LOS ANGELES — Trying to stop the spread of the novel coronavirus has proven extremely challenging in this sprawling city, where public health officials, hospitals, and community clinics are grappling with millions of immigrant residents who may be too afraid to seek testing or care and are woefully unequipped by their economic circumstances to comply with orders to self-quarantine.
As in many communities of color hard-hit by Covid-19, immigrants here are at higher risk for exposure to the virus because many cannot work from home, cannot afford not to work, and often have jobs that require interacting with large numbers of other people. They are cleaning hospitals and essential businesses, working in restaurants and grocery stores, and making deliveries.
“We are seeing this virus disproportionately impact racial minority populations. We are seeing it hit people who are in poorly paid, yet risky jobs … jobs that cannot be done via Zoom meeting,” said Margot Kushel, a physician who directs the Center for Vulnerable Populations at the University of California, San Francisco.
Worsening matters is the federal government’s new “public charge” immigration rule that went into effect in late February, just as the virus was beginning to sweep through communities here. The edict, which tightly limits noncitizens’ use of government programs, has left many immigrants increasingly afraid to seek any public services, including medical care, because they fear doing so could lead to deportation or prevent them from receiving permanent residency in the future.
Edgar Chavez, a family practitioner, founded and runs Universal Community Health Center, which operates three clinics in some of LA’s poorest neighborhoods. He says many of his patients are afraid. “I have one family where one person is very sick with pneumonia and the whole family has probably been exposed [to the coronavirus], but they say, ‘We’re afraid to get the test. We’ll be deported,’” Chavez said.
On March 16, U.S. Citizenship and Immigration Services officials announced that the public charge rule would not apply to those who seek testing or treatment for the novel coronavirus. But many physicians fear news of the decision is not getting out.
Los Angeles is a city of immigrants; 1 in 3 residents of the county is foreign-born and 1 in 5 is either undocumented or living with someone who is undocumented. Many of these immigrants are at increased risk of complications or death from Covid-19 due to high rates of underlying chronic illnesses such as heart and lung disease and diabetes.
Public health officials have reported 10,047 cases of Covid-19, the disease caused by the novel coronavirus, and 360 deaths and they are cautiously optimistic the outbreak here may be reaching its peak; the 239 new cases reported Monday were the fewest recorded in the past two weeks Among the 292 deceased residents whose race was disclosed, 34% were Latinx, 32% were white, 17% were Asian, and 16% were African American. The death rate was lower than expected in the Latinx community, which makes up nearly half of the county’s population. Barbara Ferrer, director of the LA County Department of Public Health, warned the numbers were early, incomplete, and might not be fully accurate.
While not all states release racial or ethnic information, data from Florida, Michigan, and Louisiana show people in communities of color are being infected and dying at far higher rates than white individuals. In New York, Black and Latino individuals are dying at rates twice that of white people. Health experts attribute the disparities to the high rates of underlying health conditions, lack of health insurance, and poverty widespread in working-class immigrant communities.
“In moments like this, our divisions in class are so illuminated,” said Louise McCarthy, president and CEO of the Community Clinic Association of Los Angeles County. “This really lays it all bare.”
One of the first to recognize the potential unfolding public health crisis here was Congresswoman Norma Torres (CA-35), who represents a district in California’s Inland Empire that is 70% Latinx. Torres, who is increasingly seeing nervous constituents unenroll from public services like school lunch programs and Medicaid, has been arguing since last fall that the public charge rule could spark a health crisis. When the virus hit, her worst fears were realized.
“For me, the red flags went up really, really early, when we started talking about Covid-19 and social distancing and getting treated,” said Torres, who sent a letter to Vice President Mike Pence on March 2 asking that the public charge rule be suspended because of the viral outbreak. “How do my constituents do that when they’re afraid?”
Chavez has been seeing the direct impact of the public charge rule on his clinic’s supplies: He said he has a large amount of unused flu vaccine because so many of his patients were afraid to come in for immunizations after the rule was announced last August. “Those flu shots are all going to expire in June,” he said.
Chavez understands the fear of his immigrant patients. Now a successful clinician with a degree from Stanford Medical School, he was born in El Salvador and raised in a mixed-status household in the neighborhood where he now runs clinics. “I was an immigrant and I always lived in fear that a knock would come and I’d be taken away or my parents would be taken away and I’d never see them again,” he said.
Torres said that in addition to their fears about immigration status, many of her constituents are struggling because they are gig workers with no paid sick leave or health insurance who are unlikely to benefit from current stimulus packages. “These people are breaking their backs for us and have no health care or benefits,” she said.
The inability for large sectors of the community to access care or self-quarantine has enormous public health ramifications. “One cannot contain a virus outbreak by providing care to only some of the population,” said Daniel Turner-Loveras, an assistant professor of medicine at Harbor-UCLA/David Geffen School of Medicine.
Chavez said he’s also found it very difficult for his patients who live on the margins to obey his directives to self-quarantine or shelter at home. “Unless you’re so sick you’re dying, if you have to feed your family, you’re still going to work,” he said.
Living conditions in poor communities are another reason the new virus may be hitting those communities harder. Asking people who must work to pay for food and rent to instead stay home and asking those who live in large, multi-generational households or in cramped, illegal boarding houses to isolate themselves in a private bedroom and bathroom can be all but impossible.
“A lot of the instructions for the well-off — stay home for two weeks, use a separate bathroom, use your own car instead of public transportation, use food delivery services — don’t work for those who are struggling economically,” said UCSF’s Kushel.
