The same lower income and predominantly minority communities in the South and West sides of Chicago that have the highest density of dialysis units also have the highest numbers of residents testing positive for COVID-19, a recent analysis found (1).
The analysis is part of a growing body of evidence revealing how the health inequities and structural racism that help fuel disproportionately high rates of kidney diseases and other chronic diseases in marginalized communities are also contributing to a disproportionate burden of COVID-19.
“Kidney disease is really just the perfect lens to view health disparities in the United States,” said analysis co-author Holly Mattix-Kramer, MD, MPH, associate professor of public health sciences and medicine at Loyola University in Chicago and National Kidney Foundation (NKF) president. “The COVID-19 epidemic, it just reflects those disparities and then, to compound it, people who have kidney disease are more likely to be hospitalized if they get COVID-19 and more likely to die.”
To manage these intertwined epidemics and their root causes, kidney patients in marginalized communities and their clinicians may need resources that extend beyond traditional kidney care. These include access to accurate information about COVID-19, improved access to healthcare, and COVID-19 testing.
Support in identifying and addressing health inequities during COVID-19 and beyond is also needed from professional societies. The American Society of Nephrology recently testified to the US House of Representatives Committee on Ways and Means on the “Disproportionate Impact of COVID-19 on Communities of Color” and called on Congress to pass legislation to address disparities in healthcare, the Health Equity and Accountability Act of 2020. Additionally, the society issued a statement against racism and signed on to statements against racism issued by the Council of Medical Specialty Societies and the Association of American Medical Colleges.
In August, the ASN Council unanimously approved a plan for how the society and the broader ASN Alliance for Kidney Health can help address systemic racism in nephrology. A key element of this plan is to expand the focus from supporting diversity, equity, and inclusion to confronting health disparities and social determinants of health. “ASN, the ASN Alliance for Kidney Health, and the rest of the kidney community must tackle systemic racism from every perspective,” asserts ASN Executive Vice President Tod Ibrahim.
“Addressing systemic racism is the right thing to do, it’s the smart thing to do, it will make the entire community stronger, and the time is now.”
Disproportionate burdens
(1) Individuals who are Black, Hispanic, Native American, or Pacific Islander already represent half of all patients with kidney failure, according to a recent analysis co-authored by Lilia Cervantes, MD, associate professor of medicine at Denver Health Medical Center and the University of Colorado School of Medicine in Denver
(2). These same populations are also overrepresented among COVID-19 patients.
National data from the US Centers for Disease Control and Prevention show that Native American/Alaska Native, Black, and Hispanic people are about three times more likely than white people to test positive for COVID-19 and are 4.6 to 5.3 times more likely to be hospitalized
(3). Black patients were twice as likely to die as white patients, and American Indian/Alaska Natives were 1.4 times more likely to die.
Data from New York City’s public hospital system also found Black and Hispanic patients had disproportionately higher rates of positive COVID-19 tests, hospitalizations, and deaths
(4). More than one in 10 of those hospitalized with COVID-19 and 15% of those who died had chronic kidney disease.
“It has become increasingly clear that the disproportionate burden of COVID-19 infection, hospitalization, and death among Black people and other people of color is driven by longstanding health and socioeconomic inequities,” said Roopa Kalyanaraman Marcello, MPH, director of research and evaluation in the Office of Population Health at NYC Health + Hospitals. “Systemic racism and inequities in the social determinants of health—employment, income, education, housing, and access to culturally competent healthcare—have resulted in conditions that put these groups at higher risk of infection and adverse outcomes from COVID-19.”
Lower income individuals are more likely to be essential workers, be unable to work from home, to use public transportation, and to live in multigenerational or multifamily housing, increasing the risk of exposure, Cervantes said. Many may not have access to personal protective equipment or may feel unable to advocate for safety precautions in the workplace, she said.
Many individuals in marginalized communities also lack access to COVID-19 testing, health insurance, and healthcare. Lower income workers may not be able to afford co-pays if they do have insurance, said Deidra Crews, MD, ScM, associate vice chair for diversity and inclusion and associate professor of medicine at Johns Hopkins Medicine, during NKF’s Kidneys and COVID-19: Navigating Health Disparities in Minority Communities webcast
(5). They may not be able to take a day off to seek testing or care, she said.
