When Your Race Is a Comorbidity, COVID-19 Sheds Light
By Hadiya Green Guerrero, PT, DPT
I am writing this blog as a proud native of the COVID-19 epicenter — New York City. I also am a black New York native who is a health professional who now lives in the District of Columbia, one of the next projected hotspots for COVID-19. Every week, whether I know the family member or not, I am being called and told someone died or is hospitalized secondary to COVID-19.
The concepts and thoughts I share are not novel but may be new to some.
If you watch the news or browse the internet, you probably have seen recent headlines on racial disparities in the incidence and fatality rates of COVID-19:
According to a just-released report from the Centers for Disease Control and Prevention, while 18% of coronavirus patients were black, this group accounted for 33% of those hospitalized for COVID-19. (For the purposes of this blog the racial descriptions black and African American will be used interchangeably to describe people in the United States who are of African descent, depending on the terminology used by the source of the information.) The effects of COVID-19 are compounded by existing racial health disparities found disproportionately in the black community, such as heart disease, hypertension, diabetes, and asthma. For instance, a 2010 report showed that African Americans were 30% more likely than whites to die prematurely from heart disease, and African American men are twice as likely as whites to die prematurely from stroke.
Unfortunately, this type of media attention often leads to inaccurate conclusions regarding the causes of such disparities. I would like to dispel some myths and inspire the physical therapy profession to consider these factors as we endeavor to transform all of society and assist COVID-19 patients in their recovery.
The space for this blog is too short for the history lessons on injustices that have resulted in marginalization of and discrimination against certain groups of people, many of whom are black. So, why are we seeing differences in the impact on blacks with respect to the new coronavirus? In short, it is due to consistent, systemic, structural, continuous racism that permeates every aspect of what we refer to as civilized, first-world, privileged, American living — including health and health care.
Conversationally, some lay people, and even some in the media, attribute black resistance against following the suggested coronavirus guidelines to their distrust in the health care system that stems from a history of scientific "studies" and procedures, such as the Tuskegee experiment. But ongoing issues such as a lack of access to health care and, subsequently, coronavirus testing, as well as socioeconomic disparities in income and housing, play a large role in health outcomes overall. The current pandemic simply highlights these problems. Hence, we as a country should not act alarmed when this deadly virus wreaks havoc on the African American population.
Decreasing Health Inequity: Dispelling Two Myths
Myth 1: There is something inherently different about black people that leads them to be more susceptible to catching and dying from COVID-19.
The 2001 Human Genome Project states that "two random individuals from any one group are almost as different [genetically] as any two random individuals from the entire world." This means that, genetically, a white person and a black person born in the United States are more genetically alike than two Africans of different tribes.
Rather than genetics, let's consider health inequity: Doing the same for all people does not put them at a level plane. Black people are not immune to getting the virus, but they are more likely to die earlier and be diagnosed with comorbidities — such as heart disease, stroke, and diabetes — that have been strongly linked to a higher likelihood of death in COVID-19 patients. Although these conditions often are avoidable, when one equalizes income, education, and zip code, a black person is still more likely to die earlier and be diagnosed with them. Some researchers suggest that this is largely due to the fact that while the chronic condition of stress can have negative side effects on all persons, unique psychosocial and contextual factors, specifically the common and pervasive exposure to racism and discrimination, creates an additional daily stressor for African Americans, contributing to the incidence of chronic diseases.
Myth 2: Blacks are to blame for why they are dying at more alarming rates than any other group of Americans.
Black people in the U.S. are not dying at the same rate in other countries around the world. And no group of people is at fault for getting sick and dying at higher rates than another. This false narrative moves us away from the realization that we all are inevitably connected, regardless of what continent we live on or what city or rural county we live in. What would be more helpful to mitigating racial health disparities is to include more black people — and other marginalized groups — in the planning of and participation in research and in science education programs. In the absence of both, we remain on a hamster wheel of inadequate or ineffective future treatments and interventions for all.
We Can Act
There are things we, as individuals and as health care providers, can do to get off the hamster wheel of health disparities. Educate yourself on what you need to be healthy, and teach someone else. Educate yourself on what your community needs and follow up with action. Activate yourself in ways you have never done before, and contribute to change. Bring food to older people. Ensure that black people and other people of color have a meaningful voice in discussions and decisions, through elections, hiring, and invitations for participation. Advocate for patients' utmost level of care always.
