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Health Disparities in Communities of Color During the COVID-19 Pandemic

2020; Mary Ann Liebert, Inc.; Volume: 4; Issue: 1 Linguagem: Inglês

10.1089/heq.2020.29003.rtl

2473-1242

Mary Cataletto, LeRoy M. Graham, Michelle Yu, Michael B. Foggs,

Vaccine Coverage and Hesitancy

Health EquityVol. 4, No. 1 Panel DiscussionOpen AccessHealth Disparities in Communities of Color During the COVID-19 PandemicModerator: Mary Cataletto, Participants: LeRoy Graham, Michelle Yu, and Michael FoggsModerator: Mary CatalettoClinical Professor of Pediatrics, NYU-LI School of Medicine, Mineola, New York, USA.Search for more papers by this author, Participants: LeRoy GrahamPediatric Pulmonology, Founder & Medical Director, Not One More Life, Inc (member of the Asthma & Allergy Network).Search for more papers by this author, Michelle YuDivision of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, California, USA.Search for more papers by this author, and Michael FoggsMedical Director, Advocate Health, Chicago, Illinois, USA.Search for more papers by this authorPublished Online:30 Dec 2020https://doi.org/10.1089/heq.2020.29003.rtlAboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail DR. MARY CATALETTO: Welcome to our panelists and readers. We are here today to discuss disparities in SARS-CoV-2 infection and the impact of COVID-19 in communities of color in the United States. Pediatric Allergy, Immunology and Pulmonology is a peer reviewed journal designed to promote understanding and advance the treatment of respiratory, allergic and immunologic diseases of children. Today's panelists come to us with backgrounds and experience in Pediatrics, Public Health, Allergy-Immunology and Internal Medicine.Early in the COVID-19 pandemic few centers were collecting data on race. In fact at the time of this panel discussion only 12 states were collecting data on race. So our first question is why is the inclusion of race so important in data collection both in the pediatric and adult populations.DR. LEROY GRAHAM: I think it is absolutely important to collect this data, and that it needs to be collected accurately and consistently. For far too long, there have been persistent healthcare disparities in the United States. Political agendas come and go, and have not really made a substantive change in this area.I think the data is both striking and informative. And in that sense, I think the absence of a coherent plan for collection undermines or underestimates the problem, which has actually gotten considerably worse during the pandemic.DR. MICHAEL FOGGS: I agree that this is very important. The establishment of a formalized database will allow us to identify the nature of the disparities that exist within different demographics, especially within ethnic subgroups. This can become critically important in terms of looking at gene-by-environmental influences in association with genotypes and phenotypes, and also epitopic changes that may be associated with heightened expression of the virus in association with comorbidities.In addition, from an economic standpoint, if you can identify highly at-risk subpopulations within the United States, you may be able to better allocate resources for addressing some of the problems that are directly associated with the disease state, but also associated with some of the social determinants of health care that put that group at risk in the first place.DR. MICHELLE YU: I would definitely echo that the need for collecting this data comes from needing to understand the social determinants of health. And while the focus of today's talk is on children, I think there are a lot of lessons that can be learned from adults, including anticipating outcomes in impacted children and potentially on future generations, because what impacts the adult caregivers of these children is going to impact how these children grow up and the opportunities they are given.There are a lot of important questions that still surround how we are doing surveillance on a national level.DR. MARY CATALETTO: Thank you. What factors do you feel are responsible or account for some of these disparities?DR. LEROY GRAHAM: I think the answer is always access to care. And I think that some of the disparities we are seeing, to the extent that they reflect comorbid conditions of long standing, be it in a parent, be it in the child, I think these are at the heart of the severity that we are seeing.Many people that I have talked to, speak of not being able to get care or not being able to get quality care. While health literacy may play a role, health care systems also contribute to this disparity. These are the things that I think are slightly below the surface and may escape a cursory review of the data.DR. MARY CATALETTO: We have briefly touched on access to health care and health literacy. What other factors do you feel play important roles, for example, socioeconomic factors, air quality, genetic susceptibility and immune function?DR. MICHAEL FOGGS: This is a new pandemic, and the ability for this virus to inhibit early innate immune responses and to inhibit adaptive cellular responses has just been studied, and so that for some individuals there was an immune invasion, that resulted in a proclivity towards infection with the virus in association with comorbidities such as metabolic syndrome, diabetes mellitus, obesity as well as heart disease and some other conditions.So to that extent, I think the research is in its infancy for ascertaining exactly what role those comorbidities are having in association with heightened expression of the virus in any of the population, let alone a subpopulation of minorities.I think access to care is critically important, and as Dr. Graham has mentioned, the quality of care and the continuity of care are essential. Access to care is available for virtually everyone in an emergency department setting. But that is not high-quality care from the standpoint of longitudinal