Hannah Valantine, M.D., served as the moderator for a session to gain a broader view of the landscape of the pandemic. “We have an unprecedented collision of two pandemics: COVID-19 as well as the unveiling of systemic racism,” she stated. “Seeing this collision occur has created an extraordinarily tough time but also the most important time to be doing this work. We are poised for extraordinary shifts to see real movement and change in thought and action.”
The presenters were Gary Gibbons, M.D., director of the National Heart, Lung, and Blood Institute (NHLBI) at the National Institutes of Health (NIH); Garth Graham, M.D., M.P.H., president of the Aetna Foundation; and Richard Besser, M.D., president of the Robert Wood Johnson Foundation (RWJF). A discussion followed their presentations.
RISING TO THE PUBLIC HEALTH CHALLENGE OF COVID-19
COVID-19 has devastating impact on the health of adults, stated Dr. Gibbons, and particularly affects the cardiovascular system. It has also been found to have an impact in children through a multisystem inflammatory syndrome (MIS-C). As reported elsewhere, different communities and demographic groups within the United States have experienced COVID-19 differently, with growing evidence of higher rates and risk of hospitalization and death in the African American community and other communities of color.
NHLBI Research Strategy
The research strategy of the National Heart, Lung, and Blood Institute related to COVID-19 aligns with the NHLBI mission to turn discovery science into human health for all communities, Dr. Gibbons said. Research to combat COVID-19 spans the spectrum from understanding the virus at the fundamental level to research at the translational, clinical, population, and community levels.
Dr. Gibbons pointed out that deaths due to heart disease have declined over the past 50 years for all groups, although the rate for African Americans remains higher than for other races and ethnic groups. A recent troubling trend has been a flattening of these rates, he said, “suggesting we could not continue business as usual to bend the curve.” People with cardiovascular conditions and other comorbidities are at higher risk for COVID-19 complications. But there are multiple COVID-19 risk factors in addition to
these underlying health conditions, which may possibly include a genetic risk profile that shapes the immune response, as well as social determinants of health that include high exposure through essential service work on the front lines, limited access to health care, and zip code—which serves as a rough indicator of housing and other conditions.
An All-Hands Call to Action
An all-hands “call to action” is required to address unprecedented health challenges that this crisis lays bare, Dr. Gibbons asserted, in particular to reduce the fatality rate; characterize and treat MIS-C in children; elucidate the drivers of COVID-19 health disparities; develop evidence-based strategies to eliminate these disparities; and, after the acute phase, understand the long-term sequelae of COVID-19. Thus, the NHLBI research portfolio is supporting interventions along the progression of COVID-19, from prevention through treatment to convalescence and recovery. Related to observational studies in the community, Dr. Gibbons noted:
Critical, and in addition to classical clinical trials, are the observational studies that are community based or population based to better understand the patterns of this disease. These are not just to describe or understand the natural history but also to add community-based interventions. We are engaged in efforts to look at how can we get to the front lines of communities of color and change some of these curves and statistics.
NHLBI’s rapid response is based on existing resources already developed, including cohorts and clinical trial networks reflective of diverse populations that can be knitted together for assessment and understanding. The institute’s work is part of a broader effort, called Accelerating COVID-19 Therapeutic Interventions and Vaccines, or ACTIV. ACTIV is a partnership that includes federal agencies, nonprofit organizations, and biotech/pharmaceutical companies (Collins and Stoffels, 2020). “Given the scope and scale, no one partner is sufficient to have impact alone; we need all hands on deck,” Dr. Gibbons stressed. He expressed the hope that Roundtable participants will “lean in” to the importance of conducting inclusive interventional and observational research, both in clinical trials and in communities, so that those who are most affected, burdened, and vulnerable benefit from the research.
The first solicitation for a clinical trial went out in March. It was vetted, and within a month a protocol was launched on hydroxychloroquine effectiveness. (The study closed June 20, with no harm or benefit found in this controlled trial of diverse populations.) Another trans-NIH effort, called Rapid Acceleration of Diagnostics–Underserved Populations (RADx-Up), is concerned with rapid acceleration of diagnostics with the goal to leverage existing community partnerships to implement culturally relevant testing strategies in underserved and vulnerable populations.1 A series of funding opportunities is forthcoming to reduce barriers to testing, tracing, treatment, and case management.
Dr. Gibbons closed by emphasizing the current situation is an unprecedented public health crisis that converges with vestiges of systematic racism and health inequities. It represents a call to action, with all hands on deck, based on a partnership model in which only a diverse connected community can bend the curve.
