A Pandemic of Health Care Inequities

A Pandemic of Health Care Inequities “The familiar dictum that ‘prevention is the best medicine’ needs to be the focus when treating patients of color”

BY SHAZIYA BARKAT

Trayvon Martin. George Floyd. Breonna Taylor. Ahmed Arbery. These are just a few of the names that have ignited Black Lives Matter (BLM), an activist movement that promotes public consciousness about police killings of unarmed African Americans.

While BLM has sparked nationwide protests calling for the end of race-based discrimination, its concurrent nature with the Covid-19 pandemic has sparked conversations about barriers that prevent racial minorities from accessing optimal health care services. Thousands have joined the #WhiteCoatsForBlackLives movement, which calls for action to eliminate these inequities.

Health care inequities may be defined as avoidable and unjust inequalities that lead to worse health for disadvantaged social groups such as the poor, the disabled, women, and racial and ethnic minorities. Latinx, Native Americans and Asian Americans have predominantly been classified as underserved populations within our country’s health care system, with African Americans being at the top of the list.

The existing gaps have been amplified even more during this pandemic. According to the Covid-19 Tracking Project (https:// covidtracking.com/), infection rates are 2.5 times higher and deaths are 1.7 times higher among people of color than they are for Whites. Blacks, who make up about 13% of the population, account for at least 22% of all Covid-19 deaths where the deceased’s race is known.

The Washington Post poll published on June 26, 2020, stated that nearly onethird of African Americans report that they personally know someone who has died of Covid-19. In addition, more than half of all Blacks state that they know someone who has either had or died from Covid-19; less than 40% of Whites stated the same. While testing is crucial to reducing Covid-19 infection rates, Black patients are currently six times more likely to receive less testing than White patients.

Unfortunately, such realities are nothing new. Consider the following facts: On average, Blacks live six years less than Whites. Racial minorities account for more chronic medical conditions than others, putting them at higher risk of developing severe illnesses from Covid-19. The Centers for Disease Control and Prevention reports that Blacks suffer from chronic health conditions like asthma and diabetes significantly more than Whites do.

A Black woman is 22% more likely to die from heart disease than a White woman. Black infant mortality rates are twice the national average, with Black women dying three times more during childbirth than White women. As someone who works with cancer patients, it’s heartbreaking to see that Blacks have the highest mortality rate for all cancers combined when compared to any other racial and ethnic group.

Some barriers that contribute to these inequities include the limited access to necessary resources, such as food and housing, as well as a predominant history of systemic racism and unequal treatment of minorities.

Even work environments play a part. According to the Bureau of Labor Statistics, more Black than White workers cannot work remotely during the pandemic. Minorities are also more predominant in high-risk environments, such as meatpacking plants, where Covid-19 rates are higher than those in 75% of U.S. counties (https://www.epi.org/ publication/black-workers-covid/).

The increased unemployment rates have become a barrier to obtaining proper care as well. A Gallop study said that 1 in 7 individuals in the U.S. reported that they would not seek treatment due to the cost (https:// news.gallup.com/poll/309224/avoid-carelikely-covid-due-cost.aspx, April 28, 2020). According to the U.S. Census Bureau, in 2017 10.6% of Blacks were uninsured, compared to 5.9% of non-Hispanic Whites.

An analysis conducted by FAIR Health found that insured patients hospitalized with coronavirus can expect to pay up to $38,000 for their stay, while the uninsured may pay up to $74,000. However, even after controlling for insurance coverage, employment, age, gender, marital status and residence region, African Americans have worse health outcomes in nearly every illness category.

Medical education teaches that prevention is the best medicine. This is why the health care professionals’ ultimate responsibility is to fight systemic and individual racism, address the inequalities and close the existing gaps in patient care. Ultimately, this begins in the classroom, long before we even step into the world with our embroidered white coats.

Unfortunately, many medical schools’ curriculums lack the context of race in

OUR METHODS OF TEACHING WERE UNFAIRLY

DISADVANTAGING AND ‘OTHERING’ STUDENTS

FROM BLACK AND MINORITY ETHNIC GROUPS,”

TAMONY TOLD THE WASHINGTON POST. “THE OTHER ISSUE IS ONE OF PATIENT SAFETY. ARE WE

ADEQUATELY TRAINING OUR STUDENTS TO BE

COMPETENT HEALTH-CARE PROFESSIONALS

WHO CAN DETECT IMPORTANT CLINICAL SIGNS IN ALL PATIENT GROUPS?”

medicine. “I noticed a lack of teaching about darker skin tones, and how certain symptoms appear differently in those who aren’t white,” reports Malone Mukwende (Washington Post, July 22, 2020). Mukewende, a 20-yearold medical student at the University of London, along with Peter Tamony, a London University lecturer, and Margot Turner, have published a handbook called “Mind the gap: A handbook of clinical signs in Black and Brown skin” to address this absence (https:// doi.org/10.24376/rd.sgul.12769988.v1).

Mukewende explains: “The booklet addresses many issues that have been further exacerbated during the COVID-19 pandemic, such as families being asked if potential COVID-19 patients are ‘pale’ or if their lips ‘turned blue.’ These are not useful descriptions for a black patient and, as a result, their care is compromised from the first point of contact. It is essential we begin to educate others so they are aware of such differences and the power of clinical language we currently use.”

“Our methods of teaching were unfairly disadvantaging and ‘othering’ students from black and minority ethnic groups,” Tamony told the Washington Post. “The other issue is one of patient safety. Are we adequately training our students to be competent healthcare professionals who can detect important clinical signs in all patient groups?”

