Pandemic: 'Another Earthquake' Exposing Health Inequities

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Robert A. Harrington, MD: This is Bob Harrington on theheart.org | Medscape Cardiology. We're in the midst of an unprecedented situation in the United States and across the globe with the COVID-19 pandemic. In many ways it's brought out some of the best of society, with people joining together and working hard to figure out how best to address this as a society. It's also brought out some of the glaring inequities around who gets sick, who gets healthcare, who gets good healthcare, and who suffers the most when adverse situations occur in our society.

I thought I would take the opportunity to share with our Medscape Cardiology audience a discussion with a leader in the cardiovascular community who could help us research, think about, and communicate these issues of health disparities and health inequities. I am honored to be joined by my good friend and colleague, Dr Michelle Albert. Michelle is a professor of medicine and the associate dean of admissions at the University of California, San Francisco (UCSF) Medical School. She is also the director of the Center for the Study of Adversity and Cardiovascular Disease. And importantly, in terms of this conversation, she is the new president of the Association of Black Cardiologists (ABC). Michelle, thank you for joining me here today on Medscape Cardiology.

Michelle A. Albert, MD, MPH: Hello, Dr Harrington. Thank you so much for having me.

Call to Action

Harrington: I have known you a long time, and I was delighted when you took the reins of the ABC. The American Heart Association (AHA) shares a close collaborative relationship with the ABC and has for many years. I know that you are going to be a passionate voice for topics around health inequity. Before doing this conversation, I visited the ABC web page and saw your letter to your membership, "What Coronavirus (COVID-19) Means for Black Communities." Let's start the conversation there. Why did you, as the leader of ABC, decide to put this out?

Albert: Certainly, Bob. We were hearing reports a few weeks ago that many in different black communities across the country were not taking COVID-19 seriously enough and that some individuals felt that COVID-19 did not affect black people. We became concerned upon hearing some of those anecdotal reports because we know that there are stark health inequities in the United States and that a viral infection would likely immensely amplify the health inequities that we know exist by race, ethnicity, and socioeconomic status. Subsequently, we have all been privy from the media and our own practices over the past few weeks of the startling death rates related to COVID-19 infection, especially in African Americans vis-à-vis their population prevalence. In places like New York, Louisiana, Chicago, and Detroit, it is noted that there is a doubling of deaths from COVID-19 among individuals who are African American relative to their proportion in the population. Hence, as an organization that is exquisitely interested in the care of diverse communities, especially among blacks, we felt it was really important to put out a call to action related to increasing awareness at the community level, as well as at levels of healthcare, about the potential impact of COVID-19 in black populations.

Inequities Contribute to Poor Outcomes

Harrington: Early reports out of China and places like South Korea noted that people who fared the worst with COVID-19 included those with cardiovascular comorbidities, including hypertension and heart failure. It also included people with advanced lung disease. Are the disparities in terms of outcome all explained by the confounding comorbidities or is something else going on that we need to pay attention to?

Albert: I think multiple factors contribute to these inequities. As you've already alluded to, COVID-19 complications and death rates are tied intimately to underlying chronic medical conditions such as cardiovascular disease, asthma, and chronic obstructive pulmonary disease, all of which are more prevalent in the African American community. However, a number of social factors are also at play here. One relates to segregation and discrimination, wherein African Americans and other racial and ethnic minorities, such as the Latinx community, often live in environments where there is overcrowding or live in multigenerational households where it is difficult to socially distance. They also work in jobs that are disproportionately service-oriented jobs that cannot be done via teleworking and have to go out to work, take public transportation. All of these factors increase risk of exposure to COVID-19.

The flagrant issues that affect access to care for minority communities, particularly black and Latinx communities, are also at play here.

Harrington: It's been striking. There have been stories of bus drivers in Detroit almost valiantly coming to work every day with the notion that they are in a packed environment, but they feel an obligation to do their job. And they are disproportionately black, as you have said.

Your chair of medicine, Bob Wachter, who has been chronicling what goes on at UCSF every day during this time, wrote poignantly last night, saying, "Hey, I have an Internet connection, I have Zoom, I can do my job from home. I'm living here with just my wife and my dog. I've got room to distance. Let's be honest, it's not everybody who shares that." He used his own personal example to call attention for the rest of us to say, "Wait, pause. It might be uncomfortable to social-distance, but for some people, just to get through their daily life, they can't be socially distant."

