April 20, 2020
Dear Michigan Clinicians,
Thank you for your tireless efforts to care for Michigan residents during the COVID-19 pandemic. Your efforts on the front lines of this crisis are commendable. As with any disease, the epidemiology and characteristics of those who are severely or disproportionately impacted by COVID-19 is very important and has implications for clinical practice. The purpose of this letter is to make sure you are aware of our current understanding of how this disease is impacting racial and ethnic minorities, and alert you to ways you can address this in your current practice.
Racial and Ethnic Disparities in COVID-19 Cases and Deaths
The Michigan Department of Health and Human Services has identified alarming racial and ethnic disparities in COVID-19 cases and deaths. As of April 19, 2020, African American residents comprise 33% of cases and 40% of deaths due to COVID-19 in Michigan, despite comprising only 14% of the state’s population. This is consistent with what has been seen in other states as well.i The State of Michigan is actively working to perform a deeper analysis of why these disparities exist. However, based on what we currently know about other health disparities, there are many reasons why we are likely seeing this during the COVID-19 crisis.
We know that racial and ethnic minorities are more likely to have lower wage jobs and live in poverty compared to Caucasians, and may be more likely to have to work in “critical infrastructure” jobs during the COVID-19 crisis such as in grocery stores, food handling, and public transportation.ii Lack of access to a car and the need to take public transportation, as well as unstable or crowded housing conditions may mean racial and ethnic minorities are less able to implement CDC-recommended isolation and quarantine practices.
These conditions can result in a lack of access to care. Research has also shown that, once care is accessed, both implicit and explicit bias by healthcare providers contributes to health care disparities.iii One of the factors associated with implicit bias is how we are socialized. We all have implicit biases and the difficulty is that we don’t realize that we have them – assumptions about individuals and groups can cause medical providers to not use a patient’s individual circumstances or objective data to guide clinical management. Explicit biases include those that are more explicitly racist, that may also not be fully recognized.
The social determinants of health described above, as well as access to care, have consequences as it relates to the development, diagnosis, and treatment of disease. Many racial and ethnic minorities have underlying health conditions that put them at greater risk for complications from COVID-19. For example, African Americans have higher rates of asthma and diabetes compared to Caucasiansiv,vii; two conditions that have been associated with greater risk of becoming severely ill if infected with COVID-19.v
According to the Kaiser Family Foundation, among non-elderly adults, African Americans are more likely to report that they are in fair or poor health compared to their Caucasians.vi Additionally, racial minorities are more likely to be uninsured, lack a usual source of care, and may forgo testing or treatment due to fears about costs, mistrust of the healthcare system, and a lack of information about available resources.vii.viii
To be clear, the above challenges are not caused by genetics or race. They are caused by the historical inequities that are an unfortunate part of American history. All clinicians have an important role to play in addressing these disparities, particularly during the most urgent public health crisis of our time.
What can you do as a medical provider to address racial and ethnic disparities related to COVID-19 morbidity and mortality?
Everyone goes into medical professions because they want to improve the health of all of their patients. The following are things you can do now to address disparities related to COVID-19:
- Recognize that minority populations are more severely impacted by COVID-19. Early testing and close medical monitoring is warranted, and clinicians should be aware of how their own subconscious biases may impact their practice. We know that patients with COVID-19 can deteriorate quickly. Complaints of symptoms should be taken seriously in any patient, and particularly those from racial and ethnic minority groups. To support this effort, the Michigan Department of Health and Human Services has expanded testing criteria to include mildly symptomatic individuals, and people working in jobs that have been deemed “essential” during the COVID-19 outbreak.ix Furthermore, be aware that implicit bias (unconscious attitudes or stereotypes that impact our thoughts and actions) exists among clinicians and can impact patient outcomes. Be mindful of how implicit bias may be impacting your own clinical practice. Resources exist to assist you and your medical
- Recognize that isolation and quarantine may be difficult for people who have unstable housing situations or have many people living in their household. Clinicians should be diligent in asking their patients if they will be able to comply with CDC recommendations on home isolation and what additional supports they may need to do so properly. Clinicians should consider these factors when assessing treatment options for individuals, including hospitalization. For example, intergenerational households may not have the space to safely self-isolate sick members of the family, and therefore sending a patient home to recover may not be the safest option for the patient or their family. Be familiar with the resources that your local health or human services department may have available for people with unstable housing who are diagnosed with COVID-19.
