Protect vulnerable populations and promote health equity

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Melissa Bondy and Bonnie Maldonado discuss overcoming health disparities highlighted by COVID-19

COVID-19 has had a devastating impact across the country, but not all populations have felt its effect equally: Members of the Black and Latinx communities have had a disproportionate number of cases and deaths from COVID-19. Many at Stanford Medicine, including Bonnie Maldonado, MD, senior associate dean of faculty development and diversity and professor of pediatrics and of health research and policy, and Melissa Bondy, PhD, professor and chair of the Department of Epidemiology and Population Health, have dedicated research to understanding inequitable health outcomes, especially in the face of this pandemic. “This pandemic is a real wake-up call for us,” Maldonado says. “Rather than cursing the darkness, we need to light a candle. And we have plenty of candles at Stanford.”

From collecting data to better understanding disease to doing targeted community outreach to forecasting downstream impacts of COVID-19, Maldonado and Bondy have been at the forefront of Stanford Medicine’s pandemic response. Through their work and that of countless other Stanford researchers, they provide hope that the tragedy of the pandemic will serve as an inflection point for the creation of more equitable health care. Below, Maldonado and Bondy discuss how COVID-19 has shaped Stanford Medicine’s understanding of health disparities and how the institution is responding.

What factors led to the inequitable impact of COVID-19, and why have certain populations been more affected?

Bondy: A disproportionate number of children treated for COVID-19 at the Lucile Packard Children’s Hospital Stanford are part of the Latinx community. The COVID-19 pandemic has hit minority communities harder because they have less of an opportunity to distance themselves. Many have essential jobs that prevent them from working from home, or they may live in small quarters and are unable to isolate themselves. Also, there are issues with people not understanding how to protect themselves and their families. We must think locally to ensure that our most vulnerable communities are protected, and as part of that, we must continue to gather data to understand their situations better.

We must think locally to ensure that our most vulnerable communities are protected

Maldonado: We know that those who get sick are extremely likely to be minorities. With COVID-19, the lower the income and the higher the population density, the more likely people will be infected. There may be biological and virologic reasons as well, but finding solutions to those won’t fix the problem as long as you have other disparities.

This virus has democratized disease more than anything else — even more than the influenza pandemic. Anyone who has a disparity or who’s at risk for disease endangers everybody else in the community because even one person can continue to propagate this infection. What we’ve seen is that it’s not just about immunology, biology or epidemiology. Social determinants of health play a critical role. We see over and over that your ZIP code predicts your health outcomes better than your genetic code. This pandemic drove that home. As long as these disparities exist, they’ll inhibit our recovery from this virus and our efforts to improve our population’s overall health.

What has Stanford Medicine learned since the beginning of the COVID-19 pandemic, and how may that change approaches to health care?

Maldonado: We’ve learned a lot from this pandemic. Not enough, but a lot. This pandemic has pulled the veneer off of society’s deficient health care infrastructure. It also has highlighted existing problems and made them worse. Our public health infrastructures are cracking at the seams and have been for a long time. At Stanford Medicine, we talk about Precision Health — predicting, preventing and curing precisely. The prediction and prevention have an enormous impact on health care, but we need to remind people of that. When we’re doing well, we tend to forget why we’re doing well. We were doing well because we have invisible systems supporting us. We took for granted that we were well-resourced. We have started to see that the health care industry and health care systems are only as good as your local, regional and national support for Precision Health initiatives. One institution can’t do it alone.

Bondy: At the beginning of this pandemic, we didn’t have much knowledge on the disease’s epidemiology. Early on, I formed a series of meetings with a number of cancer centers as well as Kaiser to try to see how this pandemic affected people being able to access health care. We saw patients with cancer unable to get screened or to get in for regular treatment. We saw survivors not knowing what they need to do for follow-up. The fact that people weren’t able to get proper health care shows that the system is broken. Early research indicates that this may very well result in a significant shift that causes more cancer deaths because they could not get care when they needed it or were diagnosed at a later stage.

What steps has Stanford Medicine taken to address the inequitable impact of COVID-19?

Bondy: I’ve worked closely with many different groups at Stanford Medicine that are trying to roll out various research projects to understand the inequitable impact of COVID-19 better. Additionally, the Department of Epidemiology and Population Health has established a community outreach and engagement program. Through this, we’ve held town halls in Spanish on social media to understand the most significant issues related to the pandemic impacting the Latinx community. We also have engaged all of the counties in California to build dashboards that pull information together. These efforts — our research, outreach and collaborations — have provided a clearer picture of the problem and steps toward a solution.

Maldonado: Through some of our research projects and community outreach, we have developed relationships with community health centers and clinics who serve under- or uninsured populations to offer education and testing. We are partnering with Bay Area county health departments to provide prevalence and seroepidemiologic data so that they can identify areas of highest infections and with disparities that need to be addressed in the pandemic. We have provided seed grants to faculty members to conduct health disparities research related to COVID-19.

How can learnings from COVID-19 impact how Stanford Medicine addresses health disparities moving forward?

Bondy: To accelerate change, we need access to the right data, which will enable us to develop the right questions. With a pandemic, looking back is the only way for us to know how well we did and how we should move forward. Hindsight is 20/20, and at this point, we’re seeing things through the data we have.

I lived in Houston during Katrina and can still see the faces of the people affected by that hurricane. Now, we’re confronted by COVID-19’s inequitable impact. We’re also witnessing an awakening to racial justice. These factors make it clear that we’re not just fighting the COVID-19 pandemic; we’re fighting the pandemic of systemic racism. We must learn from all that we’re facing now to make real change and prepare for the next pandemic.

Maldonado: Life expectancy and comorbidities are extremely driven by socioeconomic status for just about every disease. In general, this has always been tolerated. The inequitable impact of disease is a societal issue, and I believe that is where Stanford Medicine can address these issues. For example, we can discover differences and map them from an epidemiological perspective. Or, we can conduct research that tracks genetic and epigenetic changes that occur purely as a result of socioeconomic differences. If we do a better job of making those disparities clear, it will create a rising tide that lifts all boats. We would improve our health care systems and our health care status across the board.

A great example is a Stanford program called California Maternal Quality Care Collaborative. It was started in Stanford’s neonatology and obstetrics groups, and it uses basic medical record data from children born in California to measure birth outcomes. Researchers analyze these birth records and identify factors that might be associated with better birth outcomes. By teasing that data apart, you can predict outcomes and determine how to improve the health of newborns. They’ve done the same thing with mothers to understand how to improve maternal health outcomes as well. Not only has this contributed to California having some of the best rates of maternal outcomes in the U.S., but the research also has created a rich database that informs other best practices. This model can be applied to any other disease. These approaches can be straightforward but require awareness of health disparities and resources to conduct these important analyses.

Melissa Bondy, PhD
Professor and Chair of the Department of Epidemiology and Population Health

Yvonne (Bonnie) Maldonado, MD
Senior Associate Dean of Faculty Development and Diversity and Professor of Pediatrics and of Health Research and Policy