care that has continuity of care associated with health care delivery.And as it relates to the comorbidities, I think it is multifactorial. I think part of it is socioeconomic. Part of it is lack of trust of health professionals based upon infringements in the past, and I think another part of it, (which it has not given enough attention to in my opinion), is the health-seeking behavior and risk-taking behavior in some minority subgroups of the population as it relates to their knowledge base about the importance of adopting certain habits and avoiding certain risks.In addition, there is the whole issue that is still also being debated as to what the role of vitamin D is in the expression of COVID-19. It has been proven unequivocally that vitamin D stimulates the production of natural antimicrobial peptides, specifically beta defensins and cathelicidin, and to that extent decreases the prevalence of pyogenic infections as well as viral infections, and decreases the frequency and prevalence of respiratory tract infections caused by typical microbial agents.And so by extrapolation, it has been surmised that perhaps a subset of the population has an increased proclivity for the COVID-19 infection, is associated with either vitamin D insufficiency or deficiency. We know that the overwhelming majority of the African-American population for a number of reasons has low vitamin D levels, using the standard cutpoints, 30 ng/mL being normal, up to 100 ng/mL.And so to that extent, we already have data collected extensively on African-American communities corroborating the notion that vitamin D levels are indeed low in the majority of that population, but it does not mean by extrapolation that the prevalence of COVID-19 is higher for that reason or that the morbidity and mortality is higher for that reason, but is certainly, if that turns out to be the case, it is something that can easily be remedied by taking adequate doses of supplemental vitamin D and spending adequate time outside getting abundant sunlight for a limited period of time.DR. MICHELLE YU: The question of comorbidities is a fascinating one. The CDC puts out these weekly updates, and the last one from July 4th. They looked at the comorbidities in the different age groups, and there are a few that overlap and a few that do not overlap. Asthma is one that did overlap between the pediatric group up to age 17, and the adult group, greater than 18 years of age.And that is a fascinating one, because it begs questions about the immunophenotyping—is it more of a Th1 or Th2 kind of response that is protective against the virus? And an interesting comorbidity that did not overlap was diabetes. Type 2 diabetes correlated with high morbidity in the adult group, yet type 1 diabetes with low morbidity in the pediatrics group.And so there are some hypotheses circulating out there that suggest that Th1-high kinds of immune responses actually protect against the virus, whereas Th2 makes you more vulnerable to it.There are also certain populations that we would have expected to get a lot sicker that have not. Both children and adults with Cystic fibrosis seem to be protected. Thus, there is an interesting immunologic question here.I do think that even in spite of trying to figure out which comorbidities lend these populations towards being more vulnerable, I think the real, most effective bang for our buck comes from prevention, specifically access to health care, access to testing and access to protective gear, of which masks are the most important of all.And if we take lessons from countries such as Taiwan, which is where my family is from, they have had an extraordinarily effective way of combating COVID-19 by providing masks. They took mask production over from a national, federal standpoint, ensuring production and making sure everybody had enough masks without question. And you extrapolate that to testing and to contact tracing, and just make that be kind of like a baseline standard of care universally for all patient populations, I think that is what we need.DR. MICHAEL FOGGS: I would just like to add, as it relates to asthma, some of the data may be confounding by virtue of the fact that some of the studies—in fact, a significant number of the studies—have lumped COPD and asthma together, and they are quite different diseases, as we know.And in fact, there is ample evidence to support the notion that asthma may increase the risk of developing viral respiratory illnesses, even the common cold virus, the rhinovirus. And there is a reason for that. We know that most asthmatics have type 2 asthma or allergic asthma, and that there is a known synergism between allergen sensitization and viral infections in patients with allergic asthma. They have weaker antiviral defenses and lower interferon production, all of which collectively contribute to the high risk of viral infections in patients with asthma.So this allergen sensitization and eosinophilic inflammation can compromise the integrity of the respiratory tract, and we know that COVID-19 tends to have a proclivity towards the lower respiratory tract in asthmatics as well as in non-asthmatics after attacking the upper respiratory tract in many cases. Although we do not have a full understanding of this pattern, we consider asthmatics to be at greater risk for COVID-19 infection because of an intrinsic impairment of their ability to contain viral microorganisms. And we know that the majority of asthma exacerbations, about 80%, are in fact induced by viruses.DR. MICHELLE YU: I would add that there is a robust body of literature that looks at the social determinants of health and the likeliness of certain populations to develop asthma. In New York City this has been studied very widely. These studies have been replicated internationally to looking at if you lived in cities and were exposed to certain allergens that are thought to be city pests, such as cockroaches and mice, you have an increased likelihood of developing asthma compared