Another pandemic shows the effects of discrimination on vulnerable groups
Enid Vázquez @ENIDVAZQUEZPA

‘... it is becoming increasingly evident that COVID-19 is having a particularly ravaging impact on African American, Hispanic or Latinx, and Native American communities.’

The COVID-19 crisis shows once again that good health is not equally available to all, health experts say.

Across the country, African Americans, Latinx, and Native Americans not only have higher rates of COVID-19, but also suffer greater severity of disease and disproportionately more deaths.

“The question is really, Why?” said Damani D. Piggott, MD, PhD.

The LGBTQ community and people with low income are among the many vulnerable communities experiencing worse health outcomes. Historically, these groups suffer from fewer resources. They also face discrimination that too often keeps them from accessing health care.

It’s a challenge—once again, like HIV—to figure out how to protect the people most vulnerable to illness, which in turn will help protect everyone’s health.

“The disparity impact of COVID-19 has placed a truly strong spotlight on longstanding vulnerabilities of key population groups to poor health,” said Dr. Piggott. “And it highlights the [fact that] opportunity to obtain full health potential is still yet to be afforded to all.”

Dr. Piggot, who is Assistant Dean for Graduate Biomedical Education and Graduate Student Diversity and Assistant Professor of Medicine at Johns Hopkins School of Medicine, spoke May 15 on “We Are Not All in This Together—COVID-19 and Communities of Color,” along with Dr. Virginia D. Banks (see sidebar, “We had no idea”). They addressed reporters as part of a series of media briefings on the COVID-19 pandemic held by the Infectious Diseases Society of America (IDSA), an association of physicians, scientists, and public health experts.

“As data continue to emerge, it is becoming increasingly evident that COVID-19 is having a particularly ravaging impact on African American, Hispanic or Latinx, and Native American communities,” Dr. Piggott reported. “Data from the Centers for Disease Control and Prevention as of yesterday show blacks, who make up just about 12% of the U.S. population, comprise 28% of identified COVID-19 cases in the U.S. for which race has been reported. The Hispanic or Latinx community, who make up 18% of the total U.S. population, also constitute 28% of U.S. COVID-19 cases in recent CDC data. There has also been increasing reports of COVID-19 in several Native American communities, including communities such as the Navajo Nation, which is experiencing among the highest per capita rates of COVID-19 across the entire U.S. … Not only is more COVID-19 disease being seen in these communities, these communities are also experiencing more severe disease and more COVID-related death.

“A struggle to achieve health equity as a society really has been imbedded in key social determinants of health: socioeconomic, environmental, and many other key structural conditions in which we’re born, live, work, and age,” Dr. Piggot said, “and these factors include things such as:

•     income

•     employment

•     housing

•     food and water security

•     educational opportunity

•     transportation

•     incarceration

•     access to health systems and services, and

•     multiple other determinants in our social and physical environment that have impacted our health for better or for worse over many generations.”

Dr. Piggott also discussed socioeconomic conditions more common to people of color which contribute to greater problems given the realities of COVID-19. These include high-density housing arrangements, which preclude physical and social distancing.

The same goes for congregate settings, such as jails, prisons, detention centers, and shelters for those with unstable unhousing.

There’s reduced access to medical care and medical insurance. Less access to financial resources also contributes to less health care access.

Language barriers and “other barriers to culturally congruent communication” further hurt access to health care, as well as messages around disease prevention.

Not to mention a lack of trust in institutions that have historically caused harm to vulnerable people.

There are also underlying chronic conditions which are already more common and less controlled in people of color before the arrival of the pandemic, that contribute to greater severity of COVID-19 disease. Chief among them are diabetes, obesity, and heart disease.

Once again, an unequal health background creates an unequal health risk. Social determinants of health, like low income, further add to the excess risk.

Dr. Piggott started his discussion by pointing out the vulnerability that comes from working in essential jobs during a pandemic. Many of these are frontline jobs with low wages and high exposure to others.

Essential workers include any job where someone is being touched, said Lisa A. Cooper, MD, MPH. Dr. Cooper spoke about vulnerable communities in general (see list), in a webinar presented in May by the Center for Health Journalism (CHJ), “Covering Coronavirus: The Pandemic’s Unequal Toll.” Dr. Cooper Director of the Johns Hopkins Center for Health Equity and the Johns Hopkins Urban Health Institute.

“People who are caregivers of disabled people or older people have had to work during this time when everyone is being asked to stay at home or to engage in social distancing,” Dr. Cooper continued. “They’ve had to go out and clean health facilities. They’ve had to drive buses and subway trains. And they’ve had to ride those public transportation options to get back and forth.

