• Rallying My Community to Fight COVID-19, Inequity

    The Latina community (using “Latina” from la comunidad Latina) has been disproportionately affected by COVID-19 in the United States. Hispanics make up roughly 16% of the population, according to the latest U.S. Census, but we account for 26.6% of cases.

    Medical staff member with mask and protective equipment holds Coronavirus nasal swabs test tubes at drive-through testing point in an effort to curb the spread of COVID-19 (novel coronavirus)

    Hispanics have contracted COVID-19 and died at disproportionately younger ages and also have age-adjusted hospitalization rates for COVID-19 that are approximately 4.6 times higher than those of non-Hispanic white people.

    As a member of the World Organization of Family Doctors (WONCA) Executive Committee, I have connections to colleagues in all regions of the globe. In December, I started hearing about SARS-CoV-2 and its effect on communities from family medicine colleagues in Asia. A few months later, I was particularly stricken by tales from my Spanish colleagues regarding the increasing hospitalizations and deaths from COVID-19.

    “This is going to hit our Hispanic community in the U.S. hard,” I thought, realizing that some of the factors that help our comunidad Latina be resilient – multigenerational connectedness with family members caring for each other, large family units living under one roof and social behavior – would increase transmission of the virus.

    I realized with significant concern that the emphasis of the pandemic response in the United States was organized around the inpatient setting and the hope for a vaccine. Meanwhile, little consideration was given to factors that the World Health Organization recognizes as increasing vulnerability — poor access to health care and basic services, food insecurity and malnutrition, being part of a marginalized and underserved community, living and working in overcrowded conditions, and high dependence on an informal economy and daily wages — that are common to a large portion of the Latina community here in North Carolina.

    Taking Action

    In March, a group of Hispanic faculty at the Duke University School of Medicine started weekly virtual meetings to plan a response. Pediatrician Gabriela Maradiaga Panayotti, M.D., and I were invited to a Facebook Live session conducted in Spanish to help parents and teachers of Hispanic children navigate the pandemic and make early school decisions. The meeting had broad attendance and gave us insight into how many questions the community had and how little information was available in Spanish. That presentation increased attendance at our weekly meetings at Duke, and soon we founded the Latinx Advocacy Teams and Interdisciplinary Network for COVID-19 (LATIN-19).

    We meet every Wednesday at noon via Zoom to discuss problems affecting the Latina community and create solutions. The team grew from its initial 20 members to more than 400. About 70 people attend each week, a broad partnership of community activists, clinicians, medical staff, school representatives, lawyers, faith leaders, elected officials and many others.

    Decision-makers hear concerns and stories directly from community members. Data is cited, policies explained, regulations unpacked and legal wording clarified.

    Some Wednesdays, people on the Zoom call can be seen crying, touched by a deeply sad story. Other times, people become angry or frustrated at barriers to care. Together, we make decisions for positive changes. This space for sharing activates us to make a difference, achieving better results through the power of many and creating new collaborative partnerships.

    “The Disappeared”

    Doctora, nos ha desaparecido otro paciente,” the message says — another patient has disappeared.

    A community organizer texts me every time a family can’t locate a loved one. Language barriers and cultural differences sometimes cause people to be admitted under wrong names. For example, I could be admitted as Bianchi instead of Martinez-Bianchi, and my family would not be able to find me because the hospital operator would say there was no patient named Martinez-Bianchi. Other times, the care team has not updated a family.

    Doctora, the family has not heard from the care team in five days. The children think the father is likely dead and the doctors are afraid to tell them.”

    We worked with care units, chaplain services and interpreters to make sure that “call an interpreter” was important enough to fall under care quality metrics for patients whose language is not English.

    Pregnant women were initially afraid to deliver at the hospital during the pandemic, for fear of the virus and of being separated from their babies. In response, family doctors, obstetricians, pediatricians, midwives, nurses and social workers teamed up to change internal policies to avoid such separations. We provided guidance to clinicians to improve use of interpreter services in the obstetric floors and in the ICU.

    Doctora, the son has been in the ICU for 34 days and the mother wants to see him. She thinks perhaps he will have the strength to fight if he hears her voice and holds her hand.”

    We are still working hard on the concept of strict isolation during this difficult time, seeing what can be done to bring patients and their loved ones together.

    Communication and Access

    We provide testing for COVID-19 at community events and Duke sites, and I am working with a team of residents and students to develop a mobile testing strategy. 

    LATIN-19 engaged city, county and state leaders to create awareness of COVID-19 issues in the Latina community, advocating for health departments and the North Carolina Department of Health and Human Services to publish race and ethnicity data for patients with COVID-19, and to require its reporting for confirmed positive testing, hospitalizations and deaths. This is not to racialize the problem, but rather to make sure race and ethnicity are considered in relation to access to care and equity.

    We feel strongly that an informed community is a community that can make changes to stop the spread of the virus, and that not providing ethnicity data — when numbers are high — can give a false sense of security. Data can inform the need for more appropriate, culturally sensitive information in the language spoken by the community, so we advocated for the state and city to produce Spanish language content and guided its development. We also did an extensive media outreach in Spanish with appearances at more than 40 local, state and national events, and the efforts of LATIN-19 were depicted in a recent short documentary produced by Univision Digital and Enlace Latino NC.

    LATIN-19 advocated for improved access to health care and services through mobile units, locating testing sites in Hispanic and other historically marginalized neighborhoods, as well as providing access by direct referral from contact tracing.

    We created public service announcements, infographics and videos, and we used a “mystery shopper” strategy by trying different services and providing feedback on the ability of Spanish-speaking people to access services. This resulted in the improvement of hotline access in Spanish.

    Together with family medicine residents, I have been training community health workers on personal protective equipment and COVID-19. I am mentoring a student group that is leading a food delivery program for Hispanic community members with food insecurity and chronic co-morbid conditions.

    We are working directly with Duke’s leadership to provide a health equity lens to the assessment of care quality at Duke. Our latest achievement is that medical records will be available in Spanish for those patients whose first language is Spanish.

    We also are advising the Pandemic Response Network on Hispanic issues, connections and language support.

    The many achievements of LATIN-19, my volunteer involvement with health equity issues and my work with the North Carolina HHS led to my appointment as that agency’s adviser on COVID-19 response in the Hispanic community. I am also participating in numerous local, state and national task forces and committees.

    By democratizing information and promoting scientific equity, LATIN-19 has become a trusted actor in the community and a platform to share a problem or bring a solution. A Zoom space has brought us together from many corners of the state, and recently people from other parts of the country have been joining us. We are committed to work beyond the pandemic to improve Hispanic health and quality of life.

    These times of crisis call us to be agile and dynamic so we can hear problems directly from affected communities and enable rapid change.

    My training in family medicine and passion for health equity have fueled my actions and knowledge so I’m ready for the challenges of the pandemic. And as a community, we are collectively creating a better future.

    Viviana Martinez-Bianchi, M.D., is an associate professor and director for health equity in the Department of Family Medicine and Community Health at Duke University in North Carolina. She is an elected member of the WONCA Executive Committee and a WONCA liaison to the World Health Organization. She has served as chair of the Family Medicine for America’s Health Health Equity Team, chair of AAFP’s Commission on Membership and Member Services, convener of the AAFP National Conference of Constituency Leaders, and a minority delegate to the AAFP Congress of Delegates.


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