Culture Clashes: How COVID-19 Heightened Awareness of Treating Vulnerable Populations

From a distrust of authorities to language and cultural barriers, the COVID-19 pandemic has laid bare some uncomfortable facts about treating some of the most vulnerable populations. Caregivers and healthcare professionals need to be acutely aware of how to deal with these patients by overcoming several obstacles from language barriers to accepted cultural norms.

Last November, as the COVID-19 pandemic entered its ninth month in the U.S., a paper appeared in SGIM Forum, the official newsletter of the Society of General Internal Medicine, that shed some light on the most vulnerable populations affected by the virus — those who are at a higher risk for developing more severe illnesses due to the novel coronavirus.

The authors of the paper, writing on behalf of the Presidential Leadership Scholars & Aspen Institute Health Innovators — a group of physicians and other healthcare professionals — directly address health systems across the country, pointing to segments of the population who are at greater risk of complications, and more importantly, detailing why these groups face the challenges they do, and what can be done about it. “To reduce morbidity and mortality from COVID-19, it’s critical that health systems proactively address the challenges faced by vulnerable populations, such as lack of economic resources, language barriers, fear of seeking treatment due to immigration policies, poor access to healthcare, and mobility challenges,” the authors write.

The paper focuses on three broad populations — adults, children, and residents of rural communities — and identifies the challenges patients might face while suggesting best practices for intervening and treating these patients so they receive optimal care. “During the COVID-19 pandemic, it is critical physicians and healthcare systems understand the challenges that vulnerable populations face, and the measures that will help mitigate risk for these patients,” the authors write.

Here, we’ll take a look at some of these challenges and what lessons some of our frontline healthcare workers have learned during this significant moment in medical history.

Translating to Reality

The authors of the SGIM Forum paper realized that each group had unique obstacles to address, and they knew the adult group would especially pose a problem, since that group could be broken down into any number of vulnerable groups. “In the adult group, the biggest issue is that there are multiple parts,” says Ricardo Correa, MD, EdD, FACP, FAPCR, FACE, FACMQ, program director of the Endocrinology, Diabetes and Metabolism Fellowship and director for Diversity on GME at the University of Arizona College of Medicine, Phoenix, and one of the paper’s authors. “We tried to focus as much as we can on not just one part like ethnicity or sexual preference, but on everyone in general.”

For instance, it’s been well established that racial or ethnic minorities and the elderly are at greater risk for developing more severe COVID complications, but the authors of the paper also point to the LGBTQ+ community, the incarcerated, immigrants and refugees, and the socioeconomically disadvantaged, to name a few, writing that these populations face greater complications because of stigmatization that affects not just their physical health, but their mental and emotional health as well.

And again, there’s no doubt that Black, Hispanic, and Native populations have been hit harder by the COVID-19 pandemic than their white counterparts. A study recently published in The Journal of Clinical Endocrinology & Metabolism analyzed data from 180 people with type 1 diabetes and COVID-19 from 52 clinical sites in the U.S. and found that Black patients were four times more likely to be hospitalized for diabetic ketoacidosis than Caucasians. Black and Hispanic patients were also less likely to use diabetes technology like continuous glucose monitors (CGMs) and insulin pumps, and they had worse glycemic control than white patients.

“Our findings of troubling and significant inequities call for urgent and targeted interventions, such as culturally appropriate diabetic ketoacidosis awareness campaigns, increased continuous glucose monitoring coverage for minority patients and healthcare provider participation in a Quality Improvement Collaborative,” says study author Osagie Ebekozien, MD, MPH, of the T1D Exchange in Boston, Mass.

And while awareness campaigns are definitely warranted, Correa paints a vivid picture of just how much finesse may be required to successfully deploy any messaging. For example, he says, for the Hispanic community it may not always be the language barrier that needs to be cleared, but the cultural barrier. “The way that the information was given to them was really not applicable in a way,” he says. “For example, in New York, when they were saying, ‘You have to quarantine from the rest of your family if you become COVID-19 positive.’ You can do that if you live in a house with four bedrooms, and then you just go to one of them and stay there. But when you’re living in a house with 10 people with one bedroom, then how can you do it? It was not translated to reality.”

“Our findings of troubling and significant inequities call for urgent and targeted interventions, such as culturally appropriate diabetic ketoacidosis awareness campaigns, increased continuous glucose monitoring coverage for minority patients and healthcare provider participation in a Quality Improvement Collaborative.” – Osagie Ebekozien, MD, MPH, T1D Exchange, Boston, Mass.

