Welcome to the April 2020 newsletter. You can find past newsletters with additional background materials, and different stories and initiatives in my LinkedIn articles and on my website. Join me in improving and coordinating initiatives that advance health, health equity and community and healthcare redesign.
Shannah’s Insights and Reflections
We’ve experienced a sustained month of COVID19 and lock down/social distancing. It has also been a jarring exposé on health disparities and the implications of living conditions on individuals’ and families’ health status, health risks and access to care. I am again breaking away from my standard reporting this month and instead will highlight the ways the pandemic exposes the many drivers of health disparities and our need to address the fundamental inequities across all segments of our society.
Inequalities, prejudices and social and economic disparities lay the disastrous foundation for the disparate risks, impacts and treatment experienced by African Americans, Hispanics, immigrants, low income people and communities and elderly populations. This past month coverage focuses on the need for data. There is a growing voice that the disparities not only result from social determinants and comorbidities, but prejudice and discrimination. Unfortunately, how individuals and institutions treat individuals can be influenced or dictated by factors that should have no role in testing, treatment or services. Gaining true insight on this aspect will also be data dependent.
Thankfully there is a ground swell of support for better understanding all of these differences NOW and trying to mid-course correct and plan for a better future. It is not everywhere, and this could not be more evident than in some of the research around who is collecting what data that eerily maps to the distinct approach to social distancing and when to re-open.
All of our efforts are being hamstrung by the limited availability of testing. This is further complicated if the needed demographic data is not collected. There is growing tracking of which states are collecting needed data along with disparities in contracting COVID19 and deaths from COVID19. I’ve highlighted many of these trends in this newsletter.
I again hope my next newsletter will occur at a time when we have turned the corner and know the end is in sight, but uneven policies about reopening business and sustained social distancing threaten any safe national recovery path.
This month I’ve dispensed with the subsections and concentrated on the topic of disparities. I’ve also shared a personal story that I believe is too representative of another glaring health system problem, adequate mental health services and supports. Perhaps that will be a focus for the May newsletter.
Share your personal or community stories by connecting via LinkedIn or email email@example.com I welcome suggestions in all topic areas, particularly community driven models.
A personal or individual story
A member of my extended family is clinically depressed, changed health plans for 2020 to get better mental health coverage. COVID19 hits as medications run out and access to care is severely restricted. Most therapists in network are not taking new patients, a therapist needs to refer to a psychiatrist who can write an updated prescription. All of this is in the midst of being furloughed and struggling to stay whole along with managing through the depression.
The good policy wonk that I am says this is exactly the flexibility that the pandemic allows for coverage and treatment: They should be able to extend/honor the prior script and coverage until new providers are in place. Unfortunately, easier said than done during the pandemic and when a person is clinically depressed and struggles to engage daily.
How many people in our country are dealing with the same or worse issues with limited or no healthcare coverage and non-responsive health plans?
Health disparities and inequities
A close look at the variability in reporting from Hartman and Zylla, from the State Health Access Data Assistance Center, shows which states are reporting adequate COVID19 case data by; age, gender, race, ethnicity, health care worker, residence and zip code. This demonstrates the inequitable impacts in states that are tracking the needed demographics and which states are not. It looks at the data with respect to reporting: cases, deaths, hospitalizations and underlying health conditions; while acknowledging that lacking demographic data regarding testing leaves it unclear if vulnerable populations also struggle to gain access to testing. Inadequate testing for these population could be masking even greater disparities.
Rensselaer Polytech Institute has created COVIDMINDER and is tracking state disparities in outcomes and mediation (testing and hospitalization) across states against the national average or a particular state data and tracks details in New York Counties.
I was able to attend most of the Healthcare IT CONNECT’s Indiana COVID19 Data Taskforce webinar on May 1st. One of the highlights is that Indiana is the first state I’ve heard about that is doing random sample COVID19 testing to get a handle on the base line rate of infection! Another highlight is the close working relationships that have emerged, across programs that have historically been siloed, to support data sharing and improved understanding of health and treatment disparities. Let’s watch this state for innovation during and after the pandemic. Also let me know if any other states are doing random sample testing.
