On March 3, the Arlington, Va.-based Infectious Diseases Society of America (IDSA) conducted a media briefing featuring Allison L. Agwu, M.D., fellow IDSA, vice chair HIV Medicine Association, associate professor, pediatric and adult infectious diseases at Johns Hopkins University School of Medicine; and Emily Spivak, M.D., fellow IDSA, chair IDSA Antimicrobial Resistance Committee, associate professor, Division of Infectious Diseases at the University of Utah Health. Chris Busky, CEO, IDSA, moderated. The briefing focused on health disparities and inequities perpetuated by the COVID-19 pandemic.
Agwu began the briefing by explaining how her area of HIV clinical research and her background as a provider for patients living with multiple conditions, including HIV, makes her very aware about racial disparities, infection rates, testing, treatment, and outcomes. She says that “It [disparities] really has existed since the beginning of the HIV epidemic, and unfortunately persists today. What disparities means to me is that a particular groups’ share in the population is outpaced by their share of the impact of a disease process or entity. And it's not new. We see that in multiple conditions from diabetes, hypertension, obesity, and maternal and infant mortality—we see disparate impacts of those conditions.”
“Given that American society and its healthcare system is not equitable, many including myself, were really not surprised and were waiting to see, and concerned that we would see, this disproportionate impact with COVID-19,” Agwu adds. “And we, unfortunately, suspected they [inequities] would be there but it has panned out [as] everything from the disease state itself, and also [to] vaccines, testing, and then clinical trial access.”
Agwu then says that she is going to give a few brief specifics. She notes that an important caveat with some of the data being presented is that not all states report data on deaths by misdeeds for cases or complications. The current data reflects a year and a half of recognized disparities.
“Black people make up 10 percent of people who have received at least one dose of vaccine compared to their 12 percent of the population,” Agwu comments. “There's been some push to increase rates. Then we look at monoclonal antibodies. When we look again at data, when compared to whites, Hispanic patients are 50 percent less likely to receive monoclonal antibodies when they present [with COVID], Blacks are 22 percent less likely, Asians are 40 percent less likely, and other races 47 percent less likely. So, it [disparities] exists when we talk about clinical trials, too. There are long standing challenges in terms of enrolling Americans in clinical trials. In fact, underrepresentation is a well-known thing. It is not different for COVID-19 vaccine trials, where whites are overrepresented.
Spivak says that “Under the leadership of a colleague at Intermountain Healthcare, we actually did an analysis using Utah state data to look at what the risk factors are within the state of Utah for hospitalization and death from COVID 19.”
“The usual things fell out that you would expect—age, male gender was higher risk at that time, diabetes, obesity, but something that really stood out as a very significant risk factor was people who self-identified as being of nonwhite race or ethnic groups,” Spivak comments. “What we did was actually develop a state risk score, not an automatic criteria, but weighted points for these different comorbidities and also assigned points if you are a nonwhite race ethnic group. Then over time, we have essentially set the threshold of that total aggregate score based on quantity or resources of drug and human resources we have to give these drugs, we've moved that scale based on supply and demand. At the University of Utah Health, we realized that if no one knows about these drugs, and they don't know that they're higher risk because they're of a nonwhite ethnic group. We also employed outreach efforts where we had a group of nurses who have daily access to our COVID-19 registry [positive patients] and it is electronically based on if we have the data, and someone has reported their race or ethnicity as being nonwhite, Latino or Hispanic ethnicity. We can essentially prioritize these groups and we reach out to them. We have nurses who call them repeatedly. We have messaging that goes out with their test results that says you may be of high risk and may qualify for treatment for COVID-19. It's not perfect, but it's one way that we are trying to go to people instead of expecting them to come to us for these treatments.”
Spivak adds that “We have recently rerun this analysis again, we've been in this a long time now with data of over 188,000 Utahns in 2021, and have found that these predictors still hold. Just look at the numbers compared to non-Hispanic white populations, Native Hawaiian or Pacific Islanders in Utah are 2.3 times more likely to be hospitalized, American Indian or Alaskan natives are 1.8 more times more likely, Asian Americans are 1.5 times more likely, and Latinos are 1.4 times more likely. Our African American population is smaller compared to these other groups, so they are more likely to be hospitalized, but it's not statistically significant just because of the low numbers. Despite those numbers, unfortunately, in the end of January of this year, our Department of Health released a press statement that we have removed the nonwhite race ethnic points or risks from our State Risk Calculator. But they are working through other operational means to try and get these people drugs in these communities and increase access points in different ways.”
“One thing that’s worth pointing out that is unique to this pandemic but will likely happen again, is the isolation that these people experienced,” Spivak notes. They were not allowed to have family members come into the hospital and what that meant for clinical trials for people who are non-primary English speakers, is that it was really difficult to figure out how to explain a clinical trial to them, to [explain] consent them, and to get them enrolled. There were also isolation issues with consents, it had to be electronic. We could not use paper consents and if a patient couldn't speak English or was on a ventilator, how do I get an electronic consent to their family and explain it to them with an interpreter over the phone?”
To wrap up the briefing, the floor was opened to the press to ask questions. A member of the media asked, “Is there anything that individual physicians, nurses, and other healthcare professionals can do as part of the solution?”
Agwu responds by saying that “I think one is to recognize that you present to every encounter with some inherent biases that you do not recognize that you have, I have that we all have that.”
Spivak adds that “Our health systems and medical practices are unfortunately part of a systemic problem, and these inequities and racism are all unfortunately embedded in these systems. And for an individual provider to do all of this [recognize inherent biases] is great, but we really need the culture of health systems and medical practices to change and be proactive and have interventions to reduce these inequities.”