Stay home from work if you’re not well. Stock up on supplies. Avoid close contact with people who are sick.
These are all commonsense guidelines for avoiding the coronavirus that causes COVID-19 — except for the millions of people across this country whose lives make such steps challenging or even impossible.
Homeless people, people without health insurance, those living paycheck to paycheck, and other marginalized groups can’t necessarily afford to miss work and may have no steady health care provider and no way to avoid crowded conditions. They also may lack trust in a system that has failed them in the past.
“Those communities that are marginalized, that are underresourced or underserved, will always suffer more during a crisis like this,” says David Acosta, MD, the AAMC’s chief diversity and inclusion officer. “Any health inequities that they already experience will only be exacerbated by a pandemic.”
In fact, prior experience suggests that viral outbreaks disproportionately impact the poor. For example, flu-related hospitalizations in poor neighborhoods are double those in higher-income areas, according to a 2016 Centers for Disease Control and Prevention (CDC) analysis.
So, experts worry that although emergency legislation the House passed on Friday provides some forms of relief, the outbreak may be devastating for those at risk because of social or economic issues such as racism, poverty, and xenophobia.
The reasons are multifold. Among them are that marginalized populations often live in conditions that fuel ill health, suffer from diseases that could complicate infections, and have trouble accessing care if they need it.
What's more, addressing a coronavirus outbreak among these groups will require creative approaches and extensive collaboration among numerous stakeholders, from policymakers to leaders of medical schools and teaching hospitals.
“Those communities that are marginalized, that are underresourced or underserved, will always suffer more during a crisis like this.”
David Acosta, MD, AAMC Chief Diversity and Inclusion Officer
Edith Bracho-Sanchez, MD, a pediatrician at Columbia University Vagelos College of Physicians and Surgeons, treats children who live in low-income neighborhoods or shelters in New York City. She’s been quite worried about them.
“So many families I see were already struggling at baseline, before coronavirus,” she notes. “They’re working through complicated and ever-changing immigration law, jumping through hoops to obtain federal food and housing benefits, and sometimes dealing with complex health issues. And now we are asking them to follow CDC guidelines, make decisions about the virus, and wrap their minds around fast-moving information. We are asking them to navigate a really complicated system.”
Bracho-Sanchez says she hopes her vulnerable patients will be able to avoid the worst fallout from the novel coronavirus.
But, she adds, “We can’t build solutions on hopes.”
Poverty underpins so much of what makes the coronavirus potentially devastating, experts note.
“There are people who have jobs where they don’t get paid if they stay home — and even risk losing their livelihood,” says Mary Bassett, MD, MPH, director of the François-Xavier Bagnoud Center for Health and Human Rights at Harvard University. “Also, even if they have insurance, many people feel very concerned about what a medical visit will cost,” she adds. “And tens of millions of Americans have no health insurance at all.”
Those who fear a high bill may delay seeking care, a wait that could cause medical complications, notes Barbara Taylor, MD, associate professor of infectious diseases at the University of Texas Health Science Center (UT Health) at San Antonio. Taylor also says she worries about food insecurity and ongoing care for her patients, many of whom have HIV and very tight budgets.
“I like to say that all epidemics are both biological and social. We have to take into consideration the ways in which epidemics … often reveal the fissures within our society.”
Mary Bassett, MD, MPH
There are other issues as well. For one, cramped living conditions and a fast-moving virus make a dangerous mix. That means people living in homeless shelters, prisons, overcrowded apartments, and other tight spaces face a greater risk of infection as well as difficulty quarantining if infected.
In addition, more than 2 million Americans live without access to running water, making frequent handwashing a challenge. The rates are particularly high among Native Americans, who are 19 times more likely than white people to lack indoor plumbing, according to a 2019 report.
Native Americans are also among those who face risks from the virus because of comorbid conditions. For example, 23.5% of Native Americans and 13% of African-Americans have diabetes compared to 8% of non-Hispanic whites. Problems from other concerning conditions, such as asthma, are higher among certain racial and ethnic minorities as well.
