During the COVID-19 pandemic, Black and Latino populations showed the largest spike in hospitalizations and deaths, with African Americans becoming infected with and dying from the coronavirus at a rate more than 1.5 times that of the rest of the population, according to the COVID Tracking Project. In the bigger healthcare picture, the pandemic has shone a light on a problem that has been endemic to healthcare for decades: inequities in care for people of color.
The challenge for healthcare organizations in the wake of COVID-19 is to take steps to narrow the gaps in care, in part by building awareness among themselves, as well as among the populations that have suffered from these inequities.
In his podcast, SOAP Notes with Dr. Jay LaBine, naviHealth’s chief medical officer regularly speaks with experts from various areas of healthcare about vital issues affecting the industry, particularly post-acute and senior care. Several recent episodes have touched on disparities, their root causes and what can be done about them.
Certain underlying conditions make people of color more susceptible not only to the coronavirus but also to other potentially life-threatening conditions such as heart disease, heart attack or stroke and dementia.
“If you’re a minority, you’re much more likely to have hypertension, diabetes, obesity and so on. It was predicted and predictable that African Americans would bear the brunt of COVID-19,” Dr. James E.K. Hildreth, an immunologist and president and CEO of Meharry Medical College in Nashville, Tennessee, told Dr. LaBine. “Unfortunately, this is not a new problem.”
Few things, however, could highlight these inequities as the pandemic has, Dr. Hildreth said, adding that they are a reflection of social determinants of health (SDOH). “A fraction of it is determined by access to doctors and healthcare. Most of it is determined by behavior and where you live.”
Hildreth said that managing chronic conditions must be part of the overall approach to health, but so must efforts to ensure that people don’t acquire those conditions in the first place. And addressing SDOH is essential to those efforts.
ZIP code and SDOH
Hildreth and LaBine cited David R. Williams, Ph.D., M.P.H., of Harvard University, in discussing ways in which the ZIP code where someone lives and works can make it challenging to avoid the virus (and get the proper treatment for it). Dr. Williams, who is internationally recognized for his studies of social influences on health, has called people’s ZIP code a more powerful predictor of their health than their genetic code.
A study of two ZIP codes in Washington, D.C., revealed a 10-year difference in the average life expectancy of white males versus black males, Dr. Hildreth said. “ZIP code determines whether there are parks, places to walk and exercise, access to grocery stores with fresh vegetables. A lot of these social determinants of health are illustrated quite dramatically by ZIP codes.”
Housing conditions, type of job worked, income and educational level are also factors that fall under SDOH.
Vaccine hesitancy is also an issue for racial and ethnic groups, who share a disproportionate mistrust of medical researchers. This is partly because of such previously sanctioned abuses in the United States as the infamous Tuskegee syphilis study, which over four decades enlisted hundreds of Black men who were misled about the treatment they would (or, more accurately, would not) receive; and the involuntary sterilization of people of color, immigrants, the disabled and other “undesirable” populations.
“The issue of hesitancy is complicated,” said Dr. Vincent Mor, professor of health services, policy and practice at Brown University, which is conducting a trial in four nursing home companies to identify opinion leaders, both formal and informal, to assess nursing home workers’ attitudes toward vaccination. “Some people are saying now that hesitancy is because people have inadequate information,” Dr. Mor said. “It’s not that they believe in conspiracy theories. … There is lots of misinformation in all sorts of places.”
Hildreth recommended three steps for overcoming distrust:
- Acknowledge that there is a basis for distrust.
- Identify the main questions and try to find the answers.
- Get people who are respected and trusted to communicate the answers to the communities.
Alleviating the inequities
Creating a more equitable healthcare environment in the United States will require action on multiple fronts involving healthcare workers and executives; federal and state legislators; businesses, nonprofits and community leaders; and individuals.
This is no doubt the greatest challenge because it covers so many fundamental aspects of life. But every little bit helps, and progress can be made through efforts such as food banks that provide individuals and families with fresh fruits and vegetables; transportation to doctor’s appointments; affordable housing; and more thoughtful city planning.
The Association of American Medical Colleges (AAMC) is working with medical schools to educate medical students on the importance of SDOH, Dr. Hildreth said. “At Meharry Medical College, probably by necessity, we have been more focused on these than some other places have been. I’m very proud that 80% of our graduates practice in underserved areas when they leave us, most of those as primary care doctors.”
He added that connecting the business of medicine to the impact of SDOH was crucial. “Paying for social services of those sorts will reduce the overall cost to us,” he said. “We are spending $3.5 trillion a year on healthcare, but we’re not among the top 10 healthiest nations. That’s not a good thing. We need to spend more on social determinants of health.”
Targeted outreach through trusted messengers: At-risk populations must be targeted with communications via messengers who can engage and rebuild credibility with them.
More minority physicians: “Patients feel more confident when they are able to be treated by, or at least see, someone who looks like them,” Dr. Hildreth said.
A diverse workforce: “From a UnitedHealth Group perspective, we’re working really hard to ensure that we have inclusive and diverse perspectives,” Kristy Duffey, MS, APRN – BC, FAAN, chief nursing officer at Optum, told Dr. LaBine. “And I think it all starts with your workforce: having a diverse workforce, having diverse leadership and also focusing on the training. People of color have different needs and care gaps than others,” Duffey said.
“Some real changes are happening on both sides of the equation: those who are providing the care and those who are receiving it,” Dr. Hildreth said. “But we still have a long way to go.”
Tune in to episode 2 of SOAP Notes featuring Dr. Jay LaBine with Dr. James E.K. Hildreth