The Fight for Healthcare Equity after COVID-19

Q: What have we learned about systemic racism and health as a result of COVID?

Dr. Cecelia Calhoun: COVID magnified health disparities that have been there a long time. But it wasn’t just our healthcare system in isolation Simultaneously, we had hyper attention on our political environment. We had civil unrest that heightened people’s awareness of social injustices and racial inequities. The mix of multiple factors revealed just a huge, huge issue as everybody was paused in the pandemic. This worldwide event made inequities very salient during a moment where our societal and moral compasses were being realigned and challenged.

Dr. Howard Forman: The metaphor that I’ve been using is that we pulled off a small Band-Aid to reveal an enormous, shocking wound. As Cece said, George Floyd’s murder galvanized everybody to really reflect. It was not just about COVID anymore, it was about systemic racism that permeates everything we do. It’s painful whatever your race. It’s painful if you have any humanity at all.

Q: How do you convey the inequity within the framework of COVID?

Forman: Early on Tom Hanks was diagnosed with COVID. Canada’s prime minister Justin Trudeau quarantined when his wife was diagnosed. There was this initial sense that rich people who travel and network a lot were the ones getting COVID. Then, very quickly, it migrated from the aristocracy to the exact opposite—the essential workers who keep trains, school buses, and grocery stores running. People who, disproportionately, are from the poorest, most vulnerable populations.

Early on, when testing was almost impossible to get, I knew rich people who were getting tested. Later they were the ones getting access to novel therapeutics like convalescent plasma, which turned out not to work so well, and monoclonal antibodies, which did. One group had access to that and another group didn’t.

Calhoun: It’s a privilege not just to get tested or to access novel therapeutics, but to say, “Hey, I’m going to work from home today.” That’s not a choice that everyone had. People had to go to work to survive, knowing that if they contracted COVID, it portended not only a worse prognosis but might expose everyone in their multi-generation household where quarantining wasn’t possible, because you don’t have multiple bedrooms.

It’s analogous to many of the patients that I care for with sickle cell disease, who have to decide, “Do I pay for my medication that may prevent my chronic disease, or do I buy dinner, or do I pay rent?” Populations who are disproportionately affected by disparities are faced with impossible choices.

Forman: A piece I co-authored for the Journal of Hospital Medicine pointed out some of the disparities. During the pandemic, one in three White workers had the option to work remotely. For Black workers, just one in five had the option. And a study from early in 2020 in Louisiana found 77% of the hospitalized COVID patients were Black and 71% of those who died were Black, even though just 31% of the state’s population is Black.

This persists now. Mississippi is the state with the largest Black population, percentage wise, and the lowest rate of vaccination. There are lots of reasons why some states are doing better than others when it comes to vaccination; race and poverty play in. The governor of Mississippi is making a lot of excuses, but there are things we can do. When we don’t do them, we’re making an active choice. It’s driving me crazy. We’re dooming populations to future outbreaks that richer states are likely going to avoid.

We’ve got a window of time during the summer to act aggressively and try to get vaccines out to everybody. That doesn’t mean forcing vaccines on people. It does mean making vaccination easy and accessible, making it possible for people to have a thoughtful conversation about why they might want to be vaccinated. This is our opportunity right now.

Calhoun: I totally agree. The efforts to make the vaccines available need to be aggressive in order to prevent future harm. We must have persistent and consistent effort to make sure that there are no barriers to access for populations. Individual and community conversations encouraging peers and colleagues to get vaccinated must continue. These micro conversations are so important in addressing hesitancy.

I tell my patients, who are primarily African American, “Yes, I got the vaccine, and I did this for us.” Black patients who know their Black provider got vaccinated are more willing to think about it.

Forman: You can’t deny the very clear difference in the way Black Americans experience life in America from the way White Americans do, whether it’s policing, whether it’s access to neighborhoods, mortgages, or the voting booth. All these things start to add up to why certain communities end up with less than their fair share of the full freedoms that America offers.

Vaccine hesitancy is one of the clearest examples. When I talk to Black physicians, people who are my peers in every possible way, they have a different experience around accepting a vaccine than I do. As a White male, I don’t have a lived experience of being threatened through government or healthcare. Black Americans have had both.

Q: In an opinion piece in USA Today, you cited research showing Black patients seen by Black doctors are more likely to receive optimal care. But the numbers alone are a hurdle. The Black population is 13% of the country while 4% of doctors are Black.

Forman: Bringing underrepresented people of color into medicine is a chronic problem and it’s not simple to solve. It’s certainly not a problem just at the medical-school level. If we’re impoverishing people at birth and giving them poor education in grammar school, don’t expect that they’re going to suddenly jump over hurdles later on in life.

Calhoun: I am a doctor because I had a mentor from a high school that I had a scholarship to. Kids have to know professional careers are something that’s accessible to them, and they need support throughout the educational pipeline.

Q: As doctors are being trained, as they’re practicing, how do you make sure that the care they’re delivering is equitable?

Calhoun: Health equity is a quality measure. If we, as healthcare providers, are intent on providing quality care and wellness to our patients, then we have to think critically about equity. We have to weave equity into the fabric of everything that we do, every program we design, every interaction that we have on a provider level, a clinic level, a systems level, and an organization level. It’s important for us to have equity at the forefront of our mind because, again, it’s persistent and aggressive effort that’s going to mitigate these inequities and let us do our job and provide quality care.

Naming structural inequities is absolutely critical in developing solutions. But the fact of the matter is that it has taken hundreds of years to create this system. Racism is fundamentally integrated in ways that we see clearly and ways that we don’t. It’s going to take a long time and a consistent effort to dismantle it.

