How cultural factors and health disparities impact transmission

Watch the AMA's daily COVID-19 update, with insights from AMA leaders and experts about the pandemic.

In the second part of a two-part series, AMA Chief Experience Officer Todd Unger continues the conversation with Dr. Chevez, Dr. Lemos, and Dr. Seija about the health disparities impacting the Latinx community due to the COVID-19 pandemic.

Learn more at the AMA COVID-19 resource center.

Speakers

• Diana Lemos, PhD, MPH, senior program manager, strategy & development, Center for Health Equity, AMA
• Shari G. Chevez, MD, pediatrician and regional lead, equity, inclusion and diversity, Southern California Permanente Group (SCPMG)
• Luis E. Seija, MD, internal medicine and pediatrics resident, Icahn School of Medicine at Mount Sinai

Unger: Hello, this is the American Medical Association's COVID-19 update. Today we'll continue with part two of our two-part series on the impact of COVID-19 on the Latinx community. Well, let's talk about cultural influences. How do cultural influences play a factor in transmission within this community? Dr. Chevez, why don't you start?

Dr. Chevez: Well, I'm glad that I'm not hearing it as much anymore, but we started with a lot of myths and uncertainty and theories about what COVID was and where it came from and all of that. So that was in the backdrop of trying to message and being a trustworthy source. So we have to consider, in our communities of color, that that was happening. So knowing that first would be a first step. And then secondly, just listening to people in the moment, trying to understand, okay, what do you understand? What do you need? How can we, as an organization, be trustworthy? How can we be a trustworthy source that people will go to in addition to their family, their friends, their neighbors, their leaders in their community, and say, "What is Kaiser Permanente telling us is true and helpful"?

Unger: Dr. Seija?

Dr. Seija: Yeah, something that I alluded to earlier was the fact that a lot of this is; we're living in close quarters, upwards of double digits sometimes. And the other thing too within the Latinx community is that we celebrate together. We're the loudest and proudest at all the graduations, at least that's from my experience. And that holds true for a lot of different families as well. But we also mourn together. And that's one of the hardest things too, when you're trying to get this public health message that we need to social distance, we need to do this, we need to do that in order to ensure something is safe. And so a lot of the culture aspect is missing from that. And that kind of makes this whole process a lot worse too.

And one thing that I will say, was very interesting to me that I found out was the role that religion plays. And a lot of the things that I saw in patients, especially with my Latinx patients, some patients went old-school Catholic, we got a priest to do the last rites and everything for a patient that we palliatively extubated. And it was just a lot. It's those little things. The daughter couldn't remember what it was off the top of her tongue, but then I totally just remembered from way back in the day, like, "Oh, wow, you're talking about this. I know exactly who to call." So it's like those little touches, religion or culture or whatever it may be that make the experience a little bit more supportive in that respect, knowing that their provider knows where they were coming from.

Unger: Dr. Lemos, what about the role of PPE for essential workers? Is that having an impact?

Dr. Lemos: Yeah, so I just wanted to close in on the cultural aspect and also bring a point that from an equity lens, we also want to be very mindful of how we position culture as a contributing or as a risk factor. Because a lot of these issues come back to, from an equity perspective, some of these larger structural issues. So the ongoing anti-immigrant rhetoric that's impacting access to care and keeping some of these communities invisible is really important. The disproportionate access to PPE is sometimes a result of the fact that we're not placing value on our essential frontline workers. And so when we think about it from this structural aspect, we also recognize that there is some inherent disparities that are a result of these other influences. And so I just wanted to tie that back as we're seeing that this increased impact of lack of access to PPE in these low wage essential worker roles, but also in hospitals and providers that are serving these communities and that are centered in the Latinx community and the black community as well.

Unger: Well, we had some big news this morning from the Supreme Court in regard to DACA. Immigration issues have been a challenge for both patients and the community with the latest public charge rule that took effect in February and physicians and health care workers with IMG issues and others. How's this further complicated treatment of COVID-19 within the Latinx community? Dr. Seija?

Dr. Seija: So big win for DACA recipients overall, very exciting this morning. The one thing I will say with respect to immigration and undocumented status and things like that, that was a big issue in terms of a lot of hesitancy in pursuing care, or even transitions of care. What I mean by that is we would have someone in the hospital and ready to go to the USS Comfort or the Javits Center, or somewhere transitional, they're not quite ready for home, but they still need a little TLC. But the thing is those were government run and they were undocumented and they were just scared to go there. And so they would respectfully decline or they would just say, "I don't know what I'm going to do." And we find ourselves as finding the limits of us as doctors and providers, because we know medicine, we know how to be human, but sometimes we just can't control those types of things. And so that was a very, very frustrating part of this whole pandemic and continues to be.

