Is COVID-19 a ‘Set-Up’ or a ‘Set-Back’ for
Vulnerable Populations?

[5 minute read time]

This is the first in a periodic series of conversations with NCMS members who are on the frontlines in improving the health of North Carolinians and are now responding to the COVID-19 pandemic. If you would like to share your perspective and experiences, please contact Elaine Ellis, [email protected] to discuss being part of the NCMS Community Conversation series.

Today’s conversation is with Karen Smith, MD, a longtime NCMS member and family physician in Raeford, NC who also works as the Hoke County Health Department Medical Director. Dr. Smith serves a diverse and oftentimes vulnerable patient population in this rural area. The current pandemic has magnified some of the existing health disparities in her community, she says, and national data have reinforced what Dr. Smith has been witnessing in her area.

For instance, surveillance data from the Centers for Disease Control and Prevention (CDC), which began tracking COVID-19 hospitalizations through its 14-state COVID-NET network in March, has shown the majority of patients hospitalized for COVID-19 have underlying conditions like hypertension, obesity and cardiovascular disease. The data also suggests “that black populations might be disproportionately affected by COVID-19,” the CDC report states.

In North Carolina as of May 18, the NC Department of Health and Human Services (NCDHHS) reports that for cases where race and ethnicity are known, 33 percent of the confirmed COVID-19 cases are among African Americans and 31 percent are among Hispanics. The US Census estimates as of July 2019 show that African Americans make up 22 percent of the state’s population and Hispanics less than 10 percent.

While many of those who die from the virus have underlying health issues, those are often a result of socio-economic factors like “where a person lives, learns, works and plays,” Dr. Smith said

Underpinning the recent NC Institute of Medicine’s Healthy NC 2030 roadmap to improve the state’s health over the next decade, which has been embraced by the NCMS Board of Directors, lies the conviction that “health inequities are created when people cannot attain optimal health because of unjust, unnecessary and avoidable circumstances (e.g. greater barriers to accessing healthy foods, transportation, physical activity and health care in historically segregated, low-income and racial and ethnic minority communities). These inequities lead to health disparities, or differences in health status and outcomes between groups based on characteristics like race, ethnicity, gender, geography, educational attainment and income.”

The current pandemic has held a magnifying glass to some of these disparities, Dr. Smith said. Her key question is whether the inequities highlighted by the pandemic will lead to positive change in the future.

“Can we get beyond what we know previously existed and actually try to correct some of those socio-economic issues? Is this [pandemic] a set-back for the population or is it actually a set up? We have evidence, we have proof. We know [these socio-economic conditions have] a major impact in creating this disparity. I fear that we as a society will say, ‘ok, we knew this was going to happen, let’s get over it and move on with time’ and we will not take the opportunity to say, ‘yes, we’re going to actively engage and fix the situation.’”

Collaboration, Protocols and Examining Implicit Bias

One incident stands out for Dr. Smith in illustrating some of the challenges many physicians are facing as well as lessons to be learned. On a recent Friday morning, the Hoke County Health Director called Dr. Smith to report a COVID-19 ‘mini-outbreak’ at the Canyon Hills residential facility, a 24-bed, treatment facility for boys ages 6 to 17. Two employees tested positive for the virus and were sent home. Now Dr. Smith and the health director had to decide whether and how to test the remaining staff and children.

“My gut feeling – and not to take ownership of the decision because I worked with the health director – if I were a parent and my kid was in a facility out of my home, out of my reach, I would want to know. The final conclusion — we will test,” Dr. Smith said. The problem was there were not enough kits to do the necessary testing.

With 28 years in the community, Dr. Smith knew who to call at FirstHealth of the Carolinas Moore Regional Hospital.

“I literally had tears in my eyes because of how the hospital responded. She said to me, ‘you tell me what you need. We’re going to send you the kits.’ Then, they drove the kits to us,” Dr. Smith said. By the time the testing was complete, the courier service had stopped for the day, but the local EMS stepped up and drove the specimens to Raleigh. By Monday morning, they had the surprising results – 14 positives. Canyon Hills then began addressing how to communicate with parents and how best to separate, isolate, trace, treat and monitor both positive and negative cases.

