To the Editor:
We were interested to read the article entitled “African American patient disparities in COVID-19 outcomes, a call to action for physiatrists to provide rehabilitation care to Black survivors” by Odonkor et al.1 The importance of addressing healthcare disparities in the African American (AA) community are increasingly apparent after the global pandemic created by SARS-CoV-2, a novel and highly contagious coronavirus discovered in 2019. The authors assert that “AAs have a higher percentage of COVID-19 confirmed cases, confirmed deaths, and case mortality” and “analyzing current data shows that if Black patients with COVID-19 died at the same rate as White patients, many thousands of Black Americans would be alive today.”1 Moreover, the authors implore our field as physiatrists to consider the disproportionate number of AAs who will have more severe disease and corresponding complications, many of whom will need advanced multidisciplinary rehabilitation interventions across the continuum of care. We affirm the authors in the identification of systemic COVID-19 healthcare disparities in the Black community, inclusive of although not limited to AAs, as well as challenge the rehabilitation field to “recognize the multitude of sequelae faced by COVID-19 survivors and prioritize rehabilitation services.”1 It is our intention in this letter to add to the discussion by highlighting additional areas of COVID-19 impact in the AA community, expanding the role of physiatric care in treating survivors and offering a new conceptual model for the biopsychosocial factors contributing to multidisciplinary rehabilitation needs for COVID-19 survivors.
Enduring a worldwide pandemic, recovery from COVID-19 affects all physiatrists. Regardless of subspecialty and location of practice, rehabilitation care for COVID-19 survivors is required across multiple settings. As the rate of severe COVID-19 infections is comparatively high in AAs,1 we expect more disability associated with COVID-19 in the Black community. Having a framework to support recovery at every level, physiatry can better manage patients with complex medical conditions and improve overall health outcomes for AA survivors.
Equitable COVID-19 treatment for AAs involves more than increasing access to medicine and rehabilitation services. A growing body of evidence requires us to expand our understanding of the sociopolitical influences affecting social determinants of health, which impact the overall health status of patients from disproportionately impacted communities. Nonmedical elements such as “quality and distribution of housing, transportation, economic opportunity, education, food, and air quality”2 are just some of the factors that alter healthcare outcomes. Khazanchi et al.2 conclude that “the elevated incidence of COVID-19 among Black and Hispanic communities, largely attributable to social and structural vulnerabilities, seems to drive the differences in mortality among Black, Hispanic, and White populations.” The authors argue “rather than validating long-debunked hypotheses about intrinsic biological susceptibilities among non-White racial groups, the evidence to date reaffirms that structural racism is a critical driving force behind COVID-19 disparities.”2 As in all areas of medicine, physiatry must commit to optimizing individualized, multidisciplinary rehabilitation as well as combating systemic racism.
Although recovery from COVID-19 can take weeks to months, we will be forced to address many patients with complex and new rehabilitation needs. It is now well established that many COVID-19 survivors will have long-term sequelae and multiple infection-related comorbidities.3 They will need to navigate a complex healthcare system, often with limited resources. Treating the whole patient is integral to physiatric practice, giving us a unique opportunity to interface with patients at a critical time in their recovery. It is not enough for us to know that AAs are in a vulnerable group at risk for higher infection rates and mortality from COVID-19. We must actively seek out AA communities to fill in the gaps in access to quality care.
Beyond treatment, prevention of COVID-19 infection is a strategy to avert the devastating cumulative consequences within communities experiencing inequities. Unfortunately, COVID-19 vaccine trials and other academic research studies often have low enrollment of AAs. “Although Black people make up 13% of the United States population, they account for 21% of deaths from COVID-19 but only 3% of enrollees in vaccine trials.”4 Despite having higher morbidity and mortality rates, the Black community maintains a hesitancy and skepticism toward new and experimental treatments. Reasons for mistrust are multifactorial, including a history of dangerous and unethical policies and practices toward Black and Brown communities. There is also a general mistrust because of conflicting messaging about vaccine development. Warren et al.4 outline a strategy to address concerns regarding AA clinical trial participation and emphasize that vaccine “success in Black and other communities will depend on whether members of these communities not only trust that they are safe and effective, but also believe that the organizations offering them are trustworthy.” As a trusted physician, physiatrists provide education to promote patient autonomy in medical decision making.
In addition to establishing rehabilitation facilities within predominantly Black communities, a Physical Medicine and Rehabilitation initiative for community outreach would be to personally engage and connect with AAs in socioeconomically challenged neighborhoods to provide patient education, supply targeted resources, and promote the mission of physiatry. It is incumbent that we advance individual cultural competency, diversify our specialty with more AA physiatrists to broaden inclusive perspectives of care, and promote healthcare advocacy for AAs. The effects of implicit or unconscious bias can lead to detrimental or even fatal outcomes for AA patients (e.g., pain management disparities and high maternal infant mortality rates). Further research is warranted to explore the role of race and ethnicity in COVID-19 recovery.
We commend Odonkor et al.1 for their insight and willingness to confront issues surrounding the AA community and COVID-19 racial health disparities. According to current data, “One of the many very distressing consequences of the COVID-19 pandemic is an estimated 39% increase in the Black-White life expectancy gap.”5 We enthusiastically anticipate future investment from our specialty to deliberately address the needs of AA patients when it comes to treating short- and long-term COVID-19–related disabilities (Fig. 1).6 As we move to a more inclusive society, it is imperative that we pursue a more equitable healthcare framework to deliver comprehensive rehabilitation education, research, and clinical care.
Talya K. Fleming, MD
Department of Physical Medicine
JFK Johnson Rehabilitation Institute
Edison, New Jersey
Rutgers Robert Wood Johnson
New Brunswick, New Jersey
Hackensack Meridian School of Medicine
Hackensack, New Jersey
Tracey L. Hunter, BA
David Geffen School of Medicine at UCLA Los Angeles, California
1. Odonkor CA, Sholas MG, Verduzco-Gutierrez M, et al.: African American patient disparities in COVID-19 outcomes, a call to action for physiatrists to provide rehabilitation care to Black survivors. Am J Phys Med Rehabil
2. Khazanchi R, Evans CT, Marcelin JR: Racism, not race, drives inequity across the COVID-19 continuum. JAMA Netw Open
3. Del Rio C, Collins LE, Malani P: Long-term health consequences of COVID-19. JAMA
4. Warren RC, Forrow L, Hodge DA Sr., et al.: Trustworthiness before trust - Covid-19 vaccine trials and the Black community. N Engl J Med
5. Andrasfay T, Goldman N: Reductions in 2020 US life expectancy due to COVID-19 and the disproportionate impact on the Black and Latino populations. Proc Natl Acad Sci U S A
6. World Health Organization (WHO) International Classification of Functioning, Disability and Health (ICF). Towards a common, language for functioning, disability and health ICF. Geneva, 2002. Available at: https://www.who.int/docs/default-source/classification/icf/icfbeginnersguide.pdf?sfvrsn=eead63d3_4
. Accessed February 1, 2021.