Brigham and Women's Hospitals

Health Equity and Ethics

Updated: May 7, 2020

Health Equity

Introduction

  1. Equity focuses on eliminating avoidable, unfair or remediable differences among groups, whether these are defined socially, economically, demographically or by any other stratification.
  1. Upholding equity in health allows prioritization of fair opportunities for everyone to attain their full health potential (WHO Health Systems: Equity).
  1. The COVID-19 pandemic has disproportionately affected vulnerable populations in China (Wang and Tang, Nat Med, 2020) and around the world.

Racial disparities

  1. In the United States, early release data from the CDC capturing demographics of hospitalized patients with COVID-19 across 14 states (between March 1-30, 2020) has shown that black and latinx populations are being disproportionately affected by this disease (Garg S, CDC MMWR, 2020).
  1. Boston data as of April 10, 2020 showed that 42% of individuals diagnosed with COVID identified as Black despite comprising 25.3% of Boston’s population. (2020 Census Bureau: City of Boston).
  2. New York has the highest number of reported COVID-19 cases within the U.S. (accounting for 29.8% of all U.S. cases as of April 12, 2020). As of April 11, 2020, New York City data on COVID-19 fatalities reported by race/ethnicity demonstrated that 34% of individuals who died from COVID-related causes identified as Hispanic and 28% identified as Black, despite comprising 29% and 22%, respectively, of NYC’s population (NYSDOH Fatalities). In comparison, 27% of individuals identified as White, 7% as Asian, and 4% as Other, while comprising 32%, 14% and 3%, respectively, of the city’s population (NYSDOH Fatalities).
  1. The differences between races likely reflect multiple factors, and there is not yet complete data on the relative import of each. These include:
  1. Exposure risk at work. Minority groups in most places are more likely to work in healthcare, education, retail and other jobs that preclude work from home.
  2. Exposure risk in public transit. 34% of African Americans rely on public transit relative to 14% of white people, Pew Research)
  3. Exposure risk in shared living spaces. 44 percent of African-Americans own their own home vs 74 percent of white people (Census)
  4. Comorbid health conditions. Hypertension, obesity, diabetes, and other risk factors for severe COVID complications are often more prevalent in minority populations.
  5. Access to healthcare and testing. Health insurance rates are lower amongst many minority populations. They are more likely to live in areas with less-resourced local health centers.
  6. Racism in healthcare delivery. Many minority patients experience consciously- and subconsciously-biased health systems and providers when they seek care.
  7. Chronic stress. Stress and allostatic load can affect immune function.
  1. We do not yet know if there is a genetic contributor that may explain elements of these disparities, but if there were to be one it is highly unlikely to explain them in full. Multiple studies have demonstrated that racial classifications inadequately describe genetic variations between people (Templeton AR. Stud Hist Philos Biol Biomed Sci. 2013; Tishkoff SA and Kidd KK, Nat. Genet. 2004). Race rarely explains clinical outcomes, which are more often due to structural and social inequalities.

Vulnerable Populations

  1. Skilled nursing facilities (SNF):
  1. According to the CDC about 4 million Americans are admitted to or reside in nursing homes and skilled nursing facilities each year
  1. Skilled nursing facilities by their nature struggle with social distancing practices and have populations that have significant medical risk factors for poor outcomes A single SNF in Kirkland, WA, USA had 167 COVID-19 confirmed cases (101 residents, 50 health care staff, 16 visitors) with respective hospitalization rates of 55%, 6% and 50%; and case-fatality rate of 34% for residents (McMichael et al, N Engl J Med, 2020).
  2. According to the Kaiser Family Foundation as of April 23, in 23 states that report the data “there have been over 10,000 reported deaths due to COVID-19 in long-term care facilities (including residents and staff), representing 27% of deaths due to COVID-19 in those states.” (Kaiser Family Foundation)
  1. Homeless populations:
  1. Homeless populations less than 65 years old have all-cause mortality 5-10 higher than the general population at baseline (Baggett et al, JAMA Intern Med, 2013). Living conditions, higher rates of comorbidities (including substance abuse and mental illness), difficulty for public health agencies to trace homeless individuals and limited connection with medical services are all likely challenges (Tsai and Wilson, Lancet Public Health, 2020) but data on the COVID-19 pandemic in the homeless remains limited.
  1. Incarcerated populations:
  1. People who are incarcerated (PWI) are particularly vulnerable. Overcrowding (without options for social distancing), poor ventilation, sanitation concerns, paucity of medical care, violence, and increased rates of chronic medical conditions make this group particularly susceptible to COVID-19 infection (Maruschak et al, US Dept of Just, 2016).
  2. To address this increased risk several solutions have been proposed, however decarceration remains the most significant intervention (Hawks et al, JAMA Intern Med, 2020). In addition, other solutions include mass testing of PWI and correctional facility workers, providing PPE and improving sanitation (Akiyama et al, N Engl J Med, 2020).
  1. To date, over 25 states have engaged in early release efforts, 14 states have reduced jail and prison admissions, and 47 states have suspended medical co-pays for incarcerated individuals (Prison Policy Initiative: Responses to the COVID-19 Pandemic).
  1. The medical community can play a role in advocating for this population through several measures (Sivanshker et al, Br Med J, 2020) These include: Sending letters to state legislators outlining ways to promote safe releases including efforts to ensure housing security and medical follow-up. Promoting proper health and safety policies within jails and prisons with increased testing. Calling representatives to support legislation that protects PWI. Partnering with attorneys to write amicus briefs or affidavits in litigation cases addressing decarceration efforts.
  1. Undocumented immigrant populations:
  1. This section is in development.

