Updated April 16, 2020
Marginalized and minoritized patients have and will suffer disproportionally during the COVID-19 crisis. The AMA is answering frequently asked questions on health equity in the pandemic response to equip physicians with the consciousness, tools and resources to confront inequities.
What role does public health infrastructure play in the COVID-19 response?
State local and regional public health bodies have been key in the COVID-19 response, intervention and prevention through organizing public education, coordinating general health and medical provisions, advising public agencies and operationalizing national guidance.
While not a formal part of the public health infrastructure, social identity organizations and business associations (e.g. NAACP, UnidosUS, National Urban League, National Congress of American Indians, minority business associations, etc.) are trusted health equity messengers in communities of color.
Why does it seem there is a lack of strong minoritized and marginalized voices in public health leadership?
The power and leadership of public health lies in the authority and trust of local, regional and state public health departments. Public health leadership often serves as advisors and play key administrative roles in managing the epidemic and the many facets of the emergency response. Public health systems are often under-resourced, and while more diverse then health care, public health and its leadership is still not representative of the U.S. population. Further, similar to barriers in health care, public health barriers are often financial in nature. Many public health institutions are supported by short-term grants and rely on the philanthropy of third-party institutions.
The tenuous nature of funding public health institutions weighs uniquely on its leaders, who often sacrifice their own financial gain for the sake of the organizational standing, or find themselves spending more time vying for dollars to keep the institution afloat. These are sacrifices that are terribly costly for aspiring public health leaders to make. For persons of color who do not come from financially secure means, this is not only costly, but prohibitive— they may make pivotal decisions for the sake of seeing to the immediate needs of their families, and forego positions in public health leadership, which may not pay at a rate commiserate with the sacrifice.
How have physicians who are minoritized and marginalized been impacted?
All physicians treating COVID-19 patients are experiencing unprecedented stress, including PTSD and burnout. Minoritized and marginalized physicians may experience more acute distress given the compounding factors their patients are dealing with related to their physical and social well-being. In addition, they are facing the realities of these structural inequities in these health care systems as they are not able properly care for their medical staff or their patients during this crisis.
Why is recognizing physician bias so critical during a crisis?
Bias plays a critical role in health inequity and perpetuate structural inequalities. Either explicit or unconscious physician bias will determine if a patient gets proper testing and treatment.
There is concern that minoritized and marginalized patients will bear an undue burden in morbidity and the mortality associated with COVID-19 and these inequities are amplified with reported shortages.
Are there unique equity considerations for those who are differently abled?
Many states and communities are implementing community actions designed to reduce exposures to COVID-19 and slow the spread of the disease. Unfortunately, in many instances, these policies lack provisions for those who are differently abled and may render them more vulnerable to the impacts of COVID-19 as many have health complications, rely on school-based supports, live in group settings, or depend on care staff for support.
What equity considerations surround language access?
About one in five Americans speaks a language other than English at home, according to census data, but persistent language barriers leave limited-English speakers with COVID-19 in a particularly dire situation: alone, confused and without the appropriate care.
Stories of the lack translation services delaying care or causing misdiagnosis, have become common occurrences during the pandemic.
One common barrier to providing quality information is that it is not routine or frequently updated as it is in English and therefore, materials in different languages may not be the most up to date information. In a time of COVID-19 this is particularly crucial given that information is changing rapidly as we are learning more and more about the virus.
What are the equity considerations for immigrant and mixed documentation status families?
Heightened anti-immigrant rhetoric and policies, xenophobia, increase in hate crimes may limit the patient’s ability to seek help. Further, fear can foster distrust of the medical system, thus delaying seeking care and early intervention and tracking is key to treating and limiting transmission.
For physicians working with immigrant and mixed documentation communities, ascertaining risk, susceptibility and treatment options requires discussions about patient-provider confidentiality in order to fully assess how patients will enact social distancing and offer suitable advice. It is not uncommon for immigrants or families of mixed documentation status to not be open about household size, living accommodations or working arrangements due to fear of being found out and reported to immigration authorities.
What are the equity considerations for women?
Even outside of pandemic, women frequently do not or are unable to seek care for themselves. COVID-19 provides a further barrier to care. Measures meant to safeguard the general public may exacerbate domestic violence situations and limit the victim from seeking care or leaving the unsafe situation.
Women of color face the added concern of rising maternal mortality which can be further complicated by the situational stress presented by the pandemic.
What are the equity considerations for minoritized communities?
There are deep-seated inequities that disproportionately affect many communities of color including higher rates of chronic diseases (asthma, diabetes, hypertension), lower access to health care, lack of paid sick leave, lack of or inadequate health insurance, income disparities, any of which could heighten the effects of a crisis like the coronavirus outbreak. The epidemic is concentrating in urban areas with high population density, for the most part, where marginalized and minoritized individuals live. These concentrations are putting undue burden on already stressed hospitals in these regions.
Why is race and ethnicity data collection and reporting so critical during the COVID-19 crisis?
To date, there is no comprehensive race and ethnicity data and research repository of COVID-19 testing, hospitalizations or mortality. The dearth of racially and ethnically disaggregated data reflecting the health of marginalized and minoritized persons and families underlies the struggles of the physician community to fully attend to, and be attuned to, the unique needs of their patients, and for legislators to design well-informed policies that will preserve lives. Finally, without collecting race and ethnicity data associated with COVID-19 testing (hospitalizations, morbidities, and mortalities) these communities are at greater risk of disease and death; and physicians and hospitals will not be able to properly care for their patients.
How does lack of representation impact clinical trials?
There is widespread and persistent under-representation of minoritized communities in national clinical trials despite growing evidence that, whether for environmental or genetic reasons, drugs may have different effects on different populations. Thus, the lack of representation could have direct implication on the efficacy of future COVID-19 treatments and vaccines.
In order to increase representation in COVID-19 clinical trials, trusted sources must be enlisted to help educate and recruit underrepresented groups; and barriers like transportation, time off work, and childcare must be addressed to ensure full participation.