Unequal Destroyer

COVID-19 health disparities and the search for solutions  

A husband and wife comfort one another during the Coronavirus shutdown on the Navajo nation in Arizona
Image: grandriver / Getty Images

This article is part of Harvard Medical School’s continuing coverage of medicine, biomedical research, medical education and policy related to the SARS-CoV-2 pandemic and the disease COVID-19.

What will it take to end the coronavirus pandemic?

For a number of top scientists and clinicians, the answer is clear: policymakers, physicians and researchers need a better understanding of the political, social and economic forces that are putting some populations at greater risk for the disease.

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And even an effective vaccine or treatment won’t be enough to stop the spread of the virus if it doesn’t reach the people who need it most. Success will require that care be systematically designed and delivered in a way that mitigates health disparities driven by poverty, structural racism and other social forces.

“COVID-19 is an unequal destroyer,” said George Q. Daley, dean of Harvard Medical School in opening remarks at a Harvard Medical School-led Massachusetts Consortium on Pathogen Readiness (MassCPR) public briefing, which was conducted remotely.

“In its destruction, it has epitomized so much of what is wrong and unjust about our society,” he said.

This was the resounding message during the Sept. 23 briefing, where experts discussed health disparities in SARS-CoV-2 infection risk and disease severity and outcomes, as well as possible solutions.

Top physicians and researchers examined the factors that are fueling disparities and outlined possible strategies to address both the critical, short-term needs of populations most afflicted by the virus and the long-term changes needed to address the roots of inequity.

Across the United States, data shows members of several racial, ethnic, and social and economic groups are at much higher risk of coronavirus infection and hospitalization and death from COVID-19 than others.

American Indian and Alaska native populations have hospitalization rates more than five times higher than white, non-Hispanic individuals, and Black or African American people have rates of death that are more than two times the rate of the white, non-Hispanic population, according to the U.S. Centers for Disease Control and Prevention.

The numbers are not driven by biological or physiological differences between these populations, experts said, but by social and economic factors, including gaps in health care, a lack of social supports, and voids in research in underserved communities.

Painfully familiar

Daley noted that the factors behind higher infection rates and mortality in Black, Latinx and Native American populations are both painfully familiar and copiously documented. They include poverty, lack of access to preventive and specialized care, bias, marginalization and chronic, toxic stress.

“This pandemic did not create these inequities, but it has potently magnified them,” Daley said. “It has shown us with full force the lethal effects of chronic problems we have failed to resolve for far too long.”

In the last nine months, SARS-CoV-2 has claimed more than 970,000 lives worldwide and infected nearly 30 million people globally, Daley said. More than 200,000 of these deaths and more than 6.5 million of these infections have occurred in the U.S.

But the harm is not distributed equally across the nation.

COVID-19 has had an unequal impact on racial and ethnic groups and on forgotten populations that are at particularly high risk from infectious disease epidemics, including people experiencing homelessness, incarcerated individuals, and immigrants, refugees and asylum seekers.

To change the equation and more effectively protect public health, the speakers highlighted the importance of greater collaboration between government agencies, community organizations, health care providers and the academy to develop systematic clinical and social care services.

They also outlined an urgent need to include the populations most affected by COVID-19 in outcomes research and clinical trials for new treatments and vaccines.

Physician-scientist Cheryl Clark, director of Health Equity Research and Intervention at the Center for Community Health and Health Equity at Brigham and Women’s Hospital and an HMS assistant professor of medicine, explored how the biological and social determinants of disease and health intersect to amplify infection risk and disease development for marginalized populations.

Early in the pandemic, Clark said she cared for a patient who arrived at the hospital already quite sick, in part because the woman had not been able to get tested in her community when she first began to feel ill. The patient spoke only Spanish and Clark spoke only English. Because an interpreter was not readily available, Clark said, there were delays in delivering care.

