No One Is Safe From Getting COVID-19, But Will Everyone Get Equal Access To Care?
Every day, Los Angeles County health officials announce the number of positive COVID-19 cases throughout the county — by city, and by neighborhood in the city of L.A.
When they started these announcements, in mid-March, Victor Cuevas found himself sheltering at home and bored. So Cuevas, who works in communication by day, decided to put his master's degree in urban planning to use.
He started plotting the daily case count on a map and quickly noticed something: Wealthier zip codes, like Hancock Park and Beverly Hills, had a higher number of cases. When he looked at zip codes with a larger percentage of lower-income households and people of color — communities such as Compton, Boyle Heights and Pacoima — there were few to no cases.
That got Cuevas thinking. "What's going on there? Are those folks getting extra testing?" he said when I talked to him by phone recently. The answer, health experts say, is almost certainly yes. But that's just the beginning of how wealth and poverty are likely to play out in this pandemic.
I've mapped this every day since the County released geographic data — there's been a steady pattern. Communities of color have shown the least "confirmed" cases — we know the story here is about testing. Updated per latest data...West of La Brea has been steady, SELA not really pic.twitter.com/1PHOT0Sxlr— Victor Hugo Cuevas (@urban_agent) March 23, 2020
THOSE WHO CAN AFFORD TO TRAVEL LIKELY BROUGHT COVID-19 TO LA
Historically, some infectious disease outbreaks, like cholera, have attacked lower-income communities first. But COVID-19 is different.
Dr. David Eisenman, director of UCLA's Center for Public Health and Disasters, says travel played a big part at the start of the outbreak here. That explains why, as far as the U.S. population goes, members of Congress, celebrities and vacationers on cruise ships got it first.
"Travelers that brought it over from China or Italy, business travelers, people in industries that take them across to other countries," said Dr. Eisenman. "I think that explained the early importation."
WHO GETS TESTED? WHO DOESN'T?
By the fourth week in March, cases were mounting in other parts of L.A. But the trend that Cuevas, the armchair mapper, first noticed of higher case numbers in wealthier neighborhoods still held. (Crosstown, a non-profit news organization, recently mapped out the county's numbers and found a similar trend.)
We're at the point where every community is starting to report — some doubled in numbers from yesterday. What's been clear from March 16th (first day of mapping) is the higher #s in Fairfax/WeHo/Bwood. Median home value in Brentwood is $1,905,026 & "Melrose" $1,091,736 pic.twitter.com/dJioTI7v9f— Victor Hugo Cuevas (@urban_agent) March 27, 2020
News outlets also began to report discrepancies in testing.
The L.A. Times reported that a doctor in Santa Monica was offering patients a cheek swab test for the coronavirus for $250. A doctor in Huntington Beach had also secured his own supply of tests for his patients.
Meanwhile, Dr. Barbara Ferrer, head of the county public health department, was urgently calling for more testing kits and widespread testing.
Dr. Eisenman also noticed the testing trend. "This probably reflects differences in access to health care between the rich and the poor." Eisenman said. "It's unfortunate, but it's logical.... If you have health insurance and a doctor, it's easier for you to get."
Dr. Dawn Terashita, associate director of acute communicable disease control with L.A County's health department, sounded a similar note: "Maybe this is due to an increase in insurance or increase in access to health care."
She said the county plans to do further analyses.
AS COVID-19 SPREADS, DISCREPANCIES IN CARE MAY SHOW
As the number of positive cases rises each day, it's clear the disease is spreading throughout the county without discrimination. In a letter to President Trump, Gov. Newsom estimated that 25 million Californians could be infected over an eight-week period. But how well — even whether — they survive COVID-19 could further reveal the underlying health disparities that accompany L.A.'s wealth disparities.
As you go further inland and further south in L.A. County, life expectancy generally goes down. What academics call the "social determinants of health" — access to health care, housing, income — play a huge part.