Albert: Correct. The other issue beyond social distancing relates to access to care within this pandemic. The flagrant issues that affect access to care for minority communities, particularly black and Latinx communities, are also at play here. Folks are staying at home and not going into clinics or hospitals when they become symptomatic, even with their cardiac conditions. Folks are afraid to go into a hospital if they have a cough or a fever. This is true in the African American community as well, wherein there is also a level of distrust of the medical system, coupled with the fear of going into a hospital at this point in time. In addition to some of the other social factors that we've already been discussing, as well as underlying chronic health conditions, there is also the issue of presenting for care and perhaps possibly even presenting to care later than they should present to care in the current context.

COVID-19 Testing and Accessibility

Albert: The other thing I want to talk about is the issue of testing and accessibility. My entire family is in New York City, and if one is symptomatic with a fever and a cough and calls their healthcare provider, chances are they will be told to stay at home because the system is so overwhelmed—unless they have shortness of breath or other really concerning symptoms. These are issues, because in multigenerational households and in overcrowded communities wherein one may actually have COVID-19 but has not been tested for it, the infectivity rates are going to be pretty high. Folks are not going to know whether to quarantine or not. This is a particular issue in minority communities and African American communities that are not going to necessarily be close to academic medical centers and testing facilities. One great need in the context of this pandemic is to ramp up testing; making testing easily available in communities of color is also needed.

Harrington: That is a really important point. As we move beyond just using PCR tests, for example, to look for the presence of the virus, we're going to move into an era where we also want to test serology. We don't have a definitive sense yet of what that means in terms of conferring a level of immunity and resistance to future infection. But we're learning constantly. You're right—you and I both live near and work in academic medical centers where those facilities will be available. As a society, we need to set up testing venues that allow broader access, don't we?

Albert: We do. And we need to get to some of the biology and immunology of this. There is testing for the virus, which would be more to detect an early-stage infection when the infectivity rates might be pretty high, and antibody testing to detect exposure to the virus. Certainly as antibody tests come on board, their utility may be, at least initially, most useful for healthcare workers to know who has and has not been exposed, and to help protect patients and other folks they may come in contact with. But you're right. As the tests become more specific and sensitive, and as these things get developed, antibody testing will be important to understand the population immunity levels.

Harrington: It's going to be important not just for the jobs that you and I do in healthcare facilities, but also in terms of opening up broader society. When can companies reopen? When can stores reopen? When can people begin to get back to some sense of normal? It's going to be a while before we understand all of these issues. I'm seeing from your comments that it will also have an effect on health inequities as we continue to have a slow ramp-up of our economy and getting back to normal.

Economics and 'Advantage Health'

Albert: You mentioned the economy. One of the biggest concerns I have related to this pandemic is the skyrocketing unemployment rates in the country. Traditionally speaking, the unemployment rates in the United States for African Americans are usually twice the reported unemployment rates, because after a while, folks will stop documenting that they are unemployed. In general, we know that the rates are twofold higher, at least the documented rates, which means that they are probably threefold higher than the unemployment rates of whites.

Advantage health is not only dictated by biology but by sociology and the social determinants of health.

And given the scope of this pandemic, there are massive concerns about the unemployment rate among African Americans being upwards of 25%-30% in this country, which is terrible. We already know that African Americans are paid much less than whites in this country. We know that access to jobs dictates access to education and homeownership. We know that in the United States, African Americans have a homeownership rate of only about 45% compared with 77% of whites. These things really hit the bottom line of what helps to dictate advantage health. Advantage health is not only dictated by biology but by sociology and the social determinants of health. As cardiologists, we know that 80% of cardiovascular conditions are dictated by social factors. I'm very concerned about the economics of this and its impact on the health of not only adults who are unemployed, but also their children who then also suffer. Whether children are being affected by this pandemic in a similar way to adults, at least at a biological level, is still up for debate. But I think that at the end of this, certainly for blacks in this country, the effects on children and adults are going to be enormous.

Harrington: The profound nature of this really came home for me several weeks ago when New York City was publicly having the debate about closing their public school system and the mayor said on more than one occasion, "I'm reluctant to shut down the school system because a sizable portion of our school population gets their only meals of the day from the school." And it gets at what you're saying, Michelle: It's not just biology. There does seem to be something unusual about the virus in terms of how it does not seem to, at least in the most severe forms, affect children in a broad way. But the pandemic is going to leave us with side consequences that include malnutrition, food insecurity, and a variety of other things.

Albert: Food insecurity, housing insecurity. There is also the issue of educational disparities. We know that there are educational disparities by race, ethnicity, and by socioeconomic status. We've moved to virtual classes at this point, and communities are struggling. Black and brown communities are struggling to bring computers into the homes of children in those communities. Many minority communities, especially African American, receive their Internet via their phone and not necessarily by a desktop or laptop computer. One of the things that local governments and states will need to focus on as it relates to education, especially if this pandemic is protracted, is how do we bring technology into the homes of folks who tend to not have access to the types of technology that are needed for this ongoing pandemic?

