Internet Access: A Determinant of Health?

The study in JAMA Network Open looks at structural barriers and racial disparities in COVID-19 mortality. County-level mortality data were stratified based upon

• Socioeconomic factors – “poverty, low high school graduation rates, minority status, the proportion of uninsured persons, and the number of single-parent households.”
• Limited mobility – both for disabilities and public transportation
• Urban opportunity – living in a metropolitan area with great opportunity and a high cost of living, i.e., New York or San Francisco, etc.
• Immigration cohesion and accessibility – the percentage of immigrants with both a strong family structure and language issues making access difficult.
• They added several additional variables, income inequality, uninsured rate, primary care physicians, preventable hospital stays, severe housing problems, and access to broadband internet.

The counties they chose to examine had high COVID mortality and a “high concentration” of one race, Black or White. 531 of 3142 counties met their criteria and were termed “concentrated longitudinal-impact counties. 347 were Black, 198 Hispanic, and 33 non-Hispanic White. Those concentrated Black communities “were spread across urban, suburban, and rural areas,” Hispanic areas were primarily urban, and non-Hispanic White communities were predominantly rural. 

• Median deaths per 100,000 were greatest in non-Hispanic White communities, 251; with 231 in Black communities and 218 in Hispanic communities. The researchers quickly pointed out that given the greater number of Black and Hispanic communities, their aggregate number of deaths was greater.
• Socioeconomic factors accounted for 40% of the variance, limited mobility for 13.4%, urban core opportunity for 9.3%. There are no surprises here. All of these factors create densely populated areas with significant exposure to COVID-19 and limited mobility, the perfect setting for an airborne virus.
• Across all three environments, rural, suburban, and urban, lack of Internet access was associated with increased mortality. To provide more context, 2.3% of rural homes had no access, 2.9% in suburban areas, and 5.8% in urban settings.

The bulk of the researchers' discussion was around those four more classical social determinants of health, arguing that the built environment, both physical and social/cultural contribute to individual and population health. They concluded that

• “Neighborhood characteristics and COVID-19 mortality differ by race and ethnicity.”
• “No neighborhood characteristics were associated with COVID-19 death rates among black residents….”
• “…among white residents, several [neighborhood characteristics] were associated with COVID-19 death rates.”

That certainly goes against the most common narrative. Here is the piece the media choose to prioritize.

“…we believe this finding [with respect to Internet access and mortality] suggests that more awareness is needed about the essential asset of technological access to reliable information, remote work, schooling opportunities, resource purchasing, and/or social community.”

Why would Internet access make a difference? Could exposure to medical information, true or not, make a difference?

What is the secret sauce that the Internet provides?

To begin to answer that question, we can look at the paper cited by these researchers in their decision to include Internet access. The work they cited includes a lack of “broadband Internet at home” as just one of several sociodemographic characteristics that “heightened barriers to social distancing.” In other words, Internet access increases our ability to isolate, work or learn remotely, shelter in place.

Another possible source of the Internet’s magical power comes from a recent study of the impact of digital media on an authoritarian community, in this case, the Ultra-orthodox of Israel.

The Ultra-Orthodox of Israel constitute about 12% of the population and live within and apart from the other communities. They are governed by rabbinical law and restricted in using technologies and reading materials. There are several ultra-orthodox communities in the US, a few of which were involved in measle outbreaks and early outbreaks of COVID-19. You may remember the actions by then-mayor de Blasio when members of the Hasidic community continued to meet in groups at weddings and funerals despite admonitions from the city. The Hasidic are perhaps the strictest of the three major Ultra-Orthodox “sects” in Israel.

COVID-19 was particularly hard on the Ultra-Orthodox communities, with approximately 30% testing positive and their members contributing 2 to 3 fold more Israeli cases than their percentage in the population. The Ultra-Orthodox were also sixfold more likely to die from COVID-19. Like the Amish in the US, the ultra-orthodox are late adopters of technology. Roughly 54% of the ultra-orthodox used the Internet in 2019. Most cell phone use involved “kosher” phones – altered to prevent access to secular information that Rabbinical leaders have determined to be corrupting.

Like the urban communities in the JAMA study, the ultra-orthodox lived in crowded conditions. They are rarely depicted on more secular television and then, often as troublesome individuals. The researchers in both the JAMA and this Israeli study viewed Internet access as a resource that should be fairly distributed to all.

The researchers used a scale of adherence to government health recommendations relevant to everyday life, involved both active and passive behaviors, and contributed to population health and safety. They used that scale in evaluating Internet use among the ultra-orthodox using a random interview survey of 500 adults over age 18.

• Women were more likely than men to adhere to government guidelines, as were older individuals.
• The Hasidic, the most closed of the three ultra-orthodox sects, was the least adherent.
• Educational level and socioeconomic status had no impact on adherence.
• Cell phone usage was high, but 82% used kosher phones. Only 20% read from online news, predominantly secular, and only 13% used social media.

“…only some factors related to general Internet usage (i.e., study and essential websites and apps) contribute to the level of adherence to government-issued health guidelines, while other factors related to general digital media use do not predict levels of adherence to these guidelines.”

Using the internet for study was the factor most associated with adherence; online shopping, work, and email use had no discernable effect. The use of social media increased compliance by about 5%. Overall, I would say that curiosity, especially about non-secular views, contributed the most to adherence. Unlike the US study, where Internet access is more a measure of crowded housing and lower-income, in Israel, internet access and curiosity, the ability to look outside of your friends and family for information increased adherence.

I would conclude that Internet access can be both isolating and liberating; it is just a tool with no magical powers. I would also suggest that Internet access can measure many things and that the association with mortality in the US is more complex than the media reports.

Sources:

Assessment of Structural Barriers and Racial Group Disparities of COVID-19 Mortality With Spatial Analysis JAMA Network Open DOI: 10.1001/jamanetworkopen.2022.0984

Protecting the community: How digital media promotes safer behavior during the Covid-19 pandemic in authoritarian communities—a case study of the ultra-Orthodox community in Israel New Media & Society DOI: 10.1177/14614448211063621