Article In Brief
Neurologists working in areas hard-hit by COVID-19 discuss the reasons for the disproportional impact on the Latinx communities—living in close-quarters, multifamily residences, their status as essential workers, and fear of accessing the health care system due to immigration concerns among others.
From its earliest peaks in New York and New Jersey, to later outbreaks in the Southeast, Southwest and Midwest, COVID-19 has disproportionately affected minority communities, including Latinx populations.
According to data gathered by Rogelio Sáenz, PhD, a professor in the department of demography at the University of Texas at San Antonio, as of early August, Latinx individuals were overrepresented among COVID-19 cases in 45 of 46 states that include this breakdown among their COVID statistics. (North Dakota, South Dakota, West Virginia and Wyoming do not include Latinx ethnicity in their data.) And in 21 of those 26 states, Latinx individuals were also overrepresented among COVID-19 deaths (compared with just one state in May).
“Latinos make up more than 30 percent of all persons who have contracted the virus in 19 states with the majority of these being in the southwestern and northwestern portions of the country,” wrote Professor Saenz in an August 25 blog post.
The age-adjusted COVID-19 death rates provide an even clearer illustration of the disproportionate impact of the virus on Latinx communities. In the US overall, as of August 5, non-Hispanic Whites had a COVID-19 death rate of 29.4 per 100,000 people, compared with 85 per 100,000 for Latinx people. In New York, the rate was 87.2 per 100,000 for non-Hispanic Whites and 313.9 per 100,000 for Latinx; in Texas, the numbers were 15.8 compared with 51.4.
The Bronx, NY
Neurologists in areas hard-hit by the pandemic have witnessed these disparities first-hand. Daniel Correa, MD, deputy chief of neurology at Montefiore Medical Center and an assistant professor of neurology at Albert Einstein College of Medicine, was at the early epicenter of COVID-19.
During the surge he served by supporting the design of the Montefiore neurology department's response strategy, which was described in a July 30 article published online Neurology. And he covered a COVID-19 medicine ward of patients with respiratory illnesses and COVID-associated neurologic presentations.
“Here in the Bronx, we saw a huge increase in cases starting in March,” Dr. Correa said. “Data from our hospital and New York City as a whole showed that the hospitalization and death rates for the Black and Latinx communities were nearly double those for non-Hispanic Whites.”
The causes are multifactorial, he said. “Some is due to structural inequities built into our society. Many of these individuals work in jobs that are now considered essential in our society, such as health care, sanitation, and food service establishments along with other businesses that did not close. Many of them work in positions without paid sick leave, so they couldn't afford to miss work.”
In a letter to the editor in the August 20 Journal of Occupational and Environmental Medicine, he and several coauthors advocated for expanding paid sick leave as a public health tool during and beyond this crisis.
Notably, because of the particularly high cost of living in New York City, many lower-income families (which include a disproportionate number of Latinx and Black households) live in high-density housing with multi-generational families in the same home. “Even if they could take time off work, they don't have the same luxuries to social distance or isolate when someone develops symptoms,” Dr. Correa said.
Fear that immigration authorities would misuse the health care system to arrest undocumented individuals had a disproportionate impact on the ability of Latinx individuals and families to access care, Dr. Correa added. “There were reports from around the country that Immigration and Customs Enforcement [ICE] had been detaining individuals on their way to the doctor or the hospital. Health care had been considered a safe space in the context of immigration enforcement, and the administration violated that trust. That was a major concern.”
These fears were exacerbated by the fact that in February 2020, just before the pandemic hit the US, the US Supreme Court cleared the way for the Trump administration to enforce its “public charge” rule, a regulation that gives immigration officers more power to deny green card and visa applications from people found to rely, or be at risk of relying, on government assistance. This has created concern, Dr. Correa said, “that utilizing health care under some sort of public funding would end up being considered a public charge in future applications for citizenship or a green card.”
[The administration's action was enjoined on July 29, 2020, by the US District Court for the Southern District of New York, preventing the Department of Homeland Security from enforcing, applying, implementing, or treating as effective the Inadmissibility on Public Charge Grounds Final Rule, and reverting to 1999 regulations as long as this injunction is in effect.]
Dr. Correa, who is a member of the National Hispanic Medical Association, joined in discussions among association members about the even greater impact of structural inequities on COVID-19 infection rates and outcomes among the Latinx population in other areas where the pandemic peaked later, such as Texas, Arizona, and Florida.
“For example, in the Rio Grande Valley of Texas, they have experienced just as severe of a surge as we did in New York, but with perhaps a worse impact on the region than we experienced, given a much more fractured health system and rural hospitals with very limited resources and subspecialty staffing.”
In some cases, Dr. Correa said, hospitals in south Texas have been forced to separate multiple family members diagnosed with the virus, transferring them to different hospitals due to limited capacity. “In the New York area, we had field hospitals set up and there was more state and regional leadership toward expanding bed capacity. I'm not aware of many, if any, instances where we had to split up families.”