The lack of context in terms of race in medical curriculum may also be partially due to the lack of diversity in medical schools, which forestalls much-needed conversations. According to the Association of American Medical Colleges, only 8.4% of applicants to U.S. medical schools in the 2018-19 academic year were African American. Of the 7.1% who were accepted, only 6.2% graduated (1,238 out of more than 19,900 medical school graduates). This number also plays into the workforce — only 5% of active physicians are African American.

Moving forward, we must provide better health care for racial minorities, and current efforts should focus on doing so. To control Covid-19 in these populations, effective testing, contract tracing, quarantine and treatment are needed. Testing must be free with no prescription required to allow the uninsured to gain access to it. Clinics must be widespread to provide testing for underserved communities, which means that we must have a sufficient amount of personal protective equipment to keep these clinics safe and open. Funding for accurate and rapid test results are crucial.

Contact tracing is vital to lowering Covid-19 rates in underserved communities. To realize this goal, we must overcome language barriers for non-English speakers, develop cultural competence to better empathize with our patients and develop patient-centered care plans.

In addition, quarantine is much more difficult to achieve for individuals who live in small and shared housing arrangements. For example, a Public Policy Institute of California study found that 18.4% of Latinos live in overcrowded spaces compared to 2.4% of Whites (https://www.ppic.org/blog/ overcrowded-housing-and-covid-19-riskamong-essential-workers/). The barrier to accessing free space to self-isolate can contribute to the higher rates of Covid-19 in this population. Sufficient funding must be directed toward making empty, temporary housing available to those who need to self-isolate. For those who stay home, we must increase our efforts to provide support for grocery and medication delivery services.

The federal government must ensure that uninsured patients have access to the proper Covid-19 care that they need. Some insurance companies have already altered health insurance plans to cover this treatment. For example, Blue Cross and Blue Shield companies have waived cost sharing for Covid-19 care for now. It’s crucial to have these services covered for as long as the pandemic continues to plague our country. Lastly, whenever the medical community develops a vaccine — hopefully in the near future — it must be distributed equitably and made accessible to all communities.

The ongoing protests over the murders of Trayvon Martin, George Floyd, Breonna Taylor, and Ahmed Arbery shed light on the systemic racism that contributes to the health care inequities that have plagued the country for so long. The current crisis only stresses the failings within our health care system. As we continue, the federal government, public health experts and health care systems must create solid plans to address inequities and provide truly equal, accessible health care for all. ih

Shaziya Barkat, PharmD, an inpatient bone marrow transplant pharmacist at Memorial Sloan Kettering Cancer Center in New York, is also the author of “knowing You” (2019).

Coping with Covid-19 ■ Do all that you can to put your life in order. For example, update your will to include a clear statement of your assets How to deal with the challenges of the pandemic and liabilities, bank accounts, investments and businesses. Identify the guardian and now, pulse oximeter readings help doctors call for patients to be hospitalized if their patients’ plasma with antibodies can be used to boost the immune system. executor of your will, especially in terms BY M. BASHEER AHMED of who is responsible for making the usual end-of-life decisions. ■ Accept that fear, worry and uncertainty about your health and that of your loved ones are normal. We all experience anxiety and sadness at some point in our lives, and most of us are experiencing these now. Be aware of the signs of stress so you can act or consult a health care provider. Talking to those you trust helps reduce feelings of isolation, anxiety, fear, boredom and/or vulnerability while practicing social distancing, quarantine and other safety measures. This pandemic reminds us that we are all equal, regardless of our culture, religion, occupation, financial or social status. By being “locked in,” we have developed a sense of supernatural control over our lives as well as oppression. The current restrictions placed on our daily lives should make us aware of

Living through such a widespread PROTECTING YOURSELF AND OTHERS every single day. In addition, they should also pandemic as Covid-19 understandably The Center for Disease Control (CDC) force us to realize our own powerlessness induces feelings of helplessness, depres- has listed ways to protect oneself and cause us to become humbler, sion, anger, stress and anxiety within and others from Covid-19. because a single virus really can a huge number of people. The numbers of ■ Share accurate infor- make this world stand still. people who have lost their jobs, careers and/ mation and your feelings Our reaction to Covidor savings continue to grow, as do incidents with trusted friends, for 19 is a sign of humanity’s of domestic violence, child abuse and nega- doing so will help them smallness and vulnerabiltive and/or self-harming behaviors. feel less stressed. Arrange ity. We should hope that in

We now know more about Covid-19 than video calls with family and addition to making us feel we did in March 2020. For example, the virus friends. Talk with your chil- afraid and unsure, it is also causes blood clots in the lungs, which causes dren calmly and confidently making us more pragmatic and reduced oxygenation. Aspirin and blood about the pandemic and reassure open-minded, sensible, compasthinners are now being used to prevent clot- them that they are safe. When schools sionate and understanding. We should ting. Patients showed no symptoms until are closed, create a schedule of both learning maintain a sense of hope and seek to improve the oxygen saturation level sank below 70%; and fun activities. our sense of control and endurance. oxygen saturation drops to 93% or less. As THE CURRENT RESTRICTIONS PLACED ON OUR a result, they have more time to correct the oxygen deficiency without using ventilators. Remdesivir and other antiviral medicaDAILY LIVES SHOULD MAKE US AWARE OF HOW MILLIONS OF PEOPLE AROUND THE WORLD tions can prevent Covid-19 patients from LIVE EVERY SINGLE DAY. IN ADDITION, THEY becoming severely ill. Some of these people die because their immune system responds SHOULD ALSO FORCE US REALIZE OUR OWN in an exaggerated manner — a cytokine POWERLESSNESS AND CAUSE US TO BECOME storm — that can be prevented by using steroids. HUMBLER, BECAUSE A SINGLE VIRUS REALLY CAN

Research has shown that other infected MAKE THIS WORLD STAND STILL. how millions of people around the world live