"The moral test of government is how that government treats those who are in the dawn of life, the children; those who are in the twilight of life, the elderly; those who are in the shadows of life, the sick, the needy and the handicapped."
-- Hubert Humphrey, 38th Vice President of United States, lead author of the 1964 Civil Rights Act
Many of my colleagues and friends have been sharing posts about social distancing to ease the burden of COVID-19 on our already fragile health care system. Those of us suiting up in gowns and goggles to see patients appreciate any measures that could flatten the curve and mitigate a public health nightmare.
Although social distancing is vital, I am reminded that it is a privilege, and one that is not afforded to most of my patients:
The mother of three who doesn't have enough disposable income to stockpile a month's worth of necessities.
The veteran with an alcohol addiction who depends on group meetings to maintain sobriety.
The survivor of domestic violence who is terrified of isolation with her abuser.
The child with special needs who is undergoing behavioral and speech therapy.
The stroke survivor who needs help with dressing, cleaning and eating but whose caretaker will stop coming.
The grocery cashier who can't clean her hands between customers because the store no longer has hand sanitizer.
The millions of people who use the emergency room for primary care due to tenuous insurance status and those who will forgo SARS-CoV-2 testing altogether for fear of cost.
The immigrants and refugees, with their low-wage and high-risk jobs, who will not seek out necessary medical treatment for fear of the public charge rule.
The tragic irony is that these vulnerable groups surviving in the shadows of life already suffer the most significant health disparities. The prospect of a pandemic respiratory infection pushes their strained resources to the brink of collapse; without the capacity to self-isolate, these groups are at significantly greater risk of serious adverse health outcomes at both the individual and community levels.
This is not a novel phenomenon; our society collectively failed these vulnerable people for years through a combination of negligence, avarice and fear. Our communities are complicit in tolerating public officials who act from their own self-interests and wreak havoc on public trust with discriminatory dog-whistling and targeted misinformation. We whisper about the prospect of impossible ethical dilemmas that physicians will face in rationing ventilators and respiratory support. But the dismal truth is that we accelerated these decisions with the sum of our own inaction; we've been effectively rationing care for years if we abstained from voting or civic action out of our own misplaced self-righteousness.
Now, we face another opportunity for community action in the face of adversity. The ability to practice effective social distancing is a privilege of financial freedom and independence; that precious liberty engenders an important civic duty to our community. Any prevention strategy to flatten the curve is an act of solidarity with those around us, not a sign of panic or weakness. If we disregard our civic responsibility at the first sign of trouble, our social contract is worth less than toilet paper. After all, a community is only as strong as its most vulnerable members.
In a sense, the COVID-19 pandemic is a reminder that we are all vulnerable as individuals, but our collective strength comes from the actions we take to improve our communities. Those of us with any position of privilege must recognize that our action -- and inaction -- has both short- and long-term consequences.
I'm reminded of the heroes in time-travel stories, from Marty McFly to Harry Potter, who fear that changing even one small act in the past could alter the course of the future. Yet back in our real-world communities, we fail to realize how even one small act could alter the course of our future. This abstract thinking is decidedly much harder when our faith is eroded by anti-science sentiment and misinformation from our elected officials, who spread discord rather than unite.
The good news is that we can make decisions that improve the health and well-being of our communities today, tomorrow and long after the pandemic is behind us. By recognizing that we are part of something bigger than ourselves, we can support these vulnerable populations through direct actions on a community level:
1. Communicate: First and foremost, we must encourage our neighbors to follow public health practices (such as hand hygiene) and continue effective physical distancing for as long as possible to flatten the curve. I much prefer replacing the concept of "social distancing" with "physical distancing and social solidarity." The combination of these efforts engenders both a specific public health practice and a reminder that we are in this together, especially for those vulnerable populations under the greatest threat of both health and economic injustice.
In this time of divisive rhetoric and uncertainty, it can be challenging to find consistent facts in evidence. But our collective identity is stronger than the grip of fear. As family physicians, we can share trusted information within our communities to dispel myths and turn panic into focused action. We can further work with our clinic staff to implement effective screening and self-quarantine strategies for our patients. These measures will ease the burden on emergency departments and allow for appropriate evaluation and treatment of our most vulnerable patients. As an aside, as we support health care workers in the coming weeks, let's remember to include all parts of the team, for example, the environmental services crews who silently clean, disinfect and sanitize every single patient room without so much as a fist-bump.