WHAT TESTING IS REVEALING
Dr. Graham, president of the Aetna Foundation, has been involved in large-scale COVID-19 testing through CVS Health. The data from this testing show the pandemic is unfolding in Black and Brown communities very differently than across the general landscape. It is critical to understand the differences, he said, and to recognize that the solutions are not simple. It is particularly important to engage partners on the ground, location by location.
As the company set up its testing, they looked at historic efforts, including the 1918 influenza epidemic and, more recently, H1N1 to see how minority communities have been affected. African American medical leadership mobilized and helped turn things around in these situations, he said. CVS Health has partnered with the National Medical Association because of its reach in local communities.
Testing takes place in about 1,000 retail stores, mostly in areas of high social vulnerability as defined by the Centers for Disease Control and Prevention (CDC), and in free clinics to reduce barriers.2 Once community members are approached with the right information they come in to get
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1 For more information, see https://www.nih.gov/research-training/medical-research-initiatives/radx/radx-funding-opportunity-announcements-foa-frequently-asked-questions.
2 For more information about the CDC’s Social Vulnerability Index, see Chapter 3 in this proceedings, and also https://svi.cdc.gov/.
tested. A key lesson learned is that reducing barriers to getting tested is critical, he said. As other presenters noted, the pandemic is unfolding differently in Black and other minority communities, with numbers exponentially higher than in majority communities. At the time of the workshop, the Phoenix testing sites were seeing a 35 percent positivity rate; Atlanta, 30.3 percent; and Houston, 37 percent. “Understanding that concept has been a call to action,” he stated, noting that testing is important to bring people into the system. As the nation reopens, communities are sensitive to mixed messaging. If people hear that the pandemic is “over,” they may behave in a different manner because they think the risk is low. He urged workshop participants, “We have to be spending our days reaching communities right now with pertinent messages. We can’t wait to publish in a peer-reviewed journal a couple of weeks from now. We have to be very concrete in our mobilization.”
Dr. Graham questioned the concept that comorbidities among Black and Brown communities explain the disparate rates of severe outcomes:
The concept of what is driving these numbers is perplexing. Many of us, including myself, have defaulted to the idea that maybe increased incidence and mortality rates are because of the comorbid diseases in Black and Brown communities. Looking at the data from the UK and our own data, when controlling for these factors, that is not entirely clear. We have to be thinking in real time about the kinds of things that may be causing this, such as overexposure by workers on the front line and the kinds of messages making their way into communities in real time.
He also noted the need to get away from such narratives as “this is a hard-to-reach population” or the disparities are “inevitable.” Looking at H1N1 vaccinations, the percentage of Blacks who were vaccinated increased significantly between the 2008–2009 and 2010–2011 seasons, in part because of a focused effort by the Department of Health and Human Services and other public and private partners to reach minority communities (CDC, 2011). Dr. Graham said this effort reinforces his view that positive change can happen.
He closed by again calling attention to the very different pandemic unfolding in Black and Brown communities. “If we saw these testing rates in the general population, the efforts would be very different,” he said. “That makes me understand that how this pandemic unfolds in the future
is going to be very different. It’s almost like two worlds diverging. How we deal with it has to be different as well.”
A CULTURE OF HEALTH TO ADDRESS COVID-19
Dr. Besser noted his perspective on COVID-19 is influenced by his previous work at the Centers for Disease Control and Prevention in addition to his current position. RWJF is concerned with conditions that promote or place barriers to health. A “culture of health” is more than access to high-quality health care to extend to what takes place in workplaces, schools, and neighborhoods, and it is based on a concept of health equity. Structural and interpersonal racism are a barrier to health equity, he stated.
In early March, Dr. Besser wrote an op-ed that foreshadowed the disparate impact on Blacks, Hispanics, and Native Americans from COVID-19 (Besser, 2020). “The themes raised by Dr. Gibbons and Dr. Graham about different pandemics are critical,” he said. “When you look at the status of individuals and groups coming into this pandemic, the issue of differential exposure risk is key.” People have had to work despite the risks to their health. In contrast, other countries with more success stemming COVID-19 have found ways so that people could stay home without worrying about food or rent. Coming into the pandemic, he pointed out, more than half of low-income workers did not have unemployment insurance or sick leave. The idea that the disproportionate impact of COVID-19 is the result of personal behavior choices, he underlined, flies in the face of a society that has different opportunities for health for different groups.
