The quest for Health Equity in America has been a long journey, and it has taken the COVID-19 pandemic to further expose a long history of racial injustice and healthcare disparities. In addition to the COVID-19 forced pause on how we live, technology and the availability of information continues to provide additional lenses for all to view how people are born, grow, live, learn, work and age in their respective communities.
Multiple viewpoints from novice and professional photographers, videographers, fact finders and storytellers present us with broad and rapid content that has lifted layers of avoidance and ignorance regarding how underserved and under-resourced communities are coping with the implications of COVID-19. These stories also magnify all forms of racism, personally mediated, internalized and systemic, that continue to be pervasive.
The need to reframe and respond to the conversation of racism, as described in a gardener’s tale by Dr. Camara Jones in 2000, is still a work in progress.1 If we believe that all people are valued equally and have the right to achieve their best health, then we must take the time to actively collaborate with private and public sectors to address Social Determinants of Health and eliminate racism as a force driving the distribution of resources that support these determinants.
As physicians, we have a responsibility to improve the quality of care that we provide to patients by being intentional about achieving health equity in our practice and our communities.
The Institute of Medicine states the aims of quality care are safety, timeliness, efficiency, effectiveness, patient centeredness and equity. Achieving health equity begins with addressing health disparities and leveraging the data to eliminate gaps.
It is important to understand that health disparities are not only health differences between compared groups but are differences in health outcomes that are linked to social, economic and/or environmental disadvantage. COVID-19 has amplified existing health disparities that are impacting underserved minority communities.2
In March, over 80% of patients hospitalized from COVID-19 in Georgia were African American, while African Americans comprise only 31% of the state’s population. Moreover, 49% of COVID deaths in Georgia were African Americans.3 Nationally, when you drill that down to an age group of 35-44 year-olds, there is a death rate that is 10 times higher in Black people than white people.4 These statistics look strikingly similar whether looking at data around COVID-19, maternal mortality, HIV (Human Immunodeficiency Virus), and chronic diseases such as asthma, diabetes and obesity.
COVID-19 forms another chapter in the story of healthcare disparities highlighting lack of access and structural racism. The likelihood that an individual lives in proximity to healthcare services is intimately tied to “neighborhood quality” defined by resources available to that community — this refers to food, transportation, greenspaces and safe streets.
These social determinants of health are deeply tied to federally led housing policies, disinvestment from black neighborhoods, segregation and the legacy of Jim Crow policies. As Sewell explains in her one block metaphor, one additional block of exposure to inequitable policing (such as those evident in Stop and Frisk policies disproportionately affecting Black and brown communities) increases the likelihood of diabetes, hypertension, obesity and asthma.
Not only is there a link established between neighborhood stressors/socio-environmental factors and physiological conditions such as hypertension and anxiety, but there is also the impact on trust in institutions of care and help-seeking behavior.5 These factors are further compounded by the differential in the availability of services. A recent 538 analysis found lower access to testing in Black and Hispanic neighborhoods — whether geographically farther away, having less capacity or serving more people and thus having longer wait times.6
Lack of access to healthcare information and resources is a major determinant of health experienced by underserved populations during the pandemic. The public health prevention recommendations to contain COVID-19 disease spread severely limited in-person visits with a healthcare provider, which is not trivial for COVID and non-COVID illness.
Although technology has increased our connectivity, the ability to leverage this tool effectively to access healthcare resources remains discordant. Over the course of the COVID-19 pandemic, there has been rapid expansion of virtual care, but the reality of the digital divide has further exacerbated access to care for underserved populations.
In the U.S., nearly half of rural populations do not have broadband at home, and a recent Pew Research Center study finds that 25% of Hispanics and 23% of Blacks compared to 12% of whites are smartphone dependent—meaning that they do not have home broadband and access the internet via their smartphone only.7 This has ramifications not only on access to virtual providers but also access to information. The intentional design and creation of multichannel outreach, education and services is then fundamental to equitably providing care.
Healthy People 2000, a strategy by the U.S. Department of Health and Human Services for improving the health of Americans by the end of the century, initiated the practice of displaying health disparities data to illustrate outcome measures by race to track progress towards addressing health equity.
To fully understand the impact of the pandemic on vulnerable populations, several collaborators focused on displaying COVID-19 health disparities data such as The COVID Tracking Project-Racial Data Tracker and the Emory COVID-19 Health Equity Interactive Dashboard.
As data availability and analytical tools have improved, we are able to layer various streams of data such as patient-reported syndromic data, testing data and zip code data to help target and direct where and what type of healthcare resources a specific community, neighborhood or street would benefit from.
In designing the Metro Atlanta COVID Messaging Campaign launched by Emory’s Collaborative Community Outreach and Health Disparities group, we observed that African-American patients were significantly more likely to have an underlying condition that placed them at elevated risk for severe COVID-19 illness. Accordingly, it was critical to identify both hotspots with higher-than-average reports of COVID-19 positive tests and blind spots, where there are above-average underlying conditions and below-average reports of positive COVID-19 test results.
Recognizing the potential role of decreased availability of testing and mistrust of information in these blind spot areas, we designed a campaign that would proactively engage community voices and target both hotspots and blind spots. It is just as critical to explore the meaning and impact of the absence of data as we seek to address health inequities.
The COVID-19 pandemic can be the lens we use to focus on the vision of health equity in America. Unless we open our eyes to see the connection of racism on social determinants of health, all patients will not be successful in achieving their best health. Communication technology, data sharing and the right infrastructure provides real-time information that can be leveraged to implement meaningful interventions to address health disparities.