Addressing health equity during a pandemic.

INTRODUCTION

Structural racism and both explicit and implicit bias lead to poor individual and population health outcomes. , The COVID‐19 pandemic has highlighted and further exacerbated existing racial, ethnic, and socioeconomic inequities within health care and other sectors. , Simultaneously, the maltreatment, brutality, and murders of Black people disproportionately affected by our criminal justice system have heightened national focus and conversation on racism. Amidst these crises, we as residents felt an augmented responsibility to address these issues in creative and impactful ways. Specifically, we aimed to discuss, reflect upon, and develop solutions for the stark inequities we were witnessing during the pandemic and stimulate conversations within our multidisciplinary health care community.

Health Equity Rounds (HER) was our platform to accomplish these goals. HER is a trainee‐led, case‐based, longitudinal, and multidisciplinary grand rounds conference curriculum established in the Departments of Pediatrics at Boston Medical Center (BMC) in 2016 and Boston Children's Hospital (BCH) in 2017. The goal of each HER is to discuss how structural racism and bias contribute to health and health care inequities, engage in self‐reflection, and learn tools to mitigatethe impact of racism and bias on clinical care. HER participants share a communal sense of accountability and vulnerability that allows our institutions to confront our role in participating in and perpetuating a system fraught with racism and inequities. Our group of residents and faculty advisors utilised the HER framework to execute a year‐long educational series across our institutions (BMC and BCH) focused on understanding new and existing health inequities and advancing anti‐racism through the lens of the pandemic.

HEALTH EQUITY ROUNDS: A COVID‐19 SERIES

The presenting team for each session consisted of a group of three to four residents, a senior resident leader, a faculty advisor, and panellists who were institutional experts or community leaders. Each HER was presented via ZOOM® during departmental grand rounds with a multidisciplinary audience of up to 130 participants.

Table 1 outlines the content presented and resources provided in each conference. The most pressing pandemic‐related inequities occurring at the time of each HER informed the topics. The first HER described COVID‐19‐related health disparities and illustrated connections between these disparities and legacies of structural racism. The second occurred during ongoing debate on school reopening and highlighted resultant inequities. The third occurred as vaccine distribution was ramping up and focused on community perspectives and the role of medical distrust in COVID‐19 vaccine deliberation.

TABLE 1

Summary of Health Equity Rounds (HER) conference series on the COVID‐19 pandemic

Conference title, date, and location	Learning objectives	Historical/present day contexts reviewed	Participant engagement tools	Panellists	Resources provided
COVID‐19 Health Equity and Advocacy June 2020 Boston Children's Hospital	‐ Describe the link between structural racism and implicit bias ‐ Correlate pre‐existing socioeconomic disparities in Boston to current disparities in the ability to practice social distancing ‐ Examine racial inequities in COVID‐19 testing and treatment ‐ Evaluate gaps and limitations in data collection to fully understand inequities in the COVID pandemic ‐ Highlight opportunities for advocacy	‐ Racial and ethnic inequities in COVID‐19 cases, testing access, crisis standards of care, and therapeutic trial enrolment ‐ Structural and historical factors contributing to these racial and ethnic inequities, including disparities in housing stemming from redlining and generational wealth, employment type, transportation access, and built environment ‐ Lack of rigorous data collection related to racial and ethnic inequities in COVID‐19	‐ Perspective‐taking exercise (participants asked to actively consider the perspective of patients and families presented in clinical cases)	‐ None	‐ Links to advocacy opportunities for state and national policy changes, including how to identify and contact legislators ‐ Social media advocacy guidelines ‐ Existing resources to address housing and food insecurity
Multisystem Inequities due to School Closures September 2020 Boston Medical Center	‐ Outline the disparate impacts of school closures on children and families in terms of school education and services, food insecurity, and internet access ‐ Highlight recommendations for school opening from the state of Massachusetts, American Academy of Pediatrics, and Centers for Disease Control with a focus on how equity and racial justice is implicated in guidelines	‐ Factors contributing to racial and ethnic educational inequities in the pandemic, including socioeconomic status, access to technology, limited English proficiency, and student disability status‐ History of redlining in Boston leading to “digital redlining” ‐ Impacts of school closures on learning, food security, digital access, and other essential school services ‐ How food insecurity before and during the pandemic was exacerbated by school closures	‐ Perspective‐taking exercise ‐ Participants asked to share de‐identified patient stories and personal experiences and engage in community reflection ‐ Virtual polls	‐ Lead family navigator, BMC Paediatrics ‐ Director, BMC Individualised Education Plan Clinic ‐ Director, BMC Developmental and Behavioural Paediatrics ‐ Social worker, Boston Public Schools (BPS)	‐ Community resources to help advocate for digital equity ‐ Resources to address food insecurity ‐ Resources on school services from BPS
Why Hesitate to Vaccinate? February 2021 Boston Medical Center	‐ Identify concerns patients and community members have expressed regarding the COVID‐19 vaccine ‐ Distinguish different types of vaccine hesitancy ‐ Describe the historical and current contexts that contribute to lack of trust in the medical system ‐ Utilise tools to connect with patients and provide education to inform personal decision making about the COVID‐19 vaccine	‐ Timeline of events that have led to medical distrust (i.e., Tuskegee syphilis study, J. Marion Sims experiments on enslaved Black women) ‐ Examples of medical error contributing to medical distrust (i.e., thalidomide and phocomelia) ‐ Present‐day forces leading to medical distrust among communities of colour including negative encounters with police, perceived discrimination, ongoing trauma, and lack of physician workforce diversity	‐ Perspective taking exercise ‐ Participants asked to share personal concerns and de‐identified stories of conversations with patients and families about the COVID‐19 vaccine	‐ Lead accountable care organisation specialist, BMC ‐ Program coordinator, BMC Pediatric Mobile Health Unit ‐ Assistant Professor, BMC Infectious Diseases	‐ COVID‐19 vaccine communication toolkits ‐ Multilingual vaccine resources ‐ BMC community vaccine sites