These social factors already make it harder for people in low-income neighborhoods, many of them communities of color, to be as healthy as their wealthier counterparts. For example, about 89% of Beverly Hills residents have health insurance, compared to only 69% of people in Compton.
Dr. David Hayes-Bautista, a UCLA professor of medicine and director of the Center for the Study of Latino Health and Culture, believes that puts Latinos and other communities of color at a disadvantage when it comes to COVID-19.
"The public service announcements always say at the first sign of a fever to contact your doctor," Hayes-Bautista said. "[Latinos] often don't have a physician to whom they can contact."
Still, as more free testing sites start to pop up across the county, Hayes-Bautista thinks the patient demographic will shift.
"We will see that initially the positive cases were non-Hispanic white areas, but they will very quickly with a matter of a couple weeks shift over to the largely Latino areas," Hayes-Bautista said.
UNDERLYING CONDITIONS COULD MAKE SOME COMMUNITIES MORE VULNERABLE THAN OTHERS
Not only do poor people and some communities of color see the doctor far less than their wealthy, white counterparts, they tend to have higher rates of certain health conditions, such as hypertension, heart disease and diabetes — underlying conditions that could make them very sick if they were to get COVID-19.
In some parts of the country, including Chicago and Louisiana, the virus is hitting black communities especially hard. Surgeon General Jerome Adams said Tuesday that African Americans are at higher risk during the pandemic because of underlying health conditions and because it may be harder for lower-income black people to practice physical distancing if they're living in close quarters.
"Testing is a concern, we're going to be at 2 million tests this week and it's rapidly ramping up with the commercial industry... at the end of the month we should not only be doing diagnostic testing but also doing surveillance testing across the country." — @Surgeon_General pic.twitter.com/7JFuZMrcYN— CBS This Morning (@CBSThisMorning) April 7, 2020
On Tuesday, the L.A. County Department of Public Health released some preliminary data on the race and ethnicity of COVID-19 cases and deaths.
Relative to population size, county researchers found that black Angelenos have a slightly higher COVID-19 death rate compared to other racial and ethnic groups.
However, the county still has no racial or ethnic data for 43% of reported COVID-19 deaths.
With scarce equipment and staff to treat people with the virus, hospitals across the country may face tough ethical questions: Who gets priority for treatment? The healthy or unhealthy patient?
Dr. Matt Wynia, director of the Center for Bioethics and Humanities at the University of Colorado, said medical decisions should not "further disadvantage people who are already suffering disadvantage." He recommends that doctors not make decisions based on race, ethnicity, or religion.
"Those types of considerations should be explicitly excluded from triage protocols." Wynia said.
But he suggests that hospitals should have an independent triage team that is not treating a patient to make a neutral decision in a critical life or death situation.
Recently, the Office for Civil Rights in the U.S. Department of Health and Human Services issued a bulletin reminding hospitals and clinics that it's illegal to discriminate against patients based on race, disability, age and other federally protected characteristics.
Still, in a pandemic, some medical experts worry that discrimination may happen anyway.
Dr. John Dividio, who studies medical discrimination at Yale University, said doctors and other health care workers may have unconscious, or "implicit," bias — ingrained stereotypes with regards to race, gender or social class. And that can affect their treatment of patients, whether they realize it or not.
Several studies compiled by the National Institutes of Health found that black patients were given worse medical treatment than white patients when it came to the same diagnosis.
Dividio said health care professionals can usually mitigate their biases by being reflective and taking their time to make decisions, but he's concerned that the stress and high stakes of the coronavirus pandemic could impact the quality of care that patients get, including end-of-life care.
He added that many of the problems in the health care system, especially during the pandemic, are tied to poverty and racial and ethnic disparities.
'Socioeconomic (status) is going to add to that cascade of who's getting help and who's not getting help," Dividio said, and "that's tied to race in America."
2:32 p.m.: This article was updated with new data on race and ethnicity of COVID-19 victims in L.A. County.
This article was originally published at 12:25 p.m.