Amplifying inequity: The compounding impact of COVID-19 and violence.

While "stay-at-home" orders for COVID-19 were in effect, many American cities witnessed a rise in community and interpersonal violence. Our own institution, the largest regional trauma facility and Boston's safety net hospital, saw a paradoxical rise in penetrating violent trauma admissions despite decreases in other hospital admissions, leading to our most violent summer in five years. It has been established that minoritized and marginalized communities have faced the harshest impacts of the pandemic. Our findings suggest that the conditions created by the COVID-19 pandemic have amplified the inequities that exist in communities of color that place them at risk for exposure to violence. The pandemic has served to potentiate the impacts of violence already plaguing the communities and patients we serve.

Opinion

In March 2020, state and local governments in the United States issued “state of emergency”, “stay-at-home”, and “shelter-in-place” orders in an effort to curb the spread of the COVID-19 pandemic. Many hospitals saw steep reductions in both elective and emergent admissions alike. As the region's largest trauma center and safety net hospital, our institution became witness to the pandemic's unequal impact on traumatic injuries.

Despite restrictions, many urban areas have reported persistently high firearm violence and spikes in domestic and intimate partner violence cases during the pandemic. The Boston Police Department has reported a 5% decrease in overall crime but a 29% increase in shootings compared to 2019 and a 34% increase in deadly shootings. The Massachusetts Coalition to Prevent Gun Violence has correlated these increases to the loss of youth programs, employment opportunities, increased economic stress, and overall psychological trauma associated with the ongoing and unrelenting burden of the pandemic. Previous epidemics and environmental emergencies have been associated with domestic and intimate partner violence and studies have proposed that this is due to increased stress, displacement, and remaining in confined spaces for extended periods of time.

While many hospitals reported decreases in trauma during the first wave of COVID-19, our institution observed decreases only in blunt trauma with a continued rise in violent penetrating trauma. The pandemic amplified rather than muted the scourge of interpersonal violence. As compared to 2019, our institution saw an initial 23% decrease in trauma volume in March and April but by July, noted a 33% increase in overall trauma presentations (Fig. 1 ). Additionally, from May through August, we witnessed our highest volume of trauma compared to the past 5 years. When stratified by blunt and penetrating trauma, we saw decreases only in blunt trauma and, most notably, in falls. Penetrating trauma, even during the spring peak of the COVID-19 pandemic, continued to increase (Fig. 1). Additionally, during the months following the declaration of the pandemic, penetrating trauma accounted for a higher proportion of all trauma patients at our institution.

Fig. 1

Changes in overall trauma and penetrating trauma cases in January - September of 2020 compared to the previous year. After an initial decrease at the start of the COVID-19 pandemic, all-cause and penetrating trauma rose to higher levels than the year prior. The horizontal axis represents the studied timeframe in both 2019 and 2020. The vertical axis on the left represents total all-cause trauma case counts. Trends in the overall number of all-cause trauma cases in 2019 is represented with the light gray line and, in 2020, with the black line. The vertical axis on the right represents total penetrating trauma case counts. Trends in number of penetrating trauma cases in 2019 is represented with the light gray bars and, in 2020, with the black bars.

It is unsurprising that COVID-19 infections and firearm violence disproportionately affect marginalized communities of color. Historical discriminatory policies, the effects of which are perpetuated today, created the intergenerational poverty and lack of social mobility that set the common groundwork for both chronic conditions and violence. Our institution historically has cared for the majority of patients presenting with penetrating trauma in Boston and the COVID-19 era has been no exception. According to the Boston Hospitals Violence Collaborative, of the five level one trauma centers in the city, our hospital alone cared for approximately 60% of the penetrating trauma admissions in Boston in the first seven months of 2020. This experience is reflective of a rise in community violence exacerbated by the troubling circumstances of a pandemic disproportionately affecting these minoritized communities. Our institution faces a unique challenge in balancing the fight against COVID-19 and the need to be evermore involved in efforts to combat the plague of community violence; both with etiologies disproportionately imposed on minoritized communities.

The pandemic's harshest impacts have been felt by our most vulnerable patients living in minoritized and socially devalued communities. Entrenched, racist societal processes have led to inequities in housing, employment, education, and healthcare opportunities particularly for Black and brown Americans with resultant intergenerational poverty that has manifested in disproportionately higher rates of COVID-19-related mortality and morbidity in these communities. These same factors lead to higher rates of firearm violence in these areas. While some of the disparities in COVID-related outcomes have been attributed to increased burden of comorbidities in these populations, this explanation fails to completely acknowledge the complex interplay of the social determinants of health, based in discriminatory practices. Poor housing, limited employment opportunities, and food insecurity worsened by the conditions of the pandemic may result in members of minoritized and marginalized communities needing to engage in work that risks exposure to the virus or in activities placing them at higher risk for violent injury. Additionally, for those living in communities impacted by violence, devoting efforts to COVID-related safety measures may be of lower priority. To dismiss the pandemic's role in the rise in violence in our city is to ignore its full impact. Only when we work to ensure the safety of our patients and their communities can we more effectively battle this pandemic.

This rise in penetrating violent trauma carries with it lasting psychosocial impact. For nearly a decade, our trauma service has implemented violence prevention efforts including case management, advocacy, and the provision of free mental health services. With efforts to contain the spread of COVID-19, these services have been harder to deliver during the pandemic. Community outreach efforts have also been strained in attempts to stop the spread of infection. Not only has our institution had to manage higher volumes of trauma during this period, but we have had to take creative approaches to continue our efforts to mitigate its long-term impacts. This included quickly shifting mental health services to telehealth and providing video therapy and support to our patients with every effort made to avoid delays or lags in care. Our engagement required new flexibility as we worked to accommodate the ever-changing needs of patients’ shifts in work schedules, homeschooling, etc. Additionally, we purposefully broadened the focus of these services from addressing solely violent trauma recovery to the added mental health impact of the pandemic and racial trauma. It has become increasingly important to provide such services given the potential for a compounded effect of psychological trauma from violent injury and the current pandemic.

Immediate efforts must be made to address the consequences of continued isolation and reductions in availability of programming. This involves working closely with our Boston Hospital Violence Collaborative (a group of all violence prevention programming from trauma centers across Boston) to promote equitable care for victims of violence across our city, regardless of the center where they receive services. Continued collaboration with city-wide community partners is critical and, in addition to increased outreach in neighborhoods most impacted by violence, efforts have been broadened to address those stressors which have led to disparate impacts of COVID-19 and violence in the communities we serve. Examples include city-wide partnerships to secure resources to address increased food insecurity, providing and promoting COVID-related safety tools including masks, and working to decrease isolation by creating virtual forums of connection and support for COVID and non-COVID-related trauma. In the setting of the COVID-19 pandemic, comprehensive and equitable care requires continued rethinking and reevaluation of those resources we provide to stem community violence in collaboration with government and community partners.

While measures to limit the spread of COVID-19 are admirable and should be encouraged, we must not miss the opportunity to learn from and react to what the virus has revealed to us regarding long-standing racial inequities worsened by increased pressures at home, in the workplace, and societal uncertainty; pressures that have led to the most violent summer our trauma center has experienced in the past five years. Hospital and community-based resources developed to curb violent trauma should be reinforced and strengthened during times of crisis and uncertainty. Most fundamentally, we, as healthcare providers, must act and advocate for structural change and anti-discriminatory policies, as we stand witness to the impacts of COVID-19 that extend far beyond the treatment of respiratory illness.