publication date: Mar. 20, 2020
The COVID-19 pandemic gives us the urgency—and one more chance—to address health disparities
By Robert Winn, MD
Director, Virginia Commonwealth University Massey Cancer Center
This story is part of The Cancer Letter’s ongoing coverage of COVID-19’s impact on oncology. A full list of our coverage, as well as the latest meeting cancellations, is available here.
As the crisis triggered by the COVID-19 pandemic deepens, the two separate, unequal societies that make up the United States of America are equally frightened, bewildered, and unsure of what comes next.
One thing that has become even more clear during this crisis is the “digital divide” that has created a wall between America’s rich and poor (The Cancer Letter, Nov. 16, 2018).
Almost all people of sound mind and body, independent of their social economic status, are in search of good, up-to-date, reliable information about COVID-19.
Alas, actually obtaining good information isn’t so easy, and the accessibility of such information isn’t equal for all.
In fact, it’s terribly difficult for many vulnerable populations (e.g. urban underserved, rural, new immigrants, homeless, and the working poor) to learn what’s going on and what to do about it.
Even otherwise reputable sources of information have been inconsistent, unequally accessible, and at times just outright incorrect about the COVID-19 crisis. Rumors and misinformation about COVID-19 are plentiful on the various social media platforms; one of the more disturbing stories in the social media world postulates that COVID-19 doesn’t affect African Americans to the same extent as it affects other people.
Another example of misinformation is the widespread rumor that ibuprofen accelerates COVID-19 viral replication.
While some of these have been addressed by reputable sites, including Politico or Forbes, there’s likely an equal amount of misinformation that frequently goes unchallenged by “high-quality” information.
In fact, a number of high-profile and not-so-high-profile black actors and athletes (e.g. Kevin Durant, Idris Elba, Callum Hudson-Odoi, to name a few) have contracted COVID-19.
Transparency, honesty, and expert opinion continue to matter.
Access to information is also unequal, and those with limited digital access may rely on word of mouth, which makes them more prone to receive misinformation or uncontested, biased information.
For example, many rural areas throughout the U.S. have little or no broadband, thereby significantly limiting the availability of potentially useful information. It’s becoming more obvious that not having trusted universal sources of easily accessible good information for all has led many to seek information from other sources that often conflict with information from state and federal sources.
In fact, on March 19, 2020 The Washington Post reported that while social distancing makes crowded cities seem like the deadliest environments, the flu pattern over the past five years suggests that it’s the very rural areas that stand to suffer from the highest mortality due to their inherent distance from healthcare resources.
I also wonder about the meaning of “shelter in place” for someone who has neither shelter nor place.
The current threat of academic medical centers becoming overwhelmed with the pandemic paints a grim picture for what may happen to smaller, more rural health care facilities.
This contributes to increased confusion and mistrust that put our vulnerable populations at an even higher risk. The lack of coordinated, consistent, clear and unifying directions from Washington further feeds confusion and mistrust among the most vulnerable.
Even before this crisis, our at-risk populations had health outcomes that were disproportionately worse than those of the general public. This was visible in all areas of medicine, including cancer. Now, these same populations are at an even greater risk for having a potential poorer outcome from COVID-19 exposure.
On the opposite side of the tracks, the more affluent population enjoys access to a cornucopia of electronic apps (e.g. food delivery apps, various shopping apps etc.), and, of course, an abundance of information.
The rich and the educated appear to be stuck in a twenty-four-hour state of connectedness to information provided through various electronic and high-tech gear (e.g. laptops, e-readers, and smart watches etc.). Literally gorging on information, this group often complains about “information overload,” which leads to information exhaustion and a sense of being overwhelmed.
In recent days, I’ve become more keenly aware of the “digital divide” that exists among the various communities and the irony of how the haves—those who get abundant information—are rarely sharing information outside their own circles.
The haves simply don’t know how to address the have-nots, i.e. the low-tech or no-tech informationally non-abundant communities.
