COMMENTARY

The Convergence of COVID-19 and Structural Racism

Robert D. Glatter, MD; Ali S. Raja, MD, MBA, MPH; Megan L. Ranney, MD, MPH

Disclosures

July 01, 2020

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This transcript has been edited for clarity.

Robert D. Glatter, MD: Hello. I'm Dr Robert Glatter, medical advisor for Medscape Emergency Medicine. As the curve begins to flatten throughout the country, the number of COVID-19 cases is rising in 26 states, and this is certainly concerning.

To discuss this, I'd like to welcome Dr Megan Ranney, associate professor of emergency medicine and public health at Brown University, along with Ali Raja, associate professor of emergency medicine and executive vice chair at Mass General Hospital in Boston, Massachusetts, part of Harvard Medical School. Welcome.

Megan L. Ranney, MD, MPH: Thanks for having us, Robert.

Ali S. Raja, MD, MPH: Thanks, Rob.

Glatter: The Northeast is doing much better, but certainly we're looking at a problem in 26 states. Part of this is due to data reporting, according to Centers for Disease Control and Prevention (CDC) guidance. Megan, are we headed for a second wave pretty soon based on these data?

Ranney: We're certainly still seeing new hot spots pop up across the country right now. There are many challenges in identifying when and where those appear, because we have some states that are ramping up testing and others that are ramping down testing. There is uncertainty about the accuracy of the reporting of cases, hospitalizations, and deaths that make it tough to trace.

As we reopen, we suspect that we'll see more infections, but there's one thing that may protect us over the next couple of months, which is that it's the summer and there is less inside, close-quarters activity. We suspect that there will be smaller hot spots over the summer and that the true second wave will hit come fall.

Glatter: What role do you think the protests will have? Certainly, from a public health standpoint, they're outside and people are wearing masks, but are you concerned?

Ranney: Obviously, it would be ideal to not have people outside standing so close to each other, but the issue of structural racism is a major health issue and is deeply intertwined with COVID-19.

I'm encouraged by the fact that most protestors are wearing masks. I'd like to see the police wearing masks, too. The more that we can maintain social distancing and the less that protestors are exposed to such things as tear gas, then the lower the incidence of infections from these protests will be. It's going to be a sad but interesting experiment to see if and to what degree infections go up after these protests.

Glatter: Ali, would you agree with Megan in principal?

Raja: I would be foolish to disagree with Megan on just about anything. In this case, I absolutely do agree with everything she said. We're not yet seeing a second wave. What we're seeing is a very prolonged first wave as the areas that maybe weren't hit as hard early are finally experiencing COVID-19 cases.

In New York, Providence, and Boston (where the three of us work), we saw cases months ago and we went through our surges. Now places like Nashville, rural western Massachusetts, upstate New York, and Texas that thought they wouldn't be as heavily affected are seeing surges — they were just delayed.

Like Megan said, we're probably going to see a second surge later this fall, but that's not what we're seeing now. We're still seeing the first surge in many of these places.

In terms of the rallies, at least those that I've been part of and those I've seen that have involved healthcare workers, participants have all been great about covering their mouths with masks.

What we haven't seen a lot of, though, is eye protection. Given the close contact, I've been telling patients who mention that they will be attending these rallies that they need to protect themselves as much as possible.

And in such close quarters with a lot of well-deserved yelling and screaming, there needs to be much more protection, given the potential for aerosolization. Now that we're outside, it's a lot safer, but when we're shoulder to shoulder, there are still risks that we need to try to mitigate.

The Role of 'Structural Racism'

Glatter: That brings us full circle, Megan, to the fact that we need to embrace the spirit of what's going on and talk about the issues of structural racism. Can you define what this means?

Ranney: What does structural racism mean? It's basically the way in which our society has been set up to systematically disadvantage Black persons and other minorities. It's things like unequal access to housing, and the old practice of redlining, where mortgages would not be given to Black persons or other minorities who lived outside of a certain red line, and so therefore essentially segregated minorities even in areas that were not officially segregated. Philadelphia is a great example of this.

It's about the fact that Black persons and other minorities are more likely to hold those essential worker jobs, which are often [underpaid], don't have sick leave, don't come with adequate insurance, and are more likely to be exposed to people who are sick. Because of housing inequities, they are more likely to live in crowded circumstances and are unable to social distance from others in their household.

If you look on Twitter right now, there are threads on #BlackintheIvory that talk about the ways in which structural racism affect our Black colleagues in academia and in medicine. It's about all of these things that, as someone who is white, I don't think about every day, but that affect the daily lives, opportunities, choices, and health consequences for minorities in our country.

Maternal mortality is exponentially higher for Black women than for white women even when they're treated at the same hospitals. We know that there is an increased risk of dying for Black persons. Black persons are between two and four times more likely to die if they catch COVID-19 than a white person. It all plays in together.

As we're talking about how to change those patterns, we have to talk about those structural factors that affect disease prevalence and severity. It's not because of genetics; it's because of the way that our system is set up.

Glatter: We're seeing the convergence of two large issues. It's really quite a wake-up call to everyone in society. Would you agree, Ali?

Raja: I would. We had been talking about this for many months in terms of the racial disparities in the treatment and prevalence of COVID-19 in some of the areas of Boston, for example — and I know this is just as true in New York and in Providence — where some of the hardest-hit communities were those who already had exceptionally poor access to healthcare and were forced to go to work because they didn't have much of a choice.

