Watch the AMA's daily COVID-19 update, with insights from AMA leaders and experts about the pandemic.


AMA Chief Experience Officer Todd Unger speaks with AMA Health Equity Policy Director Mia Keeys, Chief Medical Officer of Cook County Health Claudia Fegan, MD, and Chair of Medicine of Cook County Health Suja Mathew, MD, on updates regarding COVID-19 including the ongoing challenges of treating medically underserved communities during the COVID-19 pandemic.

Learn more at the AMA COVID-19 resource center.

AMA COVID-19 Daily Video Update

AMA’s video collection features experts and physician leaders discussing the latest on the pandemic.


Unger: Hello, this is the American Medical Associations COVID-19 update. Today, we're discussing the ongoing challenges of treating historically medically underserved communities during COVID-19. I'm joined today by Mia Keeys, the AMA's health equity policy director in Washington, DC, Dr. Claudia Fegan, chief medical officer at Cook County Health in Chicago and Dr. Suja Matthew, chair of Medicine at Cook County Health in Chicago. I'm Todd Unger, AMA's chief experience officer in Chicago.

We've seen again and again, how COVID-19 has exacerbated the health inequities already present in our health system. Ms. Keeys, can you give us an update on access to useful data and how this pandemic continues to affect historically medically underserved, marginalized and minoritized populations?

Keeys: Sure thing, Todd. So just to ground us, to date the CDC is reporting about 1,600,000 or so positive cases, and almost a 100,000 deaths in the US with respect to COVID. But yet, the data are still not granular enough in terms of demographics. And more specifically, with respect to racial and ethnic identity, gender, orientation, language, preferred spoken and written language by patients. We're still lacking those health data that include ethnicity and race, which is a problem. Up until last week, actually last Friday, HHS released a four page document on health equity issues, but it's quite paltry. It's not yet complete.

And so what we do know we have to depend on anecdote is that the pandemic is disproportionately affecting low-income persons, Black Americans, Latinx peoples, and acutely, Native Americans, especially the Navajo Nation, which has surpassed all states in terms of COVID-19 related cases. And each of these populations has increased the comorbidities and make them especially vulnerable to complications from the disease. But not just comorbidities, also social determinants of health that our data need to reflect so that our resources may be allocated in a strategic and effective way. And also, unfortunately, I don't see these issues easing anytime soon, Todd, especially as the states are beginning to reopen. And so that whole limited access to evidence-based public health recommendations is problematic right now.

Unger: Dr. Fegan, Dr. Matthew, how are you addressing these challenges at Cook County Health?

Dr. Fegan: Well, as many people know, we have always taken great pride at Cook County Health to take care of everyone who comes through our door regardless of their ability to pay. So we are a known quantity to our community that we serve. And so we have had to be especially sensitive in terms of trying to make sure that our patients get the information they need when they need it. We have attempted to reach out to our patients who we know by phone, especially patients who have multiple comorbidities, calling them, having their providers call them and talk to them about what's going on.

And patients have really appreciated that. They appreciate a valid source of information that helps them understand what needs to be done. And as we're doing more of these telephone visits with our patients in terms of making sure they're okay. We have patients that we're concerned about, who we have targeted that need to have a call from us about their health and what they should be looking for. I don't know, Suja, if you want to elaborate on some of what we've done in the clinics.

Dr. Matthew: Yeah. I mean, we've certainly seen all of what Mia has already elaborated. We see that in our everyday practice. And that is the disproportionate effect, as we see it, on the most disenfranchised within our communities in our country. And this is something we need to better understand. So there may be a chronic comorbidity component to this. There are clearly socioeconomic aspects of what we're seeing. But there may still be even more than other differences that we as a community, a medical community, have yet to better understand, but everything that Mia elaborated, we see it day-to-day at Cook County Health.

Unger: Many health care systems, including Cook County, have leveraged telehealth to help treat patients with chronic conditions. Ms. Keeys, what new challenges come with implementing telemedicine and treating marginalized populations virtually?

Keeys: Telemedicine is a game changer with respect to providing care, especially for those who aren't presenting with fatal symptoms, with respect to COVID or anything else. And it's been really fantastic, providers, such as what's happening in Cook County, have been able to leverage these technologies to expand care. But where we are seeing issues has to do again with those socially determinant factors. So it was expressed that there are concerns for patients who may not have access to smartphones or smart technology, such that they are able to connect readily with their provider. Fortunately, what we are seeing, however, is an extension of coverage parity and also payment parity for providers who are able to touch base with patients who are on landline telephones. Prior to COVID, most states didn't have any payment parity or coverage parity with respect to audio only or synchronous technologies.

But now we are seeing these emergency provisions that governors are providing so that patients who don't have smart technology or who are in low broadband access environments, are able to access their physicians. But if after COVID these provisions are lifted and they're no longer provided, we are going to see a return, detrimentally, to lack of access of care for those patients who don't have broadband access, who don't have smart technology. So it's great to have telehealth and telemedicine capabilities. We have to do everything in our advocacy power to ensure that those provisions remain following in the wake of coping.

Unger: Dr. Fegan?

