Reid Shaw

ABSTRACT

Racial health disparities have a long history in the United States, dating back centuries. People of the medical community have tried to explain racial health differences based on innate biological differences. However, these theories have been grounded in racism and not any genetic differences; it is now widely accepted that the health differences among racial groups that are present today are due to long standing social injustices and systemic racism. The pandemic of COVID-19 has further propagated health disparities, leading to worse outcomes for people of low socioeconomic status and people of color. Telemedicine has been proposed as a potential solution to some of the health disparities; however, even this solution is far less than ideal. To mitigate health inequalities in the United States, it is important to view differences through a lens that takes into account systemic racism. Furthermore, for actual change to occur, resources need to be distributed in an unequal manner that favors Black, Hispanic, and people of low socioeconomic status.

INTRODUCTION and BACKGROUND

HISTORICAL HEALTH DISPARITIES

There is a long history of attempting to identify biological differences among racial and ethnic groups to explain health differences.1 For example, current ventilator settings are based off of the race of the patient; Black individuals are believed to have a lower lung capacities than White individuals.2 This practice originated from a 1896 publication: Race Traits and Tendencies of the American Negro by Frederick Hoffman, a white supremacist and German statistician. Although Mr. Hoffman made a number of important contributions to society, his ideology was often flawed. In his 1896 publication, he stated that the higher mortality rates among Black individuals after emancipation was due to racial differences and decreased lung volume. Today, this claim is laughable as Black individuals had (and continue to have) significantly poorer health and social conditions which contributed (and continues to contribute) to higher mortality rates. Perhaps more appalling than Frederick Hoffman’s racism is the fact that these ‘scientific’ findings provide the basis of patient care in the year 2020.

Calculating kidney function is another example of imperfect science and a failure of modern medicine. Black people’s kidney function has a correction factor of 1.2 when compared to White people, meaning that a Black person’s kidney function is overestimated when compared to that of a White person. This is reportedly due to Black individuals having a higher muscle mass than White individuals – a sentiment that has been proven to be false in subsequent studies.3 However, when a Black person’s kidney function is estimated to be within the ‘normal range,’ it can also be early stage kidney disease in a White person. This leads to delayed diagnosis of chronic kidney disease in Black individuals – a disease that is progressive, non-reversible, and more prevalent in Black individuals.4 Although current research does not have an explanation for the differences seen among Black and White individuals, it is likely that race is a poor surrogate for social inequalities.

Examples of how social differences and systemic racism affect health includes are numerous. Residential segregation and redlining have contributed to inequalities of health care access, utilization, and quality for minorities.5 Primary and preventative care is associated with improved population health and fewer health disparities; however, Black and Hispanic individuals struggle to receive adequate primary care.6 If minorities were to have access to preventative services, there would still be significant hurdles as Black patient’s interactions with providers are not always positive. Physicians are 23% more likely to be verbally dominant and engage in 33% less patient-centered communication with Black patients in comparison to White patients.7 The care that Black patients receive is also worse than the care that White patients receive. In a study from 2020, Black newborns have three times higher rates of mortality than White newborns when under the care of a White physician.8 The mortality rate differences shrink drastically when a Black physician is the provider.

Not only is the care for minorities worse, but it is also more expensive. Black and Hispanic individuals have the lowest rates of health insurance in the US and thus some of the largest healthcare bills.9 Understandably, the low quality of care throughout the health system and the high costs have contributed to Black and Hispanic individuals having the highest rates of distrust of healthcare workers.10