to if you lived without these kinds of allergens. Yet in the countryside, it was more protective against asthma.DR. MICHAEL FOGGS Just to piggyback on top of what Dr. Yu said, to my way of thinking, the whole issue of comorbidities has to be interpreted within the context of disease state control based upon early diagnosis and maintenance of those diseases with state-of-the-art optimal therapeutic interventions and behavioral modification. And this treatment has to be individualized.For instance, in the case of asthma, after you have individualized the treatment to establish control, it is critically important to maintain control because we know that poorly controlled asthma remains the greatest risk factor for an asthma exacerbation with any viral infection, including COVID-19. So to that extent, part of the social determinants that are impacting health care outcomes in association with subpopulations that are minority that have higher risk is that they have late diagnosis, late intervention, wrong intervention or no intervention, and also that the maintenance of their disease is not optimal for a variety of reasons, some of which has to do with social and/or psychosocial dysfunctions that are sometimes related to their immediate communities.For example, I live in Chicago, and Chicago, as we all know, is one of the most violent cities in the world. And to that extent, I can guarantee you that many of my patients who have asthma, as well as other diseases, are negatively impacted by the stressful situations within which they live that is contributing to destabilization of their disease states.DR. LEROY GRAHAM: I would add to the points that have been made by both of my colleagues. One of the things I think that is not optimal among people of color, minorities, and African Americans in particular, is concerted efforts to improve health literacy. And part of this I think is due to a receptive factor of historic distrust about information provided. And I think we go back to the Tuskegee experiment and a lot of other things.However, one thing that we have found to have utility is partnerships with validated community organizations like churches, like community centers, like cooperatives. In our experience with Not One More Life, a not for profit organization based in Atlanta, GA, the messages that we are giving are more successfully received.I think there is a lot of distrust in the Black community, some of which, but maybe not most of it, has been earned by historic factors that we are well aware of. But I think going forward, I think we must be resolute in finding those partners that give us validation so that we systematically improve health literacy. This is not a handout, and it is not 30 s at the end of a visit. It is a concerted effort.In an upcoming partnership with the Asthma and Allergy Network we hope to improve health literacy through education. We need to look at these models where we can systematically go into these communities, partner with validated allies to improve health literacy.DR. MARY CATALETTO: What aspects of health care and treatment do you find that is most problematic in communities of color? Are there specific myths or things that we need to focus on?DR. LEROY GRAHAM: I think the concept of an anti-inflammatory agents, particularly in chronic asthma therapy. Many people with asthma still suffer from the idea that "My asthma is fine until it is not." And we have problems with adherence. That is often compounded by dysfunctional formularies in many cases.And I think that what we need to do, and I think this could happen to a certain extent through government action, is that it would make more sense to make things easier to give medications to those people who are the most morbid with it. Because I think what people are finding out all across this country is these populations that have been so poorly treated are very morbid, and they are capturing resources. It is important that there is focused and ongoing the dialogue about access to quality care. There is no reason that people with the most severe asthma should have limited access to asthma specialists. I think this has to be combined with some self-actualization facilitated by effective information and education among those populations.DR. MICHAEL FOGGS: I concur with Dr. Graham's statements and conclusions. When it comes to asthma in particular, whether you are talking about children or adults, as has been mentioned, part of the problem is access to the best medications available for maintaining optimal control of asthma. There are very few generic asthma medications for maintenance therapy.And to that extent, that becomes problematic for many patients if they have infrastructure changes or if they are temporarily without insurance, and one insurance company may have one formulary, another insurance company another formulary. So now they switch medications, and the cost of these medications for many of our patients is actually prohibitive, so it is very problematic.Also, as stated in the current 2020 GINA report for asthma, overuse of albuterol or other short-acting beta agonists as a reliever medication is detrimental because albuterol actually is proinflammatory and has the ability to upregulate interleukin-6 (IL-6), which is a proinflammatory cytokine.So to that extent, the entire paradigm for managing asthma has evolved, and even though GINA has come up with a maintenance and reliever therapy regimen in conjunction with the appropriate combination of long-acting beta agonists in the form of formoterol coupled with an inhaled corticosteroid or monotherapy with an inhaled corticosteroid or combination therapy with as-needed short-acting beta agonist used in conjunction with inhaled corticosteroids. This changing of the paradigm is something that is not part of the new information available for a lot of the primary care doctors, who take care of two-thirds of the asthmatics in America, and quite frankly, not even for some of the asthma