“Some people have to take two or three buses just to get to a healthcare facility so . . . getting tested is almost out of the question,” said Francesca Weaks, MS, DrPH, policy and research manager for the National Association for the Advancement of Colored People, during the webcast. “They are more likely to be frontline workers and go to work sick rather than get a test.”
Individuals in historically underserved communities may be wary of COVID-19 exposure at health facilities or may mistrust healthcare institutions because of previous experiences of discrimination, Crews said. Recent high-profile incidents of racism may further exacerbate Black patients’ distrust of the system and the effects of COVID-19 on Black communities, noted Crews and Tanjala Purnell, MPH, PhD, associate director of Johns Hopkins Urban Health Institute, in a recent commentary
(6). Immigrants, particularly undocumented immigrants, face a unique set of hurdles in accessing care. They are excluded from Medicare, the Affordable Care Act, and most forms of Medicaid, Cervantes said. Those with kidney failure may only be able to access dialysis in an emergency room when they are critically ill and receive coverage through emergency Medicaid, despite such care being associated with higher costs and worse outcomes
(7). “Right now, [undocumented immigrants with kidney failure] are being unnecessarily exposed to COVID-19 because they have to come into an emergency department once a week,” Cerventes said. In addition to the risk to the patient, this exposure may contribute to further community spread and added burdens on emergency department and nephrology clinicians
(8). Undocumented immigrants, who often live in mixed status households, may also be reluctant to seek medical care or testing for COVID-19 or kidney diseases because they are worried about deportation, especially after recent changes were made to the Public Charge Rule. The changes, which were temporarily suspended during the pandemic, have already had a chilling effect on Medicaid participation
(9). “They don’t know if coming in for emergency care will impact their ability to later on change their immigration status,” Cervantes said.
Additionally, misinformation about COVID-19 has been rampant in marginalized communities. “There is a tremendous amount of misinformation,” Crews said. “It is overwhelming and dangerous.”
Proactive and protective policies
Nephrologists may need to reach beyond their traditional toolbox to help patients, argued Mattix-Kramer, including working more closely with social workers to help patients coping with economic and other challenges associated with the pandemic. In addition to addressing pandemic-related fallout, Crews and Purnell also advocated for nephrologists to acknowledge the emotional toll for patients coping with high-profile incidents of racism.
“Nephrologists can support their patients by first acknowledging that these are tremendously difficult times and inviting them to share how they are coping,” Crews said in an e-mail interview. “We can also inquire about any changes in our patients’ abilities to meet basic needs relevant to their health, such as food and shelter. If needs are identified, then we should refer or connect our patients to resources to help them meet these needs.”
John Wagner, MD, MBA, Service Line Lead in Nephrology at NYC Health + Hospitals, also recommended that nephrologists take time to discuss COVID-19 preventive measures with their kidney disease patients. This discussion should include encouraging them to get up to date on vaccinations, including the seasonal influenza vaccine; recommending those starting dialysis to consider home-based options; and encouraging in-center dialysis patients to review and follow protective procedures at their facilities.
Healthcare institutions should also reach out to communities at high risk of COVID-19 and kidney disease to help prevent infections and ensure timely care. Crews suggested institutions and nephrologists work with trusted community leaders or faith leaders to debunk COVID-19 myths and ensure that socially disadvantaged communities have the information and resources they need to stop the spread of the virus. For example, Johns Hopkins Center for Health Equity is partnering with members of its Community Advisory Board to disseminate information about COVID-19; resources for assistance with food, housing and other needs; and support for people coping with the grief, Crews said. The center has used webinars, teleconferences, and its website to share this information
(10). Cervantes and her colleagues have also partnered with community-based organizations in Colorado that are working to reduce the burden of kidney disease among Hispanic patients with diabetes to spread information about COVID-19. She emphasized the need to work with organizations that can provide culturally concordant information in accessible language to the many different immigrant communities in the United States.
“By creating trusting relationships with these communities, you are not only able to facilitate communication about COVID-19, but you’re also welcoming them to the hospital if they get sick,” she said. “Many of these patients wait until they’re too sick from COVID-19 [to go to the hospital]. Treating them earlier or seeing them sooner is better.”