The lack of adequate care due to systemic racism has led to minority populations suffering the majority of the health burden of COVID-19. The prevalence of chronic health conditions, which are present more often in minorities, has led to worse health outcomes during the COVID-19 pandemic. Chronic medical conditions, such as: diabetes, obesity, and kidney disease are risk factors for severe illness from COVID-19.11–13 In April, during the initial peak of the pandemic, one New York City institution found that Black individuals were 4.3 times more likely than White individuals to use the Emergency Department versus telehealth for medical care.14 The use of a crowded emergency department increases human-to-human contact, furthering the risk of contracting COVID-19. According to the CDC publication from August 18, 2020 on health disparities, Black individuals are 2.6 times more likely to be infected by COVID-19, 4.7 times more likely to be hospitalized due to COVID-19, and 2.1 times more likely to die than White individuals from COVID-19. The same report states that Hispanic individuals are 2.8 times more likely to be infected by COVID-19, and 4.6 times more likely to be hospitalized than White individuals due COVID-19. In New Mexico, where Native Americans make up roughly 11% of the population, more than half of the individuals who have tested positive for COVID-19 are Native Americans (New Mexico Department of Health).

In an attempt to explain these differences, one recently published study in JAMA found that Black race, even after controlling for age, sex, comorbidities, poverty status, neighborhood disadvantage, and zip-code clustering, may be a risk factor for more severe COVID-19 infetions.15 Unfortunately, this research failed to acknowledge the social and structural vulnerabilities that Black individuals face.16 The statistically significant differences seen in this study are more likely due to racism rather than race. Intrinsic biological susceptibilities among minority racial and ethnic groups is a theory that has long since been debunked, as there is more genetic diversity in Africa than on all the other continents combined.17 Therefore, COVID-19 health disparities should be viewed as a cause of the low socioeconomic status, structural racism, and location-based risk – not due to any racial biological difference.

SOCIAL DISPARITIES

Social disparities have continued and increased since the beginning of the COVID-19 pandemic. The Bureau of Labor and Statistics reported that 12% of Latino and Black individuals lost their jobs between February and June of 2020 – more than 50% higher than the rates of White individuals. Racial and ethnic minority groups have proportionally higher representation in ‘essential’ work settings than White individuals, leading to more human contacts and higher chances of exposure to infection. Essential work includes: building cleaning services where 40% are Hispanic, child care and social services where 19% are Black, and transportation services where 57% are workers of color.18 Additionally, Hispanic householders have the highest average family size while White householders have the lowest (2016 US census), making physical distancing more difficult for Hispanics than Whites.

TELEMEDICINE in a COVID-19 PANDEMIC

Since the beginning of the COVID-19 pandemic, healthcare in the United States has changed in dramatic ways. Healthcare visits have transitioned from primarily in-person to incorporating more virtual visits – with some locations now seeing >70% of their patients virtually.19 Telemedicine is defined as the use of technology to provide health care to those that are not in immediate proximity of a provider. In 2018, 18% of physicians were providing telemedicine; that number has increased to nearly 50% of physicians in 2020.20 One of the most obvious reasons for that increase has been an attempt to decrease human-to-human contact. Fortunately, the increased rate of adoption of telemedicine is in part due to the acceptance by medical insurers. For some types of medical visits, Medicare now has the same reimbursement policy for those who use telemedicine as those who receive in-person services. Additionally, some private insurance companies, have waived copays for telehealth visits since the start of the COVID-19 pandemic.

Telemedicine has incredible benefits; it has been shown to improve patient outcomes by enhancing quality of care, increase access and efficiency, and decrease costs.21,22 For example, tele-ICU intervention decreased the rates of pressure ulcers, ventilator-associated pneumonia, and shortened the length of hospital stays.23 Telepsychiatry has provided improved access to mental health services for inmates – a population with one of the highest rates of mental health problems.24,25 Telemedicine has also been shown to divert potential emergency department visits by 12%, saving up to $1,546 per successful diversion.26 In addition, the use of telemedicine may eliminate barriers to healthcare for families of low socioeconomic status by eliminating the need for transportation or childcare.27

