HealthManagement, Volume 20 - Issue 9, 2020

The Serious Public Health Consequences of Health Disparity

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As hospitals and clinics rebuild and reorganise from the public health and financial challenges of the ongoing coronavirus pandemic, there has never been a better time to address health disparity in medicine. The American College of Radiology is collaborating with patients and other health care organisations, to develop solutions to eliminate health disparity and improve the care of all patients.


Key Points

  • Public health systems have never been free of disparity in medicine. This has come into the spotlight even more during the COVID-19 pandemic. 
  • As COVID-19 continues to rage havoc across the globe, it has become clear that certain patient populations are affected at a much higher rate. 
  • Health inequities run deep into nearly all areas of healthcare – from maternity care to chronic health conditions to clinical research. 
  • The American College of Radiology and other professional medical organisations are also addressing the issues of health disparity, and are working on developing solutions.


The U.S. public health system has never been free of health disparity in medicine despite continued efforts over several decades to solve this critical issue, but it is the COVID-19 pandemic which has shined a bright spotlight on this (Bassett et al. 2020).


As rapidly increasing numbers of people in the U.S. and across the world continue to become infected with COVID-19, with many dying, it is becoming clear that certain health populations are being affected at a much higher rate. A recent CDC study found that more than 75% of children dying from COVID-19 are minorities, a finding that is also reflected in death rates among adults (Wan 2020; Fisher 2020).


While urgent action is needed during COVID-19 to save lives, health inequities run deep into nearly all areas of health care from maternity care (Snowbeck 2020; Barrett 2020), to care of chronic health conditions like diabetes, heart disease and cancer (Cooney 2020; Flowers 2020; Rodriguez 2020), to health inequities in research ranging from drug trials to neuroscience research to COVID-19 vaccine research (Girten et al. 2020; Hamilton 2020; Zenooz 2020).


So what are some successful strategies to solving health disparity? Some of the most powerful strategies have started as grassroots initiatives by individuals. Research centres, private companies and government are also contributing to solving health disparity. Here are some examples.


Dr. Stanford, a Black paediatric surgeon in Philadelphia (USA) noticed that black people were contracting the coronavirus, at nearly twice the rate of their white counterparts, and dying from COVID-19 at higher rates. She also started hearing from Black friends that they were unable to get tested for COVID-19 and were being turned away. Dr. Stanford started recruiting volunteers among the health care professionals in her network, and she formed the Black Doctors COVID-19 Consortium (BDCC 2020) to test more than 350 people per day in her area. To date, BDCC has tested more than 10,000 people in Philadelphia and the surrounding regions (Feldman 2020).


Dr. Upshaw, a Black biomedical engineer, from Atlanta (USA) recognised the importance of vaccines in preventing disease, but she also recognised America’s history of non-consensual medical experimentation on Black Americans which has caused a wide mistrust in the Black community toward volunteering for research trials. Dr. Upshaw is one of the first two Black participants in Moderna’s first 45-person COVID-19 vaccination trial. She is sharing her experience with the Black community, and is putting out a message that the vaccine is safe. She is hoping that her positive experience will encourage others in the Black community to volunteer for research trials (Barnes 2020).


New York Genome’s Center two-year-old initiative called Polyethnic-1000 (NYGC 2020) is providing cancer research grants dedicated to deepening the understanding of the contributions different ethnicities make to the incidence and behaviour of cancer. This research is bringing genomic innovation to patient populations generally under-represented in research and hence deprived of the benefits of scientific progress. One of the goals of this research is to improve outcomes for a diverse group of patients (Goldberg 2020). 


Boston Scientific has a long-running health disparity programme called “Close the Gap” which uses data from public sources like Medicare and private sources like Truven Health Analytics MarketScan to produce statistics on disparity of care. They are focusing on detecting health conditions such as peripheral artery disease which affects Black men and women in greater numbers. Their programme focuses on educating the public and medical community (Carlson 2020).


The state of California (USA) has introduced a “health equity metric” that will require large counties to bring down the spread of COVID-19 in disadvantaged communities that have been hit harder by the pandemic before these counties are allowed to reopen. Dr. Ghaly, the state’s health secretary said, “We can’t allow transmission rates to so disproportionately impact those communities without significant effort to reduce that disparity and reduce the burden on those communities” (Taxin et al. 2020).


Another solution that has been proposed is providing reparations to disadvantaged communities to end health disparity (Bassett et al. 2020). Reparations would focus on expanding the extremely limited health resources available to minorities. Better neighbourhoods, better schools and access to clean air and water are all tied to improved health care. Addressing issues of stress in minority communities would improve overall health. Addressing and eliminating food security in disadvantaged communities is critical (Santhanam 2020; Silva 2020). These interventions would require a long term commitment over many generations, and currently across living generations to immediately improve public health and reduce health disparity (Sullivan 2020; Fortier 2020).

The American College of Radiology and other professional medical organisations are also addressing the issues of health disparity, and are working on developing solutions.


The American College of Radiology, in addressing population health issues, recently collaborated with the American Medical Association during a recent population health management webinar on health equity (September 20, 2020). During this webinar, several solutions were discussed (American College of Radiology 2020).