And then there’s the burden of stress. “A lot of research shows that stress decreases immune response and makes people more susceptible to disease,” says Philip Alberti, PhD, senior director of health equity research and policy at the AAMC. “We are seeing communitywide stress because of such factors as racism and xenophobia,” he notes.
“Fear that seeking services will lead to deportation or having to report one’s close contacts is another source of stress for immigrants,” Alberti adds. What’s more, such fears may also deter the 10 million undocumented immigrants in the United States and their family members from getting tested and seeking medical care.
Given the many factors that increase risk and hobble access for vulnerable populations, experts note that multifaceted solutions are essential.
“I like to say that all epidemics are both biological and social,” says Bassett. “We have to take into consideration the ways in which epidemics, and emergencies of all sorts, often reveal the fissures within our society,” she says. “And we have to look at the reality that we have not yet achieved a society in which everyone has the right to health.”
Easing the burden of a coronavirus outbreak on vulnerable groups is no simple matter, say experts. For one, financial concerns must be tackled quickly and thoroughly.
Congress is moving to address some of these concerns in an emergency bill that may be signed into law in the coming days.
As currently drafted, the bill provides paid sick leave for many but not all workers. It also enables free coronavirus testing, including for those without health insurance, and allocates significant funding to bolster food insecurity programs.
In addition to addressing economic issues, leaders argue that the government also must make it easier for immigrants to come forward. In a March 11 letter to Vice President Mike Pence and congressional leaders, AAMC President and CEO David J. Skorton, MD, outlined several essential steps for addressing the outbreak. Among them were that the government suspend or withdraw any policies that would deter undocumented or recent immigrants from accessing care. If the government takes any such steps, they must be clearly and thoroughly explained to any concerned populations, other experts add.
Other types of proactive communication are also essential in dealing with the outbreak. For example, the CDC posted a page on its website that urges avoiding stigmatizing certain groups during the outbreak and provides tips for communications that avoid fostering fear.
For Acosta, another vital solution is one that is sometimes overlooked. “Stigma, discrimination, and stress increase mental health disorders. Sometimes, these may not seem as important as some of the other diseases that we take care of, but we need to focus on encouraging people to access mental health services that will help them get through this crisis,” he says. “That’s really critical.”
How teaching hospitals can help
As possible ways forward evolve, teaching hospitals are already working to offer care and other supports to marginalized populations.
At the University of New Mexico (UNM) Health Sciences Center, for example, leaders are acting quickly to train community health workers (CHWs) — front-line public health workers who come from the neighborhoods they serve — to work with vulnerable groups around the virus. In addition to training local CHWs who work in places like homeless shelters, UNM partnered with Project ECHO, a national telehealth effort, to educate more than 120 CHWs nationally.
“CHWs will be able to teach people about steps to prevent the spread of coronavirus like handwashing, social distancing, and wiping down counters,” says Laura Chanchien Parajón, MD, MPH, executive director of UNM’s Office of Community Health. “New Mexico even has CHWs who are homeless themselves, so they can really reach people where they are.”
Because CHWs often are trusted more than the medical establishment, they can also help combat confusion and misinformation. In addition, says Parajón, “not only can CHWs educate people, but we as medical providers can learn from the CHWs about what people actually believe and understand about coronavirus.”
“Our duty is to give our all to our patients and protect as best as we can the most vulnerable among us.”
Janis Orlowski, MD, AAMC Chief Health Care Officer
At UT Health San Antonio, leaders are working on such education efforts as a coronavirus-related video and are collaborating with the End Stigma End HIV Alliance to provide essential information to an email list of 120 members. “Passengers from the Diamond Princess cruise ship are quarantined in an Air Force Base here,” says Taylor, “and people in the community were very nervous. Some were asking, ‘Why are these people staying here? Are we in danger?’ We were able to leverage existing networks to disseminate accurate information.”
Efforts to educate and serve underresourced communities is at the heart of academic medicine, notes AAMC Chief Health Care Officer Janis Orlowski, MD. “This epidemic is testing American society, and it’s testing everyone in medicine. We don’t know how bad things will get, but our duty is to give our all to our patients and protect as best as we can the most vulnerable among us.”