“We are advocating for routine testing of patients who are on dialysis if they live in areas that have a high risk,” said the NKF’s Mattix-Kramer. She explained this may help identify asymptomatic individuals who may pose a risk of infecting fellow patients or other close contacts and ensure that these individuals can self-isolate and are carefully monitored for worsening illness.
Some states are pursuing policy changes to increase healthcare access for marginalized populations, Cervantes said. For example, several states have revised the definition of emergency care to include kidney failure in order to expand coverage for undocumented immigrants. Some states are also providing economic relief to undocumented immigrants who have lost jobs, cannot pay rent, or have been ill who do not qualify for federal aid.
“They realize that it doesn’t make sense to have someone come in [to an emergency department] on a weekly basis from a quality of life perspective or a cost analysis perspective,” she said. “We can only be as healthy as the most vulnerable among us and so if we’re not protecting our undocumented patients, then this virus will continue to spread.”
Greater kidney patient and nephrologist advocacy is needed to support more funding for community outreach to educate high-risk communities about both kidney disease and COVID-19 as well as policies and funding to improve care for kidney patients.
“The nephrology community as a whole really needs to have a much stronger voice politically,” said Mattix-Kramer.
1. Bhayani S, et al Dialysis, COVID-19, poverty, and race in Greater Chicago: An ecological analysis. Kidney Medicine 30 July 2020, doi:10.1016/j.xkme.2020.06.005
2. Novick TK, et al “COVID-19 and kidney disease disparities in the United States.” Advances in Chronic Kidney Disease 2020 doi:10.1053/j.ackd.202.06.005
3. US Centers for Disease Control and Prevention. COVID-19 Hospitalization and Death by Race and Ethnicity. https://www.cdc.gov/coronavirus/2019-ncov/covid-data/investigations-discovery/hospitalization-death-by-race-ethnicity.html
4. Kalyanaraman Marcello R, et al Characteristics and outcomes of COVID-19 patients in New York City’s public hospital system. Preprint. medRxiv. 2020;2020.05.29.20086645. Published 2020 Jun 2. doi:10.1101/2020.05.29.20086645
5. National Kidney Foundation. Kidneys and COVID-19: Navigating Health Disparities in Minority Communities. https://kidney.zoom.us/webinar/register/rec/WN_HaoazmBfRuiRO-MLnV2b5Q?meetingId=uJBENZegqFxOTqf1yR31BKgbXZrbT6a81CBM8vtbnbLbDBF4klDtraLJ3s0fbg0&playId=&action=play&_x_zm_rtaid=nvwOwBSwTumTEji-Ba5-1A.1590680269213.c805579f9e7f372e11754aae1f932be2&_x_zm_rhtaid=489
6. Crews D and Purnell T. COVID-19, racism, and racial disparities in kidney disease: Galvanizing the kidney community response. J Am Soc Neph 2020; 31:8 doi: 10.1681/ASN.2020060809
7. Nguyen OK, et al Association of scheduled vs emergency-only dialysis with health outcomes and costs in undocumented immigrants with end-stage renal disease. JAMA Intern Med 2019; 179:175–183. doi:10.1001/jamainternmed.2018.5866
8. Rizzolo K, et al Dialysis care for undocumented immigrants with kidney failure in the COVID-19 era: Public health implications and policy recommendations. Am J Kidney Dis 2020; 76:255–257. doi:10.1053/j.ajkd.2020.05.001
9. National Conference of State Legislatures. Immigration and Public Charge: Rule Suspended During Pandemic. August 5, 2020. https://www.ncsl.org/research/immigration/immigration-and-public-charge-dhs-proposes-new-definition.aspx
10. Johns Hopkins Center for Health Equity. COVID-19 Resources Page https://www.healthequityhub.com/covid19-resources
11. Longino K and Kramer H. Racial and ethnic disparities, kidney disease, and COVID-19: A call to action” [published online ahead of print, 2020 Jul 21]. Kidney Med 2020 doi:10.1016/j.xkme.2020.07.001
Source: https://www.kidneynews.orgSeptember 2020: Volume 12, Number 9