Joseph Betancourt MD, MPH (VP and Chief and Inclusion Officer at Massachusetts General Hospital [USA]), proposed several solutions or lessons required to improve health equity during COVID-19 and beyond: 


Lesson 1: We need to incorporate an equity analysis into emergency preparedness. That is, communities of colour were hit early and hard during the pandemic, and due to health inequities in diagnosis and treatment they suffered disproportionately relative to the general population.


Lesson 2: We need to incorporate a race/ethnicity measurement in all we do. That is, improving surveillance and monitoring of disadvantaged populations is critical. Developing dashboards and analysing the results can act as a catalyst for change.


Lesson 3: As we redeploy for emergencies, language is an asset. This requires multilingual registries, care groups and trusted messages/messengers. Diversity is critical to making this effective.


Lesson 4: As we evolve clinical care, we need to assure equity. This requires multilingual hotlines, patient information, virtual health, and maximising the use of the electronic health record to improve the care of diverse health populations.


Lesson 5: We need to care for those within our walls (and institutions), and communication is key. Democratising information is a quality/safety issue.


Lesson 6: Social determinants of health will always worsen in the case of disasters, and will hasten spread of disease. Community health needs to take a “doorstep to bedside” approach.


Lesson 7: We must have equity in all efforts.


As Dr. Betancourt discussed, leveraging technology and improving communication through clear language is critical to improving care. Arun Krishnaraj, MD, MPH (Vice Chair of Quality and Safety at the University of Virginia [USA]), is using technology to improve communication for patients. He is using procedure-specific videos, rich in animation with clear language, to explain procedures to older patients and non-English speaking patients. This has improved communication for the patient, and has resulted in a better understanding of their care.


20% of the U.S. population speaks a language other than English at home so this is a daily challenge in providing optimal care to patients. Improving communication is critical to obtaining an accurate patient history, explaining a procedure to a patient, requesting consent, and collaborating with a patient on their treatment. Improved communication increases patient satisfaction, and is one of the fundamental principles of patient-centred care (Nickel et al. 2018). 


Dr. Kirshnaraj shared a story from Dr. Vanni Rodriguez, an Emergency Medicine resident from Harvard University (USA) where she said, “Gotta love it when they a call a patient altered “mental status”, then you go and chat with them in Spanish and they give you a history…like he’s not altered, he just doesn’t know English.” 


Andrea Borondy-Kitts, a retired aerospace engineer, aerospace executive, and a strong patient advocate, who works closely with physicians suggests that radiologists are well positioned to lead the effort to reduce the health disparity gap. She says that “Radiologists are tech-savvy, have developed strong patient advocacy networks, and are involved in the full continuum of care.”


Other organisations like RAD-AID International (a nonprofit organisation dedicated to improving and expanding radiology services in the developing world and poor areas) are forming collaborations with private industry and public health advocacy groups such as the Black Women’s Health Imperative (an organisation formed out of a need to address the health and reproductive right of African American women) and national patient advocacy committees such as the American College of Radiology’s Patient and Family-Centered Outreach Committee to deliver innovative multidisciplinary women’s healthcare, including public health outreach, nursing and community navigation, breast and cervical cancer screening, radiology, and other medical services to women of colour in the United States (RAD-AID Intl 2020; Black Women’s Health Imperative 2020; American College of Radiology 2020).


These are examples of health care organisations collaborating with private industry and patient advocacy groups to reduce health disparity and improve patient care.


The American College of Radiology has been closely working with patient advocates, such as Andrea Borondy-Kitts, to improve health care and eliminate health disparity since patients and families’ best understand the challenges that they face, and they offer a critical perspective to improving care. Patients are at the centre of care (NEJM Catalyst 2017).


As hospitals and clinics are rebuilding and reorganising from the public health and financial challenges of the ongoing coronavirus pandemic, there has never been a better time to reach out to underserved communities to offer them the same level of health care offered to the general public.


The time is now to address health disparity in medicine, and the American College of Radiology is collaborating with patients and other health care organisations, such as the American Medical Association, to develop solutions to eliminate health disparity and improve the care of all patients.


Conflict of Interest

None. 



References:

American College of Radiology (2020) Physician resources for patient and family-centered care. Available from https://www.acr.org/Practice-Management-Quality-Informatics/Patient-Family-Centered-Care


Barnes J (2020) A Black participant in Moderna’s COVID-19 vaccination trial: Trust the vaccine. Available from https://abcnews.go.com/Health/black-participant-modernas-covid-19-vaccination-trial-trust/story?id=72654085


Barrett K (2020) Black maternal mortality rates and the implicit biases—how can we address them? Available from https://thehill.com/opinion/healthcare/516452-black-maternal-mortality-rates-and-the-implicit-biases-how-can-we-address


Bassett M, Galea S (2020) Reparations as a public health priority—a strategy for ending black-white health disparities. Available from https://www.nejm.org/doi/full/10.1056/NEJMp2026170


