Experts from the front lines of COVID-19 discuss how lessons learned could help close health disparities.
Coronavirus disease 2019 (COVID-19) has exposed weaknesses in the healthcare delivery system and the glaring inequities that result, a group of experts from the front lines of the pandemic said this week during Academy Health’s Datapalooza and National Health Policy Conference.
Academy Health President and CEO Lisa Simpson, M.B., B.Ch., MPH, led the discussion that featured John Brownstein, Ph.D., chief innovation officer at Boston Children’s Hospital; Shereef Elnahal, M.D., M.B.A., president and CEO at University Hospital Newark; Brian Caveney, M.D., J.D., M.P.H., executive vice president, president for diagnostics and chief medical officer for Labcorp; and Kara Odom Walker, M.D., M.P.H., MSHS, senior vice president and chief population health officer, Nemours Children’s Health System.
The mobilization that has occurred to rein in COVID-19, including the data systems developed to track the disease and develop a vaccine, must not be forgotten when the pandemic ends, but instead must be deployed to tackle the health and economic disparities that have led to higher infection rates and more loss of life among minorities, the group said.
It won’t be easy, because the inequities are so deeply rooted, Walker said.
“Many of us are just trying to figure out how we embrace this moment to undo some of the underfunding by government,” she said. “We can't undo 60 or 70 years of a lack of investment in Black and brown communities, just by elevating and talking about it. We actually need to put money into those efforts, that is going to take time.”
Supply Chains a Symbol of Challenges
Caveney said the pandemic has pressed every part of the health system to its limits, including the global supply chains that provide consumables, equipment, reagents and primers, and, as many saw early on, personal protective equipment (PPE).
“The gloves, masks, everything else—all the different components for clinical and drug research” were in short supply, he said. Few appreciate the global of supply chains, or that during the first days of the pandemic, “Some very specific border closures—for both political and health reasons—massively disrupted the supply chain and the ability to move those goods around the world.”
Thus, healthcare delivery relied not only on good clinical care but also on dealing effectively with agencies such as Homeland Security or the the Transportation Security Administration. Caveney recalled one episode that derailed testing early on: “Most of you will remember that the first epicenter outside China was near Milan, Italy. Well, it just so happens that by far the most important nasal pharyngeal swab manufacturer in the world, Copan, is just a few miles east of Milan, which was just down.”
This created the massive shortage of nasal swabs when COVID-19 testing was just ramping up. Business and emergency plans that called for redundancy suddenly became more important than ever. “We made a decision very early on that we needed to make sure we had many different labs all across the planet, but particularly across America,” Caveney said. This becomes important not just in a pandemic, but in events such as the winter storms that have gripped Southern states, knocking out power.
“We're diverting so many clinical specimens, not just for COVID, but for all of the other 5000 tests we do to our other labs,” he said. The United States needs to be more nimble at these types of logistics, “for whatever the world throws at us next, including the next pandemic.”
“It Took This Moment”
Just as the pandemic exposes the need for change, it has also propelled long overdue changes in areas such as telemedicine. “We’ve had a telemedicine program and efforts in digital health for so many years,” Brownstein said. “But it took this moment to bring all these stakeholders together—clinicians, researchers, business leaders, and we’ve seen an unprecedented level of innovation both within our system, but also on a global level.”
Hospitals, which he said “are not known for their agility,” were able to mobilize in novel ways: Brownstein’s own hospital has built a Digital Health Accelerator that was deployed to identify “pain points,” showing where to increase testing capacity and implement contact tracing. Use of telemedicine has soared.
In the process, he said, “We’ve built what we think is the foundation and institutional muscle” for additional data gathering and healthcare delivery, including the leveraging of social media streams. “This is the starting point.”
There were many disappointments and frustrations in the public health arena early on, and information was lacking, Walker said. But she agreed that the ability to pull together a data infrastructure that ultimately guided the healthcare response was a bright spot.
“Ripple Effects” of Inequity Revealed
Walker, who previously served Delaware’s secretary of Health and Services, said the intersection of politics and public health was “pretty shocking and surprising to me, in that we had no ability to bring those two worlds together in a coordinated way as a nation, and certainly at the state level.”
It’s shocking, she said, that U.S. deaths from COVID-19 account for 20% of all such deaths worldwide—a far higher share than its population—because politics overwhelmed common sense, public health guidance. Elnahal agreed, saying anti-vaccination activists have targeted the communities of color that make up 80% of the population near his safety net hospital. It’s taken diligent work to move the vaccination acceptance rate from 40% to 60%.
“I can’t tell you how many times I’ve repeated, ‘Wash your hands, stay away from people, stay home,’” Walker said, and yet economic inequities meant some people could not stay home, because their front lines required them to show up if they were going to pay the rent. “The ripple effects were intense,” and that led to nursing home deaths “the inability to protect our most vulnerable.”
Overall, health systems should have been better prepared. One area where society has been least prepared, she said, “is around the outpouring around anti-racism and around our need to focus on equity.”
The issue of health disparities has been raised in a glaring way, but Walker questions whether the country is ready to deal with this issue in an ongoing way.
“Cracks Became Earthquakes”
Like Walker, Elnahal served in state government as New Jersey’s health commissioner, and taking on disparities was already part of his portfolio before the pandemic. But with COVID-19, “The cracks in health equity essentially became earthquakes in our community.” As a hospital leader just a few months into the job, Elnahal confronted challenges even the veterans he worked with had not faced.
There were nursing-patient ratios like none anyone had seen, pharmacists who worried about running out of sedating medications for the ICU, and, echoing Caveney’s comments, the constant worry about running out of personal protective equipment—while bidding against the cash-rich hospitals that populate the New Jersey suburbs.
“We couldn’t help but notice that every single person in our hospital that was filled with COVID patients was a person of color, and we have a much more diverse community that we serve at baseline,” Elnahal said. “That was heartbreaking.”
Working with allies in the faith-based community to build trust in both COVID-19 testing and vaccination, while promoting social distancing and contact tracing, “has never been more important.”
Beyond COVID-19 to Chronic Disease
Elnahal and other panelists said that if the health system and the pharmaceutical infrastructure can mobilize to get people tested and vaccinated, and develop data systems to track the disease, there’s no reason they should not be able to use this model to take on the other plagues of minority communities.
“What about late stage breast cancer in black women? What about colon cancer and rectal cancer and prostate cancer and black men? What about chronic disease and our communities?” Elnahal asked. “Where’s the will and the effort to do that? We have to make a promise and fulfill that promise to community—that are we begging for their trust at this point on the vaccine, because it impacts all of us—and we have to deliver on that.”
Like Walker, he said that to change outcomes for the long haul, data on health inequities must be put front and center in front of policy makers and health system leaders, “and everyone in between.”