Dr. Fegan: Yeah. I was going to say, it's wonderful that we are able to use a variety of technologies. But as Mia's pointed out, our patients don't always have access to it. And even a landline, we have lots of patients who don't have a phone line, don't have access and how can we make sure that their needs are met? We often have bad phone numbers for patients, or we have the issue that a patient calls and they don't know who—they don't recognize. It doesn't say Cook County Health on the line when they're getting, and they may not want to receive that call. They may not take those calls. And so it's trying to get the word out that we're reaching to these patients and providing them with information. And it's been very helpful to have the parody, but the technologies are greater than that in terms of meeting the needs of our patients on a day-by-day basis.

Dr. Matthew: I think also it's important to remember that patients bear some responsibility of assessing the severity of their symptoms as well. And in some of the populations that we serve, it's harder for our patients to know whether a non-acute issue is in fact, one that they can stay home with and communicate with their physician via telehealth. Or sometimes whether it's a more serious condition that requires them to come in. So there's some of that learning and education that we also struggle with in our patient population.

Unger: Well, let's talk about testing. I know Cook County Health has made efforts to ramp up testing, yet our country as a whole is still testing fewer people per capita than other countries. How is this impacting in marginalized populations, in particular as states relax their stay at home mandates? Dr. Fegan, Dr. Matthew?

Dr. Fegan: Well, so that's a very important question. We have made testing available to our patients. And we have created drive-in tents that allow a patient to come to this Stroger campus or Provident, our other hospital, campus. We also are doing testing of our patients in each of our community sites. So if a patient comes in or if they talk to their provider, their provider believes that they should be tested. We have them come in and we test them. So that's making it relatively easy for them to get access. What we're looking at now are what are the opportunities to provide testing to patients who haven't seen us before, who don't have a relationship with us and what is our capacity to fit those folks in? Not everybody has a car who can drive up to our tent. We do take walk-ins to the tent.

We're in communication with the state about what's the feasibility of opening this up to more folks. Anyone who has relationship with us can get tested easily. And we are able to turn those results around in a day, which has also been very important in terms of addressing the needs of once you test, you want to do the contact tracing. If you test someone and they're positive, as quickly as possible getting that information to them so that people who have been in contact with them, first of all, will minimize exposure by having them contain. But also begin reaching out. And that's one of the reasons we've fallen behind as a country in terms of testing, because we don't have the capacity yet to do the amount of contact tracing that's indicated. And that tracing needs to happen early on. So if you test someone, it takes five days to get the results of the test. They've already exposed so many more people. Whereas, if we can do it quicker, it's more beneficial for our community as a whole.

Dr. Matthew: We would love to expand our testing outside of the patients who we already serve. I mean, what a great way to bring them into care. We recognize that there are legions of individuals who are not in care right now, and that would be a wonderful opportunity to bring them in through this mechanism of testing for COVID. So we would welcome that opportunity. We just are sorting through how we can make that feasible.

Keeys: The only thing, Todd, that I'd like to add if possible, is that in addition to diagnostic testing, there are concerns even with serological testing and how people understand the uses of serological testing. Just because one might test positive for COVID-19 antibodies. It doesn't mean that they're completely in the clear, because there are cases of being reengaged with the virus. I think a Navy ship just had a number of people who had COVID before, and then tested negative and then eventually tested positive again. So, that's problematic. And then also for a lot of people who are really anxious to get back to work and really appreciate and want serological testing, because their economic livelihood depends on having that antibody, you can't use the serological testing as a clearance to then resume in the same way prior to COVID without adhering to other guidelines with respect to physical distancing and so on and so forth. So there's certainly a component to echo what Dr. Matthew was saying of education and making sure that we're using testing in the correct ways. Both diagnostic and serological.

Unger: Last topic is around physician wellness. Treating patients in a pandemic takes a huge mental toll on physicians, and treating marginalized and minoritized populations during the pandemic even more so. How should systems be supporting their physicians at this time, Dr. Matthew?

Dr. Matthew: Well, I've often thought that the work that we do at Cook County and others who do work like us are somewhat protected from burnout because we're so mission oriented. And I do believe that that provides us some protection, but this has been a stress unlike any other. Whether at Cook County or anywhere else in the world. This has been a great opportunity for leadership to really prove its value to our profession. And I use the term leadership very broadly. And of course it's our own senior leadership, but department leadership, divisional leadership, clinical leadership, even sort of work group leadership. Communication has been key, making sure that individuals are given information about the virus, about the pandemic, but also about our response to the pandemic. How are we protecting our patients? And very importantly, how are we placing the safety of our staff also as a significant priority for us?

So communication has been key. We've been able to offer more flexibility at Cook County Health than we have in the past. I think that's been enormously helpful for our physicians. Providing clinical support, whether it's in the form of technology or educational resources, AMA resources and other resources that are in-house grown, as well as externally to support individuals as they take care of COVID patients. And then also peer support. We've been able to be there for one another through hotlines and other gatherings of bringing our physician community together, because we are in it together. And we need that support of one another to continue this fight, which is long ahead of us still.

Unger: Well, thank you very much. That's it for today's COVID-19 update. I want to thank Ms. Keeys, Dr. Fegan and Dr. Matthew for being with us here today and sharing your perspectives. We'll be back tomorrow with another COVID-19 update. For updated resources on COVID-19 go to the AMA COVID resource center at ama-assn.org/COVID-19. Thanks for being with us and have a great day.


Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.

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