Highlighting Race and Chronic Illness As Key COVID-19 Disparities

Keeya Onieka Charleston was diagnosed with a meningioma brain tumor in January 2019, over a year before the coronavirus pandemic settled into the United States.

The 46-year-old mental health therapist, who lives in Oceanside, Calif. with her husband and two children, underwent surgery to remove the mass in February.

As COVID-19 spread across the U.S. and more states enacted emergency responses, Charleston worried about her recovery.

She feared her radiation therapy would be canceled, the tumor cells would return and she’d endure brain surgery “all over again.”

COVID-19 hospitalizations and deaths are six and 12 times higher, respectively, among patients with underlying conditions compared to those with no reported conditions, according to the U.S. Centers for Disease Control and Prevention.

Charleston knew she was at risk.

Afraid at one point to get tested for COVID-19 out of fear of being infected and therefore becoming unable to continue radiation therapy, Charleston enlisted local friends and neighbors to help maintain her health and care for her family.

“I created a new village after the pandemic hit,” Charleston told MedTruth. “At first it was hard because I didn’t factor in homeschooling, but once we got a rhythm and I figured out who I can call on… it all ended up working out.”

Charleston leaned on a friend of 20 years, Sonya Hampton, 54, to ferry her to the almost daily radiation appointments. No stranger to illness, Hampton lives with a range of chronic conditions including fibromyalgia, arthritis, a clogged artery and two brain cysts.

Patients with one or more underlying conditions who develop a primary condition, such as COVID-19, have what is referred to in medicine as comorbidities.

Comorbidities often exploit the body’s weakened state and can result in “worse health outcomes, more complex clinical management, and increased health care costs,” according to the National Institutes of Health.

Since the pandemic began, Hampton rarely ventures in public. She runs a few errands a week, slipping out early in the morning to avoid crowds. And she always drives her friend Keeya to radiation.

Comorbidities, Race and Resources

Most U.S. adults have a chronic condition, but rates are disproportionately high among Black, Latinx, Native American, low-income and uninsured people.

In fact, a recent New York Times analysis found “Latino and African-American residents of the United States have been three times as likely to become infected as their white neighbors.

The analysis, published on July 5, 2020, examined the racial identifiers of 640,000 infection reports from the CDC, which included nearly 1,000 U.S. counties. It did not include information from an estimated 8 states.

For Hampton, preparing for the pandemic as a Black American woman with chronic illness meant trusting her own common sense.

“When I started hearing about [the pandemic] more and more, but the president was still denying it, I just went with my gut,” Hampton said.

Hampton is vigilant about her exposure to the coronavirus, yet confident in managing her conditions during the pandemic. She remains in close contact with her neurologist, and she hasn’t felt the need to discuss care with her providers.

“I just pay attention to everything that’s going on,” she said. “You can’t wear shoes in my home, everyone has to get washed when they come in… you can’t come in my house without a mask.”

Charleston and Hampton benefit from regular access to healthcare, and it has been critical in managing their health conditions during the pandemic. Some individuals with chronic conditions, however, lack the same resources.

Social Determinants of Health

Healthy People 2020 defines social determinants of health as conditions in the environments in which people live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.

Public health experts have long documented how social determinants of health — such as neighborhood environment, health coverage, discrimination, housing and even access to quality food — lead to marginalized populations having poorer health outcomes.

“This is not surprising, you know, this is just a new assault on an already fractured system,” Tomi Akinyemiju, epidemiologist and professor at Duke University School of Medicine, told MedTruth.

Akinyemiju led a study that found states that failed to expand Medicaid under the Affordable Care Act have a greater proportion of poor, uninsured adults with more chronic disease and conditions.

She added that it’s “almost inevitable” that people who are already sicker with chronic conditions, and have the least access to healthcare, face the greatest risk of dying from COVID-19.

“Again, because of lack of access putting them at higher risk,” she noted.

COVID-19 and Economic Challenges

In many cities, including Los Angeles, Dallas (and other Texas cities), St. Louis, Chicago and Washington, D.C, residents in predominantly Black, Latinx and low-income neighborhoods are hit hardest by the novel coronavirus, mirroring geographic patterns of structural neglect and removal.

Dr. Catherine James is a family physician of over 24 years in San Francisco working for the city’s Public Health Department. James regularly provides care to residents of The Fillmore, a historically Black neighborhood in the city.

James told MedTruth that the once-thriving neighborhood, like many in the city, has undergone gentrification for the last decade. Decades of urban renewal efforts“sliced up the community” and destroyed Black residents’ homes to make way for more lucrative developments, she added.

The history is critical to understanding why Black and Latinx neighborhoods have become current coronavirus hotspots. Many of James’ patients are low-income and reside in subsidized housing, often with many generations crowded into a single apartment.

Common threads emerge among the residents. “A lot of unemployed people, a lot of people who are disabled as well, who were certainly working people who were injured at a construction job or at a security job,” she said, describing the neighborhood.

James spends her days in this community and similar ones, conducting coronavirus swab screenings and triaging patients in “quarantine hotels,” part of California’s initiative to house the state’s estimated 150,000 homeless people.

“People who are coming in off the street have issues that put them on the street,” James said. “They may have mental health issues, they may have substance use issues.”

James works to provide medical support for the temporary hotel residents, assisting by staffing the hotels with medical providers.

In San Francisco’s Mission District, a predominantly Latino neighborhood, results from a joint effort to test residents for novel coronavirus infection show that infection rates are correlated to the ability to shelter in place. Of the 3,000 screenings, 2.1% tested positive.

Eighty-two percent of those who tested positive said their finances were affected by the pandemic’s economic fallout, 90% said they were unable to work from home, 89% earned less than $50,000 a year and most lived in households of 3 to 5 people (60%) or more (29%).

COVID-19 and Essential Workers

Miles south in Glendale, Calif., Simson Lao, 64, was finishing his two-week recovery from COVID-19 in a quarantine hotel. Lao has been managing Type 2 diabetes, high blood pressure and high cholesterol for 15 years, regularly seeing his doctor.

Lao is an essential worker — a nursing assistant at a skilled nursing home.

He discovered he was positive for COVID-19 after being ill for a week.

“I have a cough but I don’t have a fever…it’s really, really bad,” he told MedTruth. “I was thinking I was going to die because I cannot breathe, I cannot breathe.”

When it came to managing his chronic conditions and fighting the virus, his doctor’s advice was simple: “Just drink a lot of water and a lot of rest, a lot of rest, and eat.”

Lao is excited to go home but is concerned because his employer wants him to return to work the day after his two-week quarantine ends.

“I don’t know,” he said. “I feel like I’m okay, but I’m not ready.”

Like other essential workers, Lao may not have a choice.

Researchers have indicated that addressing the root causes of these conditions is essential to fighting COVID-19 in the United States. Gathering detailed data could help them to better understand key demographic and social factors, Akinyemiju said, not only to document COVID-19 disparities — but to construct solutions.

The goal is to target “our prevention efforts to align with where the greatest risk is,” she said.

Simple solutions, such as access to primary care and doctors to track illnesses, plus a concerted effort to address food deserts, can improve a range of chronic conditions that are affecting COVID-19 disparities.

The solution, Akinyemiju maintained, is “not anything fancy.”

By Akilah Wise

Akilah Wise is a public health scientist and journalist based in Atlanta, Georgia.

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