We need to see more headlines that read: "COVID-19: Investing in black lives and livelihoods." We need to see this because racial health disparity is not a black problem. Raising and tending to the most vulnerable improves everyone's lives, and COVID-19 is shining a bright light on all health care professionals to ignite change. Together.
Hadiya Green Guerrero is senior practice specialist at APTA. A board-certified sports clinical specialist, she participated as a scholar at the National Institute on Minority Health and Health Disparities Translational Health Disparities course in Bethesda, Maryland.
Have an interest in learning more about what roles the physical therapy community can play in mitigating health disparities in the face of COVID-19? On Thursday, April 23, at 2 p.m., APTA will host a Facebook Live Event, "Health Disparities Brought to the Forefront as COVID-19 Spreads: What the Physical Therapy Profession Can Do." Experts in physical therapy and public health to discuss the impact COVID-19 has had on the United States, including how the pandemic interacts with existing geographic, economic, racial, and age-related health disparities. A recording of the event will be available afterwards.
Flexibility in the Face of COVID-19: Lessons From a Rural Washington Critical-Access Hospital
By Amanda A. Chilvers PT, DPT
On the morning of Monday, March 16, the number of COVID-19 cases and deaths was growing exponentially in the state of Washington, where I work at a facility-based outpatient department for a critical-access hospital and rural medical clinic. With initial business closures just beginning, our rehab department was still seeing patients and scheduling new evaluations, albeit very reluctantly. When the stay-at-home recommendations went into effect that afternoon, the flood of cancellations began. As the Rehab Department director, I was struggling with how to have my staff of three physical therapists (myself included), one physical therapist assistant, one occupational therapist, one rehabilitation aide, and two front office coordinators abide by the recommendations to decrease exposure. How were we to keep the six-foot distancing in place during our direct patient care without any PPE other than surgical masks? I faced an ethical dilemma. By asking my staff to continue with outpatient treatments, I risked potentially exposing them and our patients. Was it more harmful to keep the doors open or close them?
Our facility is located in the town of Republic in northeastern Washington, just 26 miles south of the Canadian border. As the only facility within 50 miles in all directions (within the U.S. border), it serves a county with a population of just over 7,500 people. It became very clear, very quickly, that to keep our patients, employees, and small community safe, the best course of action would be to reach out to the hospital administration team and discuss a temporary closure of the rehab department. The motion was 100% supported with little hesitation, even though closing down one of the hospital’s revenue-generating departments would affect the hospital's bottom line. The hospital CFO/COO asked if our team was able and comfortable in taking on additional staffing needs in the lab, clinic, and hospital in response to the COVID-19 crisis.
So, on March 18, the department was closed with hopes of opening back up after the recommended two-week social distancing period. Patients were informed of the actions taking place, department staff members with underlying high-risk factors were sent home (with benefit pay), and our new roles on the frontlines shifted into high gear.
Over the next three days, we were trained as temporary lab technicians at a new drive-up triage unit to assist with direct testing and "running collections," oriented to be greeters and implementers of the new screening procedures now taking place at the hospital and clinic entrances, and placed in the role of helping to handle the influx of patient phone calls with questions about COVID-19 and how to navigate their regular medical care. By Friday, March 20, our staff was relocated to a training room in the administration building and the rehab department was converted into an emergency respiratory isolation clinic.
After the governor declared a state of disaster on March 22, the hospital implemented an Incident Emergency Plan and I was appointed to the role of emergency planning chief and operations deputy for the hospital. As a department director, I have undergone the more detailed FEMA training, but I still felt underprepared for this new territory. However, as I've settled into this new position, I have had quite the variety of "missions." Some of my main projects thus far have been as follows:
- Appointing floating staff members in the labor pool to their needed posts, which vary day to day.
- Laying the groundwork for telehealth services for the rural health clinic to ensure ongoing access to medical providers and visits.
- Assisting the infection control officer with disseminating Centers for Disease Control and Prevention and state guidelines and Action Plan review.
- Assembling a team to identify local businesses and restaurants that are willing and able to help provide meals to hospital employees and isolated COVID-19 patients.
- Working with our public information chief to establish a "volunteer reserve" to help with evolving hospital needs.
- Educating and collaborating with local grocers to implement specific shopping times for seniors and high-risk groups.
- Coordinating with the Search and Rescue Team regarding the logistics of patients entering and exiting the drive-up testing area and isolation respiratory clinic.
- Collaborating with our county commissioners to identify and understand new emergency processes and budget needs.
