April 22, 2021, 8:48 a.m. Michael Devitt — While the number of people in the United States who have been vaccinated against COVID-19 increases every day, certain populations have been and continue to remain disproportionately affected by the pandemic, highlighting considerable ongoing health disparities among the general population.
The HHS’ Office of the Assistant Secretary for Planning and Evaluation recently published an issue brief that examines these disparities from the perspective of race and ethnicity, while also offering a number of short- and long-term approaches that could be used to achieve health equity.
“This report is yet another reason why our role as family physicians is so crucial,” Santina Wheat, M.D., M.P.H., A.A.H.I.V.S., an associate professor in the Department of Family and Community Medicine at Northwestern Feinberg School of Medicine and program director at Northwestern McGaw Family Medicine Residency Program at Humboldt Park in Chicago, told AAFP News.
“We see the challenges our patients face on a daily basis,” Wheat added. “As family physicians, we can help provide for our patients while continuing to advocate for COVID resources to be moved into our office. This would allow us to provide better direct care.”
The issue brief focuses on health disparities in four areas: testing for COVID-19, infection rates, hospitalization and death rates, and vaccination.
Testing. One review cited in the brief found that in many major cities, COVID-19 testing sites located in Black and Hispanic communities could potentially face higher demand for tests than sites in higher-income areas and predominantly white communities, while another analysis found that Black, Hispanic and Asian patients were more likely than white patients to test positive for COVID-19. The brief stated that the higher disease burden in Black and Hispanic communities indicates that COVID-19 testing rates in these groups should be significantly higher than it has been, but because national testing rates have appeared similar across racial and ethnic groups, it is suggested that patients in some minority groups may lack adequate access to timely testing.
Infection rates. While overall testing rates have been similar across racial and ethnic groups, the report stated that Native Hawaiian/Pacific Islander, American Indian/Alaska Native and Hispanic populations have experienced higher age-adjusted COVID-19 case rates compared to Black, white and Asian populations. The brief also stated the disparities in infection rates may be underestimated based on possible disparities in access to COVID-19 testing among racial and ethnic groups.
Hospitalization and death rates. Several analyses indicated that American Indian/Alaska Native, Hispanic, Black and Native Hawaiian/Pacific Islander individuals had experienced higher death rates from COVID-19 than white individuals. Black and Hispanic patients also had higher hospitalization rates and, among those who tested positive for COVID-19, Black, Hispanic and Asian patients were at higher risk for hospitalization and death compared to white patients, even after controlling for underlying health conditions and socioeconomic factors.
Vaccination. The report indicated that as of March 10, 2021, of more than 62 million individuals who had received one or more dose of a COVID-19 vaccine, more than 65% were white, 8.5% were Hispanic or Latino and 7.2% were Black. In comparison, data from the U.S. Census Bureau indicate that just over 60% of the population is white, while Hispanic/Latino and Black individuals account for 18.5% and 12.5% of the population, respectively.
“It is important to monitor disparities in vaccination rates considering the existing evidence about disproportionate death rates among racial and ethnic minorities, as well as possible racial and ethnic differences in attitudes and access, and in the racial and ethnic composition of COVID-19 priority groups,” the brief stated.
The issue brief cited “longstanding systemic inequalities and structural racism” as the driving factors behind the health disparities that have occurred during the pandemic. Rather than using racial stereotypes, the brief stated, COVID-19 disparities “should be studied in the context of resource deprivation caused by historical and ongoing discrimination, low socioeconomic status and place-based risk factors.”
With regard to vaccination disparities, the brief listed several contributing factors, including a lack of information about vaccine availability, difficulties with transportation, concerns about vaccine safety, limited access to pharmacies and a lack of internet access to obtain appointments. The brief also cited results from various surveys indicating that some minority populations expressed concerns about gaps in information and whether vaccine distribution programs took their communities’ needs into account. To increase vaccine confidence in these communities, the brief stated that “coordinating with community leaders to share targeted messaging and accurate scientific information about vaccine safety may be especially important.”
The brief outlines several potential solutions for reducing or eliminating racial and ethnic disparities in response to the pandemic. These include
It should be noted that many of the policy solutions the brief proposes reflect the Academy’s advocacy efforts.
In April 2020, the AAFP, as part of the Group of Six, sent a letter urging HHS to “collect, analyze and make available to the public explicit, comprehensive, standardized data on race, ethnicity and patients’ preferred spoken and written language related to the testing status, hospitalization and mortality associated with” COVID-19.
In June 2020, the Academy sent a letter to Reps. Richard Neal, D-Mass., and Kevin Brady, R-Texas, the chair and ranking member of the House Ways and Means Committee, asking Congress to pass several pieces of legislation that would address the disparities associated with the COVID-19 pandemic.
This February, the Group of Six sent a letter to President Joe Biden outlining a list of health care priorities, including several recommendations that focused directly on ending the COVID-19 pandemic.
And in March, the Academy sent a letter to Sens. Patty Murray, D-Wash., and Richard Burr, R-N.C., the chair and ranking members of the Senate Committee on Health, Education, Labor and Pensions. Among other things, the letter asked Congress to support and recognize the efforts of primary care physicians in ensuring equitable vaccine distribution and reducing disparities in vaccination rates. The letter also recommended that Congress pass legislation to increase production of personal protective equipment and ensure that community-based primary care physicians can access PPE distributions from the Strategic National Stockpile, extend Medicare telehealth flexibilities and address issues concerning inadequate reimbursement for COVID-19 testing.
The Academy has also issued policies and statements that strongly oppose all forms of racism, including institutional racism, and has adopted numerous other policies to raise awareness of health equity and related issues.
Wheat said while she was not surprised by the report’s findings, some of the statistics caught her attention.
“I thought that the distinction between rates of COVID-19 and severity of COVID and excess death rates among persons (who) identified as Black and Hispanic was quite striking,” Wheat said. “Also, despite the fact that many are looking at vaccine hesitancy in BIPOC (Black, Indigenous and people of color) communities, I have also seen this contradicted in other surveys.”
“Access is having a stronger impact than concerns about hesitancy,” Wheat added. “I have been told by several patients that they are not hesitant to obtain the vaccine, but that they needed to wait until it was available at a location accessible on public transportation and a reasonable commute time.”
Wheat said that one statement in the report — that racial discrimination can result in chronic stress and contribute to socioeconomic factors that put individuals from certain racial and ethnic communities at increased risk for COVID-19 — should be of particular interest to family physicians.
“I have recently heard it argued by well-intentioned physicians that disparities are not about race, but about socioeconomic status,” said Wheat. “It is extremely important for us as family physicians to understand that it is not about social economic status, but also the chronic discrimination that continues to occur every day.”
Wheat also related that many of her patients have encountered the same types of health disparities described in the report, and offered suggestions to help FPs address those disparities.
“I have personally cared for patients where I wasn’t able to provide testing within my institution for one or two days,” Wheat said. I have had patients unable to access available vaccines because of transportation challenges, or inability to have others watch their children, (and) I have had patients who didn’t understand the information provided to them because it wasn’t in a language they understood.
“As family physicians, we can continue to advocate for resources within our offices,” Wheat continued. “We can offer to answer questions our patients have before we ask. We can provide information to everyone about the nearest testing resources and vaccination locations if it is outside of our office. We can also offer to help schedule for our patients when possible.”