COVID-19 Made It Impossible to Ignore Racial Disparities in Health Care. Here's What's Needed for Equity
Three days a week, Philadelphian Wanda Callands woke up hours before the sun. She had to in order to be on time for her job at a local YMCA, where from 4:45 until 11:00 a.m. she was the temperature screener for anyone entering the facility. While her position is not listed as essential by the CDC, she faced the public every day in the midst of the pandemic.
On November 3, 2020, election night, Callands stayed up late as a volunteer at the polls. She thought lack of sleep was the reason she felt under the weather, but in the following days, her symptoms—a cough, chills, and low-grade fever—worsened. A nasal swab test confirmed that she had contracted COVID. For anyone, this would be upsetting, but because Callands is diabetic with a history of heart conditions, the 66-year-old was terrified. She ended up hospitalized due to dangerously low oxygen levels.
"It was a wake-up call, and I've completely changed how I'm living my life now—quit social organizations, grocery stores, shops, it's all changed," Callands tells Health. After four days, she was released from the hospital and finished recovering at home. She is also on leave from her job and wonders if that is where she got COVID. Callands is one of approximately 28 million Americans who has contracted COVID since the virus hit the United States last winter. But because she is African American, her likelihood of getting the illness was higher. According to the CDC, Black, Latinx, and Indigenous Americans are 1.1 to 1.9 times likelier to be infected with COVID-19 than white Americans, and Black people have died at 1.4 times the rate of white people, according to The Atlantic's COVID Tracking Project.
A genetic condition or predisposition does not account for these disproportionate numbers. Instead, the reasons are social and economic. Those who work outside of the home in jobs without paid sick leave—a reality, says the ACLU, experienced more by people of color than white Americans—are at higher risk. Other factors include higher rates of being uninsured among Black, Latinx, and Indigenous people and higher demand—but fewer resources and less access—at COVID testing sites in neighborhoods of color, according to ABC News.
COVID isn't the only illness or condition that disproportionately affects communities of color. Maternal mortality, high blood pressure, and heart disease are three of numerous health conditions that have kept Black life expectancy rates years below that of white Americans. And while this information isn't new, COVID has prompted the media, medical practitioners, and public health experts to more aggressively focus on finding solutions.
"The research has long been established on the connection between racism and health. So I wouldn't say COVID woke the medical community up to the reality of these health disparities," Regina Davis Moss, associate executive director of public health policy and practice for the American Public Health Association, tells Health. "It's more that COVID basically slapped them in the face so they couldn't deny it."
Now, as the pandemic enters its second calendar year and cases (and deaths) continue to skyrocket, more is happening to protect Black and Brown people not only from COVID, but from all race-based health disparities. The Centers for Disease Control (CDC) defines health disparities as "preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by socially disadvantaged populations." The key word in this is "preventable," and, as a growing number of medical experts argue, certain steps can be taken to reduce these disparities, including these outlined below.
In January, President Joe Biden made a historic appointment when he tapped Marcella Nunez-Smith, MD, an associate professor of internal medicine, public health, and management at Yale University, to co-chair the COVID-19 Transition Advisory Board and lead a new White House task force dedicated to health equity.
The task force was inspired by legislation that then-Senator Kamala D. Harris introduced in the Senate in May 2020. According to a fact sheet from Harris on the legislation, the group will "identify and address racial and ethnic disparities in our health care system and improve future infectious disease response."
In Milwaukee, a Black resident's life expectancy is, on average, 14 years shorter than that of a white resident. In response, in 2019, the city became the first in the US to label racism a public health threat. This declaration put racism in the same category as smoking or air pollution because it too has the capacity to shorten life spans. The category change led county officials to develop a racial equity budget tool that requires departments to detail how their budgets affect communities of color. Training programs across municipal departments were also established so employees can better understand how racism impacts public health.
Since 2019, about 150 states, cities, and counties have joined Milwaukee. This includes Chicago, which in 2020 hired a chief sustainability officer to prioritize the city's racial equity goals with its climate goals. In July 2020, DeKalb County (which includes Atlanta) became the first county in Georgia to make the declaration and pledged racial equity training for county employees, policies that center communities of color, and a future study that will help to clarify additional steps. In Kansas City (which made the declaration in 2019), $2 million in pandemic relief aid was not distributed equally across the city, as it once would have been. Instead, more went to Black neighborhoods because they were harder hit by COVID.
