COVID-19 is highlighting health inequalities that span race, ethnicity, and socioeconomic status as emerging data show the disease burden on vulnerable and disadvantaged American populations.
Explore This IssueACEP Now: Vol 39 – No 07 – July 2020
Recent studies show disproportionately high rates of morbidity and mortality across different races. A recent Centers for Disease Control and Prevention report found that Black Americans have been disproportionately hospitalized by COVID-19 compared to other races, and another study found even higher death rates among Black Americans in the major hot spot of New York City.1,2 Another study found that the Latino population had a SARS-CoV-2 positivity rate about three times higher than that seen in other racial/ethnic groups.3 Similar disparities are found in other populations, including undocumented immigrants, the homeless, nursing home residents, and those who are incarcerated. As an Annals of Emergency Medicine editorial stated, “When one further considers that our nation has even more religious, cultural, sexual, gender identity, and other forms of diversity, it is apparent that the magnitude of the opportunity for improvement is enormous.”4
COVID-19 has again made it clear: patient- and public-centered approaches are needed to improve population health, particularly for vulnerable populations. Authorities must balance public health trade-offs, including balancing personal freedom, economic growth, and social unrest. For example, social distancing is the most effective way to slow the spread of the virus, even more than masks.5 But how can we ignore the moral imperatives, let alone health benefits from systemic change that could result from protests after the recent killings of George Floyd in Minneapolis, Breonna Taylor in Louisville, and Ahmaud Arbery in Atlanta? Protesting is risky, but so is not protesting.
Public health interventions need to account for all community types and all needs, both immediate and future. However, our failure to address longstanding disparities around adequate housing and high-density neighborhoods in the past renders today’s policies less equitable. Social distancing was employed as a “one-size-fits-all” national policy. But some communities lack the necessary infrastructure to achieve this or to do it safely. Social distancing might increase COVID-19 exposure in some communities of color rather than protect them from it by displacing individuals from their sparse network of family and friends who often help insure social protection and preserve a person’s well-being.
Even at the individual level, long-standing disparities across communities affect a person’s chances of becoming ill. Some minorities are either in, or close to, the level of poverty that is most immediately and detrimentally impacted by any serious illness episode or economic downturn. Even small setbacks can push people over the poverty line, irrevocably. Statistics show the alarming, disproportionate rates of infection and death in the Black American community despite the best intentions of public health officials.5,6 Have we fully considered the effects of our prior inaction? To solve these complex problems, how can we make new policy and formulate new solutions?
Partnerships between hospitals, community organizations, and local establishments are important. With sufficient coordination, public policy can use evidence-based strategies to reduce COVID-19 health disparities in high-risk populations while accounting for social determinants of health. National and state health equity task forces should bridge the gap between services being provided and public health interventions being implemented for those living in higher risk communities.
For communities, testing and contact tracing are a necessary first step. With knowledge of those at highest risk, the COVID-19 spread can then be more easily contained and appropriately targeted. For example, drive-through testing cannot apply to many low-income individuals who don’t have access to vehicles. Instead, testing sites should be deployed to zip codes with high infectivity rates. We also need to consider how to isolate people who are already living “at capacity” in tight spaces. Otherwise, what’s the point?
Hospitals have the ethical obligation of allocating scarce resources towards those individuals in greatest need. Often, patients confined to small spaces and living quarters—including homeless shelters—are most vulnerable to the infectious spread of respiratory illness and failure to properly social distance. Even basic interventions like educating the underserved with better techniques for handwashing, social distancing, and physical protection will go a long way. The electronic medical record system should be used more effectively, too, by linking patient addresses to neighborhood data so that disparities are minimized, whether it’s finding the closest pharmacy or building a more targeted discharge plan.
Knowledge needs translated into meaningful practice with use of better outreach programs and technology. We can direct funding and expand social work programs plus community dissemination of basic supplies (such as hygiene kits) to ensure that the uninsured have equal access to life-saving measures.
Moving forward, research, assessment of existing ED interventions, and new ideas will be integral for proper resource allocation and population health. As states only recently began to release more race/ethnicity data timed with states reopening, we need to be completely transparent with this data at the state level, identify hot spots, and move appropriate mitigation strategies to these areas. Our ability to do this will help address some of the immediate aspects of health inequalities exposed or exacerbated by COVID-19.