Celebrities and public figures like Madonna and New York Governor Andrew Cuomo have called COVID-19 a “great equalizer.” While it may seem as if we are all currently united by a common threat, COVID-19 is no shared experience.
As the media has repeatedly reported, COVID-19 has disproportionately affected communities of color. NPR found that nationally African American deaths from COVID-19 are nearly two times greater than would be expected based on their share of the population. In four states, the rate is three or more times greater. In 42 states plus Washington, D.C., Latinx cases account for more than their share of the population—in eight states, it’s more than four times greater.
Statistics from the Centers for Disease Control and Prevention show just one reason why this disparity exists. Nearly a quarter of employed Hispanic and Black people work in service industry jobs compared to 16% of non-Hispanic whites. Hispanic workers account for 17% of total employment but constitute 53% of agricultural workers. Oftentimes, these jobs don’t offer the insurance needed to cover the medical bills resulting from more serious cases of COVID-19.
African Americans make up 12% of all employed workers but account for 30% of licensed practical and licensed vocational nurses. Essential jobs such as these require interaction with others, increasing the chances of COVID-19 exposure.
Add to this the systemic inequalities in health care and it’s no wonder that such a gap exists. COVID-19 has held a mirror up to just how broken our health care system is.
Nayeli Chavez, Ph.D., Counseling Psychology Department faculty, wasn’t surprised that COVID-19 particularly affects communities of color more.
“We knew this was coming, we saw it happen, and the systems and the people in power really did nothing to prepare for it or stop it,” Dr. Chavez says. “I often hear students, clients, and others talk about how many of us feel like we have been left to our own devices. We have been abandoned by the very institutions that we help to support. And to me that is disheartening. This country is running because people of color are working so-called essential jobs. So our jobs are essential, but our lives are not? It has become very, very evident that our lives are expendable. The government is willing to sacrifice the lives of vulnerable people so that the economics of this country can go on.”
The U.S. health care system
When examining COVID-19’s impact on racial minorities in the U.S., we must also look at the system upon which they rely for health care.
“The system of health care was designed by a particular group of people for a particular group of people—white people,” Dr. Chavez says. “And then the entire design of this system is impacted by cultural and racial context. For example, how services are provided, where they are located, and how interaction with a patient takes place. Every single aspect of the medical system is impacted by context, history, and culture.”
The system has caused a health care divide between racial minorities and white people that goes way beyond what health care professionals can tangibly treat. It has also led to distrust in the system. A 2003 study from Johns Hopkins University found that African Americans and other ethnic minorities report less partnership with physicians, less participation in medical decisions, and lower levels of satisfaction with care—leading them to a higher risk of negative health consequences.
“When people look at health care, they assume that it is objective. It is not looked at with the idea that it represents the values and culture of the people who created it,” Dr. Chavez says. “However, when we look at all the communities of color in the United States, we see how they are deeply impacted by history, by context, by structural forces, and lack of access to basic necessities that are connected to health, like access to health insurance, stable jobs, education, a place to live that is free of pollution. Sadly, individuals with decision-making power within the health care system have individual level solutions for problems that are systemic and structural.”
Then factor in limited health care resources. Many organizations have released Crisis Standards of Care guidelines with input on how to determine which patients get priority treatment. Within these guidelines, doctors must include “comorbidities”—underlying medical conditions that can put infected patients at a higher risk—and are experienced at higher rates by communities of color.
Mudita Dave, Ph.D., chair of the Master of Public Health program at The Chicago School’s Online Campus, explains that interprofessional collaboration, on multiple levels, is key to fixing the health care system.
“We want to work collectively and collaboratively with all stakeholders to address and understand the problems first, because oftentimes we may not be investing as much or as deeply as we could to understand the problem,” Dr. Dave advises. “Then work toward a solution in a very collaborative manner with stakeholders. It is very difficult to go from an approach that’s outside in versus inside out.”
How do you get those stakeholders at the table to build a better system? The answer is a three-pronged process, involving representation, cultural competence, and integrated care.
Representation and cultural competence
Research shows that having diverse clinicians, who are prepared to deliver high-quality interpersonal and technical care to a racially and ethnically diverse population, can help address disparities in health care, yet only 5% of active physicians in the U.S. are Black. 56.2% are white.
“It is important for people to see and interact with others who look like themselves in the health care setting. We need to make the pipeline strong and robust,” Dr. Dave says. “What we need even more in such times of a pandemic is equity—something that can have a much longer-term, positive impact in communities, especially communities that are vulnerable. We want to empower those communities for better health outcomes by ensuring access to resources and representation, whether it is it in health care and public health or any other field.”
