Why Has COVID-19 Hit Minorities Harder?

John Whyte, MD, MPH; Valerie Montgomery Rice, MD

Disclosures

September 08, 2020

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  • Black Americans make up about 13% of the US population, but in some states they represent 30% of COVID-19 cases. Their death rate is also two to four times higher.

  • Social determinants of health have a greater impact on people of color. In addition, Black and Hispanic people are more likely to work in essential services, where they have more contact with the public, increasing their risk for COVID-19.

  • We need more minorities in clinical trials, including for vaccines. Clinicians who build trust with their patients can help recruit for these trials.

  • The four historically black medical schools in the United States will be COVID-19 vaccine trial enrollment sites. They can help address minorities' distrust in and fear about trials and vaccines.

  • "Political determinants of health" are systemic political policies that dictate the continuance of health inequities. Advocacy makes a difference.

This transcript has been edited for clarity.

John Whyte, MD, MPH: You're watching Coronavirus in Context. I'm Dr John Whyte, chief medical officer at WebMD. Today I have a very special guest: my good friend, the dean and president of Morehouse School of Medicine, Dr Valerie Montgomery Rice. Dr Montgomery Rice, thanks for joining me.

Valerie Montgomery Rice, MD: Thank you for having me. It's nice to see you again.

Whyte: You and I have been talking about disparities for many years. And now we see the impact of COVID on marginalized populations, communities of color. What has been the impact of COVID on minorities?

Montgomery Rice: It's been significant. I was sitting here and I said, "Okay, let me go find the latest data." What we're seeing now is that African Americans make up somewhere around 13% of the overall population. Dependent on the state that you're in, though, they may account for 30% of the cases. And you and I know that that's defined as a disparity. But what's even more troubling, of course, is that it leads to about two to four times higher death rates. And so we are seeing a significant impact on African American communities.

Whyte: We know it's access to the healthcare system. We know it's because of underlying hypertension, other underlying risk factors. But what about the social determinants of health, the access to food, the access to a safe place to be active and work out? What are we doing about that? You're in the city of Atlanta, where there is disproportionate impact on communities of color, people of brown and black skin. How do we address that? It's not just about coming to Morehouse; it's also about other aspects.

Montgomery Rice: The first thing we do is start with education, right? And so I tell people, first of all, that this virus does not discriminate. It doesn't matter that you are Black or White; if you come into close proximity of someone with the virus, then you are going to catch the virus. If you're White that's going to happen, or Black, or brown.

What we are seeing, though, are the challenges that occur when the person is infected with the virus. We then see the impact of all of those factors influencing. You talked about the chronic diseases. We know that this virus causes inflammation. We talk about the cascade, the burst that you see of inflammatory cells, etc. And we know that is going to impact the heart, the kidneys, the lungs. So if you have diabetes, COPD, lung disease, or any of those challenges, you're going to have a worse outcome. That's the first thing.

Now, if you couple that with those social determinants — when I am complaining of symptoms, can I get a test, first thing? And that is an access issue. Do I have the transportation means to go somewhere to get the test?

Whyte: Yeah, if you don't have a car...

Montgomery Rice: Right. Can I get off of work? All of those things impact health. The most impactful issue around the social determinants is that African Americans and Hispanics tend to work in those essential jobs, those essential positions, where they are going to come into more contact with the public — whether it's driving the bus, working in food service, or working for one of our delivery services that have just been wonderful in keeping us safe but not necessarily themselves safe. Those are all issues that have influenced and caused the negative impact that we've seen this virus have on our communities of brown and Black people.

Whyte: Everyone's talking about the vaccine. But what they're not talking about are the challenges in recruitment.

Montgomery Rice: Yeah.

Whyte: And we're seeing challenges in recruiting minority populations. You and I have been conversing for years about the low number of Blacks and other minorities in clinical trials, especially in cancer trials. So how are we going to fix this? Is COVID going to show us the way to more equity? Or is it only going to exacerbate the current situation?

Montgomery Rice: You bring up a good point. You and I have talked for years. When you were at the FDA, we talked all the time about how we could increase the number of Blacks participating in clinical trials. This was even before COVID. I had the opportunity to serve on an FDA advisory panel for reproductive and neurologic drugs for 7-8 years, and we talked about it then.

At Morehouse School of Medicine, we actually have a clinical research center that has a really great track record for enrolling people of color in trials. And the reason that we can do that so successfully is because we are a trusted entity. We have worked really, really hard all of these years to build trust within the community. We work really, really hard to build a partnership with primary care providers: We train them and we train their nurses to participate with us in a trial, because most of the people that we want in a trial are patients of primary care providers. So if you can build that trust network, it makes a difference.

Now, we also have to continue to educate. We all have heard the Tuskegee syphilis story. We've all heard the Henrietta Lacks story. But we know that the mistrust and distrust that occur between a provider and a patient, or the Black community and the health system, started way before that.

I'm reading this book again, Medical Apartheid by Harriet Washington. I've picked up this book and read parts of it several times, and some of the information is so disturbing that it makes me have to pause. But it reminds me where that mistrust and distrust came from. It started way back in slavery, John, when Blacks were used for medical experimentation without their permission. Stories were told over the years, and they were real stories.

