Meet Ashley; she is a 43-year-old woman with heart disease living in Brookline (an upscale suburban neighborhood of Boston). Over the last 6 months, Ashley has been able to see all of her doctors (including myself) through virtual video visits. Throughout the pandemic, she has not had to step foot into the hospital environment, yet was still provided with all of the necessary resources to manage her condition
Now, I’d like to introduce you to Silvia, a 37-year-old mother of two also suffering from the same heart disease as Ashley. Silvia lives with her family in Chelsea, a town that is just as far away from our hospital as Brookline is, but with markedly different demographics. Unlike Ashley, Silvia has not had the comfort and assurance of virtual visits. Due to her unreliable internet connectivity, Silvia has had to resort to telephone conversations (which are often insufficient) and sometimes even show up in person, despite her concerns of the pandemic.
By way of this pandemic, we have more willingly accepted and implemented the world of virtual healthcare. For clinicians, telemedicine overnight became the best thing since sliced bread. In the midst of the contagion, physicians were able to continue to provide care to their patients in spite of the circumstances keeping us all locked at home. Patients had the opportunity to maintain their necessary care while still limiting their risk of exposure.
But not all patients actually have that privilege. Patients like Silvia had to continuously make trade-offs: does she take care of her chronic condition or does she preferentially avoid the risk of infecting herself and her family with COVID?
The reality is that much of our population faces the same dilemma as Silvia; in fact, approximately half of the US population has slow or unreliable internet connection. In the cardiology practice that I work at, over half the patients were unable to have video visits and had to resort to either telephone calls or in-person visits. Research shows that this proportion of patients is predominantly minority groups as a consequence of their increased likelihood to be either uninsured or covered by public insurance options such as Medicaid. This contributes to a 3-fold less likelihood of being able to connect with their doctor via virtual video visits. Moreover, if patients do not speak English, there was a 5-fold increase in not getting to see their doctor virtually. This inequitable reality constitutes what is known as the Digital Divide.
Digital inequity = Health inequity
The lop-sided damage of this pandemic on the African American, Latinx American and Native American community has exposed the long-standing structural racism that exists within the US healthcare system.
Our society and government were built on ideals that have inherently devalued the lives of minorities. The structural discrepancies — across living standards, education, social inclusion, and much more — remain part of the foundation of this country. It is worth noting that the lingering inequities in healthcare continue to leave our already disenfranchised patients even more vulnerable.
Hospitalization and death rates in these communities have shocked the world and shown us that the system has done little to improve health care access and the quality of care for the disenfranchised. Delayed diagnosis, suboptimal treatment and lack of preventative care measures has existed for too long. Coupled with this insufficient access to care, Black and brown Americans with low median household incomes and living in high density neighborhoods have become the perfect hosts for the COVID-19 virus.
On top of all of this, many individuals from these marginalized groups have co-morbid conditions like high blood pressure, diabetes and heart disease, that make them all the more vulnerable. Moreover, Black and Brown communities fill most of the essential and frontline jobs that cannot be done remotely. This includes healthcare, transportation, food supplies, waste management, etc. With continuous environmental exposure, lack of sufficient care, and the multitude of other social inequities that impact them, minority communities are consistently more vulnerable in the wake of the ongoing pandemic.
The worst part of it is that the system has always tried to explain it away; never tried to fix it. Time and again, behavioral, psychological and cultural issues have been inappropriately propped up as the key reasons for poor health conditions of minorities. And regrettably, there remains an overwhelming ignorance of the everyday actualities that shape the lives of these underserved communities. And now, the Digital Divide only amplifies these deeply rooted inequities.
Why is it Important to Fix?
Firstly, lack of internet access is an important contributor to digital and social isolation. It limits educational opportunities and impedes self-development and wealth generation. All of this contributes to the vicious downward spiral that is etched into the lives of the disenfranchised. This exists not only in rural communities but inner-city and urban areas with limited resources.
Additionally, the need for an in-person clinic visit in a fear-ridden surge environment leads to procrastination in seeking care, consequently suboptimal care delivery and complications that convert an elective care situation to an emergent one. In many situations the disease has progressed to a point of no return. This is the COVID collateral damage.
Importantly, of the many social determinants (e.g., food, housing, transportation, etc.) contributing to poor health and worse outcomes in minority communities, the digital divide has gained the notoriety as a prominent contributor. It is well known that upstream and early interventions in these vulnerable populations can reduce hospitalizations, readmissions, and costs. Consequently, access to high quality digital healthcare can not only improve equitable care, but can also help solve many administrative issues.
So, how do we bridge the divide?
We need to use the pandemic to launch digital initiatives that can help with the immediate provision of care, but also right the wrongs of the past. The journey to ensuring health and digital equity cannot be done with just good intentions and without partners in the community. Every community needs individualized solutions.
i) Measuring the extent of the crisis and then using data to drive behavior change is always the first step. I think we are already in the drive-change mode. We cannot and should not lose the current momentum. Efforts need to be multi-pronged- at the federal, state, municipal, community, hospital, clinician and individual level.
ii) A formidable problem is the lack of broadband connections with high-speed internet access. This is a big challenge to deliver, especially since the internet pipelines are controlled by the corporate goliaths such as Comcast, Verizon and AT& T. They have a for-profit agenda, and a corporate culture with a different set of priorities. This is where federal and state regulation with or without incentives are needed to solve the problem. We need a national intervention to standardize the delivery of care. Like food, water and electricity, internet access should be a human right.
iii) Institutional and hospital efforts at prioritizing and correcting the inequity need to become more than lip service or photo-ops. Incentivizing culture change needs to be a part of the mission, that is fully resourced and accompanied by structured payment models to ensure the durability of the culture change. There can be no ambivalence here and there needs to be support and a mandate from the highest rung of leadership within hospitals. Rather than setting up expensive ambulatory care centers in areas with high-end commercial insurances, putting up healthcare ‘kiosks’ with digital access within the community centers, schools and libraries of disenfranchised communities needs to become a priority.
iv) Setting up hot spots for free Wi-Fi access in multiple locations within rural or inner-city regions to facilitate access to healthcare, education and opportunities for upward social mobility.
v) At the individual clinician level, a continuous feed of metrics to maintain the heightened sensitivity to existing inequities and personal accountability towards individualizing care to mitigate them, are equally important as national policy changes.
We are all connected with one another. COVID-19 has shown us that we cannot separate our health from those around us. If we want to stay healthy, we need to improve the overall health of our society. We need upstream interventions. Interventions that will help address many of the aforementioned social determinants of health and systemic inequities. Without digital equity, we cannot achieve health equity. Let’s use the momentum from the pandemic to bridge this divide with the disenfranchised and do everything in our power to right the wrongs of the past.