Vibrant colorful dresses, skirts and shirts in bold floral patterns hang from racks inside Newberry Pacific Trends, a store in Springdale, Ark. But dresses worn for funerals of people from the Marshall Islands community recently sold out, says a saleswoman on a day in mid-August.
The Marshallese community is unusual: They are immigrants to the United States who don’t need a visa, but can’t vote and mostly aren’t eligible for social programs, their status granted because the U.S. used the Marshallese islands for nuclear bomb tests starting from 1946-1958.
But they are similar to other indigenous and minority populations in the United States: They’ve been hit much harder by COVID-19. Out of the Northwest Arkansas’s approximately 12,000 – 15,000 Marshallese inhabitants, 2,000 were infected and 47 died. They are about 3% of the region’s population, but as of June, had suffered 50% of the COVID deaths. By September, the infection rate had been reduced to 15% from 20% in June.
The Marshallese, like many immigrant, Black, brown and indigenous populations across the US, have been experiencing a higher rate of COVID-related deaths than white populations. According an August CDC report, Native Americans and Alaskans have a 1.4 times higher chance of death that white people, while Blacks have a 2.1 times higher chance and it’s 1.1 times higher for Latinos.
There are many factors in the high death rates – the chief one being that people in populations that have historically experienced discrimination are more likely to be in lower-paying jobs, like those at meat-packing plants. There are less obvious barriers to the health care system as well, such as the distrust in a system that experimented on Henrietta Lack’s DNA, or that dropped bombs on Pacific atolls.
The health disparities have long existed. But today’s attempts to work across cultures and ethnicities and to reach underserved populations in the interest of controlling the pandemic may yield innovations that help in COVID-19 pandemic and in the health care system overall. Telehealth, particularly, is seen as a lasting and profound innovation — not only for COVID , but more broadly. If people who have long not had access find their way into the system in greater numbers.
In Kansas City, for instance, an entrepreneur is working on an app that cues up a telemedicine visit after a patient misses an in-person doctor’s appointment.
As more of the underserved find their way into the system, practitioners and insurers within the health care system may be more wiling to listen. A consultant working in Alabama finds herself explaining that $100 prescriptions don’t work for people who bring home $400 a month when a generic version is available; other innovators, recognizing that language could be one of the most powerful barriers and easy-to-solve problems, are making health care information available in rare languages, like those in the Pacific Islander community.
The lack of access to and level of distrust in the U.S. health care system may make it harder to develop and deliver a vaccine. There are signs drugmakers are having a hard time recruiting people of different ethnicities as part of the trials.
Reaching The Marshallese Community
Bringing infection rates down in the Marshallese and LatinX population required extensive health education initiatives communicated on social media and the radio in Marshallese and Spanish, using nurses and physicians from those communities, serial testing and a special populations contact tracing center.
The protocols around quarantining and self-isolating had to be communicated, said Pearl Anna Mcelfish, PhD, the vice chancellor for the NWA region of the University of Arkansas for Medical Sciences. Dr Mcelfish and her team worked with university’s Office of Community Health and local organizations.
“The other part of (quarantine),” adds Dr Mcelfish, “is having the food and housing and other resources to do that successfully.”
These innovations in technology, process and increased understanding may help the underserved populations, as they have been hit the hardest.
When the initial death toll rose drastically in March and April, scores of bio-tech and health-tech companies began adding COVID-19 components to their platforms. These innovations facilitated patient monitoring for hospital staff like the AI digital health company,based in Seattle, KenSci’s Command Center. Other startups are creating solutions for contact tracing, supply chains, and data gathering, among other services.
“The epidemic patterns that we see for COVID really reflect the structural inequalities that we have in our society,” says Latifa Jackson, PhD, an Assistant Professor at Howard University’s College of Medicine. Dr Jackson researches on diversity in data science, algorithm bias, racism and public health, among other subjects and adds, “The fact that that many people who come from traditional, or historically marginalized populations, are in more essential jobs—it’s not by chance.”
In the Marshallese community, the lack of access to Medicaid and Medicare often leads to more comorbidities; going to the doctor is prohibitively expensive for many. Also, the US nuclear testing programs exposed RMI residents to high levels of radiation.
Other common factors among many underserved communities: close living quarters, likelihood of working essential jobs, language barriers and a general mistrust of the health care system. But there are deep-seated fears in many ethnic communities of past horrors that may not be immediately obvious to those who are white. The Tuskegee Study, which began 1932 in Alabama, experimented on Black men to cure Syphilis without their consent. In Baltimore, Henrietta Lacks died and her DNA was used for medical research without her consent while alive. There have been experiments conducted on Black inmates in Philadelphia prisons and in 1989 Arizona State University researchers collected DNA of the Havasupai Tribe for type 2 diabetes research, but used the DNA to study schizophrenia, migration and inbreeding without consent.
