By CHRISTIAN B. RAMERS
More than five months after San Diego county’s first reported case of COVID-19, much has been learned about the novel coronavirus that causes the disease, the global pandemic, and the complex social and political forces at play in our often-unsuccessful efforts to control its spread.
It’s been challenging to make sense of the explosion of published scientific research and social -driven pseudoscience; however, we have made progress in our understanding of the transmission, pathophysiology, treatment and prevention of the coronavirus and the disease it causes.
Hospitalized patients receive a consistent package of evidence-based interventions, including oxygen therapy, prone positioning, intravenous remdesivir, corticosteroids and convalescent plasma. Treatments for less severely ill patients have unfortunately lagged, leaving only self-isolation, frequent telemedicine check-ins, supportive care and advice to prevent transmission. But as the pandemic rages on, so does the feverish pace of research trials of new treatments and vaccines, providing hope that a breakthrough may help us out of this mess.
Yet one of the most shocking revelations of the pandemic has been the stark racial and ethnic disparities in case rates, hospitalizations and deaths, particularly among the Latinx community.
Many have postulated reasons underlying these blatant health disparities: Latinx families comprise more essential workers, are more likely to have multigenerational households, depend more on public transportation and are more likely to live near or across the border where transmission is still intense. Latinx families also historically had less access to health-care services well before the pandemic. Family Health Centers of San Diego (FHCSD), where I practice, was, in fact, established 50 years ago after peaceful protests demanded better health services for Latinx working families in Barrio Logan.
These underlying reasons are deeply rooted in more significant systemic issues such as income inequality, educational opportunity and lack of affordable housing. These longstanding social determinants of health aren’t easily mitigated in the short term. To that end, shouldn’t targeted allocation of resources to increase access to testing be an easy fix?
While the county’s overall test positivity rate for the coronavirus was around 3% in early June, community clinics like FHCSD, operating in neighborhoods with the most significant challenges in social determinants of health, were reporting rates of 15% to 20%. With the efforts of the state of California and our county to increase the number of free testing sites in the hardest-hit ZIP codes, shouldn’t we see a leveling out of these disparities and better pandemic control?
Unfortunately, as with many aspects of the pandemic, a closer look reveals the testing problem is more complicated than it seems.
FHCSD has diagnosed more than 2,500 of the county’s 30,000 reported COVID-19 cases. I have cared for many of them and become familiar with the menacing impact of this disease, not only on physical health and vitality but, more importantly, on livelihood and economic well-being.
For many low-wage and essential workers, getting a test and isolating is not a simple decision. Consider the following scenarios that have played out in the lives of our patients:
A single mother working a minimum wage job at a sandwich shop making just enough to support her three children. She develops a dry cough but tries to hide it from her boss. She has no sick leave so taking time off work for illness — much less for a test — might mean the difference between making rent or not.
Another man works in a food-processing plant and noticed co-workers who reported exposures to the coronavirus at home were forced to get a test. Some have not been back to work for weeks; he wonders if they will even have a job when they return.
And yet another patient holds a job with a housecleaning service with no sick leave or medical benefits. She notifies her supervisor of fever and chills before her shift but is told it is too late to find a replacement and she must work.
These real-life scenarios reveal the impossible choices so many Latinx essential workers must make, and why it is not as simple as setting up testing centers in highly impacted neighborhoods. In one of the most cruel twists of the pandemic, data reveals that the very neighborhoods with the highest rates of the coronavirus are also experiencing the highest rates of job loss and unemployment.
The pandemic reveals in stark relief the inequities in our society. While wealthier, white-collar workers can easily shelter in place, telecommute and avoid exposure, essential workers must do what they need to do to survive. Until we take steps to address broader societal inequity, the racial and ethnic disparities revealed in COVID-19 data will persist.
Ramers, M.D., is a specialist in infectious diseases and the chief of population health at Family Health Centers of San Diego. He lives in Burlingame.