Nearing the end of the first two weeks of stay-at-home orders, further discussion with the administrative team took place and it was decided to keep the rehab department closed indefinitely in order to best protect and serve our rural community during the COVID-19 situation.
And so here we are today, April 16, still somewhat displaced but extremely productive, industrious, and motivated. While we all miss delivering standard physical therapist interventions, we are excited and driven to start moving into uncharted waters in order to creatively provide patient care during this unique time. We are laying the groundwork and exploring how to provide telerehabilitation services, with the goal of starting e-visits with our current postoperative and acute neuro patients. At this time, the state and individual insurance regulations on payment for telerehab are very gray, and only four commercial insurers allow limited reimbursement for these services when provided by PTs. Until reimbursement rules for telerehab align with demand, or until it is safe to resume providing direct, in-person outpatient care, we will continue to be forward-thinking pioneers in our community and our profession by offering these services pro bono in order to assist our patients in their recovery.
I am extremely proud of the rapid actions, assembling of resources, and preventative work that we — our rehab team and the hospital district as a whole — are accomplishing. We do not regret the decision to step away from our roles as hands-on clinicians, and we collectively have felt supported and valued by our hospital administration. Our rehab team is discovering that we are implementing transferable skill sets, such as strong critical thinking and reasoning, the ability to perform big-picture assessments, and networking through the direct connections that we already have established within our community. Applying similar approaches to those we use to provide progressive physical therapist services has allowed us to be successful leaders, collaborators, and influencers in our new roles out on the frontlines of this pandemic.
Amanda A. Chilvers is the acting emergency planning chief and operations deputy and rehabilitation department director at Ferry County Health in Republic, Washington. She is vestibular rehabilitation and concussion-certified by the American Institute of Balance.
For a different perspective on responding to the COVID-19 pandemic, also read this Defining Moment column being made available in advance of the rest of the May 2020 issue of PT in Motion magazine. Enjoy this published-ahead-of-print article now, and look for the entire May issue around the first of May 2020.
Staying Resilient in a Time of Crisis
By Stephanie DeShano Wakeman, PT, DPT
The physical therapy profession always has focused on the health and wellness of our patients and clients, but we as health care providers must practice what we preach in these stressful times. Around the world, across our country, throughout our communities, but also within our profession, life as we know it has come to a screeching halt. Most of the world's children are not in school. The global economy is faltering. In the United States, physical therapists and physical therapist assistants are among the 13% of unemployed workers — the highest since the Great Depression.
Many PTs who are employed are facing a variety of difficult challenges: Acute care specialists are struggling to provide care in the absence of strong leadership or direction and are overburdened with constant policy changes. Some PTs working in a skilled nursing facility are expected to continue providing services, in patients' rooms, without adequate personal protective equipment. More often, physical therapists are not being used in some way at the frontline of COVID-19. These experiences have left members of our profession and the health system at large with many questions.
The COVID-19 pandemic is a disruptor that is forcing many of us to consider and innovate alternative models of delivering care, such as telehealth. How will we continue to operate and sustain these new delivery models, and how will we measure success and outcomes of said models? What is the landscape going to look like on the other side? These tough questions will need to be tackled not only by our leaders, but through actions by each one of us. So now is the time to listen to each other, help one another, and support all PTs and PTAs in all settings through empathy, advocacy, and action.
APTA's House of Delegates has long recognized the importance of health and wellness in "transforming society" and our role in this space, and the Board of Directors established the Council on Prevention, Health Promotion, and Wellness to promote positive change in society. But to competently deliver this message, we must be able to practice it. During this crisis we can study and apply the principles of wellness into our own daily lives.
Let's first break down the basic building blocks of health prevention and wellness:
Exercise. We are movement experts. This is the perfect time to assess your own fitness level and improve upon it. Test yourself with a simple YMCA step test or Rockport 1-mile walking test. Cardiorespiratory fitness is an indicator of cardiovascular disease and all-cause mortality from noncommunicable diseases. Exercise has been shown to mitigate these risks and have positive effects on anxiety and regulation of stress. The Centers for Disease Control and Prevention guidelines for physical activity for adults is a minimum of 150 minutes of moderate-intensity exercise or 75 minutes of high-intensity exercise per week. Get your sweat on, try some new exercises, and go outside to experience the calming effects of nature.