Correa also points to the deep distrust many people in these populations have for physicians and other medical professionals. There were reports last year of officials sterilizing undocumented females in Atlanta — women detained by ICE were allegedly forced to have hysterectomies. “We are still living in that world,” he says. “How do you convince them that [a vaccine or treatment] isn’t a chip to monitor you?”

Multi-Generational Impact

Children have been relatively less impacted by COVID-19, at least as far as the virus itself goes. Correa and his co-authors note a Chinese study that found there were about 6% of pediatric critical cases compared to 18.5% of adult cases. But children are impacted all the same when it comes to the more intangible consequences of the pandemic. “It’s more of a problem not for the children per se,” Correa says, “but for the people who provide for the children — parents losing jobs, and then not having money to buy food, which affects the children.”

Many schools remain closed, which means parents who work full time have to make accommodations for educational opportunities, which can often mean it falls to the grandparents — an extremely high-risk population themselves — to care for the children. “Living in a house with your parents and grandparents, someone has to go out and make money,” Correa says. “And if that person gets contaminated, what will happen to the household?”

And with schools closed, the children who relied on school meals may experience food insecurities. The authors write that food banks and pantries are already strained, and that several caregivers have reported the inability to buy baby formula as stores sell out. What’s worse, some children have even lost caregivers to the pandemic, leaving child protective services struggling to find appropriate placement of potentially COVID-19-positive children.

Rural Healthcare Needs

When the pandemic began to first sweep over the country, all eyes were on places like New York City and other metropolitan areas, since the density of a population contributes to a virus’s spread. But the authors write that about 46 million Americans live in rural areas, and even before the COVID-19 pandemic, this population was already at higher risk of adverse health outcomes due to higher rates of obesity, smoking, opioid overdoses, and car accidents.

Compounding the problem is that rural hospitals and health centers struggle with finances and capacity. The authors write that 117 rural hospitals have closed in the past 10 years. “We are seeing an increase in rural cases,” Correa says. “And one of the main reasons is the closure of hospitals because they weren’t profitable.”

However, rural hospitals and providers seem to be pulling together to address these problems to fight the pandemic. Elective surgeries have been canceled to preserve PPE, telemedicine continues to expand, and according to the Correa and his co-authors, governors in states like Tennessee and Illinois have plans to open closed rural hospitals to handle overflow demand from urban facilities.

Combatting Distrust

The SGIM Forum paper ends with a call to action — a roadmap of solutions for healthcare providers to ensure that these vulnerable populations they care they desperately need, including dissemination of educational materials that are culturally sensitive, providing free or subsidized access to the Internet for those distance learning or working from home and who would benefit most from telehealth, and providing food to low-income COVID-19 positive families.

“Health systems serving these populations often lack needed resources but have opportunities to create strategic partnerships with other regional medical centers, businesses, foundations, community-based organizations, or local and state government programs,” the authors write. “Through these partnerships, they may have potential to increase their capacity for rapid lab testing and obtain PPE, hospital beds, ventilators, medications, and social services programming.”

“The way that the information was given to [Hispanic communities] was really not applicable … For example, in New York, when they were saying, ‘You have to quarantine from the rest of your family if you become COVID positive.’ You can do that if you live in a house with four bedrooms … But when you’re living in a house with 10 people with one bedroom, then how can you do it? [COVID-19 awareness campaigns were] not translated to reality.” – Ricardo Correa, MD, EsD, FACP, FAPCR, FACE, CMQ, program director, Endocrinology, Diabetes and Metabolism Fellowship, University of Arizona College of Medicine, Phoenix, Ariz.

And at least for now, things seem to be looking up. Several pharmaceutical companies have produced FDA-approved COVID-19 vaccines, and many healthcare workers have received their first dose. (Correa tells Endocrine News he received his at the end of last year.)

But again, much work has to be done. Distrust about the vaccine among vulnerable groups has to be addressed, as does distrust among elected officials who argue certain groups should not receive the vaccine. “That’s my only concern and that’s why we’re working a lot harder in this vulnerable population and minorities, because of all the prior stories and conspiracy theories about the vaccine, like the Bill Gates one to inject things and all of that,” Correa says.

It’s February, which marks the one-year anniversary of the spread of this novel coronavirus. And as the virus continues to disrupt society as we know it, it has also laid bare deep, long-ignored issues that affect millions of who need our attention the most.

“The COVID-19 pandemic has unveiled the uncomfortable truth about the existing socioeconomic inequities of our society,” the authors of the SGIM Forum paper write. “It has exposed the festering and often neglected problems facing our vulnerable population that are rooted in systemic racism.”

Bagley is the senior editor of Endocrine News. In the January issue, he wrote about a new mouse study that could possibly hold the key to better understanding obesity.