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Equity360: Gender, Race, and Ethnicity—COVID-19 and Preparing for the Next Pandemic

O’Connor, Mary I. MD, FAOA, FAAHKS, FAAOS

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Clinical Orthopaedics and Related Research: June 2020 - Volume 478 - Issue 6 - p 1183-1185
doi: 10.1097/CORR.0000000000001282
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In my lifetime, I have never experienced anything as frightening and disruptive as the coronavirus disease 2019 (COVID-19) pandemic. As I write this column (early April 2020), Connecticut is in the throes of the crisis. But by the time you read this, given the pace of new knowledge being discovered about COVID-19, things will look quite differently for my home state and the entire country—and not necessarily for the better. As of early April, elective surgery is prohibited. Personal protective equipment shortages—seemingly simple things, like masks and gloves—are raising anxiety levels for healthcare providers. And our scientific leaders are warning the public that the country has not yet seen the worst of this pandemic. Every day we see an increase in both the number of patients with severe infections and deaths. We are concerned for our loved ones, our patients, our colleagues, our hospitals, our communities, and our economy.

Amidst all this, a recognition of how epidemiology, public health, health access, and health equity intersect is ever more important, especially among policy makers, community leaders, and healthcare providers. They—and we—need to realize that COVID-19 is unlikely to be the last pandemic we experience together.

Two Striking Observations

Money and status will not guarantee that an individual will remain free of infection. Social distancing is a powerful strategy against the spread of COVID-19, but we are so interconnected and interdependent that personal isolation is not possible. Every person is essentially an individual cell in one single, global, human organism.

In a pandemic, existing structural healthcare inequalities are particularly devastating for disadvantaged communities. In the face of an international health and economic crisis, our patchy safety net gives limited protection both to lives and livelihoods. And so, while money and status may not prevent you from contracting COVID-19, it will probably provide more access to ambulatory treatment. Indeed, COVID-19 affects certain populations much more than others.

Pandemics Don’t Impact Everyone Equally

Access is influenced both by health-system capacity and insurance status. Underinsured patients may struggle to find ambulatory physicians who accept their coverage. In rural areas, record closures of hospitals threaten access [6] and many counties with aging populations have no hospital at all [7]. For infected individuals who experience acute respiratory compromise, where you live could mean the difference between life and death.

An individual’s baseline health impacts his or her risk of illness and severity of infection with COVID-19. Older people are at higher risk, likely as a function of other co-morbid conditions. But younger people can also get sick. Early data suggest that people with diabetes are at a two-to-three-fold increased risk of infection independent of other comorbidities [3]. People who are black and Hispanic, especially women, are more likely to have diabetes than are whites [1].

Sedentary lifestyles increase the risk of obesity and the development of diabetes [8]. We also know that disparities in physical activity levels start as early as high school in disadvantaged communities and continue throughout one’s life [10]. Add to this the risk factors from historically underserved populations who have higher rates of hypertension [11], smoking, and poorer nutrition, and it becomes clear that we need to focus our resources on underprivileged patient populations [10]. But as of this writing, several questions remain: Caught in the midst of a crisis and anticipating future pandemics, will we be able to effectively target communities of color with appropriate information in time? Will recommendations on the federal level be adopted, rejected, or delayed? Will new federal policy, which takes into account an immigrant’s use of public services to determine approval for permanent residency status [4], make such individuals afraid to seek appropriate medical care thereby increasing the risk of exposure to others?

The Digital Divide May Worsen

The gap between individuals and areas of the country that have access to the Internet and computers and those that do not (the digital divide) may have a profound impact on health and economic outcomes in this pandemic. With the rapid adoption of telemedicine and the pivot to working from home, individuals and communities with poor access or use of digital communications will be disadvantaged. Older people and people of color are less likely to access online portals and use telemedicine [2]. At the time of this writing, Medicare and Medicaid reimbursement for telehealth services has been expanded to allow remote consultation during the pandemic [5] and to reduce the risk of contagion. This is an important and positive action, but risks an increase in disparities by favoring those populations that have the resources to access this technology.

