Health Care After COVID: Racial Disparities Laid Bare
Deidre Johnson spends her days leading a center that provides resources to help Black people in her community overcome health disparities and other societal challenges.
She understands the impact this can have. As a mother of two and a Black woman, Johnson faced discrimination in the hospital when her sons were born and she experienced postpartum preeclampsia, a serious medical condition. She felt her concerns went unheeded and put her life at risk, not unlike tennis superstar Serena Williams, who has publicly shared a similar story about her experience with complications after childbirth.
Stories like Johnson's and Williams' aren't unusual. The ongoing COVID-19 pandemic has simply exacerbated what health experts have worried about for decades. Social inequities and health care discrimination have created a system in which minorities are more likely to have poor health outcomes.
"Sometimes I tell people, we'll be needed as long as racism exists," Johnson said of The Center for African American Health in Denver, where she is CEO and executive director.
The organization, which offers services such as screening events, health education on topics such as diabetes, and now COVID-19 testing through partnerships, serves a clientele that's 70% Black. Most other clients are Hispanic or white.
"Ironically, we share some of those disparities with other communities, so I think we do cast a broad net, but our mission is really how can we close the gap on these persistent health disparities that the African American community has faced," Johnson said.
The issues are no different during the pandemic: People from racial and ethnic minorities are at increased risk of getting sick and dying from COVID-19, according to the U.S. Centers for Disease Control and Prevention.
Discrimination is, of course, one of the problems. Among the many other reasons that people from minority groups are more at-risk of COVID-19 is that they are more likely to do essential work, so they have more exposure to the virus.
Health care access is another issue, whether it's because minorities are less likely to be insured or may also experience lack of transportation, lack of child care or the inability to take time off work. There's also mistrust of the medical establishment because of historical mistreatment.
Doctors on the forefront
In position papers published last week in the Annals of Internal Medicine, the American College of Physicians (ACP) highlighted those same issues in what it called a "comprehensive framework to address disparities and discrimination in health care."
"There are clearly things that need to be addressed, and between the COVID pandemic and the race issues that we dealt with this year, that just made this all very front and center," said Dr. Jacqueline Fincher, incoming president for the ACP.
The ACP's effort to highlight the problem was an expansion on previous policy and an answer to "a call from our members to look more closely at many of these things and address them in whatever way we could because, bottom line, all these things were impacting our patients," Fincher said.
Fincher highlighted some of the key recommended solutions for addressing disparities, including that there needs to be a more diverse physician workforce.
One way to accomplish that is to identify students who are interested in medicine, give them the tools they need to study and do well in school, and guidance for what they're going to need to go to college, Fincher said. It's similar to addressing the question of how to recruit doctors to rural areas, where the answer is to recruit students from rural areas to be doctors, she said.
"Medicine for so long was only white males, or mostly. Women now represent half of all medical students and soon will represent half of all residents. And within a decade, maybe 15 years, we're going to be close to half of all the practicing doctors," Fincher said. "It's that same sense. We need our physician workforce to look like our country, and because we know that people who are from those backgrounds are more likely to go back to those communities and serve as physicians and help improve the health care of those communities."
The ACP papers include policy recommendations to address issues that affect: the health and health care of specific populations; education and the physician workforce; and law enforcement and criminal justice. Recommendations range from policy changes to addressing social drivers of health, such as poverty, improving access to care and eliminating disparities in maternal mortality.
Differences in care, outcomes
The COVID Racial Data Tracker, which is a collaboration between The Atlantic's COVID Tracking Project and the Boston University Center for Antiracist Research, reports that Black people have died from COVID-19 at 1.6 times the rate of white people, with 139 deaths per 100,000.
Numerous studies have highlighted the disparities for minority groups and COVID-19. Dr. Osagie Ebekozien and Dr. Shivani Agarwal were recently part of a study published earlier this month in The Journal of Clinical Endocrinology & Metabolism that found Black people with type 1 diabetes and COVID-19 were nearly four times more likely to be hospitalized for a potentially fatal diabetes-related condition.