Clark used the example to point out that although there are clinical risk factors for severe COVID-19 disease, such as diabetes and hypertension, the narrative behind health disparities is not solely a clinical story.

Systemic social factors such as segregation, uneven distribution of paid sick days, inconsistent workplace safety policies, economic inequality and uneven access to testing put some people at more risk for infection and more severe disease than others, she said, as do discrimination-driven stress and violence, language barriers and concerns about immigration status.

Clark noted that the challenge she experienced communicating with her patient and the challenges the patient had getting the care she needed highlight why there’s a need to develop a structural and systemic health care response that can mitigate the social forces driving COVID-19 in specific communities.

Clark said her team quickly began collecting and analyzing social data about the patients they were seeing. When they saw that the pandemic had caused a 30 percent increase in patients at the hospital who did not speak English, they rapidly increased access to interpreters and language services.

They also provided pop-up testing centers in the communities hit hardest by COVID-19 to screen for SARS-CoV-2 infection and for social risk factors, such as food insecurity. They also worked to ensure that there was equitable access to drugs and to clinical trials across demographic groups.

Clark stressed the importance of collaboration across different teams in the hospital and across the community in order to meet these challenges.

“None of this can be done alone,” she said. “As we are thinking about bridging the clinical, the social and the structural, we have to do that in community.”

COVID-19 and homeless people

James O’Connell, president and founding physician of the Boston Health Care for the Homeless Program (BHCHP) and an HMS assistant professor of medicine, noted that the inequities in the health care system magnified by COVID-19 have been evident for years to those who provide care for homeless people.

He cited a study his team produced that shows that unsheltered homeless people in Boston die at 10 times the rate of the average adult population in Massachusetts.

When news of the coronavirus pandemic hit, O’Connell said he worried about what would happen to those living in close quarters.

“Our big fear was that the shelters would become particularly dangerous during epidemics of communicable disease,” he said.

Because the supply of virus tests was so limited, BHCHP clinicians were only authorized to test people who had potential COVID-19 symptoms, O’Connell said. Using these protocols though March, he said almost no homeless people tested positive. Then a small cluster of cases arose at the Pine Street Inn in Boston.

When the cluster emerged, BHCHP received permission to begin testing everyone staying in the shelters it serves. Workers discovered a vast asymptomatic spread of infection, with an average positivity rate in the shelters of 20 percent from early April to early June. Some peaked at nearly 40 percent infection rates.

One night at the Pine Street Inn shelter, O’Connell said, “147 people tested positive, with nowhere to go.”

The Boston Healthcare for the Homeless Program quickly began working with public agencies and private companies to build a temporary shelter for people waiting for test results.

The program then set up respite care in its own facilities and helped to open Boston Hope, a hospital that included 500 beds for respite care for homeless people who were infected but did not require hospital care.

O’Connell noted that infection rates have since gone down, with less than 1 percent positivity rates in Boston shelters in recent weeks. His program's interventions have seemingly proven effective. While early models predicted high mortality in the homeless population, there has been only one death to date.

Incarcerated populations

Alysse Wurcel, attending physician at Tufts Medical Center, assistant professor at Tufts University School of Medicine, and an infectious disease specialist who consults with Massachusetts jails on COVID-19, discussed how jails have confronted the pandemic.

“We know that there is a synergistic impact of incarceration and infectious disease,” she said. “These are places where there is a high concentration of people who are at high risk for infectious diseases.”

Massachusetts jails were able to avoid potentially dire outcomes by developing a collaborative approach to overcome the challenges that they faced, she said.

The Massachusetts Emergency Management Agency helped jails procure the personal protective equipment they needed for correctional officers and incarcerated individuals. The Massachusetts Department of Public Health provided testing supplies, and the jails partnered with laboratories at regional academic medical centers to do the testing.

Moving into the next phase of the pandemic, Wurcel said the keys to limiting infection and deaths in the jails will be implementing flu preparedness strategies, working to keep incarcerated populations low, and continuing partnerships with industry and academic medical centers.