Hard-Hit in Rio Grande Valley, TX
After finishing his multiple sclerosis fellowship in June, Roberto A. Cruz Saldana, MD, moved to McAllen, TX, in the Rio Grande Valley, where approximately 85 percent of the population is Latinx. As of mid-August, DHR Health, where he practices neurology and neuroimmunology, was “very overwhelmed,” he said. “The governor recently approved the use of McAllen Convention Center as a COVID-19 center. We have the freezer trucks that they had in New York in March and April. We have 12 hospitals in the whole Rio Grande Valley, and basically 11 out of those 12 are at capacity right now. We were not equipped to provide care in a surge like this.”
At his institution, Dr. Cruz Saldana said, the administration has adapted facilities that were used as a hospice into a COVID unit, relocating the hospice patients. “They are trying to keep the main hospital as non-COVID and adapt the buildings surrounding the hospital as COVID units, because people are afraid to go to the hospital for other things, like chest pain and stroke symptoms. That leads to neglect of their health, so we are trying very hard to advocate for them to feel safe at the hospital. We also have an ER designated solely for COVID, and everyone with symptoms is triaged there.”
He warns that multigenerational family gatherings can be particularly dangerous. “We are seeing a lot of people come in from the same family,” he said. “One person has symptoms but doesn't think anything of it, or is asymptomatic, and they go spend time in big family groups without masks or social distancing.”
At this point, neurologists in the Rio Grande Valley have not yet been called upon to provide overflow care for COVID patients, but Dr. Cruz Saldana said that may be because the few neurologists in the region are already overwhelmed with the existing demand for their specialty care.
But he has seen several COVID-19 patients in whom the virus appears to have triggered new-onset migraine symptoms where none had previously existed. “They were all in their 40s or early 50s and none of them had had a history of migraine in the past,” he said. “I'm wondering if these might be related to a vascular component caused by COVID. There's not much in the literature right now, so I'm managing them as I would any other migraine patient, tapering them off other medications with a five to seven day oral steroid taper and then prescribing triptans.”
He also recently cared for a patient who developed acute disseminated encephalomyelitis (ADEM) following COVID-19. “She is very young lady in her 20s, with an otherwise unremarkable history and a very benign course of COVID-19. However, about four weeks after initial symptoms she developed severe headaches, confusion, and focal neurological findings.”
Cases in Miami
At the University of Miami Health System in Florida, neurointensivist Kristine O'Phelan, MD, has been battling the ebb and flow of COVID-19 cases since March. “There was an initial small wave, then a bit of a reprieve in June, and then it picked up again at a much bigger magnitude at the end of June and has just started to abate in mid-August,” she said.
“During that time, I've been caring for other neurocritical care patients, neuromedical as well as neurosurgical, including traumatic brain injuries and acute strokes, as well as for our COVID-19 critical care population.”
“The population at our hospital has a much higher representation of underrepresented minorities, including Latinx,” she said. She agreed with Dr. Correa about the systemic inequities that place Latinx individuals at greater risk of both contracting COVID in the first place and having a more severe outcome. “The ability to work remotely is related to your profession, and a higher percentage of people in the Latinx community work in jobs where they can't work remotely, such as the service industry or child care. Nor do they have the resources or savings to go without a steady income. That definitely plays a role in increased risk.”
Asking Latinx families to socially distance from one another is a big lift, she added. “It's often not an option to avoid those interactions. They are either in the same household or a vital part of keeping things moving forward as far as financial support for the family. It's very difficult to ask people who may not even be symptomatic to take precautions that can be an enormous burden on an entire family.”
In addition, underlying health conditions, such as diabetes, cardiovascular disease, and obesity, are generally more prevalent in the Latinx population—factors that have their own roots in societal disparities.
“These play a role in how sick you get if you are infected with COVID, and this is something we definitely see in our ICUs,” Dr. O'Phelan said.
She urges communities to provide resources to assist with compliance with distance learning, working remotely, and utilizing masks. “We've had quite a lot of press here in Florida about some of the migrant communities who work in the fields in the northern part of the state, and they live in trailers with many people in a small space, sometimes without access to hand sanitizer and masks,” she said.
“How do you social distance when you're living with 20 people in a trailer? Our greater community needs to recognize that it's everyone's responsibility to figure out solutions that will help everyone. Often people want to comply and be safe and just are not able to.”
One of the most painful aspects of the pandemic is the fact that patients and their families are separated. “We're a county hospital, we have limited resources of people and technology, and not every patient can have an iPad on a pole in their room for their families to see them,” Dr. O'Phelan said. “Families are relying on a short phone call from the team to give them an update every day. That's super difficult in Latinx communities that are so closely knit.”
The isolation wears on clinicians as well. “We want to show our patients' families that we are completely dedicated to their loved one getting better, which is very difficult to impart in a five-minute phone call. Normally when a patient is in the ICU, the families are at the bedside and see how hard we are all working to save their mother or father or sister or son. Now, all of our care is being done in a bubble, and I think that takes a toll on all of us.”
But she said that she remains optimistic. “I believe that the strength and bond of the community, in families and between families, will help us get through this. With education we will be able to get to the other side. Part of the reason for my optimism is the strength of the Latinx community to move forward, hold each other up, and make the changes needed to be safe.”