COVID-19 & the Widening Health Equity Gap: Increasing Access to Vaccines, Effects on PWID in Puerto Rico, and the Exacerbation of Mental Health Issues Among BIPOC

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On Tuesday, February 8th, 2022, the Center for Ethics Education hosted a Zoom conversation on the topic of “COVID-19 & the Widening Health Equity Gap.” This was the first installment of the Center’s Spring 2022 discussion series on Advancing Health and Social Justice. The three speakers present were Dr. Argentina E. Servin, MD, MPH; Dr. Roberto Abadie, PhD.; and Dr. Celia Fisher, PhD. Servin, Abadie and Fisher engaged in discussion on how the ongoing pandemic has affected the health equity gap, particularly in marginalized populations.  

Argentina E. Servin, MD, MPH
Argentina E. Servin is an Assistant Adjunct Professor at the Division of Infectious Diseases and Global Public Health, Department of Medicine at the University of California, San Diego (UCSD). She also conducts research and participates in the mentorship program at the Universidad Xochicalco. Dr. Servin received both her Medical Degree and her Master’s in Public Health from the Universidad Xochicalco, Baja California campus. She completed the mini residency program at UCSD’s AIDS Education and Training Center (AETC) and a fellowship at the London School of Hygiene and Tropical Medicine. Most of her work focuses on sexual & reproductive health amongst vulnerable populations. She is currently the Principal Investigator for UCSD’s Project 2Vida! COVID-19 Vaccine Intervention Delivery for Adults in Southern California.

Dr. Servin’s talk focused on the results found during her Project 2Vida! COVID-19 research. This research is a multi-level intervention that addresses individual, social, and contextual factors related to the access to, and acceptance of, the COVID-19 vaccine by implementing and assessing a COVID-19 vaccination protocol among Latino and African American (AA) adults (>18 years old) in San Diego. Dr. Servin began her talk by explaining that Latinx and Black Americans have a COVID-19 death rate higher than that of White Americans and Asian Americans. This, amongst other factors, proves that the pandemic has affected such communities at a stronger level. The Project 2Vida! Covid-19 research had two objectives. Its first aim was to evaluate the preliminary impact of 2Vida! compared to the standard-of-care for COVID-19 vaccination services among Latinx and AA adults in San Diego. The second aim was to assess feasibility, acceptability, and intervention effects of 2Vida!. Phase 1 of the study, focused on COVID-19 awareness, community outreach & health promotion, as well as individual health education and linkages to medical services. Phase 2 of the study, focused on providing vaccines at participating pop-up community events at San Ysidro, Lincoln Park and Logan Heights. Controls for this phase of the study were standard-of-care clinic sites. During phase 1, multiple education materials and outreach campaigns were in place. During phase 2, the pop-up community events’ goals were to (1) provide COVID-19 vaccinations, (2) increase access to reliable and accessible information, (3) continue promoting COVID-19 testing, (4) reduce COVID-19 infection rates, and (5) provide additional screening and follow-up referrals for those who faced challenges accessing healthcare during the pandemic.

The preliminary findings of the study showed interesting results. The sociodemographic of the study was: (1) a mean age of 39 years old, (2) low education, (3) low income, (4) more than 50% born in Mexico, (5) 51% female, 46% male, and 3% non-binary, and (6) 92% Latinx, 4% Black American, and 4% other race. Dr. Servin shared that, currently, the study is focused on creating more pop-up community events in communities with a higher Black American population in order to achieve equal representation in the sample size. In terms of employment, 62% of people reported being employed, with most of them working in retail, food service, delivery, housekeeping, construction and landscaping. In terms of medical insurance, the tendency was to have a government funded insurance such as Medicaid. Regarding medical conditions, the most common were obesity (15%), hypertension (13%), asthma (7%), high blood sugar/ diabetes (6%), and mental health illness (6%).

The study also showed that 65% of the population get the vaccine that medical providers recommend taking. Regarding vulnerability factors, 33% reported not having enough money to pay rent, while another 33% reported having no financial issues. Dr. Servin was interested in knowing who the population trusted. This is why one of the questions asked has to do with people’s most common sources of information. The results showed that people were getting their information from the following sources: Health Departments (57%), Health Workers (54%), CDC (54%), WHO (48%) and National COVID-19 Websites (47%). In terms of actually trusting them, however, the results were Health Workers (83%), Health Departments (82%), CDC (80%), WHO (77%) and National COVID-19 Websites (72%). As someone in the medical field, Dr. Servin shared her content about knowing that a large population trusted health workers. This stresses her belief that health workers must be conscious about what they share, how they express themselves, and how they communicate what is happening to their communities. Most people within the study reported having a strong belief that the vaccine can help in reducing the spread of COVID-19. Interestingly, although 86% reported that they would vaccinate their children if the CDC recommended it, and 85% reported that they would vaccinate their children if their provider recommended it, only 65% reported that they would vaccinate their children today[1].