“There was no existing protocol, yet people and things just kind of gelled and came together. People stepped up to the plate. Different organizations stepped up to the plate. It reminded me of “The Practical Playbook” in terms of how community collaboration makes sense even in a non-pandemic or non-crisis,” Dr. Smith said. “It doesn’t matter if you’re working independent, solo, like myself, or if you’re working in a hospital setting. In an issue of this nature, it’s no longer you the physician that takes ownership of the problem and the solution, it’s the team that is going to take ownership of the problem and the solution.”

The importance of collaboration is one lesson driven home by this incident. Having an emergency protocol in place is another – in fact, having a standardized protocol is first on the list of guidance from the CDC when addressing the needs of vulnerable populations during an emergency.

Number two on the CDC’s guidance is to identify and address implicit bias. Dr. Smith recalls examining any bias that may have existed about the kids at Canyon Hills.

“It’s very important to pay attention to the implicit bias. ‘Yes, they are from vulnerable population backgrounds, and yes, their life matters. They matter and therefore yes, we should test,” she said in describing her thought process.

Understanding the Community; Educating the Community

State officials identified testing and contact tracing as key components in understanding and mitigating the spread of the virus and have been working to ramp up both. Dr. Smith has a window into what that may mean in reality for the people in Hoke County.

“The tracing is interesting because this is where we start to see some of the disparities,” she said. “For example, the very first person who was identified and tested positive according to the county data, their telephone was disconnected. So, this person was lost to contact. We have vulnerable populations who may have lost their employment and cannot maintain those services like telephone or internet connectivity. Or maybe they’ve had to move because of a housing situation. These issues will have impact as regards the ability to trace.”

Some of her patients flat out refuse to be tested because a positive test means they will not be able to work.

“They literally have made the decision that ‘I have the disease and my disease is mild enough that I can get away with going into my job because my job, quite frankly, isn’t doing temperature testing. I have to work. I need to make money, and I’m mild and I’m just going to get by.”

Then there are those who have dangerous misinformation. For instance, that the cotton on the testing swab is from China and will actually infect them with the virus. Dr. Smith recently went on the local radio station to try to dispel the myth that drinking bleach – even a small amount – will cleanse the virus from a person’s body.

Her practice also is proactively reaching out to about 350 risk stratified patients identified as very high risk and high risk of serious health impacts if they contract COVID-19. Practice staff screen them for any COVID-19 symptoms as well as other vulnerability factors, such as how they get their food, medications, assess their emotional well-being and health resources and educate them about shelter in place.

“I also ask them about their advanced care decisions,” Dr. Smith said. “I ask the patient. Tell me about what do you want to have happen in the event you can’t speak for yourself? I refer them to the Sometimes I get a response back – well, am I about to die? No, I tell them, you’re not about to die, but we should have held this conversation a long time ago. What it says is that I care about you, your desires as a person and, as your doctor, I want you to be comfortable with shared trust as part of our relationship. I want to do what your heart desires to have done.”

Set Back or Set Up?

As Dr. Smith asked at the outset, is the spotlight the pandemic shining on health disparities yet another set-back for those impacted most severely by the virus or a set-up to make positive and lasting changes to improve the health of everyone in the state?

The NCIOM’s Healthy North Carolina 2030 sets out 21 goals necessary to make real improvements in the state’s health and 21 health indicators to statistically measure progress toward those goals. Among those goals are:

  • Decrease the number of people living in poverty to be measured by the number of individuals below 200 percent of the federal poverty level.
    • Increase economic security as measured by the unemployment rate.
    • Dismantle structural racism as measured by the short-term school suspension rate.
    • Decrease the incarceration rate.
    • Improve child well-begin by addressing adverse childhood experiences.
    • Improve access to healthy food.
  •   Improve housing quality.

At its core, the NCMS’ mission always has been protecting and improving the health of North Carolinians, and the Society has taken up Healthy NC 2030 to further that goal.This means, however, challenging some of our usual thinking about what drives health outcomes and how we, as an organization representing health care professionals, can effect positive change. For instance, income is one of the greatest predictors of disease and mortality rates – and an even stronger predictor of health disparities than race when considering the rates of disease within racial/ethnic groups. For what policies do we advocate in order to decrease the number of people living in poverty? Healthy NC 2030 offers various ‘levers for change’ for each health indicator. Access the full report to review what might activate this change.

The NCMS wants to hear from you about how best to improve the health of our state. What do you see where you live, learn, work and play? What needs to change? How can the NCMS help empower you to make the solutions possible?

Please help us keep the conversation going.