Massachusetts Rep. Ayanna Pressley brought the issue to the national stage in September when she introduced the Anti-Racism in Public Health Act, a bill that would create the National Center for Anti-Racism at the CDC. "For far too long, our federal government has failed to recognize and address the structural racism that has devastated Black and Brown communities and denied access to quality health care," Pressley said in a statement about the bill.
"When we talk about achieving health equity, which is how we reduce health disparities, one of the ways is naming racism, calling it out," says Davis Moss. "When you make this declaration, it says that it's a priority issue. We recognize this as an emergency and it requires a rapid response, including funding."
Last summer, months into the pandemic, thousands of Americans took to the street to protest in support of Black Lives Matter following the videotaped police killing of George Floyd. It seemed that after centuries of racism, people regardless of race could recognize that race-based inequality exists—and they felt their voices could be used to demand change.
This change can be achieved by voting, joining community boards, and attending town council meetings. "Speak up when you see that people are treated wrong," Venis Wilder, MD, a family practitioner and medical activist in Ft. Lauderdale, tells Health. "And make sure that there's representation across the board. If you're a part of a community where there are large pockets of people that don't look like the people making decisions, say and do something about that."
The public can also help by supporting local organizations and religious centers that partner with medical providers to assist communities. These include places like one of more than 50 Black barbershops in Los Angeles County that offer blood pressure testing for customers. The program—which began in 2015—has shown that the men who use it have had significant improvement with high blood pressure. In New York City, health workers visited Black barbershops as part of a community program and signed men up to receive information and screening for colorectal cancer, another illness that disproportionately affects Black people. Black beauty salons across the nation are also offering high blood pressure screening and hosting talks with public health workers to inform and assist clients.
Churches are another place where community outreach can happen. Project CHURCH (Creating a Higher Understanding of Cancer Research and Community Health) is a partnership between The University of Texas MD Anderson Cancer Center and Black churches in Houston. Throughout the United States, Black churches have been hosting mental health experts during the pandemic to talk about depression and coping strategies with their congregations.
Supporting these organizations can include everything from giving them your business (say, getting a haircut) to monetary donations to keep these programs going.
Life expectancy increases significantly when people get preventative care, through annual exams and screenings like mammograms. Yet researchers found that Americans only use preventative care measures at half of the suggested rate because of high costs for visits and treatments. For Black, Latinx, and Native Americans, that number is significantly lower—which is not surprising, considering that 75% of white Americans had private health insurance in 2017, compared to 55% of African Americans, 51% of Native Americans, and 49% of Latinx, according to the US Department of Health and Human Services.
"A more equitable health care system is only possible with better preventative care," Shyvon Paul, a nurse practitioner in New York City, tells Health. So Paul and a collective of 10 doctors, nurses, and licensed clinical social workers formed Healthcare for the People in New York City last fall. "Black and Brown people already had difficulty accessing health care—and then coronavirus swept across the country and killed a lot of Black and Brown people," she says. "We saw this disparity even more vividly with the coronavirus and decided to deliver free health care."
Every Saturday since September, Healthcare for the People pitches a tent in Brooklyn's Prospect Park and provides hundreds of people with preventive care—including HIV tests, blood pressure readings, glucose monitoring, and acupuncture as well as information on where to get tested for COVID to anyone who comes.
Healthcare for the People has joined a growing number of similar volunteer-led free health clinics focused on reducing health disparities. These include the Black Doctors Consortium in Philadelphia. Formed as a mobile testing unit for the neighborhoods hardest hit by COVID, it opened a vaccination site for city residents in January.
Al-Shifa Clinic in Fridley, Minnesota (a part of the Islamic Center of Minnesota but open to the public) is staffed by volunteers and provides services on the weekend including labs, X-rays, preventative care, and treatment for various illnesses. Since 2007, AccessOC, in California's Orange County, provides free low-risk surgeries to lower-income, uninsured patients through a staff of medical volunteers.
While Healthcare for the People was inspired by the belief that care should be free, professor Marshall Chin argues that there are financial solutions that can work within the current system. Chin, who is the Richard Parrillo Family Professor of Healthcare Ethics at the University of Chicago, says that health disparities can be reduced if providers are given incentives to do so. "Money is such a large part of what drives actions," Chin tells Health. "The idea is to align payments so that providing the best possible care—for everyone—will be supported." In other words, he wants a business model to be applied to this social problem.
