COVID-19 And Health (And Death) Disparities

There’s a very real likelihood that our health care system will be overwhelmed in the weeks ahead. We’re starting behind the eightball, the federal government is dithering, and our public health system has been starved for years. As Aaron Carroll writes in the New York Times, “The ability of the American health care system to absorb a shock — what experts call surge capacity — is much weaker than many believe.”

Hour by hour, America is waking up to this big problem. 

And as we do, we need to ensure that not only do we work to stem the spread of the virus, but that our response is fair and compassionate. The more inevitable triage becomes, the more necessary this is. 

Triage is a black box no one wants to look inside. But we need to, not only for this moment, but because it’s a black box in which ghosts of our national history roam free. 

Doctors in Italy have created a system that signals a blueprint for the United States. “[T]he allocation criteria need to guarantee that those patients with the highest chance of therapeutic success will retain access to intensive care….It may become necessary to establish an age limit for access to intensive care.” Simply put, younger, healthier people can be better treated with shorter interventions, leaving more resources for other sick people and saving more years of life (a 30 year old who recovers will likely live longer than a 70 year old who does). 

The guidance continues, “[In addition, the] presence of comorbidities needs to be carefully evaluated.”  Heart disease, diabetes and lung disease are particularly problematic underlying conditions for patients i with the novel coronavirus. 

And that’s what should give us additional pause. Because in America, the particularly problematic comorbidities are those concentrated in communities that historically have been disenfranchised. For example, African-American adults are 60% more likely to be diagnosed with Type 2 diabetes than non-Hispanic white adults; hypertension is far more prevalent and treatment less effective in African-Americans than in whites. This is not because Black bodies are inherently different. It is because Black bodies are treated differently in American medicine, which is a reflection of how Black bodies are seen and treated in American society. 

Growing recognition of systemic and societal roots, not simply individual behavioral causes, of disease have spawned efforts to provide additional care and interventions to backstop the biological fallout of living with oppression. These are worthwhile, but they function best when attempting to create equity in how people are treated. Whether people are treated at all is a whole different question.

Given the disproportionate prevalence of particularly problematic risk factors among African-Americans, it’s possible that African-Americans will be disproportionately represented among those seeking and needing hospitalization for COVID-19. The parameters of selection for treatment define a window. It’s possible that the parameters of this window, combined with the uncomfortable reality of racial bias in medicine, will lead to African-Americans being disproportionately selected against for treatment. Of course it’s also possible that the disportionate selection could favor the window. 

While it’s not clear how the disproportionate prevalence of the very conditions that are risk factors for complications and mortality with COVID-19 will impact triage, that they very well might is clearly something hospital administrators, physicians and government need to plan for immediately. The kind of triage we’re facing forces devastating choices for physicians, choices that devastate families of those not chosen for care. These choices also can further devastate communities and reinforce experiences too many Americans have that our healthcare system is for white people with resources. Triage plans must therefore be clear and explicit about how guidelines will be put into effect with an eye towards minimizing personal and systemic bias. And they need to be made public, as excruciating as that may be, in part to stand in contrast to past experiences of bias and differential treatment many people of color have experienced in medicine. The black box must become as transparent as possible.

Do No Harm. It’s the Hippocratic oath that has bound medicine for centuries. In moments of triage and crisis, the question is not whether we can prevent all harms; it’s too late for that with COVID-19.  It’s how can the harms— harms that will be dissected in after-action reports and history books— not be borne disproportionately by those whose pre-existing conditions reflect a society that has failed to invest adequately in its public health infrastructure, and also failed to reckon with its history of discrimination, violence and valuing some lives more than other because of skin color. 

This time, in the midst of chaos, we have the opportunity to get this fundamental human equity component right. Will we?