Brigham and Women's Hospitals

Health Equity and Ethics

Updated: September 27, 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. Upholding equity in health allows prioritization of fair opportunities for everyone to attain their full health potential (WHO Health Systems: Equity).
  2. The COVID-19 pandemic has disproportionately affected vulnerable populations in China (Wang and Tang, Nat Med, 2020) and around the world.
  3. Inclusive data collection, while key, needs to be followed by evidence-driven steps, to create an inclusive pandemic response and to be the foundation for equitable public health emergency planning (Reed NS et al, Lancet Public Health, 2020)
  4. 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

Racial disparities

  1. In the United States, multiple sources have demonstrated that Black and Latinx populations are being disproportionately likely to be infected and/or die from COVID-19 (Garg S, CDC MMWR, 2020, NYSDOH Fatalities, NYC DOH).
  2. Systemic health inequities likely reflect multiple systemic factors that adversely impact BIPOC, including:
  1. Exposure risk at work. BIPOC 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. BIPOC are more likely to rely on public transport to attend work (Pew Research)
  3. Exposure risk in shared living spaces. BIPOC are less likely to own their own living space and cohabitate with others (Census)
  4. Comorbid health conditions. BIPOC have significantly higher rates of hypertension, obesity, diabetes, and other risk factors for severe COVID complications compared to white peers
  5. Access to healthcare and testing. BIPOC have lower rates of health insurance and 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. There is extensive sociological literature to suggest that racial health inequity is primarily a byproduct of structural and social oppression. While the possibility of racialized genetic variability exists, multiple studies have demonstrated that racial classifications inadequately describe genetic variations between people (Templeton AR. Stud Hist Philos Biol Biomed Sci. 2013; Tishkoff SA et al, Nat. Genet. 2004).

Vulnerable Populations

  1. Skilled nursing facilities (SNFs):
  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 (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).
  1. 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).
  1. Early data from the COVID-19 pandemic demonstrated up to 5x higher rates of death among PWIs despite disproportionately younger age distributions relative to nearby communities (Saloner et al JAMA 2020)
  1. Decarceration remains the most evidence-based intervention to reduce infection among PWIs and by extension, the local communities that staff the facilities that house them (Hawks et al, JAMA Intern Med, 2020, Barnert et al AJPH 2020, Okano and Blower, Lancet, 2020).
  1. In lieu of full decarceration, compassionate release of low-risk offenders and elimination of cash bails that contribute to growing prison populations can also be considered to curb infectious potential (Nowotny et al, AJPH, 2020)
  2. Since COVID-19 was identified, 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. When isolation and containment strategies are deployed in correctional facilities, additional interventions should be supported to address the mental health burden they create for PWIs, especially those living with chronic mental illness (Hewson et al, Lancet Psychiatry 2020)
  1. Some safe way to support PWIs include waiving in-state licensure requirements for telemedicine and expand access to virtual family visits via videoconferencing (Robinson et al, AJPH 2020).
  2. Other solutions include mass testing of PWI and correctional facility workers, providing PPE and improving sanitation (Akiyama et al, N Engl J Med, 2020). It is particularly critical to focus these efforts on occupational health interventions that can prevent transmission of any infection from the PWI population to nearby communities (Sears et al, Annals of IM 2020).
  1. Immigrant populations:
  1. Noncitizens are among the groups most likely to experience disproportionate effects from COVID-19 but this inequity may be overlooked since nativity data is not currently collected for analysis by the CDC (Langellier BA, AJPH 2020).
  2. Structural factors that shape daily life for noncitizens predisposes them to greater risk of transmitting and acquiring COVID-19 (Langellier BA, AJPH 2020).
  1. Compared with US-born citizens, noncitizens live in larger multifamily households where bedrooms may be shared.
  2. They are also more likely to perform work that cannot be done remotely and depend on public transit.
  1. Systemic interventions to improve health outcomes among noncitizens can include: 1.) Collecting citizenship and nativity data to facilitate equitable access to testing and care, 2.) Elimination of citizenship barriers to public assistance programs, and 3.) Eliminate public assistance participation as a barrier to establishing citizenship (Langellier BA, AJPH 2020).
  1. Undocumented immigrants are not currently eligible for federally funded public assistance programs (e.g. SSI, TANF, SNAP). Paradoxically, eligible documented immigrants who receive support from these public assistance programs are ineligible for citizenship based on the “public charge” test.
  1. Patients who cannot speak English are more likely to receive inadequate care due to infectious barriers to in-person interpretation and variable quality of phone interpreter services (Ross et al. JAMA Internal Medicine 2020).
  2. International Medical Graduates (IMGs) make up roughly 25% of the specialist workforce in America but many are serving on H-1B (temporary employment) visas that disqualify them from disability benefits and expose family members to forcible relocation in the event of their deaths. Therefore, even for motivated members of the American IMG workforce, there are significant disincentives not to contribute to national COVID-19 relief efforts (Tiwari et al. Annals of Internal Medicine 2020).
  3. To date, Immigration and Customs Enforcement (ICE) has detained over 50,000 undocumented immigrants in holding facilities. Detainees in such facilities are subject to all of the same infection risks as prison inmates (see “Incarcerated Populations”), but may be more prone to poor outcomes since ICE’s operational COVID-19 containment protocols do not consistently reflect evolving CDC recommendations (Openshaw and Travassos, Clinical Infectious Disease 2020, Meyer et al, Lancet Infectious Disease 2020, Keller and Wagner, Lance Public Health 2020)
  1. People with disabilities:
  1. Individuals with disabilities may be disproportionately marginalized by COVID-19 response efforts due to inadequate documentation of their unique medical needs.
  2. Due to limited resources and structural bias, people with disabilities may not have equitable access COVID-safe accommodations or healthcare resources.
  1. More equitable protocols should be guided by near-term survival calculations and management strategies that minimize subjective bias that may limit the ability of people with disabilities to access life-saving or life-prolonging interventions (Solomon MZ et al, NEJM 2020).
  2. Health policy leaders must remain aware of ways in which their recommendations may disrupt critical aspects of daily life and/or medical care for people with disabilities (Armitage R et al, Lancet Public Health 2020). Alternative support structures should be considered for patients with disabilities who are unable to participate in standard public health protocols (Eshraghi AA et al, Lancet Psychiatry 2020)
  1. Equitable responses to the pandemic must ensure that inequities are not exacerbated, and should provide a pathway for improvements to ensure equitable access and treatment in the future (Sabatello M, et al, Am J Public Health 2020)

Patient Resources to Improve Health Equity

  1. Screen for and Address 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.
  1. Housing, Food, Unemployment, Legal Assistance resource availability is maintained by our Medicaid ACO team in Brigopedia (login required)
  1. Some 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. Find Behavioural and Psychiatric Resources for patients:
  1. See Psychiatry section on Supportive Resources
  2. Consider searching via the multi-payor Network of Care
  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).

Resource Allocation and Triage

  1. 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., Chest 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., Chest, 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, Chest, 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, JAMA, 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).
  3. It is critical to extend the same level of care and resources to all healthcare workers regardless of title, especially those such as environmental services that have increased exposure to potentially infectious materials and environments (Tyan and Evans, Annals of IM 2020, Himmelstein and Woolhandler, Annals of IM 2020).
  1. Unlike other staff, healthcare trainees are positioned to have high rates of exposure to COVID-19 and have variable ability to contribute to patient care that justify this risk.
  1. This section is still in progress