Q&A: COVID-19 Underscores Decades of Systemic Racism, From Navajo Nation To New England

Across the U.S., COVID-19 has disproportionately affected Black, Indigenous and Latinx communities and underlined longstanding health disparities in communities of color—disparities rooted in centuries of systemic racism.

Partners In Health sat down with Thomas Sequist to discuss a recent piece he wrote for the New England Journal of Medicine that examines the impact of COVID-19 on the Navajo Nation and Chelsea, Massachusetts.

In the Navajo Nation, PIH partners with Community Outreach and Patient Empowerment (COPE) to support COVID-19 efforts, a food sovereignty program, cancer care and community health workers. In Massachusetts, PIH leads a statewide contact tracing effort in partnership with state and local boards of health.

Sequist is Chief Patient Experience and Equity Officer for Mass General Brigham, a health network that includes 14 hospitals, including Brigham and Women’s Hospital, which is a leading partner of COPE. Sequist also serves on COPE’s board of directors.

PIH: Thank you so much for taking the time to chat today.  In your piece, you draw parallels between communities of color in two disparate locations—the Navajo Nation and Chelsea, Massachusetts— and their experiences with COVID-19. What led you to make this comparison?

Sequist: So I had, going back to March, been having experiences with both of those communities. The first was immediately within Chelsea—that is one of the communities that we serve in our health system at Mass General Brigham and we, early on, were seeing a very high occurrence of COVID infections for patients showing up at our hospitals who were really sick and patients who lived in Chelsea. I think shortly after that there was the increase in COVID infections among the Navajo Nation. In my role at Brigham and Women's Hospital, where we have a volunteerism and collaboration program with the Navajo area Indian Health Service, on one of the couple of the hospitals on the Navajo reservation—we started partnering with them as well to try to help address any needs that they were having around the outbreak.

And a lot of what struck me in these two interactions is—and I should say for Mass General Brigham, the reason I was so involved with Chelsea is just one of my operational roles was to help lead clinical operations for our COVID response across the system and so, in that, I ended up working and thinking a lot about the outbreak in Chelsea—my initial thoughts after several weeks of experiencing two very different communities, the Navajo nation and Chelsea, is that there are certainly some things that are very, very different between these communities. But a lot of what we were seeing was quite similar in terms of the poverty and the poor health outcomes in these communities that are really linked to structural racism.

PIH: You mentioned in your piece that many people in Navajo Nation lack clean running water, electricity, phone service. In your current role, how do you take these challenges into account? How do you weave equity into the fabric of the pandemic response?

 

Our role, from Brigham and Women's Hospital with the Navajo Nation, was really a very supportive role. So we're definitely not leading any of their pandemic responses. And our goal was, from thousands of miles away, what are the ways that we can support them? And we did it in a variety of different ways. Some of it was purely supply based—personal protective equipment, cleaning supplies, that sort of thing. The other was sort of content knowledge—helping them provide more expertise around critical care management for these patients, having clinical folks actually go out to the Navajo Nation and to the Northern Navajo Medical Center, the hospital in Shiprock, New Mexico, to actually provide care. A good example of that is our nursing staff that have a lot of expertise in critical care actually going out there and helping them in that space. We really tried to sort of bridge whatever gaps we thought they had identified that we could be helpful with.

But to your larger question—how do you address a pandemic in the setting of a place that has experienced decades and centuries of structural racism? That is the real challenge. And I guess what I would say is that the pandemic itself is new, but the issues that it's raising are certainly not new. Many of these communities across the country are simply not equipped to be able to respond to such a global pandemic.

PIH: Yeah. And as we examine why clinical outcomes have been so poor in communities of color, in your piece you urge us to look beyond comorbidities such as diabetes or heart failure and, instead, address the root cause—systemic racism—which can come in the form of food deserts or limited access to health care. What do you wish more public health professionals understood about how poor health outcomes in communities of color are linked to our societal structure?