They couldn't stay home because their typically lower-wage jobs required a physical presence, and so they were putting themselves at risk of getting hit harder, getting COVID-19 more frequently, and then not having access to the care that other more affluent communities might have had.

We were already talking about this a little bit, and then, unfortunately, we recognized this wave of Black deaths due to police that have been going on for a long, long time but have just really hit home more recently.

It's this convergence of two factors. Megan brought up a good point in that those of us in ivory towers and in medicine, especially, are not immune to this at all, despite the fact that some of us might think that we are.

Our specialty, emergency medicine, caters to every patient for any problem at any time, and is definitely not immune to this either.

There have been hosts of studies that have looked at disparities around racial lines for pain control for orthopedic issues, and patients getting cardiac caths for their chest pain. We've done some internal reviews looking at disparities in physician orders of restraints of patients. It's all there. We are not at all immune, and we need to recognize it and focus on fixing the problem without thinking that it's external to the world of medicine and emergency medicine.

PPE Is Still Lacking

Glatter: I want to move on to another topic: PPE. Obviously, that hasn't been in the headlines quite as much lately, but it's certainly still there.

Both of you are part of a very large organization called GetUsPPE. Megan, tell us your success stories in supplying healthcare workers and healthcare systems with PPE.

Ranney: This was a grassroots effort that started in mid- to late March. Ali introduced me to Dr Shuhan He, a colleague of his at Mass General Hospital. I'd been doing work externally trying to get PPE to frontline healthcare workers, Shuhan created a website, and then we brought together a grassroots coalition of software developers, physicians, nurses, and med students.

We're a nonprofit focused on getting donated protective equipment in the hands of frontline workers across the country. We didn't really track our donations in the first month or so, because we thought we were going to be a short-term solution. Since we started tracking, we have delivered well over 1.5 million pieces of protective equipment to healthcare workers. Again, that's a vast underestimate, because there's a lot that wasn't tracked in those early days.

We try to deliver the PPE according to metrics around fairness and how certain populations are more likely to be affected and less likely to have resources for protective equipment. We're looking at not only the needs of hospitals, but also nursing homes, skilled nursing facilities, and others.

One of our greatest strengths is that we work with a number of partner organizations and regional affiliates. For instance, our Chicago affiliate, #GetMePPE Chicago, which is run by a med student, has done tremendous on-the-ground work in terms of assessing needs and helping to facilitate the donation of PPE to hospitals in need.

I remember in the very early days, a group offered to do a bike ride to fundraise for us in mid-April. We said, no need, because we'll be done by mid-April and someone else will have taken over this work. Here we are now in mid-June almost, and we're planning for what we're going to look like when the second wave hits.

Glatter: That's incredible. We've been talking about disparities and there are disparities with PPE (eg, price gouging, competition between hospitals, and states competing for PPE). It's all on the same theme.

Raja: This has exposed yet another inequity, right?

I have to say, as a physician who is part of the largest healthcare system in Massachusetts, we've actually been okay. Now, don't get me wrong. I don't want to underemphasize the work that the team at Partners, which runs Mass General and the Brigham, has done to pull up PPE supplies from everywhere.

There are many organizations around the state and around the country who haven't been able to do that and don't have the PPE that they need. It's shown that additional inequity between the have and the have-not systems that calls for a more central, governmental way to distribute and stockpile PPE. The smaller healthcare systems and hospitals are not able to get all the PPE they need because of their size, despite the fact they serve these communities that really need them.

Glatter: Right. It's incredible that the national stockpile was so depleted. It sounds like it's back to some level of normalcy, but your organization certainly could play a role with the national stockpile. Megan, have you had discussions to that effect at this point?

Ranney: We've certainly had discussions with folks across many levels of government. I would love nothing more than to see our work be taken over by the Federal Emergency Management Agency (FEMA) or the Department of Health and Human Services (HHS).

Part of the trouble is that the strategic national stockpile is not designed to fill the needs of all facilities across the country. It really is designed for a time- and geographically-limited disaster. One of the things about this pandemic is that it's challenging everything that we thought about disaster management. It's causing a lot of us in the academic, medical, and humanitarian worlds to rethink how best to plan for the next phase of this pandemic, which is national.

One of the things that I've taken away from this pandemic, Robert, is the degree to which we as individual citizens can create solutions independently and create hope. Would it be ideal to have it run by government? Sure. But for now, it's on us to do this work.

Glatter: Absolutely. I want to thank you, Megan and Ali. This has been an incredible discussion, and I think our audience would truly appreciate this.

Robert D. Glatter, MD, is an attending physician at Lenox Hill Hospital in New York City and assistant professor of emergency medicine at Zucker School of Medicine at Hofstra/Northwell in Hempstead, New York. He is an editorial advisor and hosts the Hot Topics in EM series on Medscape. He is also a medical contributor for Forbes.

Megan Ranney MD, MPH, is associate professor of emergency medicine and public health at Brown University in Providence, Rhode Island. She is the director and founder of the Brown Emergency Digital Health Innovation (EDHI) program. She is also chief research officer for the American Foundation for Firearm Injury Reduction in Medicine, the country's only nonprofit committed to reducing firearm injury through the public health approach, and a founding partner of GetUsPPE.org, dedicated to matching donors to health systems in need of protective equipment.

Ali S. Raja, MD, MBA, MPH, is associate professor of emergency medicine and executive vice chair at Massachusetts General Hospital in Boston, Massachusetts. A practicing emergency physician and author of over 200 publications, his federally funded research focuses on improving the appropriateness of resource utilization in emergency medicine.

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