Coronavirus in Context: The Impact of COVID-19 on Minority Populations

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You're watching Coronavirus in Context. I'm Dr. John Whyte, Chief Medical Officer at WebMD. Today, I want to spend a few minutes talking about the disproportionate impact that COVID-19 has had on minority populations. To help provide insights, I've asked Dr. Utibe Essien, Assistant Professor of Medicine at the University of Pittsburgh School of Medicine to join me. Dr. Essien, in some cities, 60% of the cases of COVID-19 and 60% of the deaths are in people of color. Why are we seeing that?

Yeah, I think it's such a broad problem right now. We've-- those of us who are health equity researchers, those of us who are physicians of color, have really been trying to drive this idea forward that, unfortunately, it's not surprising that we're seeing these disparities that you just noted.

Disparities in COVID-19 track so consistently with the disparities that we see in cardiovascular disease, in hypertension, in diabetes, in obesity-- three of the common risk factors, clinically, that are really driving the death and severe infection from COVID-19. But they also track consistently with the social factors that are really putting individuals at higher risk, whether it's homelessness, incarceration, or food insecurity. All of these both social and clinical factors are, again, consistently going along with the disparities that we're seeing in COVID-19 as well.

Is it primarily an issue of access to care? Is it the issues of underlying conditions, as you pointed out-- a greater percentage of hypertension, diabetes, obesity? Or is it the fact that, in many areas, it's minority populations that are driving the buses, doing some of the cleaning services in buildings that are in areas where there's more population density and, perhaps, greater exposure?

Yeah, I think you nail it on the head there, where the three buckets that I have been thinking about this problem with do lie exactly in that-- both access to health care, clinical risk factors, and social risk factors. I think in the "access to health care" risk factors, one can think about, who had the opportunity to, quote unquote, "ask their doctor about their symptoms when the pandemic first began?"

We know that nearly 27 million Americans are uninsured right now, with a higher proportion of that group being from Hispanic and African-American backgrounds-- in turn, not able to actually ask their primary care doctor, quickly, about their symptoms.

We mentioned the clinical risk factors, as well as the social risk factors, that are putting individuals at higher risk of being, quote unquote, "essential workers," whether it is riding-- driving the buses or the subways, as you mentioned, or those who are delivering our food and groceries for those of us who have the privilege to work from home, or those who are the custodial staff in the hospitals-- environmental staff that me and my colleagues are often thought to be, actually, when we go onto the hospital floors.

And so I think it's really just a crisis that, put together each of these three buckets of factors, um, and that's what's really driving the COVID-19 disparities right now.

JOHN WHYTE: Another interesting data point that I found, Dr. Essien, is sometimes people associate the prevalence in minority populations correlated with socioeconomic status or income. It's not about being poor, because there's data points that showed, even in wealthy minority populations with above average wealth and health, they still bore an unequal share of deaths. So how do we explain that?

Yeah, so that exact point is the reason that I am a health disparities researcher. Back during my intern year, I saw a paper that similarly came out and showed that, regardless of your income bracket, your socioeconomic status, African-Americans were dying at the same rates-- or at higher rates, rather-- than their white counterparts. And it made me wonder, because, again, I was trained to believe, in medical school, that it was education, it was income, it was access to insurance that were the big drivers of racial disparities in care.

But when I came across that paper and the data that you just reported right now, it is quite clear that it's beyond that. And I think we can think about factors such as discrimination, whether it's the microaggressions on a daily basis that influence the very cells of our bodies, or it's the larger factors that we see on a day-to-day basis as well.

I think bias in care-- whether you are rich or poor, we see, especially in maternal health, for example, how that bias really does play a role in the care that individuals of color, and specifically black Americans, receive in our country. So I think pushing the envelope, thinking beyond social determinants, is really important as we address the disparities of this crisis.

And obviously, we can't ignore what's happening in the current news cycle with the killing of George Floyd. How do the protests and the desire for equity and justice play into these issues of health disparities?

Yeah, I think that's a really important question. I've started to do a little bit more history-- looking back and seeing what happened in 1918 around the flu pandemic, what happened in 1968 around this other H3N2 pandemic that I'd never heard about until this weekend-- and seeing just how consistently there are those times of real difficulty, both from a health standpoint and a socioeconomic standpoint, just as we're seeing today, there happened to be protests, and riots, and unrest in the same way that, unfortunately, we're seeing right now with the unfortunate death of George Floyd.

I think it's come to a head-- as I mentioned, those three buckets of clinical factors-- the disproportionate toll that the COVID-19 pandemic has taken, and this idea that racism is a public health issue. It can no longer just reside in the desks of journalists and reporters. We really, as physicians, have to start thinking about how this pandemic, in and of itself, is affecting the health of our patients.