Sleep. Adults need 7-8 hours of uninterrupted sleep each night to maintain healthy cognition, decrease stress response, maintain healthy metabolism, decrease risk for mood disorders, and decrease central pain sensitization mechanisms. Sleep is behaviorally regulated, so setting a consistent bedtime and turning off electronics 30 minutes beforehand helps to set a rhythm for our bodies to wind down. Avoid caffeine at least 4 hours before bedtime and limit alcohol intake. Caffeine is a stimulant and keeps us awake by blocking the adenosine receptor, and alcohol interferes with the REM stage of sleep.
Connection. We are social creatures. We are in this together and we need each other, now more than ever. In times of crisis, some barriers come down because we may feel more united. Reach out to a colleague, friend, or family member. Think of physical distancing with social connecting. Apps like FaceTime, Google Hangouts, and Zoom allow you to have virtual meetups to connect with others. You could also try some old-fashioned techniques like email or letter writing!
Nutrition. Eating more fruits and vegetables and less sugar and processed foods is simple in theory, but difficult in reality. We tend to snack more when we spend more time at home and during times of stress. We have more time to make and eat comfort food and indulge in celebrating seasonal holidays with more food and fewer family members to share it with. Try to limit the processed stuff and meat consumption, and stock your kitchen with healthy snacks such as nuts and ready-to-eat fruits and veggies.
Resiliency. We must learn to manage stress in a way that helps us become stronger in the end. We have the opportunity to build emotional strength during trying times, especially when all the other elements presented above are put in place. Here is a good resource on five strategies to build resiliency. Reflection, breathwork, and meditation all can help to reduce the sympathetic load that can affect our physical and mental health.
During this time, we can do a lot to advance ourselves personally through self-education and self-awareness by establishing our own healthy habits. We can reach out to others, practice our listening skills, and allow for some stillness to consider how to move forward as a more united, stronger profession.
[Editor's note: For more on this topic, tune in to an APTA Facebook Live event, The Impact of COVID-19 on the Mental Health of the Patient and Clinician, at noon on Thursday, April 16. Experts from physical therapy, psychology, and the Pan American Health Organization will discuss the impact of COVID-19 on mental health and how physical therapists play an important role in the recovery of patients' mental and physical health.]
Stephanie DeShano Wakeman is a longtime member of APTA and is delegate for the New Jersey Chapter. She has over 20 years of experience in multiple settings, but she is focused on orthopedics, wellness and health promotion, and digital physical therapy and telehealth.
Have an interest in prevention and wellness? The Council on Prevention, Health Promotion, and Wellness in Physical Therapy is a community for physical therapists, physical therapist assistants, and students who are interested in incorporating prevention, health promotion, and wellness as an integral aspect of physical therapist practice, as well as in promoting and advocating for healthy lifestyles to reduce the burden of disease and disability on individuals and society.
The Heart of the Storm: I'm a PT in Manhattan. Here's What it's Been Like
By Katie Parrotte, PT, DPT
It seemed to happen nearly overnight. One day my schedule was full and our clinic was bustling, and the next the cancellations came sweeping in. I wrapped up one work week knowing I was receiving a salary, and came in the next to be told my company could no longer pay me my salary, but would give me a set stipend per patient visit I completed. The next week, I was filing for unemployment — something I never imagined I would ever have to do as a health care provider.
I work in Manhattan, which is currently the U.S. epicenter of the COVID-19 pandemic, for a small outpatient orthopedic company. We serve nearby residents of all ages: from school-aged children to elderly patients brought in by home health aides; from the weekend warrior to newly postpartum mothers. With 14 physical therapists working over a span of 13 hours, five days a week, the clinic was humming with activity. However, in a matter of a few weeks this dramatically changed.
As the threat of COVID-19 became more imminent, the owners and clinic directors began taking steps to protect the staff and our patients. Signs were posted educating patients on Centers for Disease Control and Prevention recommendations to prevent the spread of disease, and all patients were required to wash their hands upon entering and prior to leaving the clinic. Each therapist was supplied with nitrile gloves and a container of germicidal disposable wipes for their treatment station, to clean the tables between patients (in addition to the usual changing of linens between patients). A member of our front desk staff began regularly wiping down frequently touched surfaces and door handles throughout the clinic. While the clinic is fortunate to have these supplies, it is unclear how easy it would be to purchase more in the near future.