Exposure Risk
Even controlling for comorbidities, as Dr. Besser pointed out, major differences by race point to the issue of exposure risk. Given that higher proportions of Black Americans are essential workers, if they are not being provided personal protective equipment (PPE) and other safeguards, a differential outcome will result in terms of cases. With so much attention about the need for PPE for health-care workers, little attention or energy has focused on the importance of PPE for people in food production, transportation, grocery stores, and the like, which increases their risk for disease. Moreover, lower-income Americans cannot follow much of the public health guidance. For example, “call your doctor” does not relate to the 26 million Americans without health insurance, who must go to a hospital emergency
room. The guidance to quarantine in a separate bedroom and bathroom is likewise not realistic for the higher proportions of Black Americans who live in multigenerational or more densely populated households. In response to a comment by one local official that safe places for isolation and quarantine were set up but not used, Dr. Besser stressed finding out the reasons why from the people concerned, such as the fear of losing a job or need to serve as the caregiver for an elderly relative or a child. He continued:
When you look at the decisions that people are making, in terms of if people are complying with CDC guidance, you have to ask, “Who is the guidance for?” If you apply an equity lens, we need guidance that everyone can comply with. We have to recognize many people will need additional services.
A Culture of Health
RWJF’s concept of culture of health focuses on three areas, including policy changes, such as the CARES Act and a moratorium on evictions, many of which are winding down as the pandemic continues. Efforts to protect lower-income workers in the workplace are not forthcoming. For this reason, some people do not want to share information with contract tracers because of fear of job loss. Understanding what the barriers are at the community level is critically important, he said.
Dr. Besser said the foundation has developed five equity principles related to responding, reopening, and recovering from COVID-19 (RWJF, 2020). The first calls for critical use of data, at a zip code level broken down by race and ethnicity, which is not mandated to be reported. He said he has seen more mixed messaging related to COVID-19 than in any other public health crisis. Communication is critical, he continued, especially when the science is limited, people are being asked to do challenging actions based on best available science, and their actions may need to change as the evidence changes. It is also important to engage with communities and let them drive the solutions. A top-down approach to decide what needs to take place will leave communities behind.
DISCUSSION
Dr. Valantine asked each presenter what he envisioned a year from now related to COVID-19. Dr. Gibbons said he hoped to see that the
government has mobilized and rapidly responded with community-based interventions around testing, tracing, case management, and treatment. He said he thinks an effective treatment will become available, but it must be implemented in the most vulnerable communities. “A year from now, I hope we are bending that curve [regarding treatment] and hopefully by then there will be a vaccine and those communities are first in line,” he said.
Dr. Graham said he could envision two potential futures. It could be that people come together, rise to the challenge, and define a new history. Alternatively, he said, there may be a replication of challenges and lack of vision to deal with them, leading to ongoing death and despair. He stressed, “We have the ability to change.” Dr. Besser also expressed both hope and fear. In the short term, between now and the end of 2020, he called for policy solutions so people have the opportunity to protect their health and reduce the impact of the pandemic, including a renewal of income supports, supplemental unemployment insurance, and expansion of Medicaid. A year from now, he said he envisioned that conversations around structural racism and COVID-19 will coalesce toward a more progressive agenda, such as to pay essential workers appropriately.
A third pandemic related to mental health is accompanying the pandemics of COVID-19 and structural racism, Dr. Valantine commented, and she asked the presenters about this challenge. Dr. Graham said funding for the mental health of frontline workers is a priority, but acknowledged undiagnosed mental health exists. People in underserved communities may not be thinking they are dealing with depression and anxiety, and pediatric mental health and the impact on generations to come are also an issue. Right now, he said, it is important to raise awareness to talk about these issues. Dr. Gibbons noted elements of the NIH initiative RADx-Up deal with social, behavioral, and mental issues, especially through the National Institute of Mental Health. He expressed particular concern about patients who are recovering and undergo trauma when they go back to their communities. Acute stress can be superimposed on chronic levels of stress, he noted. Dr. Besser reiterated the value in connecting chronic stress and physical health. Children may not be experiencing high rates of COVID-19 infection, but they are not protected from stress. In addition, more people are in need of mental health services, but most health insurance does not cover these services adequately. In moving forward the discussions about universal health insurance, comprehensive and high-quality coverage must provide significant mental health services, he said. In the immediate term, he said, more must be done to help people cope and be more resilient.
