“…such disparities, which are biological in their expression but are largely socially determined” – Paul Farmer, MD
I read this quote, and now more than ever, I find that it resonates with me in a new way. I am a nocturnist at a community hospital in one of the most diverse cities in our country, where over 150 languages are spoken by its residents. The last 4 months have been emotionally tumultuous trying to balance duties as a good citizen, a physician, a wife and a mother. However, there is another dimension to this pandemic that is even more disturbing albeit not surprising.
Let me briefly illustrate a usual night at the hospital. During my last shift, I assumed the care of 4 patients with COVID-19, and it was not hard to ignore the common denominator, not just among them all, but with many of the others I have been providing medical services to in the past few months. These were not the typical old and morbid, but young, 30-50-year-old, non-white individuals who came gasping for air. Two men, two women. 3 Hispanic, one African American. Three were ‘essential workers,’ working at a fast food chain, a garbage facility, a construction site and one for a haughty boss who refused to shut down a non-essential business. All work part-time for minimum wage, benefits being a far-fetched thought.
Despite the gravity of their illness, all are anxious how many days of missed work and pay this illness will translate into. In addition to the daily anguish of supporting dependent families and paying basic bills, now there is anticipation of the daunting hospital bill and financial strain they will be left with, if they pull through at all. If I were to expand the radius, there are many more similar patients (predominantly racial minorities) who have remained committed to the stay at home orders but have other household members who are a part of the essential work force. The water in their eyes and the rapid breathing not only reflects the physical fight against the cytokine storm but also the upstream struggle to keep from drowning in the whirlpool of these social problems.
This pandemic has not only decimated tens of thousands of lives and the economic stability of our country but also once again surfaced the dark reality of social inequity that lurks deep in our healthcare system. Medical and news journals have been highlighting the discrepancy in mortality rates of African Americans afflicted with the virus. However, the disparity extends far beyond just this group.
Being on the front lines not only brings validation to these reports but also unveils the true perimeter of the disparities that are deeply rooted in our social fabric. The CDC reports that almost half of the young 18-44-year-old patients that tested positive are non-white, and about 1 out of 3 patients are Hispanic. This is undoubtedly an underestimation of the racial disparity not only because racial and ethnicity data are known for only over a third of all known cases but also because most in these groups do not have the resources for testing (including the time off from work to address non-severe symptoms, as one of the above patients shared with me). Most racial and ethnic minorities don’t even seek healthcare until symptoms are unrelentingly unbearable and start interfering with fulfilling work responsibilities.
These minority groups represent the workhorse of many essential services but sustain themselves at minimum wages without any benefits. The “working poor” represents those Americans working full time but earning less than 200% of the federal poverty line. African Americans and Hispanics are more than twice and three times as likely than Whites to fall under this category. As per the U.S. Bureau of Labor Statistics, Hispanics account for 17% of total employment. However, over half of them represent occupations related to construction, maintenance, painting, housekeeping or another service industry. A similar proportion of employed African Americans occupy the service industry, including transportation, and security guard jobs.
Viruses don’t discriminate, but minority groups are rendered more vulnerable to exposure and are less likely to be able to obtain timely healthcare because the basic social determinants of health will not be on their side. The deadly intersection of poor environmental health, higher tendency of exposure to the viral agent and the chronically infirm host (often undiagnosed by virtue of lack of basic healthcare) is the basic tenet of infectious disease epidemiology and illness.
We have many lessons to learn from this pandemic. In this proud country that was built on hope, liberty and justice for all, its people, irrespective of their color, should not be deprived of basic healthcare. The essential foundation of our nation has been struck at the core. Decision makers may not find racial and ethnic disparities a priority at this point in history, but it is unfortunately an integral part of the engine of this pandemic. We doctors implore our government, policy makers, healthcare leaders and all those fighting over the legitimacy of the virus that we need effective solutions, and fast.