BDCC (2020) Black Doctors COVID-19 Consortium. Available from https://blackdoctorsconsortium.com/


Carlson J (2020) COVID widens racial gap in Minnesota’s health care system. Available from https://www.startribune.com/covid-widens-racial-gap-in-minnesota-s-health-care-system/572402602/


Cooney E (2020) Why people with diabetes are being hit so hard by COVID-19. Available from https://www.statnews.com/2020/10/01/why-people-with-diabetes-are-being-hit-so-hard-by-covid-19/


Feldman N (2020) The Black doctors working to make coronavirus testing more equitable. Available from https://www.npr.org/sections/health-shots/2020/10/01/916272046/in-philadelphia-black-doctors-bring-coronavirus-tests-to-street-corners-and-chur?utm_campaign=storyshare&utm_source=twitter.com&utm_medium=social


Fisher K (2020) How COVID-19 exacerbates inequities among vulnerable children. Available from https://thehill.com/opinion/healthcare/515933-how-covid-19-exacerbates-inequities-among-vulnerable-children


Flowers B (2020) How Black doctors are answering the call to reform medical education—and bring COVID-19 vaccine trials to communities of color. Available from https://www.marketwatch.com/story/how-black-doctors-are-answering-the-call-to-reform-medical-education-and-bringing-covid-19-vaccine-trials-to-communities-of-color-2020-09-09.


Fortier J (2020) Latinos report financial strain as pandemic erodes income and savings. Available from https://www.npr.org/sections/health-shots/2020/09/16/912847191/latinos-report-financial-strain-as-pandemic-erodes-income-and-savings?utm_campaign=storyshare&utm_source=twitter.com&utm_medium=social


Goldberg E (2020) Cancer projects to diversity genetic research to receive new grants. Available from https://www.nytimes.com/2020/09/11/science/genetic-cancer-research-race.html


Girten et al. (2020) FDA data reveals racial discrepancies in cardiovascular drug trials. Available from https://www.upi.com/Health_News/2020/09/01/FDA-data-reveals-racial-discrepancies-in-cardiovascular-drug-trials/7691598562876/?spt=su&or=btn_tw


Hamilton J (2020) Neuroscience as a whiteness problem. This research project aims to fix it. Available from https://www.npr.org/sections/health-shots/2020/09/24/915783973/a-neuroscience-project-pushes-to-include-more-african-americans-in-brain-researc?utm_campaign=storyshare&utm_source=twitter.com&utm_medium=social 


Hologic and Black Women’s Health Imperative (2020) Hologic partners with the Black women’s health imperative and RAD-AID to tackle breast screening disparities. Available from https://www.itnonline.com/content/hologic-partners-black-women%E2%80%99s-health-imperative-and-rad-aid-tackle-breast-screening


NEJM Catalyst (2017) What is patient-centered care? Available from https://catalyst.nejm.org/doi/full/10.1056/CAT.17.0559


Nickel et al. (2018) Principles for patient and family partnership in care: An American College of Physicians position paper. Available from https://www.acpjournals.org/doi/10.7326/M18-0018


NYGC (2020) Polyethnic-1000 vision. Available from https://www.nygenome.org/research-areas/cancer/polyethnic-1000/


RAD-AID Intl (2020) RAD-AID USA women’s health access program. Available from https://rad-aid.org/usa-womens-health-racial-disparities/


Rodriguez A (2020) Report aims to give ‘guiding light’ in overcoming racial disparities in cancer health. Available from https://www.usatoday.com/story/news/health/2020/09/23/cancer-health-aarc-report-outlines-disparities-how-overcome-them/5854105002/


Santhanam L (2020) 1 in 10 Americans don’t have enough food. The pandemic is making things worse. Available from https://www.pbs.org/newshour/health/1-in-10-americans-dont-have-enough-food-the-pandemic-is-making-things-worse


Silva C (2020) Food insecurity in the U.S. by the numbers. Available from  https://www.npr.org/2020/09/27/912486921/food-insecurity-in-the-u-s-by-the-numbers


Snowbeck C (2020) Born in grief. A mother’ death highlights pandemic’s racial disparities. Available from https://www.startribune.com/hispanic-new-mother-s-covid-19-death-shines-light-on-ethnic-disparities/572305372/


Sullivan K (2020) Black Americans are still dying of cancer at the highest rates. Available from https://www.nbcnews.com/health/cancer/black-americans-are-still-dying-cancer-highest-rates-n1240208


Taxin A, Melley B (2020) New California reopening rules require “equity” measure. Available from https://abcnews.go.com/Health/wireStory/california-reopening-rules-require-equity-measure-73377271


Wan (2020) Coronavirus kills far more Hispanic and Black children than White youths, CDC study finds. Available from https://www.washingtonpost.com/health/2020/09/15/covid-deaths-hispanic-black-children/


Zenooz (2020) The power of diverse and inclusive research to improve heath disparities. Available from https://www.wheel.com/companies-blog/power-of-diverse-and-inclusive-research-to-improve-health-disparities/?utm_content=138487314&utm_medium=social&utm_source=linkedin&hss_channel=lis-o0ssjtvog4





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