Socially Distant: Considering Vulnerable Populations Throughout the COVID-19 Pandemic

As global coronavirus disease 2019 (COVID-19) cases continue to increase well into the millions, this pandemic has yielded a swell of uncertainty and immense social and economic disruption and has forced change in a host of daily processes. We still await the global peak, as unemployment claims increase amid rapid government and health care system adaptation. Although each person of our global community is feeling the effect of this pandemic, the socially vulnerable populations, by way of socioeconomic status, age, gender, race/ethnicity, English fluency, and chronic illness or disability, carry the brunt of the burden brought on by disasters (1). This inequity in care and service delivery portends even greater challenges as the economic toll of this pandemic is felt over the coming months to years.

With the swell of ever-changing information both within and beyond institutional boundaries, it can be overwhelming to attempt to remain up to date. With fluctuating resources available to address the uniquely challenging needs of our patients during the pandemic, it is daunting to add one more item to the checklist. However, this pandemic and the current state of the nation have shown that multilevel advocacy remains a powerful tool for us as physicians. The American College of Physicians created a COVID-19 resource page to collate pressing information and lower the barrier of entry for your voice to also be heard (2). The American College of Physicians' particular emphasis on achieving health equity through the pandemic is particularly notable given the disproportional effect COVID-19 is having on minority communities and the co-occurring social justice movement and public health issue of racism in America (3, 4).

As medical residents navigating care provision in both inpatient and underserved outpatient environments, we have seen hospitals rapidly change to focus on care for patients with COVID-19, whereas outpatient practices have largely moved to telehealth services and sparse in-person triage. During the acute phase of this telehealth transition, patients recognized the gravity of this pandemic. Yet, the uncertainty of counseling a patient who is homeless to self-quarantine with his pregnant partner on the street while shelters restructure for social distancing does not sit well as a provider. We worry about the inability to build face-to-face rapport with a patient struggling again with alcohol use disorder in the midst of a new struggle to pay rent. We become weary of listening to tones exclaiming that “the number you have reached is no longer in service” while calling a patient who has been successfully titrating off of chronic opiate use. We wonder whether patients who rely on a health care home will feel even more isolated when screened at the door and asked to schedule a virtual visit if able. These are glimpses into current outpatient struggles for our socially vulnerable patients on top of their high risk for COVID-19 transmission because of challenges with social distancing and hand hygiene. Although communities, cities, states, and the federal government are working to address these needs, access to food, housing, and employment before the pandemic was already challenging—especially for our distressed community members (1). As of 2018, a total of 37.2 million Americans were food insecure (nearly 1 in 10) (5). Moreover, an estimated 2.5-3.5 million Americans annually were already in unstable housing, with the primary causes being unaffordable housing and unemployment (6).

The U.S. Preventive Services Task Force recently published a Position Paper in the Annals of Internal Medicine that not only provides a helpful introduction to the social determinants of health but also highlights their desire to bolster evidence-based screening in the primary care setting (7). This helpful reminder of the myriad of facets that make up a patient’s social determinants of health and emphasis on the intended and unintended consequences of screening must be underscored during this time of crisis. As our patients wade through the months- to years-long wake of the pandemic’s destabilization of their housing, food, social networks, mental health, substance use, and employment opportunities, we as providers should take pointed time to consider how and where we can meaningfully intervene in our clinics.

As we weather the remaining months of the COVID-19 pandemic, we must look forward to the health effects of the coming economic recession, particularly as the increasing rates of unemployment lead to increased housing instability and decreased access to proper nutrition for our distressed and at-risk community members (1). Steps taken with the CARES Act (Coronavirus Aid, Relief, and Economic Security Act) are important, but emboldened supports to sustainable housing first efforts, tenant protections, broadened healthy nutritional assistance, and targeted economic supports to sustain the unemployed and their struggling businesses will be key to long-term success (8). We as health care providers must understand the ever-changing resources available in our communities through institutional and local public health department coordination. We must advocate for increased resource allocation and political support for the growing number of socially vulnerable members of our community. Multiple organizations are taking steps to provide comprehensive national resources for the socially vulnerable, professional societies are advocating for change, health care and lay media are raising their voices on behalf of this community, and a large-scale grassroots movement is mounting (9–14).

We must continue to innovate to address each phase of this pandemic as we move forward toward its long-term consequences. It is our responsibility to know how to counsel the young man on the street, which detox center is still accepting patients, and where to refer our patients for additional support once that ringing telephone picks up. We must work with our interprofessional teams to address our patients’ unstable social determinants of health, create inter-institutional partnerships, leverage community activism, and bring our stories and concerns to elected officials. Health care leaders have stood up during this pandemic. We must continue to stand together for all of our patients to lead this new change, capitalizing on the flexibility and innovation we have all shown to be possible to provide all of our community members with equitable care.
 
References 

1. Centers for Disease Control and Prevention. Planning for an Emergency: Strategies for Identifying and Engaging At-Risk Groups. A Guidance Document for Emergency Managers. 1st ed. CDC; 2015.
2. American College of Physicians. Coronavirus disease 2019 (COVID-19) related advocacy. Accessed on 8 April 2020.
3. Fincher JW. Racial disparities in COVID-19 cases and public release of data. Accessed on 8 April 2020.
4. American College of Physicians. Racial health disparities, prejudice and violence. Accessed on 21 June 2020.
5. U.S. Department of Agriculture. Food security in the U.S. Accessed on 8 April 2020.
6. National Law Center on Homelessness & Poverty. Homelessness in America: overview of data and causes. Accessed on 8 April 2020.
7. Davidson KW, Kemper AR, Doubeni CA, et al. Developing primary care-based recommendations for social determinants of health: methods of the U.S. Preventive Services Task Force. Ann Intern Med. 2020;173:461-467. [PMID: 32658576] doi:10.7326/M20-0730
8. Dell’Aricca G, Mauro P, Spilimbergo A, et al. Economic policies for the COVID-19 war. International Monetary Fund. 1 April 2020. Accessed on 8 April 2020.
9. The Spirit of 1848. Resources: COVID-19 & health justice resource page. Accessed on 8 April 2020.
10. Health Equity Initiative. COVID-19 and health equity resources. Accessed on 8 April 2020.
11. Society of General Internal Medicine. COVID-19 resources. Accessed on 8 April 2020.
12. Tsai J, Wilson M. COVID-19: a potential public health problem for homeless populations. 2020;5:e186-e187. [PMID: 32171054] doi:10.1016/S2468-2667(20)30053-0
13. Oliver L. Coronavirus: a pandemic in the age of inequality. World Economic Forum. Accessed on 8 April 2020.
14. People’s Bailout. By and for the people. Accessed on 8 April 2020.