Telehealth Can Accentuate Health Inequities

Harrington: A couple of hours ago, I was involved in a conversation with the AHA about telehealth. We've seen an acceleration of the use of telehealth throughout our systems—it's really taken off here at Stanford. But it was brought to everyone's attention that telehealth can also accentuate health inequities for the reasons that you have already mentioned. If you don't have the ability to have that video connection with your health provider, either on their end or your end, it leaves you, again—perhaps unintentionally but realistically—getting less access to care than you warrant.

Albert: Yes, absolutely. Something has always bothered me about telehealth. My patients who are African American have tended not to want to do telehealth. Sometimes when we do telehealth and video, you have a scan of your background, and a lot of times people don't necessarily want folks to see where they live. I know we can do virtual backgrounds with Zoom, but we make large assumptions that everybody wants folks to see where they live or have a snapshot of a bookcase in the background, etc. Folks can have some feelings about that which others might take for granted. Also, with the historical distrust in the medical system that African Americans have, I have concerns about how that distrust interfaces with telehealth.

Harrington: I completely agree with that sentiment. I've been doing my own cardiology practice visits using both phone and video, and I definitely have patients who have said to me, "I'd prefer that you call me as opposed to being on video." I suspect that there are issues of what people feel comfortable with, and I do think that we as a community need to think about that and need to not only be sensitive toward it, but also think about other ways we can provide access and reliable, high-quality care.

What Can We Do? What Are Opportunities for Change?

Harrington: Clyde Yancy, our mutual friend and colleague out of Northwestern, had a piece in the Journal of the American Medical Association . He covers a lot of the things you and I talked about, like how it's been known for a long time that health inequities exist and that social determinants of health contribute adversely in common chronic diseases like cardiovascular disease. Then he asked: Is this the moral moment for us as a society when we finally will do something about health inequities? Michelle, what are the opportunities for us if we as a society are to use this to do some good?

There is no magic bullet, but certainly we need to double-down on our efforts to focus on education, jobs, and providing equitable access to healthcare for all communities.

Albert: Last week, the ABC put forward a webinar called At the Heart of the Matter: Unmasking the Invisibility of COVID-19 in Diverse Populations. In the last part of that webinar, we outlined potential opportunities. These include increasing testing and accessibility in all communities, particularly in disadvantaged communities; decreasing the impacts of segregation at the local level as well as the national level; ensuring that there are adequate employment opportunities available as we come out of this pandemic; ensuring that the educational opportunities that are lacking, particularly in black or brown communities, get focused on at the local and federal levels. We've had a lot of moral moments throughout the history of the United States, but we have never been able to get to the point where we pony up and deal with these issues related to employment, jobs, where people live, and how people live. This pandemic puts another earthquake into issues that we know are longstanding. There is no magic bullet, but certainly we need to double-down on our efforts to focus on education, jobs, and providing equitable access to healthcare for all communities.

Harrington: Wonderfully said. Our friend, Eduardo Sanchez, the chief medical officer for prevention for the AHA, has reminded me that it's not just social determinants of health; these are structural determinants of health. You laid them out really well and called upon us to act together to do something that many of us have been chipping away at for many years. But I do agree with you: Now is the time that a pandemic has uncovered the real failings of our system and we have to do better. Certainly from my AHA perspective, we're really privileged to collaborate with your group at the ABC to see if we can make a difference.

Albert: One of the things that I think the AHA is doing well during this crisis is making grant funding available to examine these issues so that we can have targeted responses to the effects of the pandemic, not only related to health, but also related to those structural determinants of health.

Harrington: Thank you for bringing that up. We hope to be announcing those grants very soon. Michelle, thank you for joining me here today on theheart.org | Medscape Cardiology. I want to thank our listeners for staying with us in this interview. It's been a privilege to have as our guest Dr Michelle Albert, professor of medicine, associate dean of admissions at the UCSF Medical School and the director for the Center for the Study of Adversity and Cardiovascular Disease. Michelle is also serving this year as the president of the ABC. Dr Albert, thanks for joining us.

Bob Harrington, MD, is chair of medicine at Stanford University and current president of the American Heart Association. (The opinions expressed here are his and not those of the American Heart Association.) He cares deeply about the generation of evidence to guide clinical practice. He's also an over-the-top Boston Red Sox fan.

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