Paul B. Goulet, Chair, Providence/Boston CFAR Community Engaged Research Council
The coronavirus pandemic is disrupting the lives of Americans of every age, race, gender and income. It is taking a toll on our physical, mental and financial health. But it’s not hurting all of us equally.
On a local level COVID-19 is highlighting the disparities that have always been present in our communities in Massachusetts and Rhode Island, in the most drastic and horrific way possible — disparities in health, economic opportunity and education and access to comprehensive medical care. People of color are far more likely to have pre-existing conditions like asthma, diabetes and heart disease that make them more vulnerable to COVID-19. These health disparities are a result of systemic inequities, poverty and institutional racism.
In Boston black residents make up nearly 42% of the positive cases reported despite making up 25% of the population, according to recent census data. As[GVc1] of April 2020, Boston's Dorchester neighborhood has reported the most cases of the coronavirus with 1,911. That's more than double the next highest total of 688 reported cases in East Boston, home to one of Boston's largest immigrant communities. (1) For comparison, nearby Charlestown reports the lowest number of positive COVID-19 cases in the city with 103.
People of color are far more likely to work in jobs where they don’t have the option of working from home. They are wage workers, city employees, first responders, nurses, home health aides and bus drivers. Their jobs, by definition, put them at greater risk. It is not okay for people in our own communities to be more at risk of dying simply because of the color of their skin or socio-economic or immigration status.
A “return to normal” will do nothing to eradicate existing inequities or do better for our communities of color, or our immigrant communities. Poverty and social determinates of health must be addressed in order for this epidemic to be eradicated.
The COVID-19 pandemic is showing how “one size fits all” approaches to healthcare are largely ineffective in reaching vulnerable populations who cannot socially distance or quarantine. Racial disparities should become the focal point in our conversations about COVID-19. However, communities of color are only one of many populations disproportionately impacted by this national health emergency. The elderly, the immigrant community, people with disabilities, people living with HIV/AIDS and people who are homeless or economically disadvantaged are more likely to suffer life threatening outcomes. Addressing causes of health inequities is the long-term solution to changing the corollaries to health outcomes.
Social determinants of health and cultural competence are powerful tools. The concept goes well beyond race and ethnicity to encompass empathy, curiosity, and respect for all aspects that shape a patient’s life experience, such as age, gender identity, sexual orientation, language, housing status, immigration status, value systems and more. Providing culturally competent care is a lot like adjusting a recipe to appeal to an individual’s taste, and it can instill trust in the provider relationship and make healthcare messages and interventions more effective.(2)
When we address successes, failures and gaps in culturally competent care during a national health crisis it gives us an opportunity to inform programs on how they can pivot their approach to care and better protect the health and well-being of all patients. Safety net hospitals are very well versed at tailoring care models to meet the needs of diverse patient populations, and should set the example as health systems look for ways to fill the gaps in culturally competent care models.
Boston Medical Center’s unique position caring for Boston and beyond most vulnerable residents has never been more crucial. The health and safety of BMC’s patients and frontline staff has always been a priority and especially now during this unprecedented crisis.
At Boston Medical Center (BMC), the largest safety net hospital in New England, about 25% of patients admitted to the hospital are homeless. As COVID-19 became an increasing threat to Massachusetts, healthcare advocates at the hospital quickly understood the specific barriers to safety and care that would confront this portion of their population and took swift action to adapt — the new respite facility at East Newton Pavilion that was established to help fill an emergency need for quarantine space during recovery from infection. (3)
People who are homeless or housing insecure are particularly vulnerable during the COVID-19 pandemic. The transient nature of this population, coupled with limited or no access to hygiene facilities and exposure to crowded shelter settings, makes adhering to the standard public health guidelines around coronavirus impossible. A culturally competent care system needs to factor in the unique needs or limitations of the group.(4)
Many in the homeless population also struggle with substance use disorder, and understanding this piece is important to providing culturally competent care. Glory Ruiz, Director of Public Health Programs at BMC, explains the challenge in tailoring public health messages around social distancing, which are in direct opposition of safety practices that help protect people immersed in street culture.
“The message that we have been giving people who are actively using drugs on the street has been to stay in groups, take care of each other, have a buddy in case you have a bad trip. The COVID messages around social distancing precautions have been completely contradictory to this message of unity,” explains Ruiz. “We have to adapt our education for patients on the street by getting the message out there about how people can protect themselves in their own context.”
She reiterates the importance of expanding the understood definition of cultural competence: “Working with homeless people, people who are actively using drugs, people who are doing transactional sex work — that goes beyond the traditional concept of cultural competence.”
Joanne Timmons, director of the Domestic Violence Program at BMC, had to make a tidal shift in her outreach approach when Massachusetts locked down in response to COVID-19. Like many others, the program moved to a virtual office presence, but staff are available around the clock to field calls from survivors struggling with an abusive partner. Timmons has also seen the chaos of COVID-19 turned into a psychological weapon used by abusers to assert control over their victims, who have lost all other external support systems because of quarantine.
As the complexity of cases has increased, advocates at BMC are tailoring their outreach case by case. The Domestic Violence Program has been offering more assistance to survivors who are fearful of contracting the virus, providing basic needs such as food and transportation to shelters or critical medical appointments. Providing culturally competent care in this setting means never making assumptions about a person’s living situation: Will the person have access to make a phone call? Do they have privacy? Do they have access to technology to seek restraining orders or continue custody battles?
“We can never assume we know what somebody means if we don't ask them. We should always be asking, ‘What do you mean by that?’ or ‘Why does that concern you?’ When it comes to COVID-19, we never make assumptions that people know what is safe. A partner could be telling a patient that they can’t go out of the house, for example, but that's not technically true,” explains Timmons.
Boston Medical Center has been working around the clock over the past eight weeks to translate COVID-19 health information for the 30% of BMC patients who have limited English proficiency (LEP). Reaching these patients in their households, many who reside in COVID hot spots, is crucial to helping to slow the spread of the virus.
“When we interpret, we don't convey words — we convey meaning. We convey the nuances, the tone of voice. We identify the gaps in communication,” explains Alegna Zavatti, the director of interpreter services at Boston Medical Center. “All of these things need to be communicated in a way that accounts for people's cultural codes.”
But truly effective interpretation requires face-to-face interaction with patients, says Zavatti. “If you see the person's face, you immediately know what they're saying without even speaking.”
With in-person communication limited in the face of coronavirus, the obvious solution is telehealth. But as a blanket solution, it leaves some important groups behind. For example, health professionals are finding it challenging to provide video conferencing in Latino households where interpreters are needed for reasons beyond interpretation alone.
Beyond cultural barriers, these households are also more likely to face limited access to internet and phone service. Providers are continuing to strategize on how to best provide remote care to this community.
“For example, when you're talking about healthcare disparities, we know that blacks and Latinos are disproportionately impacted by diabetes. Nutrition is a crucial part of prevention. But it's also about knowing what foods are appealing in the culture, and that can be hugely impactful. It will resonate, the patient will feel heard and understood, and they will be more likely to engage with that care provider,” says Ruiz.(6)
COVID 19 has no boundaries and no borders. Neither should any health care provider or institution. Our priority should always be, exceptional care without exception, no matter the color of our skin, the country we come from, our socio-economic status, our political status, our sexual identity, our mental health status.