A different pandemic

Health care disparities and COVID-19

by

There is an oft-repeated saying: Disasters don’t create disparities, they uncover them. I’ve seen this evidenced first-hand. In 2005, Hurricane Katrina left a wake of disaster in New Orleans, and the whole world watched as Black communities suffered. America learned what these communities had known for years—due to systemic, economic difficulties they were forced to live in unsafe flood zones. When disaster struck, they were the first and hardest hit. I was interning through Louisiana State University at the time and will always remember witnessing one of my patients—a Black, homeless man—stranded in his motorized wheelchair.

Though New Orleans has since rebuilt, the impact of Hurricane Katrina is still being felt in those communities. And much as the world watched with horror as the most vulnerable of city fled destroyed homes to seek rescue on their rooftops, the COVID-19 crisis has once again lifted the veil, this time on a different pandemic: systemic racism and disparities in our nation’s health care.

The impact of COVID-19 on vulnerable populations

At the time of writing, the Centers for Disease Control and Prevention (CDC) reports that Black Americans have comprised 19.9% of COVID-19 cases and 22.3% of deaths, and Hispanic individuals comprised 30.9% of cases and 16.9% of deaths.1 These communities account for only 13% and 18% of the U.S. population, respectively. These numbers do not include data where race was not reported, and also does not include individuals who were not tested—notable, as limited testing is most prevalent among communities without access to affordable health care, without means to pay for the testing or without the ability to take time away from work to be tested.

There are clear reasons why minority populations are disproportionately impacted by a health crisis like COVID-19, such as systemic factors surrounding employment and income. While many Americans are able to work remotely and social distance, immigrants and people of color often work for less pay and take on “essential” jobs instead of facing the crisis at home.2 According to the CDC, 25% of Blacks and Hispanics work in service industry jobs compared to 16% of non-Hispanic whites. An August CDC report focusing on Utah workplace outbreaks found that 58% of outbreaks took place in the manufacturing, wholesale trade and construction industries, with Hispanic and nonwhite workers representing 78% of the cases.3 These surges arise because individuals in such sectors often do not have protections like sick leave—and so are forced to choose whether to stay home and forego pay, or come to work and put themselves and others at risk of infection.

There are social determinants that also increase the impact on Black and Hispanic communities. Limited or unaffordable access to health care and insurance has led to high rates of underlying conditions such as diabetes or hypertension. These co-morbidities are exacerbated by lack of access to healthy food, clean water, and preventative care and guidance. All of this leads to individuals with existing health conditions working in public-facing “essential” roles during a health crisis.

According to a June 26 Morbidity and Mortality Weekly Report from the CDC, “Hospitalized COVID-19 patients are more commonly older, male, of [Black] race and have underlying conditions.”4 The same report goes on to cite data from six Atlanta hospitals and associated outpatient clinics showing that, among COVID-19 positive patients, “older age, [Black] race, diabetes, lack of insurance, male sex, smoking and obesity were independently associated with hospitalization.”

COVID-19 Health Equity Response Team

In my home state of Colorado, the Department of Public Health and Environment sought to combat these disparities by creating the COVID-19 Health Equity Response Team. The task force pursued multiple goals, including: 5

  • Determining proactive measures to prevent infection in vulnerable communities
  • Increasing access to testing and care
  • Developing policy recommendations to better assist communities of color during the pandemic and in the future

Along with legislative suggestions to provide sick leave protections, the Health Equity Response Team highlighted the need for transparent racial and ethnicity data. This need extends beyond COVID-19; the need for more robust data will allow for a better understanding of which diseases disproportionately impact vulnerable populations and could inform how to treat a disease process amongst these communities. Consider, for example, transjugular intrahepatic portosystemic shunt (TIPS)—just one of countless areas that lack quality data reflecting racial and ethnicity demographics.

In my experience, radiologists—particularly diagnostic radiologists—rarely look at race or ethnicity. We focus mostly on age and sex, and use these factors to inform our research and practices. This exclusion leaves on the table a tremendous opportunity for better health outcomes. Collecting more robust data will provide better patient care—but implementing it will require reassessing and adjusting protocols and views.

Implicit bias and disease processing

The first—and most important—step in rectifying health care disparities is acknowledging they exist. Once aware, physicians and health systems can keep them in consideration when developing treatment plans and seek to counteract implicit bias.

Implicit bias, as defined by Ohio State University’s Kirwan Institute for the Study of Race and Ethnicity, is an attitude or stereotype that impacts the way individuals interact with and understand others. These attitudes are formed by our education, environment and culture, and though implicit bias can result in favorable or unfavorable attitudes, it operates in the subconscious, outside of intentional control. These biases can impact health care, informing the degree to which patients and doctors trust each other, the way team members collaborate, or even how disease processes are approached. Thus, inclusion of implicit bias awareness and training is crucial to beginning the work of diversity, equity and inclusion.

