When I got sign-out on a patient who I will call Nelson, he was already starred on my list.
"Nelson is a watcher," the nightfloat admitter said.
We reviewed him: Young African-American, obese, history of obstructive sleep apnea. What they didn't sign out to me was that he had other family members who also had been admitted. When I walked in to see Nelson, he peppered me with questions about his family.
"How's my mom? How's my brother?"
I told him I didn't have a release to talk to him about them, and I honestly hadn't even known they also were hospitalized.
Nelson told me that his uncle had tested and been confirmed positive for COVID-19 a week before and was discharged to quarantine at home. Then the whole household had gotten sick. The young kids had been fine, he said, but the older kids and parents had gotten sicker.
Nelson was from a historically black area of Boston, which is among the most segregated cities in the United States. Although Boston has yet to release COVID-19 data on race and ethnicity, it has released maps of the most highly affected areas. Mattapan, Dorchester and Hyde Park house a majority of our black population, while East Boston and Chelsea house a majority of our Hispanic population. These areas have been the hardest hit by COVID-19 morbidity and mortality.
There are many explanations for why this is the case. For example, these areas contain concentrations of essential workers who cannot work from home or shelter in place. These neighborhoods have closer living spaces in multifamily housing. The housing is older and possibly less well ventilated. The residents often cannot afford to miss work, and many work essential service jobs that don't allow them to stay home. Some are housekeepers, nannies or janitorial staff, working jobs where they are exposed to many other families and people.
On the flip side, because these workers are traveling in and out of their homes, they can expose more people if they are asymptomatic or presymptomatic carriers. They are restaurant workers and delivery men and women. Their children may need to go to a family member's residence so the parents can work. Their communities are more likely to have less access to healthy foods and health care. These factors, and many more, can increase the incidence of any infectious disease.
Social distancing is a privilege. At Boston Medical Center, our area's safety-net hospital, many of our patients don't have the luxury of individual living spaces, the ability to stay at home, or secure jobs or childcare on a typical day, much less during a pandemic. When we plan for discharge from a COVID-19 team, we ask simple questions to determine if a person can self-quarantine: Are you housed? Do you have your own room? Can you wear a mask and sanitize shared living spaces?
Sometimes they say yes, sometimes they feel pressured into a yes. And they go home. Or sometimes, they are petrified to go home, so they stay. All too often, the patients we send home come back sicker, often with an ill roommate or housemate.
We can argue whether they had already exposed their housemates, neighbors, co-workers and whomever else they had contact with before. But that isn't always true, and it's definitely not proven. What we currently know is that the R0 of COVID-19 is estimated to be between 2 and 3, meaning that one person, on average, can infect two to three others, indicating that transmission typically is by close contact. If we could test their contacts, we could determine if it was safe for them to go home. In the absence of widespread testing, I worry that we continue to put patients' families and communities at risk if we don't give them better options for quarantine.
If they can't go home, where can they go? Many have been staying in hospitals. We have set up homeless tents for those stable with pending test results, those positive for COVID-19 and stable, and those who are negative. In a city with more than 50 universities and colleges and a robust (but now mostly empty) hotel industry, there must be a way to quarantine people safely. The hotels have opened for health care workers, but it wasn't initially clear if this was for all health care workers (including the janitorial staff, the front desk staff, the supplies staff and the maintenance staff). Boston Medical Center has clarified that this means all staff.
What is open to our patients who are housed, but in large communities they could potentially infect?
What is available for our undocumented patients? It is understandable that our undocumented patients are quickly wanting to go back to work when asymptomatic and are more hesitant to register for city- or state-sponsored quarantine sites. They do not qualify for unemployment or other benefits even though their safe quarantine is safer for the entire community. There are spaces opening, such as the Boston Convention Center, and Boston Medical Center has worked with the city to reopen the previously shuttered East Newton Campus. They are currently already accepting patients and expanding as more staff and supplies become available.
When I met Nelson, he looked scared. At the time I met him, he was only on day four of COVID-19 symptoms and was on 2-3L nasal cannula. After asking questions about his family, he asked me if I thought he'd need intubation. I told him I thought he might. He pressed me for a number. I told him he had at least a 50% chance at being intubated. I was trying to be optimistic. He is young.
"Looking at the timeline," I told him, "days seven to 10 are when people start to feel even more short of breath."
He thanked me for my honesty and cried a little. I shed a few tears myself. When I went off service on day six of his symptoms, he was still on nasal cannula. The next day he was intubated, and he continues to be on a ventilator one week later. His family members have all been discharged and sent home. I will never know if sending his uncle home was the cause of his disease or not, but I worry that delay in safe quarantine options increased incidence of COVID-19 in these vulnerable communities.
He is just one of many with a similar story, coming from one of these five neighborhoods that will carry the brunt of this epidemic -- and future ones if we fail to prepare beforehand to offer better solutions.
MaryAnn Dakkak, M.D., M.S.P.H., practices full-scope family medicine and is an assistant professor in an academic hospital center in Boston. She is also women's health director at Manet Community Health Centers. Her views do not represent those of the organizations with which she is affiliated.
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