specialists.I think these are issues, especially with asthmatics, including pediatric asthmatics, that have to be taken into consideration. And this basic concept can extrapolate to other disease states, such as COPD. But the bottom line is, in order to decrease your risk for experiencing an ominous outcome to COVID-19, it would be essential for many chronic disease states to be under optimal control in addition to your attempting to avoid contraction of the virus in the first place.DR. MICHELLE YU: Two major points I would highlight here are that one way that systemic racism is built into our health care system is through the American version of health care insurance. Health insurance is simply inadequate for a lot of people. And with COVID-19 numbers increasing and job security decreasing for many Americans, as well as the extra federal unemployment benefits ending in this month in particular, we are going to start seeing a lot of people dropping off of the insured or adequately insured group.And with that, I hope our country pays particular attention to how we can get people adequate health care, because we have taken our lessons from asthma, as Drs. Graham and Foggs have said, and seen that even something as simple as the insurance formularies changing every month unbeknownst to the provider or the patient, has triggered so many asthma exacerbations. In my own population of pulmonary patients some could not access their asthma medications or controllers and would come to appointments with asthma exacerbations. And that is potentially life-threatening to them and an added cost to the health care system here; it hurts everybody. With COVID, I hope we learn these lessons, that we have to make sure that everybody has adequate health care insurance.Second, with regards to trying to understand the systemic inequalities that we are seeing in COVID, I do not know how these lessons can translate, but I spent a month in New York City volunteering at the height of COVID in an adult ICU. We would see these systemic disparities happening even in hospitals within the same umbrella system. If you looked at the outer-borough hospitals versus those in the city, the poorly resourced hospitals versus those who had more resources and these might even have been sister hospitals within the same overall, overarching system, the resource poor hospitals did worse. And although all the providers were trying to accept the patients to the places that had the resources, because we could not send them our resources, yet there was still a bottleneck in accepting transfers for reasons that were non-transparent, decisions coming from the "COO level" of the hospital. There were just so many cases where I saw there was this inherent systemic racism.And I do not know how to fix that, but I hope that there are lessons that are learned from that. Even the most basic critical care methodologies that we practice, like continuous renal replacement therapies were unavailable in hospitals in the boroughs. And that is one message that I hope we learn from COVID, is that these systemic racist issues in health care have to be addressed, and this cannot go on.DR. MICHAEL FOGGS: As a corollary to what Dr. Yu said, as it relates to availability of therapeutic interventions, we know that in the African-American asthmatic population, and also in the Puerto Rican population, there is a grossly disproportionate prevalence of difficult-to-control asthma or severe asthma or, in some cases, very severe asthma. And those patients are legitimate candidates for biological intervention with monoclonal antibody therapy.And these therapies are not uncommonly outside the reach of some of the patients who most need it, because they simply cannot afford it, and they are not set up with an institution that has sufficient infrastructure to facilitate acquisition of biologic therapy, which would decrease their need for inhaled corticosteroids and/or systemic corticosteroids, as well as decrease the prevalence of asthma exacerbations.And to date, there have been no data to suggest that biologic therapy for the treatment of asthma in any way increases the likelihood of contracting COVID-19 or that after contraction of COVID-19 it increases its morbidity or increase one's risk for mortality.DR. MARY CATALETTO: How are children being impacted by COVID-19 in the adult population?DR. MICHELLE YU: I think that the social determinants of health are going to be so negatively impactful in minority groups such that it is going to be a question of, are these children from Black and brown communities going to have less access to education, less caregiver support to provide homeschooling if needed, because their caregivers are sick with COVID? Are they going to be, as a result, more likely to get into trouble early as a result of financial hardship?And that is another population that we have not even touched on, where there is an overrepresentation of minorities in the jails, who are a very vulnerable population, too.But I think what is going to happen is that what would have been normal drivers of the socioeconomic disparities in the country are going to widen and get a lot worse because of COVID, but not directly because of COVID impacting the health of the children.DR. MICHAEL FOGGS: The fact of the matter is, no one really knows what the true risks are if children return to school. However, if you look at most of the Western countries, especially in Europe, Ireland, Germany, France, et cetera, and even in another country far removed from Europe, Iceland, they have sent their kids back to school. And in fact, in some cases, they never closed the schools. And they are reporting prevalences that are comparable to other parts of the world, where the infection has been less problematic in association with the pediatric population.That is not to say that it is safe to send children back to school, but if you weigh their not going back to school to the problems already alluded to in association with