key: cord-0756080-xxu6zspc
authors: Kountz, David; Rodriguez, Fatima; Vital, Veronica; Vora, Setu; Gough, Ryan; Seyfried, Jessica
title: Could Clinician Sensitivity to Cultural and Historical Considerations Help Reduce COVID-19 Deaths among Blacks?
date: 2021-09-03
journal: South Med J
DOI: 10.14423/smj.0000000000001288
sha: 5a003acb1d31daf666cd12b21bb590ab947a548e
doc_id: 756080
cord_uid: xxu6zspc

nan

D uring the course of the coronavirus disease 2019 pandemic, many magazines and newspapers have published articles reflecting on lessons learned during the crisis. One of the most sobering lessons that data on the pandemic have highlighted is the fractured state of health equity in the United States. The staggering impact of the >600,000 deaths from COVID-19 has been most prominently felt by the Black community, where the rates of infection and mortality are far in excess of those of Whites.

For example, in New York City, COVID-19 deaths disproportionately affect Black Americans (22% of population and 28% of deaths) and in the rest of the state (9% of the population and 18% of deaths), 1 whereas in Chicago specifically, >70% of the deaths occurred among Black residents, although they represent only approximately one-third of the population. 2 More glaring, however, a recent study by the Foundation for AIDS Research (amfAR), the acquired immunodeficiency syndrome (AIDS) research nonprofit, along with epidemiologists and clinicians at four universities and Seattle's Center for Vaccine Innovation and Access, reported that although Blacks represent 13.4% of the population, US counties with higher populations of Blacks account for more than half of all COVID-19 cases and almost 60% of deaths. 3 Various reasons for this egregious reality have been implicated, including individual, structural, and systemic issues. Regardless of the reason, the fact remains that Blacks do not receive the same standard of care as do Whites, and this cuts across various therapeutic areas. In multiple myeloma, for example, disparities in treatment use, access, and referral patterns may be responsible for the inability of Blacks to experience similar survival rates after diagnosis compared with Whites. 4 The literature has pointed to the fact that Black patients receive lower rates of cardiac interventions than do White patients. As examples, Blacks were found to be about half as likely to be referred for cardiothoracic surgery as Whites, 5 and a lower proportion of Black patients compared with White patients received surgical valve replacement although they all met the criteria for the procedure. 6 Also, a 2017 study showed that Blacks more often than Whites receive low-value health services. 7 That Blacks receive a lower level of care quality is particularly troublesome in the context of COVID-19 and may be a contributing factor to the higher rate of death in the Black community. A number of factors may be at play in this dynamic. First is the lack of Black clinicians, which acknowledges that most Blacks are not treated by providers who are of the same race. Blacks made up just under 4% of practicing clinicians, 6% of trainees in graduate medical education, and 7% of medical school graduates, which is far less than the proportion of Blacks in the population. 8 As noted in a recent study, Black men seen by Black doctors agreed to more invasive procedures and preventive services than those seen by non-Black doctors, an effect likely driven by better communication and more trust. 9 A second factor is implicit bias, which may affect the quality of conversations, guidance, and treatment recommendations that clinicians are engaged in with Black patients and their families when dealing with COVID-19. 10 A third may be underrepresentation of Blacks in clinical trials, as demonstrated by the Food and Drug Administration 2019 Drug Trials Snapshot. 11 Inadequate representation of Blacks persists, calling into question the safety and efficacy of new drugs for this group, therefore promulgating disparities in care. 12 The fourth factor may be a lack of understanding of or sensitivity to the daily racism, historical constructs, or cultural underpinnings that may drive Black patients to make decisions or behave in ways that are not aligned with the expectations of their White clinicians. A study conducted by the National Minority Cardiovascular Alliance, an arm of the Make Well Known Foundation, found discordance between clinicians and their Black patients on a number of key factors regarding cardiovascular health. Patients and clinicians both were asked about the importance of cardiovascular health. For 77% of Black patients, compared with all of the important things they face every day, their heart health is considered one of the most important considerations; however, only 23% of clinicians believe their minority patients prioritize it as one of the most important considerations. When Black patients were asked why they delayed needed cardiovascular care or treatment, responses were divided between no transportation (21%), cost of service (16%), distance to doctor (16%), inability to obtain a timely appointment (11%), and inability to get time off from work (5%). When clinicians were asked why their Black patients may delay care or treatment, the overwhelming response was cost of care (70%) (National Minority Cardiovascular Alliance, unpublished survey data, 2019). This discordance is particularly significant in the time of COVID-19, in which timely, appropriate quality of care could be the difference between life and death. In addition, guidelines have been suggested to direct clinicians when resources are scarce, as was experienced at the outset of the pandemic and may occur again with a resurgence of the virus. One of the provided recommendations is consistent with save-the-most-lives principle-that is, save the life of the healthier patient who will be more likely to recover successfully. 13 This, however, provides a challenge for Black patients who do not receive the same quality of care, are perceived as not being appropriately concerned about their health, and are not able to afford suitable health services.

Cultural competence training, when operationalized to reflect both the clinicians' awareness of how culture (values, beliefs, norms) affects patients' health behaviors and how their own culture influences how they interact with their patients, can lead to beneficial consequences. 14 These include satisfaction with care, perceptions of good-quality health care, better adherence to treatments, effective interaction when communicating with healthcare providers, and willingness to seek continued medical care, all leading to improved health outcomes. 14, 15 Incorporating cultural competence training at all levels of health services delivery, can help to meet the gaps in equitable quality and effectiveness of care.

Further exploring this dynamic will be important, including sensitizing and educating clinicians treating Black patients to the historical and cultural differences that may affect health behavior. This requires a different, but more equitable, lens when evaluating the needs and care of this population.

COVID-19: fatalities. https:// covid19tracker.health.ny.gov/views/NYS-COVID19-Tracker/NYSDOHCOVID-19Tracker-Fatalities?%3Aembed=yes&%3Atoolbar=no&%3Atabs=n

Chicago's coronavirus disparity: Black Chicagoans are dying at nearly six times the rate of white residents, data show

Assessing differential impacts of COVID-19 on black communities

Dissecting racial disparities in multiple myeloma

Comparison of frequency of referral to cardiothoracic surgery for aortic valve disease in blacks, Hispanics, and whites

Aortic valve replacement and outcomes in patients with severe aortic stenosis: is it black or white?

For selected services, blacks and Hispanics more likely to receive low-value care than whites

Diversity in medicine: the low levels of black clinicians to provide black on black care is a crime

Does diversity matter for health? Experimental evidence from Oakland

Are clinicians contributing to excess African American COVID-19 deaths? Unbeknownst to them, they may be

US Food & Drug Administration. 2019 Drug Trials Snapshots Summary Report

Increasing diversity in clinical trials: overcoming critical barriers

Fair allocation of scarce medical resources in the time of Covid-19

Health professional cultural competence reduces the psychological and behavioral impact of negative healthcare encounters

Cultural competence in healthcare in the community: a concept analysis