- Recognize the complex social determinants of health that are likely to affect patients, such as transportation issues, access to food, or employment challenges. With the Governor’s Stay Home, Stay Safe order, many businesses have had to temporarily close or reduce their hours. This can disproportionally affect minority populations who work in the service sector.x Patients may have lost access to their health insurance and may not be able to keep medical appointments or obtain medications. Additionally, critical service sector jobs such as grocery store employees or delivery drivers are at in increased risk of contracting COVID-19, due to the fact that they are unable to implement strict social distancing measures.xiFamilies may also be facing increased strain on their food resources because of school closures, difficulty accessing grocery stores, or reductions in income from loss of a job. All of these factors play a critical role in a person’s ability avoid contracting COVID-19 or recover safely should they develop symptoms. Ask every patient about their social and economic circumstances during the current pandemic. Should your patients need assistance, you may direct them to Michigan.gov/mibridges where they can apply for benefits such as Medicaid, SNAP, or housing assistance. The Department of Labor and Economic Opportunity has a comprehensive list of available resources for Michigan residents. Michigan 2-1-1 is a free service that connects Michigan residents to resources like food, housing, and financial assistance. You should also be aware of resources available through your local government.
This is an incredibly difficult and challenging time for us all. I want to sincerely thank you for your inspiring efforts on the front lines of the COVID-19 pandemic in Michigan. I am so proud of our medical professionals and it is an honor to serve alongside you every day to protect Michigan residents.
Sincerely,
Joneigh S. Khaldun, MD, MPH, FACEP Chief Medical Executive
Chief Deputy Director for Health
Michigan Department of Health and Human Services
Tracker/NYSDOHCOVID-19Tracker-Fatalities?%3Aembed=yes&%3Atoolbar=no&%3Atabs=ni New York State Department of Health. Accessed April 19, 2020 from https://covid19tracker.health.ny.gov/views/NYS-COVID19-
ii Poverty USA. Accessed April 19, 2020 at https://www.povertyusa.org/facts
iii Institute of Medicine (US) Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care; Smedley BD, Stith AY, Nelson AR, editors. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington (DC): National Academies Press (US); 2003. Available from: https://www.ncbi.nlm.nih.gov/books/NBK220358/
iv Artiga, S. Garfield, R. Orgera, K. “Communities of Color at Higher Risk for Health and Economic Challenges due to COVID-19. Issue Brief. Kaiser
Family Foundation. 7 April 2020. Accessed from: https://www.kff.org/disparities-policy/issue-brief/communities-of-color-at-higher-risk-for- health-and-economic-challenges-due-to-covid-19/
- Centers for Disease Control and Prevention, “People Who Are at Higher Risk for Severe Illness,” April 13, Accessed from: https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-at-higher-risk.html.
- Artiga, Garfield, R. Orgera, K. “Communities of Color at Higher Risk for Health and Economic Challenges due to COVID-19. Issue Brief. Kaiser
Family Foundation. 7 April 2020. Accessed from: https://www.kff.org/disparities-policy/issue-brief/communities-of-color-at-higher-risk-for- health-and-economic-challenges-due-to-covid-19/
vii Ibid.
viii Institute of Medicine (US) Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care; Smedley BD, Stith AY, Nelson AR, editors. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington (DC): National Academies Press (US); 2003. Available from: https://www.ncbi.nlm.nih.gov/books/NBK220358/
ix State of Michigan Executive Order 2020-42. https://www.michigan.gov/whitmer/0,9309,7-387-90499_90640-525173–,00.html
x Artiga, S. Garfield, R. Orgera, K. “Communities of Color at Higher Risk for Health and Economic Challenges due to COVID-19. Issue Brief. Kaiser Family Foundation. 7 April 2020. Accessed from: https://www.kff.org/disparities-policy/issue-brief/communities-of-color-at-higher-risk-for- health-and-economic-challenges-due-to-covid-19/
xi Ibid.
viii Michigan Department of Health and Human Services (MDHHS). Behavioral Risk Factor Surveillance System Survey Data. Lansing, Michigan: Michigan Department of Health and Human Services, 2015-2017.