In late February 2020, an international business conference was held in Boston with 175 attendees. At that time, no one imagined this would turn out to be one of the most significant COVID-19 superspreader events in New England. A study conducted by the Broad Institute of MIT and Harvard estimates this one event may have contributed as many as 300,000 COVID-19 cases locally and abroad.1,2
Chelsea, Massachusetts, is situated directly across Boston Harbor from downtown Boston. It has a population of 40,000 and is known to have some of the most densely populated neighborhoods in the United States with household units larger than the Commonwealth average. The population is majority Latino (65%) with high rates of poverty and pre-existing health conditions such as cardiovascular disease and asthma.3,4 Many residents are employed in essential services such as grocery stores and hospitals and rely on public transportation. Living paycheck to paycheck, many residents were reluctant to stop working in the early days of the pandemic.
The pandemic severely affected the citizens of Chelsea. By mid-April, the COVID-19 rate for Chelsea was 1,900 cases per 100,000 people—three times higher than in neighboring Boston (663 cases per 100,000 people) and four times higher than for the entire Commonwealth of Massachusetts.4 As the pandemic accelerated, Massachusetts General Hospital (MGH), which operates a clinic in Chelsea, admitted many of these patients. MGH has a well-recognized Disparities Solutions Center headed by Joseph Betancourt, MD. Dr. Betancourt recognized the disproportionate number of patients of color and primary Spanish-speaking patients affected by the most severe manifestations of COVID-19.
An initiative known as the Spanish Language Care Group (SLCG) was created so that Spanish-speaking doctors across all disciplines were integrated into the internal medicine COVID-19 care teams. This included Gloria Martinez-Salazar, MD, FSIR, an MGH assistant professor of radiology who is a native Spanish and Portuguese speaker. Dr. Salazar has been a leader in IR with over 50 peer-reviewed publications and, at SIR 2019, organized the first Spanish-language session. She has also worked to expand the international presence of SIR in El Salvador via the Giveback Program.
Dr. Salazar spoke with IR Quarterly about her time with the SLCG, and the challenges and benefits of staffing response teams with native-language speakers.
Describe the typical demographics of the communities your hospital served prior to the COVID-19 pandemic.
Prior to the pandemic, the overall number of Spanish-speaking patients at MGH was about 6%, with some clinics such as OBGYN reaching 8%. At the interventional service, 5% of our patients in 2019 were Hispanic overall, with almost 80% of these patients evaluated in my clinic.
How did the demographics change during the COVID-19 pandemic?
During the April and May surge, 33–42% of COVID-positive patients were Spanish speakers only.
How was the concept of the Spanish Language Care Group devised?
In the first week of the surge, the Center for Diversity and Inclusion under Elena Olsen, JD, in collaboration with Chris Kirwan, director of medical interpreter services at MGH, emailed all providers who spoke another language with the goal of identifying individuals who could help. Then we realized that COVID-19 was disproportionately impacting minority and vulnerable communities. At that time, the rate of COVID-19 positive individuals in Chelsea was 88/10,000, with the next closest city being Brockton at 49/10,000. Under the leadership of Dr. Betancourt and working with Steven Knuesel, MD, and Warren Chuang, MD, from the department of medicine, a system was created so that Spanish-speaking doctors might be able to volunteer to help the care teams in multiple ways.
How many providers were deployed? How many care teams were staffed with native language speakers?
The SLCG leverages native Spanish-speaking MGH physicians to aid Surge, ICU, ED and Boston Hope clinical teams in caring for limited-English-proficiency patients who are hospitalized with COVID-19. In April, a total of 60 individuals volunteered for 24/7 in-person and virtual shifts, helping with daily rounds, family updates, admissions and discharges, informed consent, goals of care, etc. There were 14 COVID floors, 11 ICUs and ED floors covered by this group daily. The group also developed 16 Spanish educational videos for a public health campaign.
How is having a native-language-speaking physician different from using a medical interpreter?
It is different because you are interviewing the patient as a physician, as part of their team, and as such, you are making real-time, patient-shared decisions and reconciling discrepancies. Having that cultural competence allows you to connect with patients and gain their trust.
Are there any challenges to creating a group like this?
As you can imagine, having a diverse workforce is costly and it requires promoting diversity at the first stages of the medical school pipeline.
Can non-native-language care teams achieve cultural competence using only an interpreter?
I believe you can learn specific aspects and be able to provide culturally competent care, but research highlights the patient perspective in which trust and communication are key factors for better health outcomes. Alsan et al., in a study evaluating the impact of racial concordance, found that African-American patients were more likely to select preventive services once meeting with a racially concordant doctor, suggesting that increasing African-American doctor representation could reduce the Black–white male gap in cardiovascular disease.5 Therefore, given the data and my personal experience with the pandemic, increasing workforce diversity is the ultimate goal to decrease health disparities along with systemic changes in socioeconomics.
Was there a benefit in having providers able to virtually communicate in the native language of family members?
Yes, particularly when we had to facilitate end-of life discussions in the ICU.
Was your IR expertise ever helpful as part of an internal medicine team?
As an IR, working in multidisciplinary teams and dealing with vascular disease, it was an added benefit to be part of internal medicine teams during the pandemic. Moreover, it was also helpful to discuss how COVID impacts the vascular system (thrombosis, etc.) and be involved in decisions to perform dialysis lines or other IR procedures that were commonly performed during the surge.
How often were you in the IR lab during the Massachusetts surge?
I continued to cover regular IR on a needed basis but, as one of the few Spanish-speaking radiologists, the SLCG team was my major contribution during the surge.
Did this experience offer you any new insights as to how IR can be more useful to internal medicine care teams, regardless of the pandemic?
Yes, absolutely. I do think there is still a gap in knowledge of what IR is able to provide and how it can help patients.
Do you have any stories regarding how your presence affected an important decision or outcome?
I was able to help reconcile medications for a patient who had asthma and was successful in convincing patients to go to rehab after they recovered from COVID. Many Latinos do not trust the healthcare system and I think I was able to connect with patients and articulate the importance of rehab post-COVID. I was also able to stress the importance of staying in a city-provided motel rather than going back home to infect others.
Do you have any advice for other IRs who are similarly situated serving diverse communities in need?
If you think you can help patients who have limited English proficiency, make yourself available. Also, anyone can discuss with their hospital leadership how they can better serve minorities.
References
- Lemieux J., et al. Phylogenetic analysis of SARS-CoV-2 in Boston highlights the impact superspreading events. Science. doi: 10.1126/science.abe3261
- Wines, M. and Harmon, A. What happens when a superspreader event keeps spreading. The New York Times. 11 Dec. 2020.
- Quick Facts: Chelsea City, Massachusetts. United States Census Bureau. census.gov/quickfacts/fact/table/chelseacitymassachusetts/PST040219.
- Kowalczyk, L. and Greenberg, Z. Chelsea’s spike in coronavirus cases challenges hospitals and state. The Boston Globe. 15 April 2020.
- Alsan M, et al. Does diversity matter for health? Experimental evidence from Oakland. American Economic Review. 2019;109(12):4071–4111.
