Bridging the Social Divide in the Pandemic

Halfway through an explanation to a patient I am treating for a suspected case of COVID-19, I realize I don’t know the Spanish term for “sanitizing wipes.”

I’m in my new clinical home base, where Massachusetts General Hospital has cordoned off special care for COVID-19 patients.

There are modular plastic walls and bright fluorescent lights. A few weeks ago, this space was converted from a parking garage for ambulances into a fully functional medical clinic for patients with respiratory illnesses.

The floor still has painted lines to indicate where the ambulances are supposed to park. Drops of motor oil from a leaky ambulance engine have stained the concrete. I’m sitting on a stool in front of a computer on wheels. The only other items in the room are three boxes of rubber gloves, a wall-mounted hand sanitizer dispenser, a floppy disposable stethoscope, and an exam table where my patient is perched, hands on her knees, waiting for me to finish my sentence.

I fill in the blank with “paper towels with Lysol.”

She nods, and we move on.

She almost certainly has COVID-19. She has a high fever and a cough, muscle aches throughout her body, and a sensation of tightness in her chest, like she can’t take a full breath. She also has an important risk factor: She lives in Chelsea, MA.

Chelsea, a community just outside Boston with 40,000 residents, most of whom identify as Hispanic or Latino and many of whom are below the poverty level, has been hit harder by COVID-19 than any other town in Massachusetts. Although it is separated from Boston by just a short bridge across the Mystic River, it nonetheless has an infection rate nearly triple that of Boston.

There has been some speculation that this discrepancy in infection rates is because of biological differences that may place Hispanic people at higher risk of infection.

I favor a simpler explanation—that low socioeconomic status is a risk factor for COVID-19.

My patient had a retail job and was still required to go into work while the pandemic ripped through Massachusetts. Being at work in a retail setting, coming into close contact with many customers per day, put her at higher risk for exposure than people in white collar jobs that can be done from home.

She also lived in a three-bedroom apartment with her husband and kids, parents, and her brother-in-law’s family. Her nephew had been sick with fever for several days. Any of those relatives, and all the people they came into contact with, could potentially have spread the virus to her.

Based on her symptoms and risk factors, I advised her to isolate herself in a room to avoid getting her family members sick. She asked me how she could do that when her nephew was already self-isolating in another room, leaving just one room for 8 other people. The math didn’t work out.

People from lower socioeconomic groups are less able to perform many of the protective measures that reduce the risk of COVID-19. They often don’t have jobs that can be done from home and can’t afford to give up hours. Call in sick day after day, and you might lose your job. They sometimes live in close quarters with large extended family units, making it hard to perform home isolation. And they lack certain amenities that facilitate social distancing. People without laundry machines at home have to use laundromats, for example, which means potentially coming into contact with other people, or touching surfaces that have been touched by many other people.

Lower income patients also have a more difficult time accessing healthcare. They may lack insurance and fear getting a large medical bill. They may not have a primary care doctor. And in the case of immigrants, like many of the people in Chelsea, they may fear deportation if they seek medical help and are discovered to be undocumented. As a result, we have been seeing many patients wait until their illness is severe before seeking care. Sadly, some have died because they sought help too late.

In theory, coronavirus is indifferent to someone’s ethnicity and bank statement. But in practice, social factors play a powerful role in determining a person’s health outcomes. Chelsea, as a low-income community, has felt the consequences of that imbalance during this pandemic.

While all our attention is turned to COVID-19, this is a lesson that applies to drug development in general. Basic science might happen in test tubes, but human disease happens in the real world and is just as complex as human society itself.

Unfortunately, biopharma’s clinical trials have not geared toward the people in greatest need. In a review of 230 oncology trials from 2008 to 2018, for example, only 6.1% of patients were Hispanic and only 3.1% were black—far below national averages for both groups. The result is that our future drugs are being studied in distorted populations that do not represent all the patients who could be treated with those drugs in the future. We are not accurately capturing the biological differences between ethnic groups, but, just as importantly, the social differences between us that affect how we experience disease.

Mass General Hospital and the local government are working together to counteract the disadvantages facing Chelsea during this pandemic. The hospital has given away thousands of ‘quarantine kits’ containing masks, soap, and educational information to residents. A hotel is now accepting COVID-19 patients who cannot effectively quarantine themselves at home. Mass General is undertaking mass testing campaigns to identify cases in the community early. And the hospital has opened the doors of its clinic in Chelsea to everyone who comes in, regardless of whether they have a Mass General doctor.

We’re starting to realize that we need to do more to support vulnerable communities like Chelsea during the COVID-19 pandemic. We should take this lesson and apply it to all aspects of medicine and drug development. People respond to diseases and therapies differently based on socioeconomic factors.  We need to make sure not to leave any groups behind.