It gives me hope that our culture as providers is changing. We’re listening to our patients—what their needs are—and meeting them in that way. We’re being less prescriptive, telling the community what to do, and instead having a knowledge exchange where the community’s concerns are heard, listened to, respected and then addressed in a thoughtful way. That’s promising.

I believe that providers have the best intentions; they want to provide the best care. There are times when my colleagues maybe aren’t necessarily aware of their unconscious bias. When there are microaggressions or major issues, we have to hold our colleagues, our students, and our trainees accountable in the clinic setting and everywhere else. That’s how we support people of color in all those spaces.

Q: The piece in USA Today mentioned the importance of trauma-informed care. What is that and is it something providers should have in mind with every African American patient?

Calhoun: Trauma-informed care is understanding that African American patients likely have a history of negative experience with the health system. A healthcare system is a microcosm of society as a whole. One’s experience as a Black person navigating a racist society, no matter what your socioeconomic status, has been traumatic.

We have to understand the historical context is different, how people feel in terms of safety within the healthcare system is different, the emotions involved are going to be different. The traditionally paternalistic system where the doctor says, “You should do this thing to get better”— that’s going to impact the way that you connect with your patients.

Trauma-informed care is delivered from an empathetic perspective of the person that you’re serving. It’s transparent about lack of knowledge. It foregrounds cultural humility. Those things are important because they help providers understand our biases and also help us understand the perspective of the patient which I believe is a central tenet of providing good care.

Q: How does structural racism shape the access and quality of healthcare for African Americans?

Calhoun: Being African American in this country is a health risk. COVID made that clear, but it isn’t something that’s new. It has a more public stage now. We’re starting to have important conversations and to pinpoint very concrete things, but part of why it’s hard is that structural racism is pervasive.

If we are raised in or have been acculturated to a system that is inherently racist, then whether it’s conscious or unconscious, that’s going to show up in every area of our lives, including healthcare and how we treat people and patients. There are so many manifestations that it’s hard to call them out.

There’s literature that supports pain is undertreated in African Americans, just based on them being Black. There’s literature on drug access. In primarily African American zip codes, certain medications aren’t available.

I treat primarily African American patients with sickle cell disease. Pain is a symptom. A lot of my patients have hesitancy going into the emergency department because they don’t want to be seen as drug seeking.

There’s also an issue of health literacy and understanding in our community to a certain extent. You have to be able to speak the language and jargon of the healthcare system to be able to navigate it.

These are all examples of structural racism impacting care.

Forman: There are so many problems that are intertwined. Recently, I was reminded that we have different standards for renal function based on whether you’re Black or not. That bias was built into the system because we thought we were doing the right thing. The distribution of renal function looks differently for two populations, so we create a different standard for Black people instead of recognizing that we don’t treat the underlying reasons for why Black people’s renal function is lower than White people overall. We’re essentially dooming people to worse outcomes by telling them that their normal is different.

Some of it may be explicit racism, but some of it is innocent—well-intentioned but still pernicious, racism that’s truly structural. Unless you really investigate, become aware, develop evidence, and build a new understanding that is used to inform policy, it just repeats itself.

Calhoun: Each example of bias has to be dismantled. And because it is so built into the system, making the policy-level changes is where the change can become sustainable.

Q: Are there broad policy-level changes that would make a big difference?

Forman: There’s no silver bullet. This requires, as Cece said, work from the ground up. It is a mammoth undertaking. We’re at the beginning of a long struggle that, just like the Civil Rights Movement, won’t come and go in one decade. We have to address health equity as a multi-decade undertaking on par with defeating cancer.

Calhoun: With something as big as healthcare equity, there’s not one policy that will solve it. There’s not one metric that will let us know we’re making progress. It will be iterative. With COVID, we’ve learned from mistakes and gotten better. I hope that we continue this momentum. I am concerned that the sense of urgency may be lost, but I hope that that’s not the case.

The pandemic is a case study that we need to learn from, not only for the ways in which the system perpetuates inequities but for examples of the system thinking critically and finding actionable opportunities to mitigate inequities. A community of scholars and healthcare providers at every level understood there were inequities early on and there have been real efforts to mitigate barriers and access issues with vaccines. The healthcare system acknowledged the bias and tried to overcome it by engaging community leaders and key stakeholders and dispelling misinformation.

Yale Insights published an article about the potential of accessing vaccines through dollar stores. That would be an example of bringing treatment to the community and not requiring the community to come to the healthcare system, which can be traumatic. It’s not just issues of time off, transportation, or other social determinants; it’s stressful coming into a hospital as a person of color.

I think the concerted effort to improve access to vaccines, particularly for high-risk populations, is an example of the system being thoughtful.

Q: Health equity is important simply as an issue of fairness and morals, but from a utilitarian perspective, would the U.S. be better off if we address systemic health inequities?

Calhoun: Absolutely. Dr. Camara Phyllis Jones was a recent presidential visiting fellow at the Yale School of Medicine’s Office of Health Equity Research. One of the things that she talks about is that healthcare disparities are a burden to society as a whole. Mitigating disparities, improving equity, benefits us all.

What we have to realize is that whether we like it or not, we share the same country, we share the same pool of resources. Increasing health equity helps us use those resources more efficiently.

When there’s a sense of scarcity, we may give in to an urge to hoard. Think of toilet paper when the pandemic started. Giving in creates panic and makes things worse. If we find the human generosity within us, we all are much calmer, we’re all better off. I think that is true of health equity.

We spend more on healthcare than any other country, yet we don’t get better results. Addressing inequity is a step in the right direction for improving our healthcare spending, our healthcare outcomes, and our society as a whole.