I constantly straddle two disparate worlds. One is in Boston, where I work for one of the country’s best health care systems and serve as a professor at Harvard Medical School. The other is in northern New Mexico, where I am a member of the Taos Pueblo tribe.
While these two communities could not be more different in population, culture, or geography, the Covid-19 pandemic has linked them in an unfortunate but all-too-common way: both are beset by racism and racial disparities in health care.
The Boston area was an early hotbed of the pandemic in the United States. In March 2020, Chelsea, Mass., a predominantly Latinx city that borders Boston to the north, had one of the highest Covid-19 rates in the country, with 2,475 cases reported among its 40,000 residents. These soaring rates soon hit surrounding areas, also with largely Black and Latinx populations.
For all its health care prowess, Boston — like the rest of the world — was not prepared for a pandemic. Clinical protocols and policies took time to put in place, guidelines were constantly shifting as public health officials and clinicians continued to learn on the fly about this new disease, and the global supply chain was in shambles, limiting access to personal protective equipment and Covid-19 testing supplies. A dearth of Spanish-speaking staff also limited hospitals’ ability to provide care for the huge volume of patients from Latinx communities.
Two thousand miles away and a world apart from Chelsea, Navajo Nation, which sits just on the other side of the Carson National Forest from the Taos Pueblo tribe I know so well, underwent similar pandemic-driven devastation. During the first three months of the pandemic, American Indians accounted for 58% of Covid-19-related deaths in New Mexico despite making up just 11% of its population.
The disparities seen in Boston were amplified in tribal communities like Navajo Nation. Even before the pandemic, hospitals serving these communities lacked full-time doctors, medical resources were often rationed, and the health system faced the constant specter of running out of funding before the end of the fiscal year.
Recognizing this historical imbalance, my hospital system, Mass General Brigham, has partnered with Navajo Nation hospitals through its Outreach Program with the Indian Health Service for more than 10 years to provide both on-site clinical care and telehealth support. This relationship allowed us to quickly provide supplies, clinical advice, and mental health support for patients and providers in the Navajo Nation, even as the Boston area was experiencing its own health care crisis.
Similar, but different
Knowing firsthand what American Indian communities were facing, and understanding the challenges presented by living in an urban environment, the pandemic crystallized for me how similar life could be like in urban Chelsea and rural tribal communities.
Upstream social determinants of health have a dramatic impact on these populations, though the specific determinants may be different. In Chelsea, dependence on public transportation and frontline jobs are prominent. In the Navajo Nation, there is limited access to indoor plumbing, which created innumerate challenges to public health, including the need to travel to congregate settings to access water.
As a group, American Indians face widely documented disparities in health outcomes. This population — my people — has a life expectancy that is more than five years shorter than that of the general population. In Chelsea, before the pandemic, more than 60% of the population was considered food insecure and 1 in 5 people lived in poverty.
In both communities, families tend to live in crowded conditions, often with multiple generations occupying one small dwelling. Employment is based largely on hourly wage jobs that never offered the possibility of remote work, forcing people to go to work and face ongoing exposures, and creating an inability to isolate, especially from vulnerable family members. In many cases, lack of home internet access impeded public health education and safety efforts.
To be clear, Covid-19 didn’t create these inequities. But it certainly exacerbated longstanding, structural issues around racism and poverty and thrust the disparities into mainstream view.
Equity first at every step
The easiest and fastest response to a crisis is always built for the majority. Taking that path of least resistance, however, often ignores those who need support the most. As Mass General Brigham’s chief patient experience and equity officer at the time, I was responsible for building the organization’s Covid-19 response plan. My two worlds, Chelsea and Taos Pueblo, drove my decision-making. Grounded in the experiences of groups that have far too often been left behind, I knew we had to take an equity-first approach to fighting the pandemic.
As hospitals became overcrowded, equity meant reevaluating the algorithms used to determine who was allocated a bed or a ventilator. As we set up testing sites, a focus on equity drove us to open locations not just where our organization had an existing physical footprint in a neighborhood but where case rates were highest and transportation was limited. When vaccines became available, equity necessitated that we look beyond online appointment scheduling and directly call individuals to make sure that a lack of internet access or digital literacy didn’t lead to their not getting this lifesaving therapy. When we communicated anything related to the Covid-19 pandemic to patients and community members, equity required us to put out communications in multiple languages and using channels beyond email — including messaging via community vans, text messaging, social media, and other outlets.
For all of its devastation, the pandemic has also been an enabler of action and change.
I’m proud to point out that Covid vaccination rates in Chelsea and the Navajo Nation are among the highest in the country, with nearly 91% and 67% of the eligible population being fully vaccinated, respectively. Those statistics underscore not only successful grassroots vaccination efforts but also the trauma these communities experienced.
The pain and suffering of Covid-19 and the events in the first half of 2020 that sparked social justice protests across the nation have opened the door to drive tremendous change in health care equity. The U.S. is at a historic moment of racial reckoning. Racism and inequities and their impacts are being laid bare and nearly every industry — including health care — has recognized its role in changing the country’s trajectory.
For example, the pandemic prompted the American Rescue Plan Act in March 2021, which made the largest single federal financial investment in Native American communities in the history of the United States. The plan invests $32 billion in tribal communities and Native peoples, including $20 billion in emergency funding to help tribal governments rebuild economies devastated by the pandemic.
Closer to home for me, this racial reckoning inspired Mass General Brigham’s United Against Racism platform, a long-term strategic commitment to examine and eliminate the impacts that racism has on patients and employees within our own system and across the communities we serve. Over the past two years, this equity-first approach has taught us about focusing on surrounding communities to help inform clinical strategies and the way we think about patient care.
This model should be standard, not unique.
United Against Racism has focused on improving the accuracy of data on patient race, ethnicity, and language preferences; eliminating the inappropriate use of race in clinical decision tools and policies; building a new community health worker program to address social determinants health; creating a new digital health access program; and establishing a culture of health equity improvement by requiring each clinical department to identify a racial disparity in health care and implement a process improvement project to address this issue.
Movements like this traditionally take years to be brought to life. But the pandemic has shown that much-needed change can come swiftly when people and organizations collectively channel their energy into addressing society’s challenges.
It’s time for hospitals, health care systems, and other organizations to address racism, health equity, and community health in ways that treat them as the urgent public health crises they truly are. Putting equity at the center of every decision is hard. It requires tough conversations, pushing back on the way things have always been done, and making considerable investments of both time and money. The extra steps, while heavy and time-consuming, are the ones that will ultimately close the opportunity gap that affects so many Americans in every aspect of their lives.
Tom Sequist is the chief medical officer of Massachusetts General Brigham in Boston; medical director of the Outreach Program with the Indian Health Service and a physician at the Phyllis Jen Center for Primary Care, both at Brigham and Women’s Hospital; and a professor of medicine and health care policy at Harvard Medical School.
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