This lack of information sharing is reinforcing systemic inequalities.
Only a generation ago, the ACT UP (AIDS Coalition to Unleash Power) movement demonstrated the importance of disseminating information to vulnerable communities one block at a time—all the while building trust.
But how will the past models of direct community engagement learned from the HIV/AIDS era work in the current COVID-19 pandemic, where transmission and spread of the virus is so fast and furious (i.e. fecal-oral and/or airborne mechanisms)?
Without question, front-line involvement and engagement by people is critical to any infectious disease crisis, e.g. the Ebola epidemic in West Africa in 2015, but the COVID-19 crisis also points out the need to reduce and disrupt the current “digital divide”.
To quote one of Otis Brawley’s Will Rogers-like sayings, “the underserved are the underserved because they are underserved.”
Coronavirus testing is a glaring example of our two separate and unequal Americas.
Yes, failure to produce our own effective testing kits compounded by failure of not accepting coronavirus testing from the World Health Organization or other outside entities (private or otherwise) has negatively impacted the trajectory of COVID-19 on all who live within the U.S., reminding all of us that there are no shortcuts when it comes to our national disaster preparedness.
However, the perception of this early phase of COVID-19 testing by many who live in disadvantaged communities is that the testing has been prioritized to those who have access, agency, and affluence. In short, the well-connected.
The most vulnerable populations, are still awaiting a plan for testing to reach their communities.
Unfortunately, this has become an all-too-common theme that provides fertile ground for the increasing misinformation spreading throughout our at-risk communities as well as waves of wrong information (and perhaps deliberate disinformation) spread on social media.
This mistrust becomes even more difficult to disarm when people are aware of the high-volume COVID-19 screening drive-through testing programs launched in other countries, e.g. in South Korea, which is testing up to 15,000 people a day.
These drive-through testing programs are mobilized to travel to hotspots within those countries.
As screening becomes available, we will need to assure our communities that we understand that not all health care should occur in hospitals and that appropriate drive-through and walk-up testing sites might also be effective. (This is, of course, predicated on having the appropriate availability of the COVID-19 screening tests.)
The focus on developmental drug research and basic science translational programs over the past decade or so has resulted in highly effective “miracle “drugs and high-tech diagnostic tools, as evinced by the recent success of immunotherapy and molecular therapies to fight cancer.
Now, even in its early days, the COVID-19 crisis has demonstrated a significant need for an equal emphasis on the health delivery science that underpins and drives our public health.
In the end, social determinants of health may begin to play a major role in determining who will end up doing well and who will end up doing poorly during this crisis.
As a cancer center director, I am proud to see the many brave teams of physicians, nurses, and staff step up to the current challenges, often despite risk to their own personal health, as they continue to man the frontline, providing care to cancer patients.
I am proud of the researchers who continue to carry out important therapeutic treatment clinical trials, which may make a difference in extending a patient’s life, and I am proud of researchers who are keeping research laboratories afloat during these trying times.
However, an important message from the COVID-19 crisis ought to be that dissemination sciences should get equal billing as discovery sciences.
I hope all of us will recognize the importance of increasing and intensifying our efforts in field of health equity research. Innovative, high-impact community outreach and engagement programs can do much more to inform communities about their health.
If done right, the community outreach and engagement programs would serve as the vehicle for combating the swirling mis- and disinformation. It has become clear that public health matters a great deal, and as cancer centers we can play a major role in impacting the health of our country by focusing even more on the health delivery sciences and its practical applications via “effective” community engagement.
It’s undeniable that we live in a bifurcated, separate-and-unequal country, but it is also undeniable that this crisis will inspire all of us to build a bridge between our two separate societies, if for no reason other than to improve our overall chances of saving ourselves.
Fear will often travel faster than the virus, but a message of unity may serve as an antidote to fear, and perhaps to the virus as well.
Stay safe and let’s stay united.
After all, we are all our brothers’ and sisters’ keepers.