“Many of these groups also lack access to health care services—during a regular time. As you can imagine, during this time it’s even harder to access health care services, when a lot of elective care procedures and routine visits are being postponed and people are being asked not to come in for care. So, you have folks who are not having access to regular care being asked to use, for example, telemedicine when they may not have access to broadband internet to be able to do that.

“And then you have an understandable mistrust of institutions and authority because of historical factors, mistreatment in the broader society, discrimination, and also disparities in health care as well as in research,” said Dr. Cooper. “A number of different situations, even current situations, that make people in these communities suspicious of authorities, and so less likely to necessarily follow through on advice without getting it from trusted sources.”

Dr. Cooper, with Joshua M. Sharfstein, also of Johns Hopkins, published a set of action steps for protecting vulnerable communities in the face of COVID-19, appearing on the Politico website in April. Recommended steps include ensuring sick leave and other health benefits, and promoting trust among communities of color.

“One of the things we said is that it’s not going to be enough for us to just use Zoom [for video meetings online] and stay at home,” Dr. Cooper explained. “And we also talk about why it’s important that protecting the most vulnerable in our society is in the interest of all of us.”

Among their other points, they wrote on the need for accurate data on race, ethnicity, and geography. Echoing Dr. Piggott, Dr. Cooper said, “It’s not enough to say African Americans are more at risk, but why? It’s not intrinsic to people being African American that they are being disproportionately impacted. Where are these infections clustering? Is it in certain neighborhoods where there are crowded housing conditions? Or where there’s not enough access to food? Are these neighborhoods where there’s an overrepresentation of multigenerational families or essential workers?

“We talked about the importance of leaders building trust and communicating frequently, authentically, and clearly with communities of color. This is particularly a challenge when leaders are not engaged with the community members who may be the trusted messengers in those communities.”

“These are the groups that experience health disparities even when there’s no pandemic,” Dr. Cooper pointed out. “People not having access to running water, to wash their hands. On the Indian reservations, we’ve heard of that.”

In summing up his talk, Dr. Piggott said, “As we continue to face this major pandemic and consider these factors, it is crucial for us to consider who has opportunity and who does not … who has access and who does not … and how do we close the opportunity and access gaps which spread to every corner of our globe. The virus has already shown us that we are all inextricably connected, and ensuring that everyone has opportunity for maximal health ultimately would be to the benefit of us all.” 

Read the Politico report: politico.com/news/agenda/2020/04/07/game-plan-to-help-those-most-vulnerable-to-covid-19-171863.

Health equity

The state in which everyone has the opportunity to obtain full health potential and no one is disadvantaged from achieving this potential because of their social position or any other socially defined circumstance.

Source: The National Academy of Sciences, Engineering, and Medicine

Vulnerable populations

•     People of color

•     Persons with low income

•     Immigrants

•     Women

•     Children

•     Older adults

•     Homeless or housing insecure

•     Persons with chronic conditions

•     LGBTQ

•     Individuals with special needs

•     Rural and urban residents

•     Persons with low literacy and numeracy

•     Persons in correctional institutions

•     Residents of nursing homes and assisted living facilities

Source: The Agency for Healthcare Research and Quality

‘We had no idea’

When I started my infectious disease fellowship in the late ’70s, somebody came up to me and said, “I don’t know why you’re going into infectious diseases. Everybody knows how to use penicillin and ampicillin.”

Here we are now with a pandemic.

When in the early ’80s, and through the ’90s, I found myself taking care of HIV/AIDS patients and watching them die, those patients were my age.

And here I am now taking care of another group of patients close to my age who are also dying of a viral illness.

I’m on the front line, daily taking care of patients. When we first started taking care of patients coming in with COVID, the large onslaught in Ohio had started about the end of March. And we had heard about the cases that were in Washington state. But I don’t think we had any idea of the impact that it was going to have with us in Northeast Ohio.

There are eight of us in our practice and four nurse practitioners. Many times on the weekends we would all be on call because we had so many patients coming in to the hospital.

Initially we were just trying to take care of patients as fast as we could. As fast as they came through the emergency room, we were just trying to basically keep people alive. Where we saw a grandfather who was bouncing a child on his knee a week before, now coming in a week later on a ventilator, and a week later he had died. This is the impact that this disease has had.

So, we really didn’t step back to look at race, ethnicity, or anything. It wasn’t until really about April that we were now able to catch our breath and step back and look and say, “There’s a disproportionate number of individuals from our society and community that are being heavily impacted with this disease.”

—Virginia D. Banks, MD, MBA, FIDSA,

Fellow and 2019 Watanakunakorn Clinician Award Winner – IDSA, Northeast Ohio Infectious Disease Associates, Youngstown, Ohio