Throughout Los Angeles, testing has also fallen along class lines. Early in the outbreak, a stream of celebrities, athletes, and well-heeled residents of enclaves like Beverly Hills and Brentwood, even those with mild or no symptoms who could easily self-quarantine, were tested. Meanwhile, community clinic doctors struggled to obtain tests for their severely ill patients. Many say this lack of early testing allowed the virus to spread widely. “If you have limited testing, I would add homeless populations or people who live in crowded settings to the top of the list,” said Kushel.
For many poor, immigrant, and minority communities, the front lines of the Covid-19 crisis have not been ERs and ICUs, but the “safety net” community health clinics many rely on for regular health care. Many of these clinics are now scrambling to train their staff in infectious disease procedures and to find equipment they need to safely triage and test patients, including gowns, masks, swabs, and even sanitizing wipes.
“You’ve seen ‘Contagion’? We don’t have those suits,” said Chavez. “The gowns we have for PPE are a joke. You touch them and they disintegrate.”
Felix Aguilar, chief medical officer of the Chinatown Service Center, one of the largest community providers of health services for Chinese Americans here, was self-quarantining at home last week after treating a patient with a cough who later tested positive for Covid-19. Aguilar said his center’s four medical clinics were less than two weeks away from running out of surgical masks; a local architecture firm is volunteering to bring in masks from their supply.
One silver lining of the pandemic, said many clinic leaders, is that their organizations were quickly able to pivot to offer telemedicine once Medicaid officials authorized that they would reimburse telehealth and telephone medical visits due to the Covid-19 emergency. “That’s been something very new,” said Aguilar.
While he was initially nervous about how well the transition would work and how patients would respond, clinic staff got the word out quickly, using the WeChat app and other means. In just over a week, the clinic converted 80% of in-person visits, for people who speak a variety of languages, to visits using a call or video. “Even the poor have cellphones,” said Aguilar. “Community clinics have always been about eliminating barriers,” he said. “With Covid-19, it’s about eliminating technical barriers.”
McCarthy, of the community clinic association, is proud of how robustly clinics here have responded to provide telemedicine services once available mostly to the privately insured, and notes the technology may help serve patients who are undocumented and afraid to seek medical care in person. “We’re innovating left and right during this crisis and hope we can keep some of those innovations in place,” she said.
One of those clinics — the Kheir Center — services LA’s Koreatown, one of the nation’s most densely populated neighborhoods. The diverse patient clientele are Korean, African American, Bengali, Thai, and more recently, an increasing number of insured young professionals who started seeking care from the clinic because their regular doctors’ offices are temporarily closed.
Responses to the pandemic have ranged, said the clinic’s CEO, Erin Pak. Korean American patients, she said, have been extremely compliant about stay-at-home orders. Bengali immigrants, with a deep fear of deportation and distrust of the government, are convinced they will be denied care even if they are gravely ill. “No matter how much we reassure them, they don’t think they will have access to hospitals or the best care,” Pak said.
Like many community health centers, the Kheir Center has a federally mandated emergency plan in place that comes into play during disasters such as fires or earthquakes. Covid-19 is no different. “In any kind of disaster, our job is to triage patients to relieve tension on hospitals,” said Navid Papehn, the clinic’s director of patient services. “The biggest concern now is how to ensure we have the proper supplies. That’s what keeps us up at night.”
The clinic is running short on gowns, he said, and Pak has been scrambling to order sanitizing wipes online from supplies now being prioritized for hospitals by Amazon.
Kheir and other clinics still seeing patients in person have experienced a steep dropoff in clientele in recent weeks, not so much because they are afraid of immigration enforcement, but because they are afraid of the novel coronavirus. “People are afraid of leaving their homes and being exposed,” Papehn said. “People don’t want to come into health centers.”
The dropoff in visits has physicians worried about health needs that are going unmet, from foot wounds of patients with diabetes, Tdap booster shots needed by toddlers, and patients struggling to control hypertension. “Just because we have Covid-19 doesn’t mean people don’t have uncontrolled diabetes anymore,” Chavez said.
Community clinic leaders say they are also afraid mental health problems are not being addressed even as they are exacerbated by the pandemic. In addition to a rise in anxiety over health and financial issues faced by many immigrants, many Asian Americans also face Covid-19 racism. “We’ve been hearing from our patients that people walk by and cough in their faces,” the Chinatown center’s Aguilar said.
The clinics are also struggling to provide other services normally offered to those in need, such as “food pharmacies,” or help paying electric bills for those who must keep insulin refrigerated. Others are worried about what comes next for those who lose jobs and can’t pay their rent.
Many of the Kheir Center’s patients work in small businesses in an all-cash economy. “They can’t apply for unemployment and won’t get a stimulus payment,” said Pak. “They have health problems already and now they’re worried they’ll be homeless next month.”
The clinics are worried about their own finances as well. The dwindling stream of patients means a critical loss of revenue for clinics that already operate on tight budgets and face uncertain federal funding. While some relief money is headed to community clinics, experts say the funding falls far short and that many clinics could close in coming months, just when they are needed most.
“It’s very dire. You have clinics that are already cutting staff, who are people from the communities they serve, because there are no appointments,” said Felix Nuñez, a family physician who serves as president of the Association of Clinicians for the Underserved. “Clinics were already on the edge. With Covid-19, you’ve put a bad situation on top of what was already an impossible position.”