Accepted article COVID-19 Community Stabilization and Sustainability Framework: An Integration of the Maslow Hierarchy of Needs and Social Determinants of Health underscores how a person’s living situation determines what their primary needs and concerns are and that basic physical needs take precedence over safety needs. This hierarchy needs to be overlaid on social determinants of health to understand what drives individual decision making. Similarly, communities need to take the hierarchy into account as they try to navigate a path forward midst and after the pandemic. The baseline requirement for using data to determine the best path forward is having adequate disaggregated data.
This article goes hand in hand with the growing coverage about all of the essential low wage workers who are put at greater risk of COVID19 exposure with little to no protections: Public transit workers, grocery store employees, transportation Lyft, Uber etc. really any worker who needs to put short term income above their own safety to address their ability to pay for shelter and food.
The recent article in the Washington Post calls COVID-19 the perfect storm for Black Americans. The article is just one discussion of the pervasive problem. Consistent with the growing data efforts and research, this article notes places like New York City where black residents are twice as likely to die from COVID19 than white residents. Similarly, in counties with majority black populations, blacks have three times as high infections rates and six times as high death rates.
It is also not just the vulnerable population but physicians of color who are experiencing these disparities and inequities that affect their patients and themselves. Coverage of a recent AMA panel from the AMA health equity center, highlights these risks to a critical and overburdened part of our health delivery system. The panel and Center overwhelmingly support getting data now and intervening now… “too often, communities of color are discussed in the after-action review and not discussed before.”
This newsletter would not be complete without some discussion of the systemic inadequacies of our long-term care services and supports for our vulnerable and frail elderly. We know many nursing homes are some of the hardest hit with cases and deaths due to COVID19. We also know that home healthcare, hospice and companion care workers are at greater risk and their workforce often fit the profiles of vulnerable populations & low wage workers. Past disasters have regularly emphasized the added vulnerability of addressing the needs of population in nursing homes and assisted living with any type of rapid response. To top it all off, the social distancing and isolation demanded by this pandemic has some of the worst impacts on this vulnerable population that already suffers from loneliness and isolation.
Focus on changing the care environment to take all comers is emerging in some locations. The following initiative is reassuring. It recognizes the disparities in available testing and the need to look at underlying living conditions and health conditions.
In Hyde park MA, Brigham and Women’s mobile testing site is open to everyone
“Anyone wishing to be tested can go to the Brigham and Women’s Faulkner Hospital community physicians practice location on Hyde Park Avenue and fill out a form… This service is available to all residents in the area and there is no requirement to get the testing. People do not need to be a patient at the hospital or of any affiliated primary care physician. There is no need for health insurance or even proof of citizenship or immigration status.”
The testing is followed by screening for social determinant needs to help address existing risk factors that make individual and families more susceptible to health risks.
This is an important step, but our nation and the world have to do more not only in this pandemic, but to move forward towards recovery and resilience. An interview with Nancy Krieger, a professor of social epidemiologyat Harvard,gives voice to hope on how we can begin this process. Her response to how we can move forward was:
“First, it’s a reminder of our common humanity. And we have to draw on that common commitment to protect people and care. Second, I think that it is bringing together many groups who have been working on different facets of all the things that COVID-19 is bringing together, as I said — the housing crisis, the environmental crisis, racial injustice. Also, issues around gender relations, what does it mean to ask people to shelter at home, if there are possibilities of domestic violence — it’s making people see the connections… And in the ecosocial theory of disease distribution, there is an emphasis on embodiment: How do people embody? Our bodies don’t care if you want to parse it out: This is a housing crisis. This is an economic crisis. This is racial injustice. This is gender inequity. Right now, people through their bodies are showing what the problems are in our society, but also what the potential is for people coming to work together to make a better world — one where people can thrive, with dignity, with their rights, in a sustainable way.”
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CURRENT & UPCOMING EVENTS
NEW DATES: RISE National Summit on Social Determinants, June 9-11, 2020 is now a virtual event.
Background and Definition
I have chosen the phrase “Living Conditions” rather than social determinants of health (SDOH) to make the concept more accessible. This focus tracks with the Centers for Disease Control and Prevention’s SDOH definition “as conditions in the environments in which people live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.”
Go here for more information from CDC on its organizing SDOH framework in Healthy People 2020