U.S. Must Avoid Building Racial Bias into COVID-19 Emergency Guidance

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Across the United States, we are seeing alarming statistics about the disproportionate toll of COVID-19 on Latino and black people. In New York City, the New York Times tells us, coronavirus is twice as deadly for these minorities as for their white counterparts. In both Chicago and Louisiana, black patients account for 70% of coronavirus deaths, even though they make up roughly a third of the population.

At Massachusetts General Hospital, where we practice, an estimated 35% to 40% of patients admitted to the hospital with the coronavirus are Latino — that’s a 400% increase over the percentage of patients admitted before the outbreak who were Latino.

In the emergency room, conversations about a patient’s end-of-life wishes are taking place in broken Spanish, seconds before they get intubated. In the intensive care unit, doctors barely have time to update family members, because they’re too bogged down by patient-care tasks to call an interpreter. For patients healthy enough to go home, our usual script around social distancing falls short, as many of our black and Latino patients are unable to self-isolate within large multigenerational households. In addition, many of these patients either are essential workers or live with one — they cannot simply “stay home”.

{snip} Several states and organizations have started to release Crisis Standards of Care guidelines in recent weeks — these are meant to help hospitals ration critical resources like ventilators and intensive care unit beds, if and when the need is dire.

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To determine which patients get priority in treatment, several of the CSCs published so far, such as guidelines from Colorado and Massachusetts, recommend that the hospital use frameworks that include the patient’s age and “SOFA” score (a measure of how critically ill the patient is at arrival, based on objective laboratory values). Importantly, they also include what we doctors call “comorbidities” — other, underlying medical conditions that can put patients who are infected with this virus at a higher risk for worse outcomes.

We know that historically disadvantaged populations — including black and Latino patients — have a higher burden of the comorbidities traditionally used by hospitals to stratify patients by risk. This is largely because of structural and socioeconomic factors. {snip}

Although the foundational principle of Crisis Standards of Care guidelines are utilitarian and aim to benefit the greatest number of people while treating “individual cases fairly,” a system that penalizes on the basis of comorbidities will undoubtedly and unfairly penalize the populations that are already more vulnerable to those conditions.

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COVID-19 is already affecting and killing a disproportionate number of black and Latino patients across the United States. Using comorbidities as a proxy for disease severity to allocate resources, without taking into account race and ethnicity, will almost certainly mean that racial and ethnic minorities will be placed in the “back of the line” for critical care resources.

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