food insecurity, disrupted routines, and school meals

Food insecurity rose for many households due to job loss, higher costs, and disrupted community supports. At the same time, school closures interrupted a key
nutrition source for many children: school meal programs. Communities adapted with meal pick-ups, deliveries, and expanded local food bank operations, but
access still depended on transportation, work schedules, and information in the right language.

Food, stress, and health are roommates (whether they get along or not)

Nutrition and chronic disease management are tightly linked. When budgets shrink, households often shift toward cheaper, calorie-dense foods. Combine that with
stress, reduced physical activity, and delayed medical care, and you get a predictable outcome: higher risk of worsening conditions like diabetes and hypertension,
which are associated with more severe COVID-19 outcomes.

The pandemic reminded us that “healthy choices” aren’t just personal choices. They’re also budget choices, transportation choices, and “what’s available at the
nearest store” choices.

Education access and quality: the digital divide became a health divide

Remote learning wasn’t equal learning

When schools went remote, learning suddenly depended on internet speed, device availability, a quiet space, and adult supportresources distributed very unevenly.
Some students had their own laptop, stable broadband, and a parent working from home. Others shared one device among siblings, relied on a phone hotspot, or had no
reliable connection at all.

Those gaps mattered for more than grades. Education shapes long-term health through income opportunities, health literacy, and future stability. A disrupted
education experience can echo for yearsespecially for students with disabilities, English learners, and children in under-resourced districts.

Technology access also shaped health care access

Education and health care collided again through telehealth. Virtual visits expanded dramatically, which helped many patients maintain care without exposure.
But video visits require broadband, devices, and digital literacy. For people without those tools, “telehealth available” could still mean “telehealth not actually
accessible.”

Health care access and quality: coverage, trust, and the logistics of getting help

Insurance coverage and care delays

Access to testing, treatment, and preventive care wasn’t uniform. People without insurance or with high out-of-pocket costs faced hard choices: pay for care or
pay for rent. Early in the pandemic, uncertainty and fear also kept many people away from clinics and hospitalsleading to delayed diagnoses and missed routine
management of chronic conditions.

Medicaid protections (and what happened when they ended)

Temporary policies helped keep many people enrolled in Medicaid during the public health emergency, reducing coverage loss during a period of extreme economic
volatility. Later, as states resumed eligibility redeterminations, some people lost coveragesometimes because of paperwork and communication barriers rather than
true ineligibility. That “administrative churn” is an SDOH issue: it turns a health coverage program into a test of time, technology, and know-how.

Vaccines, access, and confidence

Vaccine access and uptake were influenced by more than supply. Transportation, work schedules, childcare, disability access, language services, and trust in
institutions all mattered. Communities with strong local partnershipsfaith organizations, community health centers, neighborhood leaders, and culturally competent
messengersoften improved reach by meeting people where they were, literally and figuratively.

Neighborhood and built environment: exposure was baked into the map

Where you live shapes the air you breathe, the space you have, and the risks you face. During COVID-19, neighborhoods differed in crowding, reliance on public
transportation, access to parks and safe outdoor spaces, and proximity to high-exposure workplaces.

Many communities already affected by environmental burdens (like air pollution) also faced higher rates of chronic respiratory and cardiovascular conditions.
That matters because severe COVID-19 risk isn’t just about the virus; it’s also about the baseline health landscape created over decades.

Social and community context: racism, isolation, and the (very human) trust problem

Structural inequities and discrimination

The pandemic highlighted how racism and discrimination operate as upstream drivers of health outcomes. Historical and ongoing inequities in housing, employment,
education, and health care access contributed to higher exposure risk and worse outcomes in many communities of color. Discrimination within health care settings
also affects whether people feel safe seeking helpand whether they expect to be treated fairly when they do.

Social isolation and mental health

Social connection is protective for health, but lockdowns, bereavement, and disrupted routines increased loneliness and stress for many people. Meanwhile,
households dealing with food or housing insecurity experienced additional mental strain. “Just cope better” is not a planespecially when the stressors are structural.

What worked: practical moves that reduced SDOH-driven COVID-19 harms

1) Community-based health strategies

Community health centers, mobile clinics, local public health departments, and grassroots organizations played an outsized role in testing and vaccine outreach.
Successful approaches often included pop-up sites near transit, extended hours for shift workers, bilingual staff, and partnerships with trusted community leaders.

2) Data transparency (done carefully)

Better databy race/ethnicity, geography, and other measureshelped reveal disparities and target resources. At the same time, communities needed safeguards
against stigma and blame. The goal of data isn’t to label people as “high-risk”; it’s to identify where systems are failing and fix the systems.

3) Telehealth expansion (with equity guardrails)

Telehealth reduced barriers for some patientsespecially those with transportation challenges, mobility limitations, or caregiving responsibilities. But equity
required more than just turning on video visits. It meant offering phone options, digital navigation support, language access, and broadband/device investment.

