In March, just as the pandemic was heating up on the East Coast, staff at Massachusetts General Hospital’s Chelsea Healthcare Center quickly realized its location — just four miles from Boston — had all the earmarks of a possible COVID-19 hot spot. Not only were COVID-19 patients showing up at the Center in greater numbers than MGH’s Boston campus, but they also had noticeably more severe disease, as shown on chest X-rays.1
With a population of 40,000 packed into 2.2 square miles, Chelsea is the smallest and most densely populated city in Massachusetts. Most of the residents identify as Hispanic or Latinx and speak a language other than English at home. Median income is significantly lower than Boston; one in five residents live below the poverty line. Many residents are essential workers in restaurants, childcare facilities, sanitation departments, and manufacturing plants — who can’t work from home and often don’t get paid leave if they get sick.
Physicians and staff at Chelsea Healthcare Center knew the community well, says Patricia Daunais, (R) RTR, operations manager for the imaging department at the clinic, an affiliate of MGH. “But COVID-19 put it really front and center how the demographics here could actually make the community so much sicker compared to other communities,” says Daunais. “This community just was not a candidate to stay safe.”
Chelsea is not an outlier in this. Across the country, the COVID-19 pandemic has thrown inequities in our healthcare system into the spotlight. And that might actually be a good thing.
Bringing Health Disparities in the Spotlight
Just as the death of George Floyd brought systemic racism to the fore, COVID-19 has pushed health disparities into the spotlight. “We now see how we’ve been failing different populations in our community,” says Lucy B. Spalluto, MD, MPH, vice chair of health equity at Vanderbilt University Medical Center (VUMC) in Nashville, Tenn. According to Spalluto, the concurrence of these events has magnified the urgency. “All of a sudden, the whole world became much more aware of the need for change,” she says.
The best care in the world does little good for those who cannot access or afford that care, who do not have the resources to follow treatment recommendations, who do not speak English, or who do not feel welcomed by the healthcare system. COVID-19 points that out like nothing before, says Arun Krishnaraj, MD, MPH, director of body imaging for the University of Virginia Medical Center and chair of ACR’s Commission on Patient- and Family-Centered Care. From the moment stay-at-home orders were issued and non-essential businesses were shuttered, the country was divided — between those who were able to follow recommendations and those who could not.
While white collar workers adapted to working from home, essential workers still had to stock grocery stores or work in the food service industry — often arriving by public transport. Some patients without symptoms had the luxury of getting tested for COVID-19 just out of curiosity, while others experiencing symptoms avoided testing because they couldn’t afford to be sick. Those living in suburban houses with separate bedrooms voluntarily self-quarantined, while those in congregate housing and multi-generational households had no way to isolate themselves from sick family members.
“When the CDC finally released data on deaths by race, ethnicity, and other factors, it became very apparent that Blacks and those who were Latinx/Hispanic were having much higher death rates than other groups,” says Krishnaraj. “Native Americans were also seeing disproportionately high rates of infection in their communities.”
“Why does being Black or Latinx/Hispanic mean you have to die at a higher rate?” asks Krishnaraj. Answering that question may help identify the root causes of health disparities, start closing the gaps, and lead to a more equitable healthcare system, he says. “Perhaps good can come from a crisis like this,” Krishnaraj says. “It can shine a spotlight on the issue. The recognition may compel people to act and put into place systems that could minimize or eliminate health disparities. That’s the hope.”
Increasing Awareness to Drive Change
According to Spalluto, the pandemic has created a lot of necessary interest at the local, community, and national level in understanding what health disparities are and why they exist. “I hope that this very trying time will drive necessary change in our healthcare system,” she says.
In 2016, VUMC established the Office of Health Equity to coordinate and support equity efforts across the institution. “They really try to drive all the departments toward better care and encourage collaboration and cooperation to meet the needs of diverse populations and help build trust in communities,” Spalluto says. “A key piece of this is diversifying the healthcare workforce to better meet the needs of diverse populations.”
“Health equity needs to be integrated into the full triad of academic radiology departments: research, clinical work, and teaching,” she says. “There is systemic racism and bias within our healthcare system, and we need to recognize that if we want to move forward.” According to Spalluto, VUMC prioritizes research projects that involve underserved and underrepresented populations, all while encouraging patient-, family-, and community-centered care that ensures patients from widely diverse backgrounds feel safe in the radiology care environment.
Krishnaraj recognizes that building trust in the current health system is an uphill climb, especially in marginalized communities that have more than ample reasons to distrust the system. Although the progress towards a possible vaccine against COVID-19 gives him hope, he fears that those who need it most will not be willing to get it or to participate in the clinical trials. The Tuskegee experiments and exploitation of Henrietta Lacks eroded trust in the healthcare system, especially among Black patients, he points out. Wealth and education gaps don’t help either. “Members of marginalized populations may have perceptions like, ‘this isn’t the place for me’ or ‘this isn’t a situation that I feel comfortable with,’” he says. “And that’s where patient-centered care comes in.”
Making Patient-Centered Care the Cure
Connecting with patients in ways that put them at ease and help them engage in their care is the key to building back trust and addressing health disparities laid bare by COVID-19, says Krishnaraj. “The primary way we can do this is to ensure that each patient receives the same amount of education, support, guidance, and empowerment throughout the care process,” he says.
For example, patients who speak English have opportunities to ask questions and become active and engaged partners in their care and in shared decision-making, resulting in better outcomes. Patients who speak a language other than English have a much harder time — even with an interpreter available by phone. “We’re not connecting with these patients because we don’t speak their native language, thus we’re not as familiar with what their needs are,” Krishnaraj says. As a result, they are less likely to follow up on care and more likely to miss appointments.
Reframing these situations from non-adherence and no-shows to “missed imaging care opportunities” (a term coined by Efrén J. Flores, MD, officer of radiology community health improvement and equity at MGH) can make all the difference, Krishnaraj says. Something as simple as a voucher for a shared ride service or help filling out a Patient Assistance Programs application can solve a problem like getting to an appointment or filling a prescription. “The first part is just asking the question about what patients need or what challenges they face,” he says. “Even if the radiology department doesn’t have the resources to address the problem, raising awareness of the issues patients face when trying to access care can lead to greater compassion and empathy and improve care for patients.”
Krishnaraj gives the example of colonoscopy. Black people are at higher risk for colon cancer and are also less likely to come in for screening. The preferred screening tool — colonoscopy — requires a full day off from work, which is difficult for many people. However, CT colonography offers an alternative that doesn’t require anesthesia and is less costly, both in terms of time and money. “How can we increase the awareness and access to CT colonography among Black people to improve health outcomes?” he asks. Questions like that can lead to new approaches and solutions that help close gaps in care.
Spalluto urges radiologists to meet their patients face-to-face so they can better understand their needs and build trust with them. While that may be harder than ever while wearing PPE, she says, it’s more important than ever. “We need to help patients feel safe in the healthcare environment, especially patients who were not feeling safe or welcome even before COVID-19.” Spalluto says the increased awareness and discussions about health disparities in her community and across the nation have given her new hope. “It will drive solutions to address those health disparities.”