While it is helpful to focus on diversity within health care leadership and management, this kind of work requires more than annual trainings or hiring a consultant. Institutions need to set up systems that are not only diverse but also welcoming to people of all backgrounds. They must be purposeful about inclusivity and active engagement—to have their patients be a part of the decision-making process and act as equal partners regardless of race or ethnicity. We as a nation can only gain from the creative problem-solving that organically happens when a diversity of perspectives is honored and included.
Additionally, giving more attention to the health challenges faced by communities of color would help address adverse social determinants of health. One must recognize it’s not who people are that makes them ill or puts them at higher risk, but rather it is a combination of physical environment, living conditions, access to a healthy diet and health care, lifestyle factors, as well as the structures that are in place.
Training that is more congruent with a variety of different experiences and cultural contexts is needed.
Nayeli Chavez, Ph.D.
“The most foundational, fundamental thing that we want to really invest our energy and resources in as a nation are the social determinants of health,” Dr. Dave says. “Prior to the COVID-19 pandemic, Black and Hispanic Americans have faced a disproportionate burden of preventable health conditions. How can we, as a nation, as public health and health care professionals, work together to find solutions to these challenges so that good health and well-being are enjoyed more equitably by all in the U.S.?”
Nonprofits often pick up the slack when it comes to creating more equitable health care for people of color. But they can usually only provide short-term solutions that delude the actual problem. Hospitals need to allow doctors enough time and training to interact and properly care for those who need extra attention.
“The way that we communicate with each other is embedded in a context and the culture,” Dr. Chavez says. “When physicians encounter patients from different countries and cultures that are vastly different from their own, they are likely to not know what to do differently. For instance, a behavior that may feel like good bedside manner for one patient may be interpreted differently by another. But the current medical training continues to be one size fits all. I think that’s part of the problem. Training that is more congruent with a variety of different experiences and cultural contexts is needed.”
More integrated care
As physicians become more culturally competent, they also need to transcend the idea that health is purely biological.
“In the U.S. we purely look at health from a medical and biological basis,” Dr. Chavez says. “What I often see between the medical and mental health field is a disconnect in the understanding that there is a bidirectional relationship between physical health and mental health, and that if we don’t address mental health, physical health is going to be further exacerbated and vice versa.”
Health care, public health, and mental health all make up and support an entire system. Integrated care in nursing, public health education, and patient support can help pave the way forward. To take the lead, the U.S. needs smart, culturally intelligent leaders who are prepared to go to the root and offer more than temporary solutions.
The Chicago School is poised to prepare the next generation of leaders in integrated care. With a focus on preparing culturally competent professionals who are inspired to create systemic change, and with its new College of Nursing and Advanced Health Professions, The Chicago School is uniting programs and educating future experts in nursing and health sciences, with an emphasis on how to serve patients equitably while creating true reform.
“Our commitment to the integration of mental health and physical health—and our oft-stated belief that there is ‘no health without mental health’ has resulted in a focus on interprofessional education and interdisciplinary collaboration that serves as a model for the combined professions,” says Michele Nealon, Psy.D., president of The Chicago School.
Furthermore, The Chicago School is committed to ensuring that underrepresented populations are receiving more outreach.
“Through community-based partnerships at each of our campuses, students use their newly honed skills to tackle problems that range from parenting issues and family dynamics to workplace productivity and the countless challenges facing immigrants and marginalized populations,” Dr. Nealon says. “In 2020, we had 38 community-based partnerships in place. Our initiatives are designed to address specific community problems, whatever they may be, with a focus on meeting the needs of the underserved.”
Even now, our attention remains on the streets, where people have protested police brutality across the nation. To Dr. Chavez, this was inspiring—even though communities of color were hit the hardest by COVID-19, they were still willing to go fight for their lives.
“What you see is the strength; you see the determination; you see the vision of a group of people who are saying, ‘I’m not going to allow you to do this to me. I’m going to highlight it. I’m going to hold a mirror to you, so you can see what you’re doing.’ And that has been the driver of change in this country,” Dr. Chavez says. “In the midst of a pandemic, you see thousands and thousands of people on the street risking their lives to fight for their lives and their right to live free of fear. And I know for many of those people, and many people in our communities, they’re not doing it for themselves. They’re doing it for future generations and to save the lives of people they don’t even know. It’s a beautiful thing to see, and I think it speaks to the power and the courage of communities of color.”
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