One way to provide these incentives is to pay for proven performance. "If a clinic or a hospital has outcomes which show that they've decreased disparities, we will reward them with more funding," says Chin. The second is to allocate money to organizations to pay for interventions shown to reduce disparities. In the past, Chin has overseen grants used to improve the rates of dental care in Oregon and postpartum care in New York City.
When Karen Good-Marable relocated to majority-Black Atlanta, she made a conscious choice to find Black physicians. "I like the idea of seeing a doctor who looks like me. And I hate the narrative that Black people don't have faith in the medical community… actually, Black people have been hurt on a lot of fronts by the medical community," the writer and editor tells Health. Now she has a Black dentist, gynecologist, and general practitioner. "I feel like they see me, and they know I am human," she says.
Good-Marable's desire to have physicians of her own race is not unusual. A recent poll by the Kaiser Family Foundation and ESPN's The Undefeated found that only six in 10 Black adults trust doctors to do what is right (compared with eight in 10 white respondents). And one in five of the Black people polled said they were treated unfairly because of race in a medical situation in the past year. For this reason, many seek doctors of their own race.
"The assumption is that their experience in the world is similar to your own," says Dr. Wilder, who adds that many of her patients have told her they're happy to see someone who is Black like them. "Not having to explain yourself, your culture, or your beliefs to someone is in many ways priceless. There's already a synergy that builds trust, and patients are more likely to reveal information they wouldn't have to someone they don't trust. Or they're more willing to take information in a different way. It helps on many different levels with overall outcomes."
Not only does it make for better patients, but it seems to make doctors better doctors. A 2018 Stanford University study found that when Black patients saw Black doctors, the doctors were more likely to call for preventative tests than were non-White doctors, take detailed notes, and engage with their patients. Researchers estimated that the mortality gap between white and Black men due to heart disease could be cut by 19% by seeing doctors of the same race.
Getting a doctor of your own race is, in some ways, a Band-Aid solution to the much larger problem: physicians not providing equal care to all their patients. "When those who are supposed to be helping you in order to get you well, when their ignorance gets in the way of your well-being, that's a huge [obstacle]," says Wilder.
Seeing physicians of your own race if you're a person of color is also often unrealistic, since most doctors are white. According to the Association of American Medical Colleges (AAMC), in 2018, white doctors make up 56% of physicians in the United States, Asian doctors comprise 17%, Latinx are 6%, and Black are 5%. Hoping to change these numbers, medical schools across the nation have been actively working to recruit a more diverse student body and faculty. The AAMC reported increases of more than 8% in Black, Latinx, and Native American first-year medical students in 2020.
Dr. Wilder believes all doctors should receive anti-bias training in medical school and throughout their careers. "One of the things about racism, a lot of it is unconscious. I don't think most people say, 'Oh, I don't like this type of person.' A lot of times it's lazy thinking, like this is the way that you grew up and your default is to behave in this manner—but [training] can pivot you to think in other ways," she says.
Dr. Wilder's wish about mandatory training has happened—to a degree. As part of their core curriculum, medical schools now require courses on intercultural communication, also known as cultural competency. Yet instructors at Harvard Medical School stress that beyond cultural competency, what is needed is "cultural humility," which emphasizes self-awareness when treating patients of a different culture.
Medical school curriculums are just one example of efforts being undertaken to intentionally reduce bias. It is, experts agree, a step in the right direction. Says Dr. Wilder, "It is the responsibility of the system to acknowledge, not just through research, but also practice, ways to change the dynamics."
What will make the difference is ensuring that these efforts are only the beginning. Declarations that racism is a public health crisis must provide more than lip service to the problem; clinics offering free care should not have to rely on the volunteer services of physicians and nurses who are already taxed by their regular jobs. Public health expert Davis Moss believes this is possible: "[The medical community] has come to realize that racism is more deep-rooted and institutional," she says. "Before it used to be like, 'Oh, we'll just do a little training,' but we've realized that it's going to take much more than that." With the backing of the White House and the awareness of experts and physicians across the nation, reducing race-based disparities appears to have taken a top spot on the new public health agenda.
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