When the rate of infection began to increase in New York City about two weeks ago, we still did not have masks at our clinic; one of the owners was able to obtain 10 surgical masks, but was having trouble finding more. This is par for the course, as many health care providers, including those “in the trenches” in hospital settings, are unable to get enough of the supplies they need. I have friends in hospital outpatient settings who are facing the same shortages. One friend was told to make a surgical mask last for three days, so she keeps it in a Ziploc bag between her treatment sessions. Another friend has been given one surgical mask for the foreseeable future. If New York City hospitals and hospital-based physical therapy clinics are facing such shortages, it comes as no surprise that private outpatient facilities will also experience shortages, perhaps to an even greater degree.
Aside from limited supplies, the ever-worsening situation in NYC is greatly affecting the financial stability of the clinic. At first, cancellations began to trickle in slowly, starting with older or at-risk populations. However, since the clinic serves as a community clinic, many of our patients are over the age of 65, so the number of cancellations continued to increase. As more businesses closed and New York State put mandates in place restricting the workforce, more patients began cancelling appointments. After the state mandated that 100% of nonessential personnel stay home initially for two weeks, and now until April 15, many patients have canceled their appointments until at least May.
For patients who continue to come into the clinic, the task of pre-screening is a challenge. As a small business, the company does not have technology such as digital temperature readers, nor does the clinic have an isolated area where patients can be screened prior to having contact with other people. To help minimize the sick or exposed patients coming to the clinic, the company lifted all fees for late cancellation of appointments, and therapists relied on patients reporting travel, exposure, or being ill to determine whether an individual should be treated at the clinic.
Nobody was prepared for this, but it feels like a nearly impossible situation for small private practices. Owners and employees alike are forced to make challenging decisions: Stay open and risk exposure? Close your doors and risk never opening them again? If patients are willing, should therapists continue treatment despite increased risk and decreased pay? Can they afford not to? This is all compounded by the constantly changing circumstances and guidelines that we are all struggling to adapt to on –the fly.
Hopefully this pandemic will be on the downswing within the coming weeks, and other areas will not be hit as hard as New York City and New York State have been. However, for those of you in other areas of the country, now is the time for you to start planning and making changes in your practices to help minimize the impact this has on your patients and your businesses, if you haven’t already.
If your clinic is still open, try to get as many supplies as you can, including gloves, surgical masks, and germicidal wipes. If you have not already done so, begin practices of surface disinfecting (including chairs, door handles, and counters) between each patient to help minimize the spread of disease. Cut out as much nonessential spending (both personal and professional) as possible in an effort to save money, for these are uncertain times, and we do not know how long this pandemic will last, how long individual business will be able to remain open or individual employees will be paid. If you have not already, start going through your patient lists and prioritize patients. Is there anyone on your caseload who is truly essential – whose life would be worse off without having physical therapist services during this time, such as patients who recently had surgery or have acute neurologic complaints? On the opposite side of the coin, are there patients who are in the high-risk category for COVID-19 morbidity and mortality who should stay home? If there are patients who absolutely require in-person physical therapist services during this time, take the appropriate steps to ensure that these individuals are otherwise healthy, and use PPE as it is available. However, if it is not critical that a patient receives in-person services, consider transitioning that patient to virtual care.
In light of the current situation in NYC, I believe that engaging our patients via telehealth is the best and the safest way to continue providing care. We as health care providers have a responsibility to continue treating our patients, but to also minimize the risk of exposure for our patients, especially the most vulnerable ones, and for ourselves. With morbidity and mortality numbers continuing to climb in NYC, we must put the safety of the public as a whole over our fear of losing money.
While rules and coverage for telehealth vary by payer and by state, many payers are becoming more lenient in light of the current crisis the country is facing. There are many great resources available on telehealth, including on the APTA website and on many APTA chapter websites. The New York Physical Therapy Association Executive Committee and chapter staff have been working tirelessly to provide PTs and PTAs in our state with the best available information to help us all continue to practice and to advocate for our profession.
This is a challenging time for us all: Our patients are not getting the type of care we are used to providing, clinics are losing money, PTs and PTAs are losing jobs, and more people across the nation continue to get sick. I think the best we can do is be flexible and think outside the box when finding ways we can provide care for our patients. Overall, we should remember that we are #BetterTogether, and we work together to provide the best care, whether it is in person or virtually. If we can do this, I believe that when we get on the other side of this crisis, we will find ourselves stronger and more dynamic, both as individuals and as a profession.
Katie Parrotte, a board-certified orthopaedic clinical specialist, is director of pelvic health and H&D Physical Therapy. She is a director for the Greater New York District on the Board of Directors for the New York Physical Therapy Association.