Some of the best practices identified by the study so far state the need to establish a presence in the community, train and equip promotoras to do pre-event on-site outreach, strategically place mobile vaccination sites in places that lack vaccination sites, and partner with community organizations to develop targeted vaccination and education efforts for community engagement sessions. In her closing thoughts, Dr. Servin highlighted that, although the Director of the World Health Organization mentioned that it seemed like we are close to the end of the pandemic, “we do have to be mindful that there are other countries and other individuals who still don’t have access [to proper health services and vaccinations].”

Roberto Abadie, PhD.
Roberto Abadie is a Research Assistant Professor at the Sociology Department, University of Nebraska – Lincoln. He received his PhD in Anthropology from the CUNY Graduate Center. Currently, he is the field ethnographer at REACH where he is in charge of data collection for a study on Social Networks and Risk among People Who Inject Drugs in rural Puerto Rico. He is also the reviewer for the Wenner Gren Foundation for Anthropological Research. His research has appeared in Time Magazine, BBC, Australian Broadcasting Corporation, The Miami Herald, and the Philadelphia Inquirer, among others. Most of his research focuses on issues about class, race, ethnicity and health inequality. More specifically, his work addresses the ethics of clinical trials, HIV risk, People Who Inject Drugs (PWID), and health disparities among Latino populations in a variety of settings in Latin America, the Caribbean, and the US.

Dr. Abadie’s talk, “A Double Whammy: COVID-19 Amid a Fentanyl-related Overdose Epidemic Among PWID in Puerto Rico,” focused on the effects of the pandemic on PWID in Puerto Rico and what can be done. He started by providing some background/context for his talk, including some information about Puerto Rico, which is a former Spanish colony now turned US Territory. Puerto Ricans’ received their citizenship in 1917 after the US needed more men to draft into WWI. The per-capita household income is $20,539 (2019), which is less than half of the poorest US states. The first COVID-19 case was identified on March 2020. The island is still recovering from the 2017 Hurricane Maria, a protracted economy crisis, a fragile health infrastructure, and the same politicization that shaped the US Rural PWID are particularly vulnerable for COVID-19. This is due to a variety of factors, like pre-existing conditions such as respiratory issues (smoking), weakened immune system (HIV/HCV), and increased mortality rates. Another factor is that the need to “hustle” for drug money, drug acquisition, and drug sharing make social distancing difficult. Further, the war on drugs drives incarceration rates for often non-violent crimes, creating overpopulated jails that increase COVID-19 exposure. Additionally, Puerto Rico has substandard health infrastructure and lack of public transportation increases barriers. 

What is very peculiar about Puerto Rico’s situation is that life changing events, such as the Hurricane Maria and the COVID-19 pandemic, have not affected the drug market. Drug quality and pricing did not experience changes. What has changed, however, is the use of such drugs. After Hurricane Maria, Fentanyl-related overdoses skyrocketed. Because of this, many PWID decided to quit Fentanyl out of fear. Though some have entered Medication Assisted Treatments (MAT)—these are not readily accessible for many PWID’s in rural communities. Some of those who have not entered MAT, have switched over to none-fentanyl drugs such as alcohol, benzos, or crack. Long waiting lists for MAT programs increase overdose risk for those unable to secure treatment.

As Dr. Abadie mentioned, the combined effects of the Covid-19 pandemic and the fentanyl epidemic, illustrate how health disparities affect PWID. Social distancing might be difficult between drug users. Furthermore, social distancing contradicts harm reduction measure put in place to prevent overdose deaths. As a solution, Dr. Abadie presents that more resources should be devoted into improving the rural health infrastructures, including MAT. Though MAT did implement some changes during the pandemic, such as increased take-home doses, limiting urine screenings and using telehealth for counseling and consultation, more needs to be done.  However, this changed proved that MATs old hyper-restrictive approach was not necessarily essential but an effect of the war on drugs.  In conclusion, the COVID-19 pandemic in Puerto Rico is layered on top of a pre-existing economic crisis, the devastation of the health infrastructure after Maria, and the arrival of fentanyl. “Epidemics illustrate key aspects of our social organization. In particular, the combined epidemics of COVID-19 and fentanyl-related overdose deaths show how colonialism, poverty, and substance use intersect to increase health risks.”

Celia Fisher, PhD
Celia B. Fisher, PhD, is the Marie Ward Doty University Chair in Ethics, Professor of Psychology and the founding Director of the Fordham University Center for Ethics Education and the NIDA-funded Fordham University HIV/Drug Abuse Prevention Research Ethics Training Institute. She has chaired the Environmental Protection Agency’s Human Studies Review Board, the Department of Health and Human Services Secretary’s Advisory Committee on Human Research Protections (SACHRP) subcommittee on Research Involving Children, the Ethics Code Revision Task Forces for the American Psychological Association, and the Society for Research in Child Development. Dr. Fisher has also been a member of national panels including the National Academies’ Committee on Revisions to the Common Rule for the Protection of Human Subjects in Research in the Behavioral and Social Sciences, NIH Adolescent Brain and Cognitive Development Study, the Data Safety Monitoring Boards for the NIH HEAL Initiative, and the APA/SAMSHA Expert Panel on Ending Conversion Therapy: Supporting and Affirming LGBTQ Youth. Her work focuses on the rights and welfare of under-served populations, with a focus on persons-at-risk or with HIV and drug abuse. Dr. Fisher’s research has been supported by NIDA, NICHD NIAID, NIAAA, NSF, and NIMHD. She also served as the founding director of the Fordham University Doctoral Program in Applied Developmental Psychology and as cofounding editor of the journal Applied Developmental Science. 