4) Screening for social needs and connecting people to services

Health systems increasingly recognized that screening for food, housing, and transportation needsand referring patients to servicescan improve outcomes.
During and after COVID-19, more organizations explored systematic ways to connect medical care with community supports.

Lessons for the next crisis (and for everyday life)

• Build “stay home” capacity into policy. Paid sick leave, job protections, and stable income supports aren’t luxuries in a pandemic; they’re infection control.
• Treat housing as health infrastructure. Stable housing reduces exposure risk and supports recovery. Eviction prevention and rental assistance are public health tools.
• Make broadband and devices part of health equity. Digital access affects school, work, and health careespecially when telehealth becomes routine.
• Reduce administrative barriers to coverage. When coverage depends on paperwork perfection, the people with the least time and tech lose first.
• Invest in trusted messengers. Public health works faster when communities already have relationships, local leadership, and culturally competent communication.

Experiences from the pandemic: what SDOH looked like up close

The phrase “social determinants of health” can sound academiclike something you’d hear in a conference room with bad coffee. But during COVID-19, it was also
the story of ordinary days. The experiences below are composite examples drawn from widely reported patterns across the United States, meant to
illustrate how SDOH shaped real decisions and outcomes.

The grocery worker who couldn’t “opt out”

Consider an essential worker stocking shelves at a grocery store. The job kept the community fed, but it also meant constant exposure: crowded aisles, long lines,
and customers who were tired of rules. The worker’s pay was modest, and staying home wasn’t an optionmissing shifts meant missing rent. When a sore throat showed
up, the decision wasn’t just “Do I feel sick?” It was “Can I afford to get tested?” and “If I test positive, can I isolate from my family in a small apartment?”
This is economic stability and housingtwo SDOH domainsoperating at the speed of everyday life.

The multigenerational home trying to quarantine in a two-bedroom world

Picture a household with grandparents, parents, and kids under one roof. Multigenerational living can be a strengthshared childcare, shared bills, shared support.
During COVID-19, it could also be a transmission pathway. If one adult worked an on-site job, the entire household carried that risk home. When someone tested
positive, “isolation” might mean a bedroom shared with siblings or a living room improvised into a sleep space. The family didn’t lack effort; they lacked square
footage. In public health terms, the built environment shaped the possible choices.

The student whose education depended on Wi-Fi and one shared laptop

Remote learning showed how quickly education becomes a technology problem. Some students had quiet rooms, reliable broadband, and parents available to help with
assignments. Others shared a single device between siblings while an adult worked outside the home. Logging into class could require a phone hotspot, which is
expensive and unstable. For these students, school wasn’t just “online”it was “online if the connection holds.” That stress didn’t stay neatly in the “education”
category. It influenced sleep, anxiety, and family conflictbecause when a household is under pressure, everything is connected.

The telehealth appointment that worked… until it didn’t

Telehealth became a lifeline for many people managing chronic conditions. For some, it reduced transportation barriers and saved time off work. But for others,
it introduced new hurdles: passwords, apps, camera access, and a stable connection. An older adult might manage fine on a phone call but struggle with a video
platform. A patient with limited English proficiency might need an interpreter who wasn’t seamlessly integrated into the virtual visit. In these moments, the
“health care access and quality” domain collided with the digital divideand the result wasn’t just inconvenience. It was missed care, confusion, or a condition
that quietly worsened.

The community clinic doing more than medicine

In many neighborhoods, community health centers became more than clinics. They were information hubs, vaccine sites, and connectors to food and housing resources.
Staff helped patients navigate changing rules, find testing, and access benefits. Some clinics partnered with faith leaders and local organizations to reach
people who didn’t trust large institutions or who were simply too busy to hunt for reliable information. This is what it looks like when social and community
context becomes part of the public health response: relationships carry the message farther than billboards.

Across these experiences, the pattern is consistent: COVID-19 outcomes weren’t determined only by biology. They were shaped by whether people had the time to stay
home, the space to isolate, the cash to buy food, the bandwidth to attend school, and the coverage to seek care. If the next crisis arrives tomorrowwhether it’s
another virus, a climate disaster, or an economic shockhealth equity will depend on how well we’ve strengthened the everyday systems that keep people stable today.

Conclusion

The COVID-19 pandemic turned the social determinants of health from a background concept into a daily headline. It showed, with uncomfortable clarity, that health
is built (or undermined) by jobs, housing, education, food access, neighborhood conditions, and the social realities of discrimination and trust.

The good news is that SDOH are not mysterious. They’re measurable, improvable, and responsive to policy and community action. When we invest in stable housing,
reliable income supports, equitable education technology, accessible health coverage, and community partnerships, we don’t just prepare for the next pandemicwe
improve health in the years between crises.