2. Advocate: Family physicians advocate tirelessly at local, state, and federal levels for policies that support these vulnerable groups. The AAFP is consistently recognized as one of the most effective and impactful national advocacy organizations, and that influence is invaluable in this time of crisis. In their efforts to flatten the curve by protecting patients and conserving resources, physicians are adopting virtual visits as much as possible. However, the restricted coverage for telehealth visits places severe financial pressure on physician practices. As a result, community physicians are limited in their ability to operate and address the health needs of their most at-risk patients.
This financial strain is exacerbated as physicians are forced to purchase their own personal protective equipment for the safety of their staff and patients. To avoid a catastrophic burden on emergency departments, the AAFP authored a joint letter to Congress supporting critical policies to help physicians fighting the COVID-19 pandemic by ensuring they have adequate equipment, supplies and financial resources. Family physicians can use the AAFP Speak Out tool to support these measures and respond directly to members of Congress.
State chapters also can make a difference. At the onset of the pandemic, the California AFP held a virtual all-member advocacy meeting; more than 100 family physicians from the state took time to discuss important policy resolutions to address health disparities for our marginalized patient groups. These at-risk groups need support from specific policies, including rapidly expanded COVID-19 testing, increased access to food and emergency housing, providing child care and paid sick leave, and ceasing check-ins by Immigration and Customs Enforcement agents.
I applaud elected officials who promote health equity and reduce harm to vulnerable populations through emergency relief policies, whether in Washington, Colorado, Illinois, or California. These policy changes are a direct result of voting for community-minded partners who recognize the value of expanding the safety net in times of adversity, but there is still much work ahead to develop sustainable solutions to inequality beyond the immediate burden of the pandemic.
3. Engage: The most effective public health measures are multidisciplinary. Family physicians should identify our community partners that already provide year-round support to our vulnerable groups, starting with services through local departments of public health. By engaging these local advocacy organizations, we bring stakeholders from marginalized populations to the discussion table; instead of speaking on their behalf, we can pass the mic to balance the power dynamic in sharing reasoned solutions.
We can also contact the local chapters of national relief organizations to provide direct support to those in need. There are many small and important actions that every community member can take to help, from donating blood to supporting local food banks. The Nextdoor social media platform has launched an interactive neighborhood Help Map to organize volunteers and identify resources for neglected folks in their communities.
4. Educate: Family physicians are leaders in addressing health disparities for our vulnerable populations. It is imperative that we incorporate the principles of community health, social medicine and public health advocacy into our residency training. This includes a strong understanding of structural competency, or the capacity to recognize the complex systems that influence social determinants of health for these groups. Through the Center for Health Disparities Research at the University of California, Riverside, our interdisciplinary working group recently hosted a training conference on applying structural competency to care for immigrant communities, with a focus on recognizing the implicit and explicit biases that infiltrate our health care system.
At the Riverside University Health System Family Medicine Residency Program (through the University of California, Riverside), our resident physicians teach local high school students how to advocate for healthy change in their underserved communities through a yearlong curriculum. The students use their collective voices to address local health issues (such as food insecurity, vaping risks and suicide prevention) and share their brilliance. As a pipeline education program, the students are empowered to pursue careers in primary care and public health to meet the health needs of their respective underserved communities. A few medical schools and residency programs promote similar curriculum initiatives, but this level of advocacy and critical analysis must be recognized -- and funded -- as a vital part of training our future workforce in primary care.
The unique challenges of the COVID-19 pandemic generate fear from uncertainty for physicians and patients alike. Through these community actions (communication, advocacy, engagement and education), we can cut through divisive rhetoric and mitigate the profound health impact of this fear on our most vulnerable populations. As we work together in solidarity, we build a resilient foundation fostered by goodwill and civic duty.
Our legacy in community-building will remain beyond the direct and immediate impact of this global pandemic. It is through our collective action that we will weather the storm ahead and further confront the complex structural inequalities that plague our health care system. And we will look back at this seemingly dark time as the dawn of our finest hour in reaching reasoned solutions for our communities.
Moazzum Bajwa, M.D., M.P.H., M.Sc., is an assistant professor of family medicine at the University of California, Riverside, and core faculty at RUHS/UCR Family Medicine Residency, leading the program's Community Health & Social Medicine initiative. He practices comprehensive family medicine in the Inland Empire region of Southern California.