It has been several months since I saw my first patient with COVID-19. In my mind’s eye, I still picture this child vividly: putting on a brave face, struggling to hide her terror. The child’s expression was forcedly neutral, but the fear was as evident as the fast breathing, the racing heart and the uncertainty about what was coming next.
It was around that time that we pediatricians began to hear stories of children’s bodies wracked by runaway inflammation, a syndrome now known as MIS-C. Thankfully my patient survived, but more and more children with COVID-19 are now appearing at Hawaii’s hospitals.
While young bodies seem best able to defeat the virus, they are not immune. Children around the world have died from COVID-19 — and many more have suffered the devastation of losing parents, grandparents, teachers, friends and mentors. Even here in Hawaii, where to my knowledge no children have died yet, I see the virus causing deprivation, uncertainty, and loss.
By now the majority of Americans recognize this disease for what it is: a massive health crisis that threatens our families and communities while crushing many of us economically. My colleagues in Hawaii who are caring for adults with COVID-19 are filled with compassion and resolve but are also exhausted and facing fears of their own.
We health care workers have developed coping strategies, whether it’s eating too much or too little, working out more or not enough, and, above all, exercising a caution that would have seemed insane a few months ago. We bag shoes and scrubs in garages and on doorsteps, rushing through our houses naked, anxious to shower before touching anything or anyone.
While Hawaii has not been hit the way Northern Italy, New York or Houston were, and hopefully never will be, we doctors and nurses lie awake at night worrying about our patients, our children and our elderly parents, hoping we will not join the ranks of the thousands of healthcare workers who have lost their lives to COVID-19 since the pandemic began.
As if all that is not bad enough, there’s more. Across the United States and here in the islands we are confronted with an overlapping and urgent threat to health and wellbeing: racism and prejudice.
People sit outside the Institute of Human Services located on Sumner street during the COVID-19 pandemic.
Cory Lum/Civil Beat
As a physician with a longstanding interest in health equity, I have read dozens of studies showing that minority patients have worse outcomes than white patients and that implicit bias affects patient care in all kinds of ways. As a physician, I have witnessed several occasions where other physicians have labeled patients “noncompliant” simply because those patients didn’t understand — and therefore couldn’t follow — instructions given in English.
I have seen patients who speak up and patients hesitant to advocate for themselves when trying to navigate a system that at times minimizes their needs and abilities or treats them as less than capable of being responsible for themselves. These are patients dealing with pre-existing social conditions: lower rates of health insurance, overcrowded housing conditions, less-than-living-wage jobs.
COVID-19 has unmasked the public health crisis of institutionalized racism that for too long has gone unchecked and unremedied. Minorities, be they Black, Indigenous, Hispanic or other, are contracting the disease in far greater numbers and dying at significantly higher rates than white Americans.
Pacific Islanders are three times as likely to die from COVID-19 as whites, and many in the Pacific Islander community in Hawaii are particularly vulnerable: They make up 4% of the population and now account for 30% of COVID-19 cases. My patients feel exposed, anxious and, in some cases, targeted for their ethnicity even while they are fearful of COVID-19 and unsure of the resources available to them. In order to mitigate that fear and lessen the danger that vulnerable populations are facing, the needs of everyone must be met equally.
Public health interventions, such as mandatory masking and limitations on gatherings must be enforced in a fair and consistent manner. It should start with police officers, firefighters, construction workers, city and state employees and others in the public eye themselves setting an example and masking up consistently.
I was deeply concerned last week when I saw an unmasked police officer in Waikiki, apparently writing a citation to people who were standing no more than 3 feet away from him. He had no answer to offer me when I rolled down my window to ask where his mask was.
Marshallese Community Members volunteer at a health and wellness community drive and COVID-19 testing site.
Courtesy
We know that earlier this year the Honolulu Police Department disproportionately targeted minority communities for enforcement of the stay-at-home order, and there is understandable concern that disproportionate rates of citation and arrest will continue. With COVID-19 now rampant in the Oahu Community Correctional Center and possibly other facilities, arrests should be reserved for rare cases when public safety cannot be achieved any other way.
A family member’s arrest puts the kids I care for — many of whom are already at higher risk of losing a family member because of social inequities — even more in harm’s way. And many people who get citations simply don’t have the money to pay the fines. They should be given community service — ideally focused on efforts to fight COVID-19 in the community — to work them off.
The primary tools to control disease should be education and support, in collaboration with Native Hawaiian and Pacific Islander community organizations, such as papaolalokahi.org and We are Oceania.
Some positive steps are being taken. I am encouraged to hear that masks and hand sanitizer are being distributed among some of our hardest-hit communities and that contact tracing capacity is expanding, including a plan to hire contact tracers from Pacific Island communities, as suggested by (among others) this professor of social work.
This upheaval gives us a chance to create fundamental change, too.
A limited number of hotel rooms are now available for those who need to isolate from crowded living situations due to COVID-19, although access needs to be expanded and the process streamlined. Aloha United Way, though under great stress due to the demand for its services, helps anyone who calls 211 to find emergency food resources, apply for up to $2,000 per month from the Household Hardship Relief Fund, and get connected to numerous other resources.
As a physician who every day sees the effects of disparities, I believe that we must seek additional ways to provide financial and logistical support to those affected by infection or quarantine. Huge amounts of federal money have been funneled into the state through the CARES Act. The resources are there. The political will needs to be, too.
This includes adequately funding delivery of food and essentials for mothers with young children, kupuna, people with disabilities and others who should avoid going out. Agencies are now stretched too thin. The Healthy Mothers Healthy Babies Coalition of Hawaii, for example, states that they currently have a waiting list for their doorstep food deliveries for postpartum moms.
Even as we work to restore Medicaid eligibility for citizens of Palau, the Marshall Islands and the Federated States of Micronesia, the immediate need is to cover medical costs for the uninsured who require hospitalization due to COVID-19. Hospital bills for a prolonged stay for COVID-19 can easily run into the tens of thousands of dollars or more. Most hospitals have financial assistance programs for patients who cannot pay, but government funding will be required to cover the majority of those bills. Nobody should have to risk their life staying home due to concern about cost when they require care.
We should also be creating culturally sensitive PSAs with compelling stories about COVID-19 — in multiple languages — to spread knowledge and understanding without making anyone feel targeted. Outdated educational materials, such as those that do not adequately emphasize masking and physical distancing, should be updated and distributed widely. Knowledge is a form of power when it comes to COVID-19, and it is a power that can and should be made available to all of us.
In the months ahead, I know I will care for more babies and children infected and affected by COVID-19. I know their demographics will reflect the unjust demographics of the disease.
But this upheaval gives us a chance to create fundamental change, too. If we can achieve a truly inclusive approach to fighting this disease, if we can truly collaborate to remove obstacles to equity and provide adequate resources to everyone in our community, we will be taking a sizable step on our way to the healthier and more just future that those babies and children deserve.
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