And so I think, whether we're thinking about protests or thinking about how folks can safely express their views on this issue, those of us who are physicians, those of us who have an opportunity to educate the community and future trainees, really need to think about how to thoughtfully incorporate racism into our practices and teaching.

Well, let's spend a few minutes talking about, what are potential solutions? I know none of us have a magic wand to wave over and make everything equal. But what do you see as the couple of things that we can do, both short-term and long-term, to address these issues of disparities?

Yeah, I think, on the short-term, we really need to have access to data. Just last Thursday, the federal government offered that every state and local department would need to provide race and ethnicity data on every COVID-19 test. I think making sure that everyone has access to health care is still a pressing issue-- like I mentioned, the millions of Americans who remain till this day uninsured.

On the long-term, I think we need to diversify our workforce. I trained in Boston, where we know that nearly 70% of the individuals who are COVID-19 positive in the hospital, um, that I trained were Spanish-speaking. And we just didn't have the population of providers to actually, literally relate to the information around that severe new infection to that patient population.

And so diversity in our workforce is important, both at the front lines level, all the way up to leadership-- and even more broadly, just reminding ourselves that, again, this is not new. We have the tools that came forth and the H1N1 crisis in 2009 that also-- where we also saw, rather, theses stark racial disparities. And we need to just go back and take a look, dust off those papers, and see what we can do now to help address this current pandemic.

Sometimes when we're in the health care system, our immediate reaction is, they need to have more access to health care and more equity in terms of how health care is delivered. But it's also these other elements, too. And I don't want to lose sight of the role of nutrition and exercise, screenings. How does that all weight into your decision-making as to what we need to do?

I think that is super important. That's the highest level of the factors that plays a role in this current crisis-- the fact that there are still individuals residing in food deserts, where the closest supermarket is the bodega that doesn't have access to the fresh fruits and vegetables, like you mentioned, the fact that there are still individuals who are living g-- multiple generations in a single-family apartment building, again, that don't have the opportunity to socially distance, like we've been talking about over the last two or three months in this current crisis.

And so all of these social factors, as a public health researcher, are the ones that I think about far beyond the time that our patients come to us in clinic with these chronic conditions, like diabetes and hypertension. What happens that actually makes them at higher risk for those conditions? We just know that they're the social factors that they're living and residing in.

You talked about diversifying the workforce. There's data that shows the number of black men in medical school hasn't changed much in 50 years. The number of black women have increased, but the number of black men has not changed much at all. This is a longer-term strategy. What are the two or three things that we can do in order to help more minorities enroll in medical school?

So I think what we're doing right now is important. Having a conversation between the two of us, showing that black physicians do exist and are doing well in their careers, I think, is really important. My father is a physician, so I had the opportunity to see that face every day coming home, for better or worse, during stressful times in residency for him when I didn't think I'd ever be a physician.

But I think it means something really important to see folks who look like you in the field that you're going into. So I think that's an important first step. And that can be considered a short or long-term step. I think taking a step back-- and somewhere where we, as physicians, may not necessarily have the same foothold in, though, is thinking about the pipeline.

Medical students don't get created in medical school. Medical students had to be premed. They had to do well in high school to get into undergrad. And even their middle school influences the way that they do in high school, as well.

And that's something that we may feel like, well, as physicians, we just need to focus on our patients and our communities. But the role that we can play in helping build up the pipeline along the way is something that's important. And I know that several medical schools around the country are starting to do that hard work of going deeper beyond the premed solutions to look at the downstream pipeline as well.

What makes you hopeful?

That's a hard question. Really, honestly, difficult to be hopeful right now. The last two weeks have been really challenging and difficult. Um, I had mentioned on social media that faith, family, and the future are the three things that are keeping me going. As a man of faith, I have hope that things can always be better and that everything happens for a reason.

My family has always been there for me through the hard parts of medical school, residency, being premed. And several times, I didn't think being in this position right now would be possible. And I think the future holds a lot of opportunities and possibilities.

You mentioned that, 50 years ago, the numbers of black physicians have not changed much. Well, 50 years ago, the cardiovascular mortality, for example, in the black community has been much higher than where it is right now. Access to care in the black community was much lower than what it is right now. So I do think that we're bending the arc towards justice, as Dr. King says. And I'm hopeful that, in another 50 years, we'll be having a very different conversation.

Well, I want to thank you for providing your insights today.

Definitely. Thanks so much, Dr. Whyte, for having me. I appreciate it.

And I want to thank you for watching Coronavirus in Context.

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