So, I have to make sure that as we bring on the COVID-19 vaccine trials —I'm very happy that Morehouse School of Medicine and the three other historically Black medical schools will be enrollment sites —that we are educating our community, partnering with them, and addressing their fears around participating in these vaccine studies. And it starts with building trust.

Whyte: So it's trust. It's education. How has Black Lives Matter affected the discussion of health equity? Is it going to have a long-lasting impact? Or is it going to be like other times, where there's been a blip, there's been interest, and then it's gone back to the way that it's always been? What's different, Dr Montgomery Rice, this time around?

Montgomery Rice: For so many years, we've been nibbling around the edges of this problem of health inequities in the United States. But Black Lives Matter has done a couple of things. It's asked us to look at the drivers: What drives the entrenched inequities in this country, the structural inequities, the institutional inequities? Only when we address those issues will we really be able to say that we're making a difference, because it's systemic.

Black Lives Matter has said that we've got to do a root-cause analysis of what has been causing these problems, and then we have to have interventions along the way that break down the systemic barriers. At Morehouse School of Medicine, we've recently been talking about the political determinants of health.

One of our professors, Dr Daniel Dawes, has this new book, The Political Determinants of Health, and he's going to be our convocation speaker. But what he talks about there is what is it from a policy perspective that has allowed these inequities to continue? We know that whether it's housing laws that cause redlining — where people are forced to live in communities and then the tax base doesn't necessarily allow for there to be the amount of taxes contributed to those communities so you can have better schools, etc. — there have been systemic public policies that have influenced health outcomes. And Black Lives Matter is asking us to do some root-cause analysis. So I'm excited.

Whyte: Do you think it'll make a difference this time?

Montgomery Rice: I think it's going to make a difference. I am a person who believes in advocacy. So, what I say to everyone who's out there being in the marches and all of those places is to continue to do three things: Wear your masks, wash your hands, and watch your distance — but use your voice. Use your voice.

Whyte: We've also been talking about the importance of having more minorities in medicine. I want you to share your personal story. I know you're modest that, here you are, Harvard Medical School, a woman dean, a Black woman dean, and president of a medical school. That doesn't happen very often. And your portrait hung in the National Portrait Gallery . Tell us your story and how you can inspire people of color, women, to go into medical school, become a dean, become a world expert physician, yours in infertility and women's health. What was your key to success?

Montgomery Rice: First of all, I've always had this wonderful village that supported me. I was raised in a single-parent household with three wonderful sisters and a mother, a mother who had resilience and grit, and she built that as a part of our character.

We are people of faith. She allowed us, and forced us initially, to have a strong foundation. It's kind of like osmosis; it comes back to you. And when you need it the most, it's there; it's a part of you. So, when there have been times of challenge, I relied on my faith and my village.

I came from a small town in Macon, Georgia. And then I went to Georgia Tech and Harvard Medical School. I didn't always know that I wanted to be a doctor. I thought I wanted to be an engineer. And when I decided I didn't want to be an engineer, I wasn't afraid to change my mind. Again, I think that ability to be confident in that decision was really based on the strength that I had gathered from my mother.

Whyte: I saw you on the day in Washington, DC, that you went to the Portrait Gallery where your picture hung. Tell us how that made you feel. Here you are — you grew up in Macon, Georgia, and now your picture is in the Smithsonian in the nation's capital.

Montgomery Rice: You know, it was an opportunity that was really significant for me. Several people have been featured. But they went looking for individuals who had a life story that would resonate and inspire. I've just been very fortunate that my story resonates with other young people who believe that if they didn't come from a two-parent household, that whatever they want to achieve is not achievable. I think I've shown that that's not the case.

But I've also kept in mind that it really takes a village. One thing that I've never been afraid to do is to ask for help and to actually open myself up to reasonable, constructive advice and to follow that advice. What I would say to young people is that you have a story, and your story is important. First of all, do not be afraid to tell your story. But equally important is to share your story in ways that inspire others, because everybody can resonate with something in somebody else's life. And that is what actually builds that village.

Whyte: I want to thank you for sharing your story today, for your leadership, for your advocacy in helping us try to find a road map for how we address these issues of disparity.

Montgomery Rice: Thank you, John. This is important. The only thing that I would add to our conversation is that as we think about this comprehensive strategy, that when we're trying to really beat down this virus, that we would consider what it means to have a national testing strategy in this country such that we can ensure that we know who is infected. And then that we can appropriately quarantine those persons and support them so that we can mitigate the spread of the disease.

That is something that we're working on here at Morehouse School of Medicine. I hope that with all of the science that's coming out about asymptomatic carriers, all of the data that are coming out about the different testing that's available — whether it's point-of-care testing, testing using a saliva kit, or testing using different types of swabs — that we would actually put all of that information together and partner and develop a national testing strategy so that we do not let this virus continue to beat us in the way that it has.

Whyte: That's a great reminder and one that we have to work on in terms of this strategy.

Montgomery Rice: Yes.

Whyte: Thank you again.

Montgomery Rice: Thank you.

Whyte: And thank you for watching Coronavirus in Context.

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