It could be prevented with the tools to monitor diabetes at home, yet minority patients were less likely to have this equipment, possibly because of insurance restrictions or because providers weren't offering these lifesaving technologies to their patients because of racism or implicit bias, Agarwal said.
This isn't just about diabetes care. It's a systemic issue across many fronts, she said.
"I think we have to change the way we provide care," Agarwal said. "Hospital and medical system policies, we have to align them with efforts that will actually provide the right care to these vulnerable populations and meet them where they are instead of making them meet us where we are. We have to enable access to cutting-edge therapies to these populations, just as we are to every other population."
Racism can exist in interactions with someone or in institutional policies, Ebekozien added. If a health care provider doesn't offer a Spanish interpreter for patients when there are Spanish-speaking patients, that's an institutional policy affecting health outcomes, he said.
These issues can also manifest as internal racism, Ebekozien said.
"Where if I've been treated unjustly and unfairly for a long time, I start to feel inferior. I start to feel less than someone else. I start to accept that's my reality," Ebekozien said.
COVID shots a model for change?
One way to provide equity right now is in vaccine distribution, Ebekozien said.
Vickie Mays, who leads the UCLA BRITE Center for Science, Research, and Policy, also sees equitable vaccine distribution as one of the most immediate answers to the problem.
While workers and residents at long-term care facilities may be prioritized for vaccines, someone from a minority group may be caring for an elderly relative at home because of lack of access to health insurance and income to pay for long-term care. That caregiver must go out to shop for food, creating similar risks for the elderly relative, but hasn't been designated to have the same vaccine priority, Mays explained.
"What can be changed is that we need to redefine not essential workers, but essential work. That's the difference. You want to do it based on risk, not occupation," Mays said.
The BRITE Center recently collaborated with the UCLA Center for Neighborhood Knowledge to create a predictive model to identify Los Angeles County neighborhoods that should get priority help for COVID-19, including vaccines.
The researchers found that lacking a number of social resources contributed to a greater likelihood of getting infected, Mays said.
Among the many issues highlighted in that research, vulnerabilities included the environment. About 53% of Black people, 55% of Latinos and 63% of Cambodians, Hmongs and Laotians in Los Angeles County live in areas that were high-risk for the virus because of high population density, crowded housing and a lack of open space.
Preexisting conditions also played a role. The research found that 73% of Black people live in neighborhoods with high numbers of health conditions, including diabetes and heart disease, as well as obesity, food insecurity and poor overall health.
Longer-term solutions include solving these social issues, Mays said.
"It means making sure that there's equal access to higher education," Mays said. "It's meaning that you want to develop policies that make society actually have higher access around many things: housing, support programs, education, income equity and jobs."
This JAMA Network Viewpoint considers the question of prioritizing some vaccines for racial minorities.
SOURCES: Deidre Johnson, MBA, CEO and executive director, The Center for African American Health, Denver; Jacqueline Fincher, MD, president, American College of Physicians, and physician, Center for Primary Care, Thomson, Ga.; Osagie Ebekozien, MD, MPH, assistant professor, population health, University of Mississippi Medical Center, Jackson, and vice president, Quality Improvement and Population Health, T1D Exchange, Boston; Shivani Agarwal, MD, MPH, assistant professor, department of medicine, Albert Einstein College of Medicine, New York City; Vickie Mays, PhD, MSPH, professor, department of psychology, College of Letters and Sciences and professor, department of health services, University of California, Los Angeles, and director, UCLA BRITE Center for Science, Research & Policy, Los Angeles; Annals of Internal Medicine, Jan. 11, 2021; The Journal of Clinical Endocrinology & Metabolism, Jan. 7, 2021; UCLA Fielding School of Public Health report, Nov. 18, 2020; U.S. Centers for Disease Control and Prevention report, July 24, 2020