idleness, lack of interaction with other children and adults, as well as opportunities that present themselves that otherwise would be less likely presented to them if they were in a classroom instead of standing out on the corner kind of hanging out, it becomes problematic, especially when you couple with that situation the fact that many of these families in the inner city are poorer families which cannot afford to provide tutoring for their children and do not have sufficient funds to establish an infrastructure that is permissive for the children to be supervised while they are supposed to be learning online, and when, in many cases, as reported in Chicago, only a third of the children are logging in for the Chicago public school system, so it becomes problematic.And quite frankly, in some of the families, there is lack of executive structure which results in inadequate supervision of these children. And so the school becomes very important, especially when you consider that a lot of these children miss at least one or two meals if they do not attend school, because the school is providing meals for them at least once a day, sometimes twice a day, and sometimes provide them with food to take home with them.So it is a very complex problem. I am not sure there is one single correct answer for one population. But all those variables, in my opinion, must be taken into consideration when any conclusion is reached, especially when you consider that children have overall less morbidity associated with contraction of the infection.DR. MARY CATALETTO: I would like to move to talk about the multisystem inflammatory syndrome in children (MIS-C).DR. MICHELLE YU: MIS-C is a rare syndrome in children associated with COVID-19. Multisystem inflammatory syndrome presents with fever in children under age 21 years, laboratory evidence of inflammation and clinically severe illness requiring hospitalization. It affects 2 or more organ systems (cardiac, renal respiratory, hematologic, GI, Dermatologic or neurologic) and patients are positive for current or recent SARS-CoV-2 infection or have had COVID-19 exposure within the past 4 weeks prior to symptom onset. Other plausible diagnosis must have been eliminated.In adults, we saw more renal than neurologic involvement or cardiovascular disease in the form of strokes and cardiomyopathies.DR. MARY CATALETTO: Do you agree that it is especially important for both children and adults to receive the flu vaccine?DR. MICHELLE YU: 100%DR. LEROY GRAHAM: Absolutely. I would agree. I think the whole idea about immunizations both in the pandemic and in general is critical for ensuring the public health. I work with a fraternal organization where we did about 15 weekly sessions that went out to Black communities. We spent a lot of time just informing people of color about what immunization meant. And we tried to dispel a lot of the misinformation that existed. There is still considerable fear that leads to non-adherence, and we made the point that our population can ill afford the persistence of that.So I think that is going to be very, very critical going forward just in terms of eliminating preventable diseases that we address the issues of historical mistrust. If we do get an effective vaccine against SARS-CoV-2, African Americans may be reticent because they feel that they are sometimes "canaries in the coal mine." So I think we are going to have to really redouble our efforts about getting the message out that, as people of color, we are at a particular risk.DR. MICHAEL FOGGS: In order to help decrease the apprehension that is inherently present, as spoken about by Dr. Graham, as it relates to vaccines and minority communities, we as providers are going to have to have sufficient confidence that the vaccine is safe, or at least reasonably safe, so that that does not increase any distrust that may inherently exist about vaccines in general. And since this is a new vaccine, I will be looking very carefully to see what the data show as it relates to safety, especially in the pediatric population.In addition, because the vaccine is expected, if things go as planned, to be available later this year, or early next year, that will be the same time as the traditional influenza season, and so then the question is raised as to whether or not you should get the influenza vaccine and the new COVID-19 vaccine at the same time, and are there any additional risks associated with concomitant administration of the vaccines, especially in the pediatric population?These are unanswered questions so it is the risk-benefit ratio analysis that has to be carefully analyzed as the vaccine becomes available. As it stands now, multiple companies are expected to have a vaccine available later this year, or early next year. And so the profile on each vaccine may be substantially different based upon which subpopulation was studied most aggressively by the pharmaceutical company and by the outcomes analysis after the vaccine has been FDA approved.DR. MARY CATALETTO: What factors would you look at to evaluate a vaccine for efficacy and safety?DR. LEROY GRAHAM: I think we as medical professionals will want to be sure that the vaccine clinical trials are inclusive of people of color. I think that is a key point.DR. MICHAEL FOGGS: If there are not significant numbers of minorities included in the vaccine studies, then that is problematic, because we do not know if there is a differential response. Part of the problem with COVID-19, as is true with any new disease, is that there are unknown variables that are part of the host-by-environmental paradigm that can impact outcomes, especially in association with manifestation of the immune system.Personally, I would be interested in side-effects, because even if the vaccine is safe, if there are side-effects which are unacceptable, that would be problematic. I would want to know what percentage of the antibodies induced by the vaccine are neutralizing antibodies that have the capability to