Throughout the COVID-19 pandemic, the nation’s healthcare systems have sprinted to develop interventions to improve the safety of our patients, frontline workers, and communities. Lessons learned from prior public health outbreaks and crises have demonstrated that the most vulnerable patients are at higher risk of presenting with more severe illness. We compiled expertise from a group of physician leaders who have worked on various projects to improve health disparities nationally and participated in the Aspen Institute’s Global Leadership Network or the Presidential Leadership Scholars Program to provide diverse perspectives from current frontline medical staff. Our goal is to distill simple, yet impactful, actions clinicians can take to protect their most vulnerable patients.
Adults as a Vulnerable Population
Vulnerable populations include racial or ethnic minorities, elderly, immigrants or refugees, socioeconomically disadvantaged, people with disabilities, underinsured, those living in rural places, the incarcerated, LGBTQ+ individuals, and those with certain chronic conditions. These populations often face greater complications from stigmatization, affecting their physical, mental, emotional, and social health. In addition, vulnerable populations may have further barriers to participate in our healthcare system due to low literacy, language and cultural barriers, mobility challenges, and fear of seeking treatment due to immigration policies (i.e., Public Charge).
Among vulnerable populations, COVID-19 in the United States has been noted to disproportionately affect racial and ethnic minorities in many communities, but data on this issue is still missing universally. In Illinois and North Carolina, where statistics on COVID-19 include race, a disproportionate number of African Americans were infected. This data is mirrored in other communities such as Milwaukee County and Chicago, where 45-50% of cases and 70% of deaths occurred in African Americans. Although the reasons are multifaceted, one contributing factor is likely the higher rate of co-morbid chronic conditions amongst African Americans due to inequities that have caused health disparities to compound over generations. These co-morbid chronic conditions put patients at a higher risk of mortality from COVID-19.
During this pandemic, vulnerable patients who often require frequent healthcare system interactions may not be able to do so. While adhering to the guidelines of staying home, some patients present to the Emergency Departments (ED) later than they should, sicker and requiring higher levels of care. As clinicians, we must proactively find ways of outreach to vulnerable populations, many whom also lack reliable communication means, such as cell phones, landlines or the Internet, and often heavily rely on the ability to show up to clinic or the EDs for immediate care or to schedule visits.
Although virtual visits have already been utilized broadly throughout the healthcare system, some other interventions could assist vulnerable patients including advertising existing programs that provide internet services at reduced rates or free government phones (i.e., SafeLink wireless and Amerimex Mobile, which is designed specifically for Hispanics). Additionally, the re-implementation of house calls is an effective modality to ensure safe and timely patient care for our most vulnerable. Implementing a fully functioning Mobile Integrated Health unit consisting of a multidisciplinary group has proved most prudent. This team is fully equipped to triage, take vitals, examine the patient, do point-of-care testing, draw additional labs, start intravenous (IV) fluids, give IV diuretics or antibiotics, refill prescriptions, and check wounds. This team treats patients at their point of need, mitigating exposure to COVID-19 from in-person visits to clinics and hospitals, and reducing admission and readmission for common chronic medical conditions.
Children as a Vulnerable Population
Relatively, the pediatric population has been less impacted by COVID-19 and with lesser severity. A study of pediatric COVID-19 patients in China revealed that 5.9% of pediatric cases were critical compared to 18.5% of adult cases. However, younger infants were more susceptible to more severe illness with 10.6% of infants younger than one year old being critical, compared to 7.3% of ages 1-5, 4.2% of ages 6-10, and 4.1% of ages 11-15.1 In a study of U.S. cases, among those 19 years old or younger, between 1.6 and 2.5% were hospitalized versus 14.3-70.3% of those in other age categories with increasing age related to increasing hospitalizations and mortality.2
Clinically, children present in similar fashion as adults with complaints of fever, cough, and respiratory distress. It is important to note that co-infections with other respiratory pathogens, such as influenza and respiratory syncytial virus, have been described in the pediatric population.
Special consideration should also be made for women and children who are at higher risk for domestic violence and child abuse during a disaster. Outpatient clinics should consider sending a communication via e-mail and text to all active patients with domestic violence hotlines and resources. Additionally, children living in already financially stressed environments are particularly at risk for adverse childhood experiences. Every effort should be made to continue outreach to children.
Other special pediatric considerations include education and caregiver concerns. With stay-at-home orders for children, working parents are expected to ensure appropriate educational opportunities for their children. Quality educational and social experiences are not guaranteed, and there is a need for high-quality instructional materials delivered to homes or available online. In addition, these families may rely on other family members, particularly grandparents, who are themselves a vulnerable population, for childcare.
Much of the attention of COVID-19 has been on metropolitan areas where population density has contributed to rapid spread of disease, however rural areas have also been affected. In the earlier part of this pandemic, according to national statistics on April 5, 2020, there were 13,591 cases and 382 deaths attributed to non-metropolitan counties in the United States, figures that represented 3.9% of cases and 3.6% of deaths nationally.3 However, now rural counties, which have only 14% of the US population, account for 17.3% of new COVID-19 cases and 18.9% of COVID-19 related deaths, as of August 29. Rural communities now account for a disproportionate percentage of new cases and deaths.4
Forty-six million people live in rural communities in the United States. Even before COVID-19, people living in rural areas had higher risk of death than urban areas due to higher rates of obesity, high blood pressure, smoking, opioid overdoses, and motor vehicle accidents. Also, more uninsured and older adults live in rural areas.
During COVID-19, rural communities face new challenges while their health systems are struggling with finances and capacity; 117 rural hospitals have already closed since 2010. With hospital volumes down significantly and non-emergent procedures cancelled, the financial hit to certain systems could be nine figures in 90 days, raising concern of additional hospital closures. Rural hospitals also have limited capacity and are often at the end of supply chains, further exacerbating challenges in acquiring needed protection personal equipment (PPE) and other equipment. Out of 2,000 rural hospitals, 65% (1,300) have fewer than 25 beds and 32.5% (650) have one ventilator on site. Rural hospital systems are not optimized for additional capacity and are instead made to be efficient, leading to concerns about a potential COVID-19 surge.5
Despite the financial and capacity challenges, rural hospitals and providers are working to preserve healthcare through command centers with COVID-19 screening, cancelling elective surgeries to conserve PPE, telemedicine expansion where broadband allows and transfer agreements with larger hospitals that can handle acutely sick COVID-19 patients.
The COVID-19 pandemic has unveiled the uncomfortable truth about the existing socioeconomic inequities of our society. It has exposed the festering and often neglected problems facing our vulnerable population that are rooted in systemic racism. Given the indiscriminate transmission of COVID-19 and the interconnectedness of our society, it benefits our society to advance health equity among vulnerable populations and thereby protect the public welfare. Given the fact that health disparities are disproportionately killing black and brown daily, our nation must prioritize and be positioned to protect the health of vulnerable populations. Healthcare professionals, policymakers, and stakeholders must have the will and fortitude to confront and solve the socioeconomic challenges to protect vulnerable population from future insults.
Presidential Leadership Scholars & Aspen Institute Health Innovators group: Quyen Chu, Jay Bhatt, Pritesh Gandhi, Rohit Gupta, Reshma Gupta, Michael K. Hole, Benson Hsu, Lauren Hughes, Lenore Jarvis, Sunny Jha, Mansi Kotwal, Joseph Sakran, Sameer Vohra.