I was recently asked to reflect on “What is ‘fair’ to our patient populations?” as part of a discussion in my medical school’s COVID-19 Elective. I answered, “Transparency.” Data transparency is what is fair for our patients during this pandemic. Unfortunately, many institutions have failed to publish critical numbers about the social identities, particularly race and ethnicity, of the people who are becoming infected with and eventually dying from COVID-19.
In medicine, we are gatekeepers of specialized knowledge and resources. All of us, once part of this profession, are privileged in our education and standing in society. In normal times, it is our job to interpret our knowledge in the context of each patient we encounter, and then decide which resources
will best serve those patients. With this new virus, our role as gatekeepers and educators has become even more difficult. We lack the resources to protect ourselves and our colleagues from this disease and we are shepherding newly evolving knowledge. There are many unknowns in this pandemic. Although we are working to treat and cure this disease in our patients, uncertainties abound around which treatments will be successful.
We know that certain populations are at higher risk of severe disease. Throughout the country, cities, counties, and states have reported that non-White minorities are sickened, hospitalized, and killed at higher rates by COVID-19 compared with White patients. Before this evidence existed, many medical, public health, and societal scholars predicted that this would be the course of the pandemic, particularly in black communities. They were chillingly prescient in their hypotheses. The first disparities were noted in access to testing. Next, it became apparent that communities of color were disproportionately left out of working from home as many are members of service industries, and their work cannot be performed remotely. Now, these pandemic disparities are compounding well-documented health inequity experienced by non-white minorities. This has resulted in higher rates of infection, hospitalization, complications, and death in patients of racial and ethnic minorities. Knowing this, we have a moral imperative as the interpreters of knowledge and distributors of resources to publish and advocate for the publication of the race and ethnicity of our patients. With greater insight into the extent of these disparities, we can begin to study and solve their root causes.
At our institution, we have also seen these disparities. Among the first 424 patients hospitalized at our academic tertiary care center, 76% identified as non-White racial and ethnic minorities. Although our surrounding metropolitan area is among the most diverse in our region of the country, these numbers do not reflect our hospital’s usual census. Additionally, many of our hospitalized patients with COVID-19 are from linguistic minority groups. Our current estimates show 40-45% of these hospitalized patients require interpreters. While the majority of these patients speak Spanish, our COVID units now have patients whose countries of origin are a full sampling of our community’s diverse and global population. These patients represent a dozen languages and countries from East Africa to the Pacific Islands. Tragically, these patients are often hospitalized alongside family members and non-related members of their communities. This is a disease which spreads through relationships and close-knit circles. These patients are disproportionately experiencing severe disease courses complicated by invasive ventilation and intensive care stays. While members of these groups are underrepresented in medicine, and even in Colorado’s population, they are overrepresented in our hospitals.
Inequity in the healthcare system and our society has now been well-documented. In the context of the COVID-19 pandemic, its deadly impact on socially vulnerable communities has now been well-documented. As gatekeepers of knowledge, it is our responsibility to continue to share this truth. Now we must also turn to the hard work of solving this inequity. Some solutions lie in the immediacy of the pandemic. We must ensure that social distancing is being communicated in all languages of our communities. Our patients should be encouraged to come to the hospital and not wait until they are too sick for us to help. We must make sure that all people who cannot work from home are safe as they provide the rest of us with essential services.
The most important solutions require changes to the structures which perpetuate the health disparities this pandemic has magnified. I’ve heard many people make the case that as terrifying as the “new normal” might be, the “old normal” is how we got here in the first place. We must rethink whom we deem essential in society and ensure that they have paid sick leave, a livable wage, and health insurance. We need to build relationships of trust with our patients and their communities. And we need to continue to publish the data about who is getting sick. This virus may “see” us as equal hosts for its replication, but we have already determined as a society who will be the most vulnerable to infection and death. As truth seekers and gatekeepers, it is our responsibility to provide transparency as we help create a more equitable world for our patients.
-Mary Nwoke M.D.
Hospitalist, Emory Hospital/Founder & Medical Director, Homecare Medicine of Atlanta