Editors’ Note: This article was accepted on April 13, 2020, and was accurate at that time. Because information about SARS-CoV-2 and COVID-19 is evolving rapidly, please verify these recommendations and information.
Explore This IssueACEP Now: Vol 39 – No 05 – May 2020
The state of emergency was issued on March 12, 2020, in New York. All nonessential businesses were forced to work from home or shut down, and schools closed while implementing remote learning plans. As an emergency physician, I knew our duty was the same. Immediately our colleagues from near and far braced, with personal protective equipment (PPE) or not, to tackle the invisible perpetrator that assaulted lungs and closed eyes indefinitely. They say hindsight is 20/20, but somehow seeing the devastation in China and Italy was not foresight enough. As of this writing, it is April 2020, and in the United States hot zones, more patients are diagnosed, are admitted, require ventilators, and die every day. This is the new reality in America 2020—but for some, nothing has changed.
Pandemic with an Unequal Toll
Underrepresented minorities have always lacked access to health care and suffered the worst health care outcomes in the United States—and the COVID-19 pandemic is no different. As a black woman from New York City, I have many friends’ parents, childhood neighbors, and 40-year-old cousins who have died from COVID-19. The question is why?
Novel coronavirus (SARS-CoV-2) risk factors include obesity, lung disease, diabetes, hypertension, and other immune-compromising diseases. Minorities in the United States disproportionately have higher rates of all these comorbidities. We were taught this in medical school and residency, so we should be able to better identify and treat these patients, but the reality is we have not. COVID-19 makes that clearer than ever.
Data from Johns Hopkins University reveals that African Americans are three times more likely to contract SARS-CoV-2 and six times more likely to die from COVID-19 than any other racial group.1
Of course, comorbidities play a role but are not the only factors. Social factors and practitioner bias add to these glaring disparities. Mandating that citizens social distance is great—if you have space to distance. Have you ever lived in “the projects,” high rise apartments with more than five families on each floor of a 10-floor building? How are you able to go outside for fresh air at a distance of six feet? Have you lived with three generations in one household? How can you quarantine from elderly loved ones? Have you had a kidney transplant, like my husband’s mother, but have to take public transportation to work every day because you are an essential health care employee? Have you ever had your physical complaints minimized because of false beliefs of how African Americans perceive pain?
If it sounds like I’m getting personal, it’s because I am. The practice of medicine is personal, and the relationship between doctor and patient is confidential and protected. Similarly, medical outcomes of increased health disparities across race and increased mortality rates are personal to every friend and family member of mine who has lost a loved one this week.
We Can Do Better
So what can we do about this? Increasing health literacy in the African American community is crucial to helping patients understand and manage their hypertension, diabetes, asthma, and other chronic medical conditions. This is challenging in part because of the history of medical distrust in the African American community. From Dr. J. Marion Sims’s gynecological subjects to the Tuskegee Syphilis Study, our history of medical racism enforces patient bias. This discourages some African Americans from seeking and complying with the care they need. Thus, the terrible cycle continues because the lack of appropriate medical care will lead to more disease and death. Training a higher percentage of diverse physicians is one method to build trust within the black community. Currently African Americans make up 4 percent of U.S. physicians, a number that has remained the same since the 1960s. A diverse physician workforce that mirrors the population cared for by physicians will positively affect patient health literacy and medical compliance within minority communities.
Emergency medicine has the perfect platform to engage apathetic patients who eventually seek care due to the severity of disease or lack of access to primary health care. As emergency departments work within accountable care organizations, the emergency visit can serve as the entry point to primary care, case management, and community resources via electronic health records and meaningful use. Health informatics can help clinical care at the emergency department bedside by giving access to the patient’s complete health record. Interoperability of health information can incorporate primary caregivers, specialists, and case managers to better serve patients. Health informatics also gives data that can be analyzed to better serve at-risk health populations via public health initiatives. Public health resources can help address overcrowded housing, access to healthy foods, personal health literacy, and other social determinants of health.
Addressing patient bias may be an obvious method to decrease health disparities; however, practitioner bias may not be so apparent. Practitioner prejudice is based on our personal histories and subconscious preferences that affect our medical decision making. Doctors’ decisions about cardiac catheterization versus thrombolysis, pain management in renal colic, and offering knee replacements are influenced by physician implicit bias against black patients. Uncovering our own physician bias with implicit association testing is critical. However, more research is needed to incorporate implicit bias training in graduate medical education and develop implicit bias CME for physicians in different stages of their careers that is measurable and sustainable.
The COVID-19 pandemic is highlighting the importance of first responders every day. As emergency physicians, we are on the front lines treating and caring for increasing numbers of COVID-19 patients daily. We are also witnessing the effect of health care disparities, one patient at a time. We can be the first responders to health care disparities as well. The National Institute on Minority Health and Health Disparities has issued special notice of the urgent need for research on the impact of the SARS-CoV-2 pandemic within National Institutes of Health–designated health disparity populations. Emergency medicine is uniquely positioned to spearhead health disparity research.
COVID-19 has been the unexpected game changer in 2020. The economy is at a standstill, financial markets are crashing, health care capacity is bursting at its seams, and people across the world are dying. The pandemic is exacerbating health care disparities. How we handle the next pandemic will be determined by many factors, including how we address racial disparities in health care today.
Dr. Baker is emergency department associate director of Our Lady of Lourdes Hospital in Camden, New Jersey.
- Thebault R, Ba Tran A, Williams V. The coronavirus is infecting and killing black Americans at an alarmingly high rate. Washington Post. April 7, 2020. Accessed April 27, 2020.