What Can Orthopedic Surgeons Do?

Perhaps the most important thing we will need to do to improve the health of our patients and our communities is to become more resilient—through better preparedness—before the next pandemic strikes. Writing in the middle of it (or perhaps a point that will turn out to be well earlier than the middle of it), it’s impossible to be very specific about what worked and what didn’t in terms of the preparedness of our systems. I’ll return to this topic—as, no doubt, will others—with lessons learned once we’re fully through it.

But as I write this, much ink is being spilled about “flattening the curve” of this pandemic. I believe that we need to look ahead and start flattening other curvesthose of obesity, sedentary lifestyles, and health disparities. As orthopaedic surgeons, we can encourage people to stay stronger and healthier now and as they age:

  • Move, move, move. Be physically active. Discuss the importance of physical activity with your patients, and lead by embracing this advice yourself [8, 9].
  • Don’t ignore obesity. Have conversations with your patients to emphasize the importance of normal weight to health.
  • Provide care to underinsured patients because orthopaedists can help them become healthier. I know the payment for our services with these insurers is low, but we should provide some access, particularly during times of medical crisis.
  • Ensure that fragility fracture patients receive appropriate treatment for bone health directed by you or others. Our older patients are particularly vulnerable during pandemics. Help prevent their next fracture, which could occur during a medical crisis
  • Use our voices to support efforts to engage vulnerable individuals in electronic and digital health measures. Get them comfortable (and trusting) with accessing care in this manner.
  • Support healthcare policies that promote healthier neighborhoods, improved access to care, and health equity.

References

1. American Heart Association. Statistical Fact Sheet 2013 Update. Available at: https://www.heart.org/idc/groups/heart-public/@wcm/@sop/@smd/documents/downloadable/ucm_319585.pdf. Accessed April 2, 2020.
2. Anthony DL, Campos-Castillo C, Lim PS. Who Isn’t Using Patient Portals And Why? Evidence and Implications from A National Sample of US Adults. Health Affairs 2018 37:12, 1948-1954
3. Barclay L, Nyarko E. Are Diabetes, CVD Associated With Worse COVID-19 Prognosis? Available at: https://www.medscape.org/viewarticle/926097. Accessed April 2, 2020.
4. Batalova J, Fix M, Greenberg M. Chilling Effects: The Expected Public Charge Rule and Its Impact on Legal Immigrant Families’ Public Benefits Use. Available at: https://www.migrationpolicy.org/research/chilling-effects-expected-public-charge-rule-impact-legal-immigrant-families. Accessed April 2, 2020.
5. Centers for Medicare & Medicaid Services. President Trump Expands Telehealth Benefits for Medicare Beneficiaries During COVID-19 Outbreak. Available at: https://www.cms.gov/newsroom/press-releases/president-trump-expands-telehealth-benefits-medicare-beneficiaries-during-covid-19-outbreak. Accessed April 2, 2020.
6. Daly R. 47 hospitals have closed in 2019, MedPAC reports. Available at: https://www.hfma.org/topics/news/2019/12/47-hospitals-have-closed-in-2019--medpac-reports.html. Accessed April 2, 2020.
7. Kaiser Health News. Millions Of Older Americans Live In Counties With No ICU Beds As Pandemic Intensifies. Available at: https://khn.org/news/as-coronavirus-spreads-widely-millions-of-older-americans-live-in-counties-with-no-icu-beds. Accessed April 2, 2020.
8. O'Connor MI. Equity360: Gender, Race, and Ethnicity-Trapped in the joint pain vicious cycle (Part I). Clin Orthop Relat Res. 2019;477:2421–2423.
9. O'Connor MI. Equity360: Gender, Race, and Ethnicity-Trapped in the joint pain vicious cycle (Part II). Clin Orthop Relat Res. 2020;478:469-472.
10. Pampel FC, Krueger PM, Denney JT. Socioeconomic Disparities in Health Behaviors. Annu Rev Sociol. 2010;36:349–370.
11. US Department of Health and Human Services Office of Minority Health. Heart Disease and African Americans. Available at: https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=19. Accessed April 2, 2020.
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