On Answering the Call to Action For COVID-19: Continuing a Bold Legacy of Health Advocacy

All respected U.S. medical societies and associations representing physicians and public health professionals should feel secure taking bold action to measurably advance health equity within our country amid the current Coronavirus (or COVID-19) pandemic. Prompting our efforts should be the reality that our collective ability as a nation to rebound from the devastation due to this virus may ultimately hinge on protecting and equipping our most vulnerable racial-ethnic minority groups and any susceptible individuals within those populations. Highlighted here for immediate championing are commendable historic firsts initiated by the U.S. Department of Health and Human Services (HHS) in response to COVID-19 that hold significant promise if made permanent. In addition, support for a comprehensive reparations package may be warranted in order to fund the kind of in depth and informed policies that can effectively target persistent health inequities.

Indeed, the pressing need for us to remedy the unacceptable conditions that underlie disproportionate burden of death and disability from the coronavirus and that undoubtedly drive observed health disparities more broadly, has been echoed by the U.S. Surgeon General Jerome Adams, M.D.,M.P.H., Anthony Fauci, M.D., Director of the National Institute of Allergy and Infectious Disease (NIAD) of the National Institutes of Health (NIH), as well as HHS Secretary, Alex M. Azar II, J.D.^{1 , 2}

However, only thoughtful attention to our historical context as we develop tailored, group-specific measures and interventions will help us effect larger improvements in critical determinants of population health. Federal coordination of response strategies and recovery from this pandemic that can be tailored and implemented locally may also be necessary.³ An added benefit will be the overall strengthening of health and public health infrastructures in the U.S. as well as the advancement of our emergency and disaster preparedness systems.

We are seeing conclusive evidence that a powerful collective advocacy bringing that kind of thoughtful and deliberate intent can effectively sway action of the federal government as it relates to health crises like the current pandemic, which is deeply encouraging.

In early April 2020, a Washington Post analysis of nine counties showed that majority-black ones have three times the rate of infection and almost six times the rate of deaths as counties where white residents are the majority, noting that only a few jurisdictions publicly report coronavirus cases and death by race.⁴ Additionally, a letter from The Lawyers’ Committee for Civil Rights Under Law as well as an appeal from several national physician organizations formally called upon HHS Secretary Azar to direct federal agencies to collect and release information including statistics by race-ethnicity when reporting on impact and case fatality due to coronavirus.3, 4, 5 By the end of that same month the first such report by the Centers for Disease Control and Prevention (CDC) published a Morbidity and Mortality Weekly Report (MMWR) containing some of that information as available from hospitalization records.⁶

Influenced by the 400th year anniversary in 2019 of the first documented arrival of unfree Africans in North America in 1619,6, 7, 8, 9 as well as the introduction of the bills S.1080-HR40 into Congress (The Commission to Study and Develop Reparation Proposals for African-Americans Act),^{10 , 11} we strongly urge that some kind of reparations for Black Americans serve as the logical starting point for further advocacy.

Informing our assertion of an approach that could be perceived as radical by some is the National Medical Association's (NMA's) long history of advocacy within health and medicine throughout the nation whenever the cause advanced fairness and equity for all, even when seemingly at odds with mainstream culture at the time.

We are emboldened by the knowledge that former NMA President and NAACP President, Dr. William Montague Cobb, for whom the W. Montague Cobb/NMA Health Institute (Cobb Institute) is named, helped orchestrate the National Hospital Desegregation Movement as well as championed passage of the Civil Rights Act in 1964 and Medicare in 1965.¹²

The current coronavirus pandemic has been uniquely devastating and without recent precedent for our country, the new epicenter for the outbreak. While other similar global occurrences created action abroad, they usually created little panic at home given their smaller scale and relatively limited geographical spread compared to the current crisis. (The occurrences of Ebola hemorrhagic disease, severe acute respiratory syndrome, H1N1 (also called swine flu) and Zika virus disease are counter examples). The statistics are shocking as of early June – just six months after the emergence of the first cluster of cases in Wuhan, China and only five months after the identification of the first U.S. case. The virus has been detected worldwide in nearly 180 countries, resulting in the infection of almost 7 million persons, over 2 million of whom are in the U.S., and nearly 400,000 coronavirus-related deaths, 100,000 of them occurring in the U.S.¹³