Although the benefits may be immense, telemedicine also has the ability to create and increase health disparities. Telemedicine requires patients to have access to technology, and a broadband connection or WiFi. Research prior to the COVID-19 pandemic has shown that there is a digital divide in the United States based on age, race and ethnicity, level of education, and income. For example, individuals aged 18-34 were 25 times more likely to have internet access at home than those over the age of 75.28 Self-identified non-Hispanic White individuals were nearly 3 times more likely than Hispanic individuals and twice as likely than non-Hispanic Black individuals to have access to internet at home.28 College graduates were nearly 10 times more likely than those who did not graduate from high school to have access to internet at home.28 Those that made more than $75,000 per year were nearly 7 times more likely to have access to internet at home than those who made less than $20,000.28 All of these differences contribute to the unequal access to virtual healthcare during a pandemic for some of the most at-risk patient populations.

ETHICS

Global infectious pandemics raise a number of ethical concerns and issues. For example, how much can an individual’s liberty be restricted? How should patients be triaged? How should resources be allocated when limited? What are the duties of a healthcare professional? With a focus on telemedicine, the remaining article will use the four principles of Ethics: autonomy, beneficence, non-maleficence, and justice to address some of these questions.

AUTONOMY

To have autonomy, one has the power to make their own decisions – oftentimes, the decisions are made on the basis of some deliberation.29 In the case of a global pandemic, one may argue that the patient should have the ability to choose between an in-person visit and a telehealth visit. If healthcare is to be considered a right, and when there is the option for in-person or virtual visits, forcing all patients into one form of care would impinge upon one’s autonomy. If a healthcare provider closes their doors to the public and only allows for virtual visits, the clinic is effectively closing their doors to some of the most vulnerable populations: Black and Hispanic individuals, and people of low socioeconomic status. However, if a clinic were to only offer in-person visits, then people with higher co-morbidities may be at an increased risk of becoming seriously ill from COVID-19. Therefore, the choice should be made on an individual basis by the patient.

One may argue that in forcing providers to see patients in the clinic, the provider’s autonomy is now at risk. In-person visits may pose a health risk for the provider. However, as a healthcare professional, there is a duty to the patient, but additionally there is a duty to protect themself from undue risk or harm.30 It is generally accepted that the nature of the work of a healthcare provider entails a responsibility of beneficence to patients that is greater than that of a non-healthcare provider. This dichotomy then poses the next question of: what is the appropriate risk that a healthcare provider should undertake? It seems reasonable that healthcare providers should balance the immediate benefits of caring for an individual with the ability to care for future patients. However, in the case of COVID-19, when correct and appropriate personal protective equipment (PPE) is used, the rate of transmission and risk of harm is minimal.31 Therefore, autonomy of the provider is not limited by providing in-person visits.

It is also important to note that healthcare providers (doctors and nurses) do not work in isolation. Without fail, there is a team of individuals who work ‘behind the scenes’ to support and maintain the running of a hospital or healthcare clinic. For example, cleaning, kitchen, and management staff are all necessary for health care facilities to function properly. However, unlike healthcare professionals, there is not a code of ethics that requires the support staff to work and care for patients. Therefore, during the time of a pandemic, mandating non-healthcare providers to work would impinge upon their autonomy. With a lack of supporting staff, no hospital and clinic would function properly. Therefore, it is vital to create and maintain a plan for the times of a pandemic where support staff may be limited.

BENEFICENCE with NON-MALEFICENCE

As touched upon in the previous argument of autonomy, what constitutes benefit for one patient may constitute harm for another. The balance between beneficence and non-maleficence is delicate. As healthcare workers, the obligation is to provide net medical benefit to patients with minimal harm; provide care for patients while minimizing the risk to oneself and others.29

In one theoretical example where rates of COVID-19 infection are high, it may be reasonable to delay non-essential medical visits to prevent maleficence. However, would delaying chemotherapy or not going to the emergency department in the case of an acute stroke be net beneficial? According to research performed by the Commonwealth Fund, outpatient visits fell nearly 60% by the beginning of April. While minimizing human-to-human contact is important during the time of a global pandemic, neglecting other health conditions may lead to severe and unintended consequences. There was an estimated 260,000 excess cancer-related deaths caused by the Great Recession of 2008 – likely due to increased unemployment rates, loss of insurance, and decreased healthcare spending.32 Between 2007 and 2010 in the United States, 4750 suicides were attributed to the Great Recession.33 The economic shutdown due to COVID-19 has negated many protective barriers to intimate partner violence.34 Rates of depression and suicidal ideation have also increased during the COVID-19 pandemic.35 While telemedicine has the potential to mitigate some of the negative effects of not going to healthcare visits, there is still a large need for in-person visits.