Dr. Fisher’s talk, “Mental Health and Racial Justice in the Time of COVID-19,” focused on how COVID-19 affected the mental health of racially marginalized communities in the United States. Racial discrimination affects mental health, depression and anxiety in young adults in different ways. Such can be (1) personal experiences with discrimination, (2) observing discrimination against others, (3) intergenerational trauma in response to old and new forms of Jim Crow, (4) immigration laws, and (5) usurping of tribal land. Lifetime exposure to personal and vicarious discrimination has a cumulative “weathering” effect on mental health among BIPOC adults. Although the pandemic contributed to an exacerbation of mental health issues amongst BIPOC adults, it is important to acknowledge pre-pandemic mental health disparities—BIPOC sought out mental health care at rates below their needs. This was due to (1) lack of mental health services, (2) misdiagnosis and lack of culturally relevant treatment, (3) practitioner bias and discrimination, (4) medical mistrust, and (5) silence and shame associated with mental health in some cultural communities.  During COVID-19, depression and anxiety increased amongst AIAN, Asian, Black and Latinx populations. The American Psychological Association reported that discrimination was a significant source of stress for 41%–48% of BIPOC during COVID-19 (APA 2020). In their own study, Dr. Fisher, Dr. Tao, and Dr. Yip asked: How has discrimination specific to COVID-19 affected the mental health of BIPOC adults?

In April of 2020, they conducted an online survey with 100 participants from 4 racial groups (AIAN, Asian, Latinx, Black) between 18-25 years of age. Regarding demographics, about half of the participants was cisgender females (55%) and the other half was either cisgender male (23%) or another gender minority (22%). Approximately, 28% were a sexual minority and 41% had at least some college education. Regarding region, the study was well rounded, with 30% urban, 45% suburban and 25% rural. 30% of the participants were essential workers, 28% had other professions and 42% were unemployed. In terms of their economic context, 42% made less than 31k and 26% “can’t make ends meet”. Additionally, 42% reported food insecurity. Regarding health disparities, 35% had Pre-existing CDC COVID health risks, 34% suffered prescription insecurity and 19% experienced mistreatment by a healthcare worker that thought they had COVID-19.

During this study, Fisher and Yip created what they call the “Coronavirus Victimization Distress Scale” with the purpose to assess the extent by which participants had experienced verbal and physical threats based on the perception that they had COVID-19. Results showed that 25%–45% reported that they had either been physically, verbally or virtually threatened because of perceived association to the virus. Further, 29% reported that they experienced distress because of such victimization. Fisher and Yip also developed the “Coronavirus Racial Bias Scale,” which purpose was to assess perceived increases in systematic racism due to the COVID-19 pandemic. 81% of participants endorsed at least one item in the scale. The results showed that Coronavirus Racial Bias was highest amongst Asian and Black populations.

There were no group differences in terms of the clinical criterial for depression, which 38% of participants met. However, there were group differences in regards to anxiety. 51% of participants met the clinical criteria for Anxiety (GAD-7) with most of them being AIAN, Latinx or Black rather than Asian. Using Biopsychological Theory, the researchers placed Coronavirus Victimization Distress and Coronavirus Racial bias as 2 of the factors correlated to anxiety and depression. In order to fully test the theory, Fisher and Yip decided to make a structural equation model, which helps identify if Coronavirus victimization distress and increased racial bias added to anxiety and depression over and above health risk, economic risks, etc. They found that depression and anxiety increased when young adults attributed their COVID-19 victimization to coronavirus-fueled systemic racial bias. In conclusion, the researched showed that COVID-19 (1) exacerbated existing financial and health inequities, (2) led to employment becoming a health and social risk factor (3), exposed racial and nativistic national prejudices, (4) led to physical and social media attacks on groups perceived to be infected and (5) precipitated fears amongst BIPOC of increased racial discrimination. All of which, ended up increasing depression and anxiety. Fisher said that the media has presented the COVID-19 pandemic and contemporary systemic racism as “twin” and independent pandemics. Yet, their data suggests that COVID-19 has exacerbated underlying US racial prejudices leading to an increase of verbal and physical attacks on BIPOC, as well as increased public expression of racial bias. Thus, both have interacted synergistically to increase depression and anxiety amongst BIPOC adults. As a solution, mental health treatment must validate the lived experiences of BIPOC patients in a racialized pandemic climate. Practitioners must (1) move away from narrow diagnosis and recognize the effects of social-political climates, (2) discuss the impacts of racialized public reactions with patients, (3) shift from helping patients “cope” with racism to promoting hope, resilience and skills, and (4) empower patients to draw on individual and community strengths to address the forces that fuel racism.

[1] Date when the questions were asked to each individual

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