Those familiar with discussions of implicit bias in medicine may think of widely reported statistics regarding the disproportionate Black maternal death rates,6 or studies such as a 2015 paper in the American Journal of Public Health showcasing how racial bias can lead to unfavorable treatment decisions and outcomes.7 But cases of implicit bias happen on large and small scales every day in every department of every health system across the nation.

During the peak of COVID-19 infections, a colleague in internal medicine told me how the department had begun changing the workflow and standards of the ICU. Before COVID, the ICU was largely full of white patients, and any individual exhibiting pulmonary issues would receive CT scans and routine imaging. Once COVID-19 struck, however, this practice changed. It was determined that presumed positive patients would not receive default imaging, due to concerns of spreading infection throughout staff and other patients. The change in process was rooted in a well-intentioned desire to protect other individuals and keep up with the onslaught of cases.

When patients are treated by someone who looks like them, speaks like them and understands the realities of their experiences, it will create deeper levels of trust—which will result in better patient care.

The need for dedication and leadership

The second step in addressing health care disparities is education. In order to create a curriculum to enact change, the individuals most impacted by disparities must have leadership opportunities and a role in the decision-making process–with the weight, support and resources they deserve.

Many institutions have begun creating task forces, committees and diversity efforts staffed by individuals dedicated to intentional change. These take many forms: providing grants to education, writing papers and conducting research, supporting new leaders, elevating voices at all tiers of the system, and fostering a safe and welcoming environment. But these efforts often fall on the shoulders of underrepresented minorities (URMs) and, as a result, creates the “minority tax”—the additional labor and responsibility that comes with equity work.8 Individuals doing this work have tremendous passion for the subject, but because it must be done in conjunction with clinical demands and daily life, diversity and inclusion efforts may often receive a lower priority.

If this education is prioritized by systems and the work shared by non-URMs, it allows more time, freedom and resources to be dedicated to equity efforts. This approach has a trickle-down effect—URMs within systems will feel better represented and better able to speak more confidently and safely on how to enact change. It will open up avenues for a more diverse workforce at all levels of health care, which will resonate with vulnerable populations. When patients are treated by someone who looks like them, speaks like them and understands the realities of their experiences, it will create deeper levels of trust—which will result in better patient care.

Continue the conversation

Listen to Dr. Rochon discuss implicit bias, the minority tax and tackling disparities on ep. 13 of The Kinked Wire.

SIR believes that success draws strength not just from the clinical expertise of physicians but from the diversity of their backgrounds and experiences as individuals. Learn more about SIR’s commitment to diversity and inclusion (D&I) and view the SA-CME-accredited D&I module at sirweb.org/member-central/diversityinclusiveness.

References

  1. Centers for Disease Control and Prevention. CDC COVID Data Tracker. cdc.gov/covid-data-tracker/index.html#demographics. Accessed Aug. 19, 2020.
  2. Centers for Disease Control and Prevention. Health equity considerations and racial and ethnic minority groups. cdc.gov/coronavirus/2019-ncov/community/health-equity/race-ethnicity.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fneed-extra-precautions%2Fracial-ethnic-minorities.html. Published 2020.
  3. Bui DP, McCaffrey K, Friedrichs M, et al. Racial and ethnic disparities among COVID-19 cases in workplace outbreaks by industry Sector — Utah, March 6–June 5, 2020. MMWR Morb Mortal Wkly Rep. ePub: dx.doi.org/10.15585/mmwr.mm6933e3.
  4. Killerby ME, Link-Gelles R, Haight SC, et al. Characteristics associated with hospitalization among patients with COVID-19 — Metropolitan Atlanta, Georgia, March–April 2020. MMWR Morb Mortal Wkly Rep. 2020;69:790–794. dx.doi.org/10.15585/mmwr.mm6925e1external icon
  5. COVID-19 Health Equity Response Team. https://covid19.colorado.gov/covid-19-in-colorado/health-equity-response-team. Accessed Aug. 19, 2020
  6. Villarosa L. Why America's Black mothers and babies are in a life-or-death crisis. The New York Times. nytimes.com/2018/04/11/magazine/black-mothers-babies-death-maternal-mortality.html. Published April 11, 2018.
  7. Hall WJ, Chapman MV, Lee KM, et al. Implicit racial/ethnic bias among health care professionals and its influence on health care outcomes: A systematic review. Am J Public Health. 2015;105(12):e60-e76. doi:10.2105/AJPH.2015.302903
  8. Rodríguez, J.E., Campbell, K.M. & Pololi, L.H. Addressing disparities in academic medicine: what of the minority tax? BMC Med Educ15, 6 (2015). doi.org/10.1186/s12909-015-0290-9.