REFLECTIONS AND LESSONS LEARNED

Through our experience, we found that issues of health equity can be discussed effectively during a pandemic and that real time issues encountered can be essential learning opportunities for mitigating inequities. Focusing each conference on current pandemic‐related inequities allowed us to engage busy clinical staff in open and honest conversations about how racism and bias were affecting our patients and community. We engaged participants in a compelling and actionable way by using timely, real‐world examples and providing resources that could be immediately utilised, a method that is often not afforded when discussing more theoretical or historical examples of inequities. Furthermore, while the conferences were framed around pandemic‐related problems, we were able to disseminate information on addressing health inequities that could be applied in broader contexts.

Focusing each conference on current pandemic‐related inequities allowed us to engage busy clinical staff in open and honest conversations.

We also discovered several benefits of a virtual platform as compared with our traditional in‐person format for addressing issues and fostering discussion related to health equity. A moderator used the conference live chat and interactive prompts to engage attendees in rich, dynamic conversations about racism and bias, allowing for discussions to start among participants that could continue beyond the allocated conference time. We also provided links to resources and tools through the chat, helping us focus on actionable items that attendees could take away from the conference and use to mitigate inequities. Lastly, the broad reach of the platform promoted the inclusion of participants across the city and country who interface with health equity in different ways, promoting collaboration and increased awareness of the widespread challenges plaguing our health care system and our patients.

CONCLUSION

Adapting an established framework, we facilitated health equity education and dialogue through the lens of COVID‐19 to a large, multidisciplinary, and multi‐institutional audience. We discussed relevant issues in the setting of an evolving medical, political, and social climate and provided a dedicated platform for health care staff to prioritise longitudinal engagement in learning and reflecting on inequities, structural racism, and bias. In future HER iterations, we will carry forward what we learned through presenting this series, including the advantages of focusing on equity issues related to current events, providing relevant and tangible resources, and optimising interactive discussions within a virtual or hybrid platform. This series focused on the COVID‐19 pandemic, but the lessons learned will help us address inequities that existed before and will persist beyond the pandemic through fostering intentional conversations about our practices, systems, and institutions.

We facilitated health equity education and dialogue through the lens of COVID‐19 to a large, multidisciplinary, and multi‐institutional audience.

The lessons learned will help us address inequities that existed before and will persist beyond the pandemic.

CONFLICT OF INTEREST

The authors have no conflicts of interest to disclose.

FUNDING INFORMATION

No financial funding was received for this work.

ETHICAL APPROVAL

This work did not involve any research or data collection conducted on human subjects and therefore did not require the IRB review process.