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COVID-19 Healthcare inequities come to foreground during pandemic
by Matt Simonette

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In mid-April, when Chicago Mayor Lori Lightfoot called attention to the disproportionate number of COVID-19 deaths among the City's Black residents—about 70 percent of deaths related to the virus were among African-Americans—officials at the Howard Brown Health system were not shocked, said Maya Green, MD, medical director for the organization's 63rd Street, Thresholds South and other south region facilities.

"This is what happens in a pandemic," said Green. "Traditionally underserved communities get impacted the hardest. We weren't surprised and saw that coming. We were grateful that we had the [testing] tents in place."

A vital aspect of healthcare service delivery is both recognizing and meaningfully addressing socio-cultural inequities that affect the lives of clients to the point where their wellbeing can be negatively impacted. As such, Howard Brown has tried to be conscientious serving Chicagoans on the margins as the pandemic progresses.

The organization began delivering COVID-19 tests in March at multiple locations, and recently launched a new testing facility in partnership with Project Vida in Little Village. Since Lightfoot's initial comments about the racial disparities, City officials have also noted higher rates of COVID-19 transmission within the Chicago Latinx community as well.

"We are [also] grateful to the community and fellow organizations that see the needs and are moving at 'pandemic speeds' to meet them," Green added.

Howard Brown has been providing resources to allow its regular clients to continue sheltering in place, by offering visits by Telehealth and psychiatry mobile units, for example. The organization is also doing STI screenings via mobile units and working alongside food pantries in prioritized neighborhoods, Green said.

"Part of 'shelter-in-place' means you have to get food [safely]—that's primary prevention, where you do all the things you can do to make sure that someone doesn't get sick," she added.

Primary prevention strategies are based upon both how a condition transmits as well as the behaviors of a population. Green cited numerous determinants of health factoring in a patient's well-being that healthcare providers must be aware of in looking at COVID-19 at both the micro and macro levels.

Chief among those are chronic conditions such as HIV or diabetes affect persons of color disproportionately and can make a patient more vulnerable to illness from COVID-19. Other determinants include access to health resources, equity in education and equity in employment opportunities, which can have a similar impact.

One realm where circumstances directly led to mass infection was among America's incarcerated. Green noted, "Look at what's happening in our present system, where African Americans are disproportionately incarcerated, for lesser crimes, and they are in [jails and prisons] being exposed to COVID."

She was blunt in naming the "one disease' that makes persons of color especially vulnerable in the pandemic: historical oppression.

Bias was implicit in how the COVID response played out in early 2020, Green explained. For example, concerns for travelers—a demographic that is predominantly whiter and wealthier than other Americans—seemed paramount in driving initial prevention strategies. Early requirements that patients have a doctor's referral in order to receive a COVID test presupposed that the patient could make contact with a doctor in the first place.

"Access to your doctor is an issue in a pandemic," Green added. "Even people who have a plethora of hospitals and clinics in their neighborhood experience a decrease in access to care from their primary care physician. Imagine what folks do when they didn't have access to one to start with."

Howard Brown has been trying to eliminate as many structural barriers to testing as possible, according to Green. She estimated that, as of late April, the organization had tested about 950 persons for COVID-19.

Bias within the healthcare system is often internalized at both the individual and structural levels, since Americans deal with it their entire lives, Green noted. That bias is exacerbated further in a natural resistance from stakeholders to a systematic critique.

"The hardest part of dealing with bias, especially with implicit bias, is the struggle when you don't even acknowledge it," she explained. "It's hard to recognize that about ourselves as a collective society."

That denial is often followed by an impulse to assign blame onto persons in need. All the while, as communities, politicians and other stakeholders go through these processes, the pandemic only advances rapidly.

"Once they get it, some people are dealing with a two-week span of their life," Green said. "Instead of going through shock, blame and denial, we need to pivot that energy and turn to a narrative focused on determining the social determinants of health—getting them access to food, access to Telehealth, access to education. That's why I'm glad [Howard Brown] is in a space where we can do that."

Green added that, even with the strain of individualism that so infuses life in the United States, "We're seeing how much we need each other and looking for opportunities to connect. Now that we're seeing so many of the opportunities taken alway, a lot of us our saying, 'Hey, I really appreciate my fellow humans.'"

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