Infectious Diseases and Advocacy: This Is our Lane.

The disparate effects of severe acute respiratory syndrome coronavirus 2 virus on communities of color, paired with disjointed federal and local responses to the pandemic and the ongoing examples of structural racism's effects on health, highlight the need for physician advocacy on behalf of patients. The job of infectious disease physicians has always involved caring for the "whole patient," but the need for advocacy around issues related to racism, housing, food insecurity, substance use disorders, and mental health has increased. Advocacy at all levels-local, regional, and national-can make a difference and be a profoundly rewarding part of the career of an infectious disease/HIV physician.

The coronavirus disease 2019 (COVID-19) pandemic has changed so many aspects of our lives, and as the backdrop for other horrors, it has seemed at times like our society is crumbling. While Black and Brown people die at disproportionate rates from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) [1], they also bear the brunt of the economic destruction COVID-19 has wrought in its wake [2]. Also, this year, the killing of Black people at the hands of police in the United States has caught the attention of people worldwide [3]. Suddenly racist structures that have persisted and been supported for centuries have led to people marching in the streets and demanding change. We lost a visible presence for the rights of women with the death of Justice Ruth Bader Ginsburg. We lost a Civil Rights icon, Congressman John Lewis, a voice of hope for equity and an advocate for “good trouble, necessary trouble” [4]. Science and politics tangled over battles related to hydroxychloroquine, testing of asymptomatic individuals, and convalescent plasma [5-7]. In some towns, cities, and states, the very act of wearing a mask became a statement of political allegiance. A looming election amid the pandemic has heightened tensions and anxiety.

In spite of this, the confluence of crises our nation is facing in 2020 has given me more focus as an infectious diseases and HIV physician. Every day that I see patients in the midst of all this calamity, my drive and mission become clearer. As an ID/HIV physician, I regularly prescribe medications and monitor lab work, but my patients need more, and I am in a position to amplify their voices and share their stories.

I have seen firsthand among my patients with HIV how the pandemic has increased housing and food instability among lower-income adults [8, 9]. Substance use disorder and mental health struggles, always an issue ID/HIV doctors have been attuned to, are more powerful adversaries than ever [10, 11]. With structural racism, xenophobia, homophobia, and transphobia set against the backdrop of the oppression of a global pandemic, my patients already vulnerable to poorer health outcomes need more. Improving the health of our patients means advocating for all aspects of their health, including food, housing, and universal broadband internet and phone service for access to health care and basic education. In addition, we must expand access to mental health care and treatment of substance use disorders. We must end the stigma that impedes the prevention and care of HIV, viral hepatitis, sexually transmitted infections and other infectious diseases, and champion patients’ rights to gender-affirming health care. We must root out and destroy structural racism to ensure that our patients receive equal access and the highest standard of care.

In my state of Tennessee, this means calling on policy-makers to expand Medicaid and extend the moratorium on evictions during the pandemic. Nationally, this means standing up for science, advocating for increased funding for public health and infectious diseases programs, including safety-net programs like the Ryan White Program and federally qualified health care centers, expanding workforce initiatives for ID/HIV providers, and addressing systemic racism as a public health crisis in medicine and in our communities.

The most rewarding aspect of my career so far has been advocating for patients and our profession with the Ryan White Medical Providers coalition, the HIV Medicine Association, and the Infectious Diseases Society of America. It has meant inviting elected officials to visit our HIV clinic. It has meant writing op-eds to my local newspaper defending the Patient Protection and Affordable Care Act, explaining how Medicaid expansion would benefit people with HIV or describing the urgency of an enhanced federal response to COVID-19. It has meant visiting Capitol Hill each year with a group of dedicated colleagues to discuss the importance of funding the Ryan White Program, allowing federal funds to be used for syringe services programs and providing loan repayment to HIV/ID clinicians to address workforce shortages. It has required patience and has meant celebrating advocacy wins and often retooling strategies to advance long-term change. Advocacy work has been the infusion of passion and energy I need anytime my tank runs low.

We live in a society that apportions privilege unequally—a society where privilege and power are dependent upon and circumscribed by race, class, sexual orientation, and gender identity. We as physicians have privilege and a powerful platform. We are uniquely positioned to discuss what is important to improving the health of our communities and to set a course forward as we recover from this pandemic and prepare for the next. To use our platform and privilege is both an obligation and an incredible gift. This gift makes advocates out of all of us.

In 2018, health care providers were criticized when they began to have an active voice in gun control debates, posting pictures of bloody scrubs and trauma rooms, arguing that “this is our lane” [12]. The “lane” for infectious diseases/HIV physicians encompasses this and more. Now more than ever, we need to be attuned to the intersections of health and racism, political policies and climate change, housing, mental health, and substance use disorders. At a time when science is sometimes ignored and even scorned, it is an opportunity for us to take the lead on guiding policy-makers toward evidenced-based policies that will repair the damage that systemic racism and more recently COVID-19 has done to our communities. This means advocating for the whole health of our patients. As John Lewis said, “You only pass this way once; you have to give it all you have.” There is no clearer message during this confusing time. This is our lane—let’s advocate for it.