JUSTICE

The fourth principle of ethics is justice, described as the “moral obligation to act on the basis of fair adjudication between competing claims.”29 In the case of telemedicine, there are a paucity and unequal distribution of resources. As mentioned previously, the access to internet and computers at home is related to age, race and ethnicity, level of education, and income. While it is important for clinics and hospitals to provide telemedicine services to limit human-to-human contact, there is more that needs to be done. People who do not have access to resources required for telemedicine must be provided them. As Aristotle put it, “equals should be treated equally and unequals unequally.” The unequal treatment should be in proportion to the inequalities that are present. An example of distributive justice in this case would be to deliver broadband internet to everyone in America – an estimated $80 billion undertaking.36

The principle of unequal treatment for unequal persons is common in today’s society. For example, our society has deemed it just and fair when the government provides food stamps for the poor. It is just when individuals who have committed a crime are punished while those that have not committed a crime are not punished. However, it is not just when an individual who has committed a crime gets unequal punishment on the basis of age, sex, race, or socioeconomic status. It is not justice when defendants who are convicted of killing White individuals are 17 times more likely to be executed than defendants who are convicted of killing Black individuals.37

The access and allocation of resources, in particular ventilators, is another potential example of injustice. In the past, allocation decisions in public health have been driven by the utilitarian argument, stating that the allocation should be based off of objective determinations of effectiveness and utilization of resources.38,39 Existing strategies include: first-come, first-served; treat those that are most likely to survive; treat those that are most likely to recover with the minimal amount of intervention; prioritization based on those that are most likely to die without treatment; treat those that are most likely to survive after 1 year of treatment. This framework is useful in that it clearly outlines the process of resource allocation and attempts to minimize biased decisions during the time of a crisis. However, In the case of ventilator allocation, some hospitals have developed guidelines that are based upon the simple prediction model: Sequential Organ Failure Assessment score.40 Although this assessment is an easy and quick method, it only predicts short term survival and has not been validated for a number of medical conditions. Additionally, African Americans are more likely to have a worse SOFA score than White Americans.41 Therefore, allocation of ventilators based on SOFA scores have the potential to lead to worse outcomes for African Americans during a pandemic.

CONCLUSIONS

While there are social and health disparities within racial and ethnic groups in the United States, these differences are not based on genetic or biological factors. The differences that are present today are due to a long history of systemic and structural racism. Furthermore, to attribute lung volumes, kidney function, or COVID-19 illness severity to race is irresponsible and inappropriate.

There are clear inequalities that permeate today’s society – inequalities that have become more evident and broadened during the COVID-19 pandemic. However, these inequalities can be fixed with careful attention to the principles of Ethics and thoughtful action. As a country, we can train more Black physicians to ensure that Black babies do not die at three times the rate of a White baby. Health insurance can be a right of every human, preventing anyone from forgoing treatment or medication. We can provide protection to vulnerable populations by subsidizing the cost of internet and devices, allowing every household equal access to healthcare providers. Hospitals can identify fair metrics for resource allocation in the time of a pandemic, so that Black individuals are not unfairly withheld resources.

During the time of global pandemic, it is important to remember that race is a social construct and that it is a poor surrogate marker for explaining disease prevalence. It is necessary to view the perpetuation of health disparities through a lens that accounts for social injustices. One must take into account unequal employment, living conditions, long-standing stress, and food insecurities before attributing health differences to race.

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