COVID-19 unmasks health-care disparities. Tomas Ragina/Shutterstock
As a physician in one of the hot zones for the spread of COVID-19, I am haunted by daily encounters with patients and their families who have to make impossible choices.
One day it was a man who does not have legal residency receiving a positive COVID-19 diagnosis and hearing me order him to stay home. He looked at me like I was giving him a death sentence: “What am I supposed to do about work? Without work I can’t afford food, I can’t afford to stay where I’m staying, I don’t have any family here and I don’t have any family who can help me. I do not know how I will survive without work.”
In addition to not qualifying for unemployment or many social services, he shared fears of seeking out other community resources, such as food banks or the local hotel program, because of his immigration status. This patient’s survival extends beyond his COVID-19 infection; every day is centered on survival.
The next day, I saw a patient in acute respiratory distress, struggling to breathe with COVID-19. I went outside the clinic to speak with his daughter. I told her that he was very ill, that he would likely require a ventilator to help him to breathe, that this was the time to say goodbye.
The daughter, tears streaming down her face, turned to me and asked, “Could I have given him the disease? Is this my fault?” She and her siblings were essential workers in a factory without access to protective gear. The front desk staff and I watched, tears now welling in our eyes, as the daughter quickly embraced her father as he was wheeled to the ambulance, not knowing if she would see him again.
I wish I could say these dire circumstances surprised my fellow physicians and care providers. But these are the fault lines within communities like Chelsea, Massachusetts, the disproportionate suffering all too familiar to our medical staff at Chelsea Urgent Care.
We see every day how our patients are shouldered with health burdens — heart disease, asthma, obesity, diabetes — at much higher rates than the general population in the Boston area. Likewise, they are shouldered with social burdens — uncertain citizenship status that forces people into invisible lives, low-wage work, substandard or overcrowded housing.
Chelsea has a long history as an immigrant community. In recent decades, many families from El Salvador, Honduras and Guatemala have moved in, often living in a single apartment with their extended families — from newborns to great-grandparents — while working as custodians, factory workers, grocery clerks, bus drivers, airport staff. Social distancing is impossible when you live with several people in less than 1,000 square feet. Working from home is not an option for low-wage labor that is essential to keeping even limited economic activity going.
In the first months of the COVID-19 pandemic, Chelsea had the highest rate infection in Massachusetts. Despite having only 40,000 residents, less than 1 percent of the metro Boston population, Chelsea accounted for more than one-fifth of COVID-positive patients admitted to Massachusetts General Hospital. Chelsea and neighboring East Boston combined for 34 percent of the hospitalizations at Mass General — 21 percent, or 182 cases, from Chelsea; 13 percent, or 112 cases, from East Boston, according to the hospital’s data.
In theory, COVID-19 does not discriminate. In practice, it does. The novel coronavirus presents unprecedented challenges, but the intersection of health outcomes and poverty — known as social determinants of health — is not new. At a time when everyone is suffering, it can be hard to recognize the most vulnerable among us and the systemic forces that lead them to contract the virus and face mortal consequences at a higher rate.
Over the next several months, the pandemic surge and its aftershocks will pass, but the structural inequalities, the fault lines that lead to poor health outcomes in communities like Chelsea all across the country, will remain. Unless we act.
This is another voice in the chorus calling for creating a healthier and more just society where all workers, all people, have rights, protections, wages and benefits needed to sustain a life. A society committed to expanding investment in affordable housing to assist with overcrowding, yet also allow for multigenerational family living that sustains culture and community.
Vaccines and testing will not be a panacea. For communities like Chelsea, we need to address the core issues of affordable housing (publicly subsidized as a public health imperative) and robust workers’ rights, including access to personal protective equipment for all essential workers, paid sick leave, access to health insurance, workers comp and a living wage. We need political leadership to prioritize these overdue needs or our social policy will continue to inflict disproportionate suffering on those most in need.
Every day I sit with people on their worst day: adult children bringing sick parents to the clinic, hearing that they will need to be hospitalized, worrying they may not see their mother or father again; young essential workers struggling to breathe, now on oxygen, also heading to the hospital, agonizing over the idea that they may not see their children again. There’s hardly time for the shock to hit — they may die alone in the hospital.
Another COVID-19 patient I treated, a man who works in construction, lives with his family in a one-bedroom, one-bathroom apartment in Chelsea. They were all ill with symptoms of the disease.
We may not be able to palpate the hearts of others, but fear, sadness, grief and guilt have been palpable in the presence of the people bearing the brunt of COVID-19. As physicians and as citizens, it is time for us to heal the fault lines that inflict such damage in communities like Chelsea.
Ailis Tweed-Kent is an internist at the Chelsea Urgent Care clinic at Massachusetts General Hospital. She is also the founder and CEO of Cocoon Biotech Inc., a materials science company focused on silk-based human health and consumer health products.