Unfortunately, the identification of a vaccine against coronavirus is predicted to take over one year and the full spectrum and natural history of the clinical disease, transmission dynamics, pathogenesis and duration of viral shedding has not been determined. Since the initial report of the first identified U.S. case, scientists and clinicians have stated that the virus exhibits an aggressive, highly transmittable behavior, lethality and distribution in the population that is not fully understood.¹⁴ Some noted potential challenges for vaccine development are as follows: antigen design for optimal immune response; potential exacerbation of lung disease, either directly or as a result of antibody-dependent enhancement; and duration of immunity from single-dose vaccines.¹⁵

Although inconveniently timed for all of our communities, the swift and pervasive outbreak of the Coronavirus across the country might have been predicted when considering a variety of factors. Our ongoing lack of coordinated testing capability and emergency preparedness and response systems are widely acknowledged. Contributors are insufficient integration of our healthcare and public health infrastructures coupled with the fact that important social determinants of health are resigned to the periphery of our governmental decision-making processes. In addition, great geopolitical divides and broad distrust within the U.S. continue to delay and hamper a coordinated emergency response at the federal, state and local levels.

The immense burdens placed on the most vulnerable racial and ethnic groups complicate this picture to a greater extent, as revealed by relevant epidemiologic data.

Growing evidence indicates excessively high rates of death and disability due to coronavirus for Black American communities and other racial-ethnic minorities, and at alarmingly disproportionate levels given similar transmission rates across populations and our significantly smaller representation in the general population as a whole.¹⁶ Along with older age and underlying health conditions such as cardiovascular disease or pulmonary conditions,¹⁶ certain environmental exposures and other factors such as nutritional status may heighten that risk.^{13 , 14 , 16} In fact, the impact and fatality rate from this virus may likely correlate most closely with vulnerable groups and even more so with biologically susceptible individuals within those populations. Collection of additional data on the demographics of COVID-infected individuals as well as wider availability of testing for viral infection are needed to confirm and mitigate any disparate impact.

The full extent of the economic and other impacts from the coronavirus are still uncertain but may likely mirror the population distribution of the human health aspects of this tragedy once better documented.

Even though pandemic-related preparation and planning have regularly occurred in U.S. public health circles since the 1918 Influenza Pandemic, interventions accepted as public health standards historically lack scope and vision when applied to vulnerable racial-ethnic minorities. Plans to address public health emergencies like an epidemic may be drafted and possibly rehearsed for the general public but seldomly geared toward the complexity of needs and barriers for specific populations. Nor do comprehensive plans, preparations or budgetary set asides when implemented transfer well between government administrations, whether they be Congressional, Presidential, state-level, county-level or local governmental transitions even in the presence of admirable leadership in this area.

Prior to these recent efforts, highly concerning to us was that even through 2017 the HHS National Pandemic Influenza Plans developed to prevent, control and mitigate the effects of influenza viruses fails to provide strategies for limiting or eliminating racial and ethnic disparities in vaccination, treatment access or contact tracing, although it does call for attention to vulnerable and at-risk individuals.¹⁷ If not already done so by the time of this article, that plan may need to be revisited and updated with the language of concern and guidance around reaching vulnerable racial-ethnic minority groups that is reflected in current funding HHS efforts.

Now that we are beginning to observe federal agencies more readily heeding the plight of vulnerable groups and populations under the current crisis, we hope that these historic interventions, if proven effective, can be made permanent within policy, practice and funding as they relate to racial and ethnic minorities.

In early April, the U.S. Department of Health and Human Services (HHS), through the Health Resources and Services Administration (HRSA) awarded $1.3 billion to federally qualified health centers (FQHCs) to support their ability to detect, prevent, diagnose, and treat COVID-19 as well as maintain or increase health center capacity and staff.