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Over a year ago, I wrote an article entitled, “She Has Horrible Pain … Won’t Someone Please Help Us” featured in November 2019 and reprinted again in November 2020. It included my commentary on our collective “pain” navigating the challenging healthcare landscape in providing access to quality pain management and safely prescribing medications, including opioids. Then, the opiate crisis was a key focus in our national attention and forefront on our consciousness. While gravely important still, it seems slight and overshadowed when compared to the gargantuan crises of today. 2020 brought forth an unimaginable year- a global pandemic with growing numbers of sufferers and deaths potentially reaping even more havoc until promising vaccines are widely available, a politically charged presidential election year with serious healthcare implications contributing to varying degrees of anxiety, and also a social reckoning seen in response to the killing of George Floyd and as witnessed in apparent health disparities and inequities, including in the number of COVID-19 deaths impacting everyone, and yet racial and ethnic groups disproportionately. To say 2020 has been quite the year is an understatement!
Imprinted on me in the last few months are the courageous faces of healthcare providers from across the country, who have given so much of themselves despite fears and uncertainty. Many were confronted early in the pandemic by a shortage of PPE and limited knowledge of the virus yet showed up to work as always and delivered on a sworn oath to provide compassionate care, pandemic or not. From necessity, we are increasingly more adept in using virtual platforms for many interactions – patient visits, events, meetings, conferences, and socializing. Dare I say we are now reliant on virtual communication. Despite the virtual constraints, 6 feet buffer zones, facemasks, plexiglass shields, and unintentional biases and fears, decency prevails, and heroes have emerged. As a provider of palliative and hospice services at Catholic Palliative Care Services and Catholic Hospice, I am incredibly proud to be associated with such devoted and compassionate staff. We faced 2020 challenges as a team to meet the needs of our community. Countless times our employees served as a conduit for loved ones to interact, sometimes for the last time, when face to face visitation was limited. This was an unimaginable notion a mere few months ago. Forming a hospice isolation unit, a place for those with COVID-19 to receive exceptional end of life care while providing safe access to loved ones in the last hours of life meant so much to those we served and for our staff too. When battle tested, our team delivered time and time again, and when we lost one of our own, it hurt deeply.
I recognize that I am not the same physician that I was a year ago – before the pandemic, before feeling the weight of responsibility for critical decisions in the face of ambiguity, and before George Floyd’s death. I have adapted by developing a keener awareness for deciphering what I can directly shape and influence and by focusing my energy there, while not obsessing unproductively over what I cannot.
COVID-19 continues to spread across our country and the globe, and it is a dangerous and deadly virus that has taken a tremendous toll on our community and on our healthcare system. On November 22, 2020, the CDC website, www.cdc.gov, informs the United States having 11,843,490 total COVID-19 cases, with 49.8 cases in the last 7 days per 100k, and total deaths of 253,600 as reported since January 21, 2020. When reviewing data, it is also evident that people from racial and ethnic minority groups are at increased risk from getting sick from COVID-19 and dying. When compared to White, Non-Hispanic Persons, CDC surveillance data updated on August 18, 2020 demonstrates that Black or African American, Non-Hispanic persons have 4.7x higher hospitalizations with 2.1x higher deaths, Hispanic or Latino persons have 4.6x higher hospitalization with 1.1x higher deaths, American Indian or Alaska Native, Non-Hispanic persons have 5.3x higher hospitalization and 1.4x higher deaths, and Asian, Non- Hispanic persons have 1.3x higher hospitalization and no increase in deaths. Social determinates of health, those conditions in where we live, work, learn, play, and worship, have historically prevented people of color from having “fair opportunities for economic, physical, and emotional health” per the CDC COVID-19 feature “Health Equity Considerations and Racial and Ethnic Minority Groups” updated July 24, 2020. It addresses factors that contribute to increased risk; discrimination in systems (i.e. healthcare, housing, education, criminal justice, and finance), healthcare access and utilization impacted by distrust that exists for the government and healthcare systems with known historical events of inequities, occupational exposure, gaps in education, income, and wealth, and housing conditions.
When looking at health inequities beyond a COVID-19 lens, strong evidence confirms that compared to whites, ethnic minorities experience greater difficulty with access to health care services, higher rates of mortality, shorter life expectancy, higher rates of chronic disease, lower rates of cancer screening, and higher rates of having a more advanced stage of cancer at the time of diagnosis as described in “Cultural Relevance in End-of-Life Care” by Phyllis R. Coolen featured in Ethnomed in May 2012. Coolen shares information on disparities in the treatment and management of pain at end-of-life for ethnically diverse patients. Factors like limited access to care, to analgesics and opioids, to pain specialists, and language barriers all contribute to disparities. In examining the cancer pain experience, miscommunication between the provider and the patient regarding the patient’s perception and expression of pain can impact ethnic groups disproportionately. For African American and Hispanic patients with recurrent and advanced cancer, pain severity may be significantly underestimated by providers as shown in studies cited by Coolen. Other findings have also demonstrated that minorities were more likely not to receive pain medication or would receive a lower dose of an analgesic, even if the patient had advanced cancer or was receiving end-of-life care. Additionally, underreporting of pain intensity by minority patients can be a significant barrier to effectively managing pain. This information is itself “painful” and illustrates the importance of cultural competency in medicine and the need for intervention strategies to reduce health disparities with a goal of health equity for everyone.
Palliative providers are by sheer nature strong advocates, lending a voice to whole person-centered care. If this last year hasn’t forced us to look deeply within, then I don’t know what will. Perhaps more than ever we need to better understand one another to form and sustain meaningful connections. Increasing awareness, education, resources, and evolving practices will help us to promote fair access to healthcare. 2020 has tested our resiliency, and we are stronger for it. Maya Angelou said, “You can’t really know where you are going until you know where you have been.” If we examine the past with a thoughtful appreciation of the history and with awareness and presence in our daily interactions, then we can enthusiastically look forward to a collaborative spirit in 2021 that connects and enriches us all in consequential ways. While 2020 revealed health inequities in the midst of a pandemic, it also revealed what can be accomplished against tough obstacles. We are equipped with dedicated healthcare professionals and leaders who can advance health equity initiatives to ensure all people have the opportunity for long, healthy lives. The diligent and deliberate actions we take united, the healthier we will all be.