The thing that I would emphasize the most is that we often jump way too quickly to the conclusion that the circumstances that an individual finds themselves in related to their health are result of poor choices—poor life choices, or decisions that they have made. And what I was really trying to emphasize is that that is not true. That that is not the case. That many times what you perceive as being a choice really wasn't a choice for that person.

So if we think about food deserts or food swamps, you may say, ‘they're making a bad choice in terms of their food.’ Well, if that's the only food option that's either physically available—if you're in a food desert, in a rural area where healthy food supplies may not be available—or in places where there are food options available, but they're all bad food options—like a food swamp—we just have to really recognize that that's not a choice that those individuals are making. And then when you don't have a healthy food supply or you don't have the ability to exercise regularly, because you have to work two jobs to make enough money to survive, because you're a low-wage income earner, it is not their choice that they are choosing not to exercise. And so all of these things, when you put them together, then can lead to chronic disease and to diabetes, and then those illnesses coexisting with an illness like COVID increase your chance of having a poor health outcome.

And what I would really strongly suggest that we all think about is to say, it was really not a choice for them to have this risk for diabetes and really all of this can be traced back to the same set of circumstances around poverty, education, income opportunities, employment opportunities, and many other things that exist in these communities.

PIH: Right. I feel like the conversation in public health has evolved and we're talking so much more about the root causes and there's so much to unpack even within your piece. Were there topics that you didn't have time or space to address in the piece? What are some things we should be discussing more?

I think a couple of things are important. We have to make major investments in core infrastructure and the capacity of these communities to prosper if we're really going to address public health. Otherwise I fear that we are going to be putting band-aids on a very large problem and ultimately they won't be successful.

So we can develop programs that, when individuals have food insecurity, we can try to work on food pantries—and I'm not suggesting that we should not do that—but what we really need to understand is, why is there food insecurity and how do we address that? We can work on issues of trying to create health navigators and other functions and community health workers that increase access to care, but what we really have to think about is, why are there challenges in access to care? A lot of these things get to the core infrastructure and economic prosperity of these communities.

And so as public health experts, we have to really start to drill down and be open about and be comfortable with talking about that structural racism that has existed for years. Why is it the technologies like cell phone and broadband and internet access, why do those things lag behind in these communities? And we may feel initially—well, it's more expensive and if you're in a remote, rural area, it's harder and will be more costly per individual to have this type of technology available. But then when you meet a global pandemic, we shouldn't be surprised when these individuals can’t take advantage of using virtual health technology, Zoom, when these communities suffer from a lack of communication capacity.

The same is true about employment opportunities. If we don't have employment opportunities in these communities, how do we expect there to be a long-term sustained solution to food insecurity? There are so many things that I think, if we don't address these very large and expensive infrastructure issues, I fear that many of our other public health interventions are not going to be a sustainable, but also not going to be as effective as we would hope them to be.

PIH: Thank you for bringing that up. On the sustainability piece, how do you think COPE’s years of working with the Navajo Nation has helped lay the groundwork for the COVID response?

Well, I think that they were able to contribute in a really important role, ranging from being able to help with coordination of testing to contact tracing. I think there's a really valuable role for these kinds of community and clinical partnerships.

PIH: Looking ahead, what are your goals as you continue your day-to-day work in the fight against COVID, and as you strategize to prevent another surge of cases?

One of the things we're actively working on in the Boston area is we have a more robust tracking system available to identify when hotspots may be occurring. We are clearly, in the Boston area, seeing a hotspot occurring in Lynn, Massachusetts. Right now our efforts are engaged in trying to prevent recurrence, trying prevent a second surge.

We have targeted outreach programs to all of our communities that represented hotspots during the first surge in March, where we really are encouraging the basics. Wear a mask, wash your hands, keep socially distanced as much as possible. And getting that message out in targeted media outlets—social media and radio and other places which have deeper penetration into these communities. We're also having community-based spokespeople create communication messages for us, video communications and otherwise, and really stressing these messages. Please wear mask, please wash your hands, please socially distance. This is the way we will keep the infection down.