Disparities Shape COVID-19 Caseload in Georgia

Maureen Salamon

June 12, 2020

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

Patients with COVID-19 symptoms began flooding Phoebe Putney Memorial Hospital's emergency department in Albany, Georgia, in mid-March. But it didn't add up: As far as anyone knew, relatively few cases of the novel coronavirus had been reported in the state.

Then, slowly, it all started to make sense.

Many patients reported that someone they knew — their sister, their next-door neighbor, their pastor — was being examined in a room nearby. Every patient had one thing in common: they had attended at least one of two services at the same funeral home in the previous 2 weeks.

"There were hundreds of people at these funerals in very tight quarters, with a lot of crying, wiping of noses, and hugging," said Scott Steiner, chief executive officer of the Phoebe Putney Health System. "These were super-spreader events."

In the end, about 20 people who attended services at the funeral home, including six siblings of one of the deceased, contracted the virus. Albany, with a population 72,000, would become a major COVID-19 hotspot in Georgia and would come to have one of the highest concentrations of COVID-19 in the world by population.

"It was a bit surreal. We burned through 6 months of PPE in 7 days, so we knew we were in for a fight," Steiner said.

Steiner's southwestern Georgia health system has since treated more than 520 inpatients for the virus, he said, and has converted five additional hospital wards into dedicated COVID-19 intensive care units.

It was a bit surreal. We burned through 6 months of PPE in 7 days, so we knew we were in for a fight. Scott Steiner, CEO, Phoebe Putney Health System

The widely publicized Albany-funeral cluster — which occurred just before the Centers for Disease Control and Prevention issued guidelines limiting gatherings to no more than 50 people — positioned Georgia prominently on the COVID-19 map.

As of June 12, more than 55,000 people in the state had tested positive for COVID-19, and there have been more than 2400 deaths, according to data from the state's Department of Health. But the pandemic has played out in several striking ways in this state of 10 million residents, health officials say.

Disparities Shape Caseloads

With distinct racial, socioeconomic, and health disparities contributing to who contracts the virus, Georgia represents a "collection of states" in one, said Carlos Del Rio, MD, professor and chair of global health at the Rollins School of Public Health at Emory University in Atlanta.

"Even Atlanta is not one place," he said. "When you look at this city, wealthy neighborhoods actually have seen very little impact of this disease."

More than 85% of the COVID-19 inpatients treated at Phoebe Putney Health System have been black, Steiner said. A similar disparity was seen at the 640-bed Grady Memorial Hospital in Atlanta, where Del Rio will be on service in July and is now enrolling patients in studies of the antiviral remdesivir.

Heart disease, stroke, and diabetes are well-known problems in Georgia and have contributed to the disproportionate effect of the virus there, officials say. Not only are they known risk factors for severe COVID-19, but they also tend to be more pervasive among racial and ethnic minorities.

"The biggest challenge we've seen is that this is a disease of primarily racial disparities," Del Rio said. "Hopefully, COVID will be the wake-up call."

The biggest challenge we've seen is that this is a disease of primarily racial disparities. Dr Carlos Del Rio

"We have an unhealthy population," Steiner said. "Eighty percent of our COVID-positive patients and 94% of those who died had hypertension. That's not a coincidence."

Northeast Georgia became another hotspot when more than 400 poultry farm workers — many of whom are Latino — tested positive. The region is home to about a dozen chicken processing plants, which employ 16,500 people. The Latinos who overwhelmingly staff the farms often live in crowded, multigenerational households where the virus can spread like wildfire, said Clifton Hastings, MD. Hastings is the chief of medical staff at Northeast Georgia Medical Center in Gainesville, which is considered the "poultry capital of the world."

"Anytime you have a viral issue like this, it's those patients and families that are least able to adapt. Some of these people have 10 to 15 people living in one house," Hastings said. He said that his health system worked with state and local organizations, including the Latino Chamber of Commerce, to test and educate affected groups.

"It took us a couple of months to get hold of this and make a difference," he said. "You can't socially distance when you have that many people in one house."

"Litmus Test" for Reopening

In the southeastern part of the state, however, the pandemic has taken a completely different shape. In Savannah, which lies on the Atlantic coast, the 630-bed Memorial Health University Medical Center saw only 29 COVID-19–positive inpatients at its peak on May 7, says Stephen Thacker, MD, who is associate chief medical officer.

Not only is Savannah wealthier than Atlanta and other areas of the state, fewer residents have comorbidities that predispose to worse COVID-19 outcomes, Thacker said.

"We prepared for an impressive surge of patients in the early phase of this pandemic, but we're very thankful we didn't experience that in southeast Georgia," he said. "Our region is somewhat protected compared to southwest Georgia, where there's greater density of obesity, diabetes, and patients of older age."

Regardless of region, all health systems in Georgia have been exposed to problems at the level of state government. Hospital leaders didn't know whether they could trust state tracking data after the Department of Health posted graphs in May that showed steadily declining COVID-19 case counts with data that were not in chronologic order.

"I think all of us scientists are skeptical of data, and when they look that perfect, you think something is wrong," Del Rio said. "The great advantage today is that we have so many other sources of data. We didn't lose anything, but I think [the Department of Health] lost credibility. It's an embarrassment."

Statewide shelter-in-place orders allowed businesses such as waffle shops, barber shops, and tattoo parlors to reopen after only 3 weeks of lockdown. This seemed too short for some healthcare leaders, who were concerned that the public's desire for reopening would lead to a new surge.

But that hasn't happened so far. The rate of new COVID-19 cases in Georgia has remained consistent since the shelter-in-place order was lifted on April 24.

"There is an appetite in the community to get back out there," said Michael Covert, chief operating officer of Northeast Georgia Medical Center. "It's really a mixed bag. You still see people here doing the things they need to, keeping social distance, but it's all over the map."

Thacker hopes that a cautious attitude will prevail. "The shelter-in-place was taken to heart, but now as we start to reopen, the biggest challenge I see is remembering how we got to this point," Thacker said. "Since we're one of the first states to open up, we're going to be a litmus test on how you safely — hopefully — reopen a state, and businesses, in a well-thought-out fashion."

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