Addressing Health Equity at the Clinical Level

  1. Collect transparent data:
  1. Collect and share data within and between institutions as well as at a population level (e.g. city, state, nation-wide)
  1. Demographics should include at a minimum, age, sex, race/ethnicity, primary language, and socioeconomic status (or zipcode as a proxy) (Geronimus AT et al, J Am Stat Assoc, 1995).Other demographics such as sexuality, education level, religion, country of origin, immigration/legal status, housing status, and disability status should be collected if possible.
  1. Screen for Social Determinants of Health (SDOH):
  1. SDOH are the conditions under which people are born into, grow, live, work, and age (AAFP's The EveryONE Project). Examples include housing, transportation, neighborhood safety, access to sanitation/heating/electricity, job security, and exposure to violence.
  2. Identify resources available to individuals and their communities to help alleviate local disparities. Some Boston-area resources include:
  1. Project Bread hunger and food resources
  2. Harm reduction strategies for people who use substances (English)
  3. Boston and Massachusetts community resources (multiple languages)
  4. State-by-state guide to government services available as part of COVID-19 relief (English)
  1. Employ communication tools for people with limited English proficiency (LEP):
  1. Below are strategies shared by the MGH Disparities Solutions Center:
  1. Create language-concordant screening and educational materials based on the languages spoken in your population.
  2. Ensure interpreting services (e.g. in-person interpreters, bilingual phones, and/or mobile screens such as iPads) during clinical interactions.
  3. Employ staff hotlines with people who are multilingual.
  4. Target communication updates to LEP populations in multiple languages and through multiple platforms (e.g. email, website, text messaging, flyers, etc)
  5. Create a registry with clinical staff who are multilingual and deploy them to applicable sites that care for LEP patients.
  1. Develop communications tools for patients with disabilities:
  1. Surgical masks with clear windows can enhance communication for those who are deaf of hard of hearing.
  2. Photos of clinical care team members can alleviate anxiety in a time when medical care is provided with abundant use of PPE.
  3. Trauma-informed care can help build trust (CDC guide).
  1. Involve diverse personnel in the creation and implementation of clinical and ethical guidelines.
  1. Healthcare institutions should strive to institute diversity and inclusion measures at all levels in order to mitigate implicit bias and assure that the viewpoints of multiple stakeholders are incorporated into policy

Resource Allocation and Triage

  1. Further details about the BWH and Partners HealthCare model will be linked here when available.
  2. Below are general considerations and references about resource allocation in the setting of scarcity. For a comprehensive framework for resource allocation, please see the model developed Douglas White and colleagues at the University of Pittsburgh.

Crisis Standards of Care

  1. A “crisis standard of care” is a set of principles to help guide triage when there are insufficient resources (including ICU beds, ventilators, dialysis machines, etc.) to meet medical needs (Institute of Medicine 2012).
  2. It is triggered by “a substantial change in usual healthcare operations and the level of care it is possible to deliver, which is made necessary by a pervasive (e.g. pandemic influenza) or catastrophic (e.g. earthquake, hurricane) disaster” (Institute of Medicine 2012)
  1. It must be formally declared by regional/state authorities and hospital leadership.
  2. It typically involves contingencies for different stages of a crisis
  1. It allows transparency. Transparency in decision making, particularly when resources are scarce and cannot be allocated to all who are in need, is essential (Biddison et al. 2014)

Stages of crisis

(Christian et al. 2014)

Triage principles

  1. The goal of triage is to maximize population benefit while treating individuals fairly.
  1. This is different from the usual goal in medicine of promoting the wellbeing of individuals.
  1. The most widely endorsed strategies are to maximize lives saved or life-years saved:
  1. Lives saved (no explicit preference given based on age)
  2. Life-years saved (some explicit preference given to younger patients all else being equal)
  1. Several other strategies have been proposed to allocate scarce resources, but have been criticized for failing to maximize benefit (NY State Task Force 2015). These include:
  1. first-come first served
  2. lottery
  3. preferential allocation (e.g. for healthcare workers)
  1. Consensus statement policies (Biddison et al. 2014) suggest no ethical difference between withholding and withdrawing care.

Structure of triage teams

  1. Consensus guidelines suggest that all decisions about triage are made by a Triage Officer, not the bedside clinicians caring for patients (Christian 2014).
  2. The Triage Officer should be a physician with critical care training.
  3. Decisions about triage should be made based on protocols established by the hospital. These protocols should be evidence based and nondiscriminatory (Gostin & Hanfling 2009)
  4. Bedside clinicians, patients, and families should have mechanisms for appealing triage decisions.
  5. An oversight committee should be established to review decisions made by Triage Officers to ensure consistent application of the triage protocol and to adjudicate appeals.

Duties of Health Care Workers

  1. Regardless of scarcity, clinicians have a duty to care for all patients—including by providing compassionate comfort-oriented to those who will benefit from it.
  1. The duty to care requires that clinicians accept a reasonable level of risk in the provision of care, founded in the principles of fidelity, respect for persons, and non-abandonment.
  2. There is a corollary obligation of organizations to ensure risk is minimized to clinicians as much as possible through, for example, the provision of personal protective equipment (Veterans Health Administration 2010).