Ravi Kavasery, MD, is the Medical Director of Quality and Population Health, AltaMed Health Services, Los Angeles, CA, Associate Faculty, Department of Global Health and Social Medicine, Brigham and Women’s Hospital, Harvard Medical School
Recently in the midst of closing out patient charts after a busy day in the medical clinic, I received a call from an extremely worried patient. Her brother, who was sleeping on the couch of her cramped two-bedroom apartment in East Los Angeles, had a fever and cough, and just tested positive for COVID-19. My patient – a single mom with serious health problems of her own – had just been discharged from the hospital for a non-COVID lung infection. She already had her hands full caring for her son, who has a developmental disability. She knew her brother needed to be quarantined at home with them—the CDC website says that people sick with COVID-19 should stay in a separate room, even use a separate bathroom—but how could they possibly do that? “Home” was a couch, and even though she was particularly vulnerable to serious complications from COVID-19, their family simply had no other options.
I am the Medical Director of Quality and Population Health for the largest federally qualified health center in the country, serving Los Angeles and Orange Counties. This is the type of problem our patients deal with every day. The “doctor’s orders” we give about social distancing and quarantine are frighteningly difficult to adhere to in the real world for everyone, but the oppressive financial and social circumstances our patients face make adherence almost tragically impossible.
While calls to prepare hospitals and protect our frontline health care workers for a coming wave of COVID-19 cases are critical, I know we must urgently ramp up our efforts to support the full continuum of health care in the community. COVID-19 has laid bare that there is no such thing as individual health in isolation; our individual health is fundamentally interdependent on our public health. If we are to defeat COVID-19, it will require rapid investment in those communities that are often overlooked. Doing so will protect us all.
It is easy to lose sight of the fact that the vast majority of medical care in the U.S. is delivered in our community doctors’ offices. If hospitals are highly monitored environments where patients are given tremendous support and resources to adhere to treatment plans, the same is not true once patients leave the hospital and return to the community. Take California’s “safer at home” order, for example. This is fundamentally a health intervention. And yet, studies show that 34 million workers in the U.S., have no paid sick leave. Among Latino and black workers, that includes more than 50% and 38% of workers, respectively. Studies show that working people without paid sick days are three times more likely to go without medical care for themselves, and 1.5 times more likely to show up to work with contagious illnesses.
The good news about COVID-19 is that many people, even the most vulnerable patients, will recover from the disease, but it would be perverse and counterproductive if people with milder cases continue to spread the disease because the proper safety net systems do not exist to allow them to stay home and follow doctor’s orders. We must immediately begin preparing for housing security, paid sick leave, and affordable access to health care. Without these guarantees, how can we reasonably expect our neighbors and all of society to socially distance, to self-quarantine, and flatten the curve?
It goes far beyond paid sick leave, housing and affordable care, however. Basic preventive care can be difficult for the medically underserved to navigate — with long wait times, arcane rules around specialist referrals and getting a provider on the phone. Studies show that when care is difficult to navigate, people’s health suffers, and they simply don’t get the care that they need. With COVID-19, such barriers to care are simply unacceptable, as they would be a lost opportunity to suppress spread. The good news is that some regulatory barriers have been lifted to allow reimbursement of televisits for Medicaid populations and the exclusion of COVID-19 testing, screening and treatment from the Public Charge rule. These changes foster positive transformation in health care access. I am optimistic about the direction we are going, but we need to be sure these rules will remain in place for the long haul.
Stories of overloaded hospital systems and heroic efforts by providers dominate the headlines. We are fighting a multi-front war, but the battle doesn’t stop in the hospital. While it is imperative to expand our hospital surge capacity and protect our frontline health care workers and support staff, we must not forget about the value of community health. We must follow through and make sure that once patients leave the clinic, emergency room or hospital, they have the supplies they need in order to protect us all.
For my patient in that cramped two-bedroom apartment in East LA, the medicine she needs most are food, shelter, and access to care. Addressing these “social determinants” for her and the millions of people in similar circumstances, might not only reduce the suffering of COVID-19, but also transform American health care in a way that dramatically enhances our ability to support community health going forward.