Asylum seekers and immigrants

J. Wesley Boyd, co-founder and staff psychiatrist at the Human Rights and Asylum Clinic at Cambridge Health Alliance and an HMS associate professor of psychiatry, described the challenges the pandemic has wrought for immigrants and asylum seekers, many of whom have already faced life threatening hardships in their homelands and on their journeys to the U.S.

“When individuals are seeking asylum, the overwhelming majority of them are coming because they face death if they remain in their own countries,” Boyd said.

“If you're gay or transgender, if you say no when you are asked to smuggle drugs, if you refuse to be the girlfriend of a gang member, you're going to be killed,” he said.

On their travels to the border, asylum seekers and immigrants face grave risks of extortion and kidnapping, he said, and as many as 80 percent of women attempting to cross the border may be sexually assaulted.

For those who do make it into the U.S., risks from COVID-19 are quite high, Boyd said. In U.S. immigration detention centers, there is very little screening, poor sanitation, little opportunity for social distancing and very little access to health care when needed.

Solitary confinement—widely considered to be a form of torture—is also being used to contain people who become ill with COVID-19, he said.

To protect immigrants and asylum seekers, as well as the larger population, Boyd said those held in border camps in Mexico — 92 percent of whom have family in the U.S. — should be allowed to enter the country and stay with relatives, where they could isolate safely and reduce the risk of COVID-19 transmission.

People held in detention in the U.S. who have not committed crimes should be released, he said, and new pathways for legal immigration should be opened so the U.S. can take advantage of the benefits that immigrants provide.

He added that asylum hearings, which have been put on hold during the pandemic, should be resumed, and detainees should have access to basic medical care and to common-sense public health measures, like flu shots. He said that last year flu shots were intentionally not given to immigrants held in detention.

Diversity in clinical trials

Barbara Bierer, co-founder and faculty director of the Multi-Regional Clinical Trials Center of Brigham and Women’s and HMS professor of medicine, noted how crucial it is that the clinical trials needed to develop new treatments and vaccines for COVID-19 include participants who reflect the populations most affected by the disease.

Underrepresentation of Black, Hispanic, Asian, Native American, women and other underserved populations has long been, and continues to be, a problem, Bierer said.

Because the COVID-19 disease burden is many times higher for communities of color than it is in white populations, it is especially important to recruit and retain people from these populations for COVID-19 trials, she said.

“You need to have data on the people who are most impacted by the disease,” she said.

Building more representative trial cohorts is a long-term process, with many prerequisites, she said. “It starts with information. It starts with trust. It starts with public and community engagement.”

It also requires a concerted, long-term commitment, she added.

“We need to make sure that we have sustained partnerships. We cannot have investigators popping into a community, taking from that community and leaving,” she said.

Bierer also emphasized that research, collaboration and care delivery must include a broader definition of diversity than just ethnicity or race. She said scientific investigations and health care should work for people of all kinds, across categories of sex, gender, age, race, ethnicity, social status, environmental exposure, comorbidities, concurrent medications, ancestry, genetics and all the other threads that make up the tapestry of human diversity.

The speakers all noted that these approaches require broad collaborations across different facets of the community, involving researchers, clinicians, industry leaders, policy makers, community members and educators.

“Scientists have been working tirelessly to unravel the biology and behavior of the virus and to develop treatments and vaccines for the disease that it causes,” Daley said. “They have made tremendous progress, but all this progress will be squandered if we fail to equalize access and availability for all.”

Led by Harvard Medical School, MassCPR involves hundreds of scientists across 17 institutions whose collective goals are to address both the immediate challenges of the COVID-19 pandemic as well as the long-term need for enhanced preparedness for emerging pathogens like SARS-CoV-2.

MassCPR was made possible thanks to a commitment from China Evergrande Group to provide research funds to Harvard and the Guangzhou Institute of Respiratory Health to study SARS-CoV-2 and COVID-19.