March 4, 2022 — With new cases of COVID-19 continuing to fall, this could be the time to focus on making sure everyone has equal access to vaccines and other drugs before the next public health emergency.
The coronavirus pandemic, now in its third year, saw major issues develop around equal access to diagnosis, care, and vaccination.
Inequality in the U.S. health care system may be nothing new, but the pandemic magnified problems that could and should be addressed now, experts said during a Thursday media briefing sponsored by the Infectious Diseases Society of America.
The “big picture” message is for public health officials to listen to people in disadvantaged communities, address unique challenges around access and trust, and enlist local officials and faith leaders to help promote the importance of things like vaccines and boosters.
Health care providers also can do their part to help, said Allison L. Agwu, MD, an associate professor of pediatric and adult infectious diseases at Johns Hopkins University School of Medicine in Baltimore.
“If you see something, say something,” she said. Using your voice for advocacy is important, she added.
Asked how individual providers could help, Agwu said it is important to recognize that everyone has biases. “Recognize that you may present to every encounter with some inherent biases that you do not recognize. I have them, we all have them.”
Consulting the data and evidence on health inequities is a good strategy, Agwu said. When everyone uses the same numbers, it can help lessen bias. Intentionality addressing inequities also helps.
But the best intentions of individual providers will only go so far unless the biases in the overall health system are addressed, she said.
Emily Spivak, MD, agreed.
“Our health systems and medical practices are unfortunately part of this systemic problem. These inequities in racism — they’re all unfortunately embedded in these systems,” she said.
“For an individual provider to do all of this is great,” Spivak said, “but we really need the culture of health systems and medical practices … to change to be proactive and thoughtful [and devise] interventions to reduce these inequities.”
Equity and Monoclonal Antibodies
Closer to the other coast, Spivak, an associate professor of infectious diseases at the University of Utah in Salt Lake City, considered how to lessen inequities in Utah when monoclonal antibodies first became available for treating COVID-19.
“We already had the clinical experience to know that things were not equal and that we were seeing far more patients infected, hospitalized, and having really bad outcomes who were essentially of nonwhite race or ethnic groups,” she said during the briefing.
“We tried to get in front of it and say we need to think about how we can equitably give access to these medications.”
Some early research helped Spivak and colleagues identify risk factors for more severe COVID-19.
“And the usual things fell out that you would expect: age, male gender — that was higher-risk at that time, it’s not anymore — diabetes, and obesity,” she said.
“But something that really stood out as a very significant risk factor was people who self-identified as being of nonwhite race or ethnic groups.”
So Spivak and colleagues came up with a state risk score that incorporated the higher risk for people from nonwhite groups. They reached out to patients who identified as nonwhite in a database to raise awareness about the availably and benefits of monoclonal antibody therapy.
Nurses called people to reinforce the message as well.
More recently, Spivak and colleagues repeated the research on data for more than 180,000 Utah residents and “found that these predictors still hold.”
Risk Adjustment or More Inequity?
“Unfortunately at the end of January of this year, our Department of Health released a press statement that removed the nonwhite race ethnic points or risks from our state risk calculator,” Spivak said.
“But they are working through other operational means to try and get people drugs in these communities and increase access points in different ways,” she said.
The statement from the department reads, in part, “Instead of using race and ethnicity as a factor in determining treatment eligibility, UDOH will work with communities of color to improve access to treatments by placing medications in locations easily accessed by these populations and working to connect members of these communities with available treatments.”
Data on Disparities
The CDC collects data on COVID-19 cases, hospitalizations, and deaths, but not all states break down the information by race and ethnicity.
Despite that caveat, the data reveals that, compared to white Americans, Native Americans and Alaska Natives are 1½ times more likely to be diagnosed with COVID-19. Hospitalization and death rates are also higher in this group.
“That also is seen for African Americans and Latino populations, compared to white populations,” Agwu said.
And about 10% of Americans who have received at least one dose of a COVID-19 vaccine are Black, even though they account for 12% to 13% of the US population.
For Agwu, addressing inequities that arose during the COVID-19 pandemic felt reactive. But now, public health officials can be more proactive and address major issues in advance.
“I completely agree. We already have the data,” Spivak aid. “We don’t need to stall next time. We know these inequities or systemic [issues] — they have been here for decades.”
If progress is not made to address the inequities, she predicted, with the next public health emergency, “it is going play out the same way again, almost like a playbook.”
Agwu concurred, saying action is needed now “so we’re not starting from scratch again every time.”