Unger: Dr. Lemos?

Dr. Lemos: Yeah. I think the ongoing issue around access to care and concerns around continued immigration enforcement is a relationship that we continue to see and it's a significant contributor to people retaining and staying away from getting needed care. When we were doing our assessment, we heard of stories of people who were really sick and who really should be going to a hospital and were afraid to go so were abstaining from care. As it relates to DACA I think was part of the question, again, I think it's particularly meaningful that it is a win for us. It's also national immigrant month so it's also particularly compelling. And we recognize that there's over 27,000 professionals, health care professionals that are impacted by this. And having the potential to lose this workforce would have a significant impact on the Latinx community since we know these providers are more culturally relevant and in some ways educated to be able to attend to the needs of this community.

Unger: Dr. Seija, go ahead.

Dr. Seija: The one thing that I will add is that the delay in care was very frustrating, mostly because there were certain clinical trials or treatments that you could be eligible for, but if you're outside the window, you're ineligible. And options were limited and are still kind of limited. There are some breakthroughs now. But the thing is, you just can't delay in care because you could present one day later outside that window and you're excluded from a trial. It was very heartbreaking.

Dr. Lemos: And we have genuine concerns about under-representation of minorities or minoritized communities as it relates to emerging vaccine or clinical trials that may have the potential to reduce the mortality. So that is a very serious issue and we're definitely paying attention to that as well.

Unger: Dr. Chevez, what should healthcare organizations be doing to combat inherent bias in the system and among their physicians that could impact care for this community and others?

Dr. Chevez: Yes, it's such a great question. And so here's the problem is that would require equity in the system. And in our American society, there isn't a model for equity, not in healthcare, not in education. I could go through the list of things where it is not built on equity. So when we think about it from an equity lens, always it's what do people need, meeting people where they're at because of the underlying inequity in all of our systems. But we're starting to think about at KP (Kaiser Permanente), okay, yes, we definitely need to meet people where they are at, but how do we take down the fences that require the boxes for them to stand on to see over? What are the fences in our system? And so is that related to diversity and representation in our workforce? Is that related to the socioeconomic status of our patients? And leaning in as a healthcare organization to that. Is it the educational system? Is it all of it? So I think there's a mindset shift around what are the reasons inequity exists? And finally, if the focus is that, and if we stay focused on that, I think that we will make a difference.

Unger: Dr. Seija, Dr. Lemos, anything to add?

Dr. Seija: Sure. So from the medical education perspective, we're just not doing enough. We have a new generation of doctors that are very proactive, very involved with social justice. And that's great. But we need more from our institutions and working from the top down in terms of instilling that and being consistent. Because I think one of the biggest things that is a shocker when medical students transition from preclinical to clinical is that a lot of that you learn in your humanities class about implicit bias or this or that, it's kind of out the window. And that's no one's fault. People are sick, we've got work to do. And it's not that we don't care, it's just that we're not making time for it or prioritizing it like we need to.

And I think this pandemic has really, really shed light on the social determinants of health and what those play and inequities and promoting those. And so I think we're going to start seeing it changing the way that we do curriculum and making sure that we are making it a priority. And I know something that I've done at least is I started a social justice book club for the internal medicine residency program here. It's weekly and it's voluntary. But eventually we'll get to things about anti-racist, anti-bias things in real time in the wards and how do we respond to those, whether that's from our colleagues or from the patients and learn how to address those in real time.

Dr. Lemos: Yeah. I think starting to really understand the role of equity and how it really is coming from a structural perspective is one of our priorities, and really shifting how we talk about health independent of all of the other issues that we're seeing related to workforce, related to the increased burden of educating children at home, and knowing what a toll that has on families in general. And so when we think about this, we think about it from that lens of how do we address the health needs of our communities, but also how do we start to relate that to other issues that are also impacting people's ability to access and stay connected to care? I think, for us it's really important. And we on our end have really been doing that deep work to try to better understand how we can connect all of these issues and really implement an equity perspective into the work that we're doing.

Unger: Dr. Chevez, Dr. Lemos, Dr. Seija, thank you so much for being here today and sharing your perspectives on the impact of COVID-19 on the Latinx community. That completes our two-part series. If you missed part one, you can find it on the AMA's YouTube channel. We'll be back tomorrow with a different COVID-19 update. For updated resources on COVID-19, go to ama-assn.org/COVID-19. Thanks for being with us here today and take care.

Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.