Stress connected with the pandemic will have an impact on the scientific and physician workforce and will exacerbate disparities, Dr. Valantine said. Dr. Graham referred to an article in Forbes that included interviews with young Black physicians about the strains under which they are working (Gold, 2020). One solution, he said, is learning from leaders who have lived these experiences. That is one reason that the percentage of Black members in the National Academy of Medicine is important, he said, to create a culture that brings forth these problems.
Financial strains, Dr. Valantine added, may mean backpedaling in the progress to have greater representation in the scientific and medical workforce. Dr. Gibbons pointed out the importance of resilience within Black and Brown communities. “This is a call to action for leaders,” he said. “We have representatives of communities of color in leadership or have access to resources who can respond in a way that is authentic and based on lived experience…. There is no greater moment in our careers than this moment.”
Dr. Valantine then asked about global coordination to deal with COVID-19. Dr. Besser pointed to RWJF’s Global Ideas for U.S. Solutions program that attempts to apply lessons learned from other countries in a U.S. context. He expressed worry about the United States withdrawing from the global community and what he termed the demonization of the World Health Organization. Not only will this impact other nations, he said, but also there is a strong case that it places the United States at greater risk. Dr. Gibbons agreed and said he was struck by the international voices participating in Black Lives Matter protests. He continued that vaccines and therapies, some of which are being tested in other countries, must also be made available in other parts of the world. Dr. Graham said, “If we think the solution is based in one country or community, we are mistaken. We are in this together and we cannot fool ourselves otherwise.”
A participant asked about herd immunity against the virus. Dr. Gibbons replied a very high proportion of the population would need to be infected. He instead urged enhanced testing, tracing, case management, and treatment. Dr. Besser pointed out uncertainty about the numbers needed to reach herd immunity, if it can be reached at all, and the devastating burden and loss of life of such a strategy. Dr. Graham opposed a path to herd immunity for Black America if it is not a path that America as a whole would choose for itself.
In response to a question about testing in rural communities and in community health centers, Dr. Graham said most of his program’s testing
takes place in free clinics, which he termed a good leverage point. He said COVID-19 is and will continue to hit rural communities hard, but baseline data are not being captured. A vaccine, once one is found that is safe and effective, must be distributed in an ethical way to protect the most vulnerable, another participant commented, and asked how to do that. Dr. Gibbons replied that RADx-Up includes an effort related to the social and ethical dimensions of a response to COVID-19. The federal government is making investments in research, development, and manufacturing of vaccines, he said, and this gives the public leverage to ensure that the fruits of taxpayer investments reach communities. He urged partners to become involved in that dialogue. A participant asked about the mistrust of the medical community, particularly of medical research, by many in the African American community and asked how this might play out related to testing and immunization. Dr. Gibbons said NIH as a research agency needs to turn to trusted voices who have been on the front lines, and community engagement and partnership should be the key drivers. The key, he said, is beneficence: that is, that the individuals and communities who participate in medical research should reap the benefit of the understanding that is gained.
REFERENCES
Besser, R. 2020. As coronavirus spreads, the bill for our public health failures is due. Washington Post, March 5. https://www.washingtonpost.com/opinions/as-coronavirus-spreads-the-bill-for-our-public-health-failures-is-due/2020/03/05/9da09ed6-5f10-11ea-b29b-9db42f7803a7_story.html.
CDC (Centers for Disease Control and Prevention). 2011. Interim results: State-specific influenza vaccination coverage. Morbidity and Mortality Weekly Report 60(22), 737–743.
Collins, F. S., and P. Stoffels. 2020. Accelerating COVID-19 Therapeutic Interventions and Vaccines (ACTIV): An unprecedented partnership for unprecedented times. JAMA 323(24), 2455–2457. DOI:10.1001/jama.2020.8920.
Gold, J. 2020. “I am tired”: What Black doctors need you to know right now. Forbes. https://www.forbes.com/sites/jessicagold/2020/06/12/i-am-tired-what-black-doctors-need-you-to-know-right-now/?sh=6e6b95e24ad7.
RWJF (Robert Wood Johnson Foundation). 2020. Health Equity Principles for State and Local Leaders in Responding to, Reopening, and Recovering from COVID-19. Issue Brief. https://www.rwjf.org/en/library/research/2020/05/health-equity-principles-for-state-and-local-leaders-in-responding-to-reopening-and-recovering-from-covid-19.html.