“The situation that all of us find ourselves in, no matter what ethnic group you come from, is an accumulation of 400-plus years of either respect or indignities brought upon your people,” says Dr. Jackson, “everything in this society has unwritten rules about who’s who; what power you potentially have.”
Social Entrepreneurs Respond
In Fayetteville, Arkansas, a 20-minute drive south from Newberry Pacific Trends, a University of Arkansas class is in its 10th week. A joint initiative between the university’s Biomedical Engineering department and its Office of Entrepreneurship and Innovation, the class’s goal is to find innovative solutions to help COVID-hit communities in Northwest Arkansas and Bangalore, India. The connection was born because Raj Rao, one of the leaders, hails from Bangalore.
“This is an interdependent world where the well-being of one individual is intrinsically connected with the well-being of the entire ecosystem,” says Rogelio Garcia-Contreras, PhD, one of two professors teaching the class. “We thought that this kind of experience would be very valuable for the students and on top of it, could create innovations that could be implemented in the market.”
Dr Garcia-Contreras is director of the Social Innovation Initiative and Raj Rao, PhD, the co-teacher, heads the Biomedical Engineering Department. Students have listened to multiple guess speakers, currently via Zoom. “They’re getting to hear from clinicians in India,” says Dr Rao, and “clinicians in Northwest Arkansas.” The students are also working with a class of engineering students in Bangalore, Dr Rao’s hometown.
Among the ideas emerging: telehealth, technology that allows hospital beds to adjust remotely, sanitation gadgets using ultraviolet light, and communication or tracking apps, among others. “Not just to use technology,” says Dr. Garcia-Contreras, “also addressing some potential socio-economic issues, cultural issues, as well.”
Many social impact entrepreneurs have created some form of COVID help in a short time. In Pakistan, the AI platform featuring chatbot Raaji, founded by Saba Khalid was originally created to help girls with female health issues, added a COVID-19 section so kids can ask questions in Urdu and English about coronavirus.
In Kenya, Access Afya, founded by Melissa Menke, added COVID-19 resources to its platform that’s used for primary healthcare in the slums of Nairobi. Users are able to book an appointment via telemedicine with a healthcare professional.
The COVID Telehealth Explosion
Most experts, from Silicon Valley analysts to healthcare workers on the ground working in underserved communities, believe telehealth is here to stay.
Shelly Cooper, PhD in Kansas City, Kansas, and Iris P. Frye in northern Alabama, have businesses that focus on medical care for underserved Black communities, the population with the highest COVID death rate.
Based on CDC data from 148,419 deaths, Blacks suffered about 20% of the US’s COVID deaths, despite being approximately 13% of the population according to the last census data; whites suffered 52% of the COVID deaths and comprise 73% of the US population. (Note: only 82% of the ethnicities of the 148,419 COVID deaths in the CDC data is known, leaving room for error).
Cooper who has a PhD, is the founder of Diversity Telehealth, which launched in 2015. “I felt that if I started Diversity Telehealth, I could bridge that healthcare disparity gap by bringing healthcare into underserved areas using technology,” says Cooper, who had previously been a public and private school teacher for 25 years.
Diversity Telehealth offers customized programs for schools, Federally Qualified Health Centers, medical clinics and very low cost individual telehealth memberships for families, “which I’m sure my accountant and my husband aren’t too happy about that,” laughs Cooper.
Dr Cooper doesn’t think telemedicine will magically make people who don’t go to the doctor eager to dance their fingers across their smartphones seeking out medical treatment, but the easy access is there if they want it.
When it comes to mental health, Cooper thinks telehealth can have an especially positive impact. “We all know that the brain is another organ, part of the body,” says Cooper, “but it takes on a different stigma as opposed to the heart or the lung.”Given the prevailing stigma,Cooper thinks more people might opt for taking care of their mental health from the privacy of home through telehealth if possible. “No one knows what’s happening,” she says, “and you’re able to get the treatment that you need and get better.”
In order for telemedicine to work, patients need smartphones and wifi, which one might assume would be difficult for those living in underserved communities. But Diversity Telehealth recently partnered with a homeless shelter and found that most people, even if they are unemployed, homeless, they are likely to have a smartphone. “The power of telehealth is in that phone,” Cooper said.
Telehealth Seen As A Viable Option For The Underserved
Cooper is also working on an app called SureShow, which replaces the “no-show” doctor visit with a cued-up telehealth visit. “Income for the doctor increases, the continuity of care for the patient is better,” she explains, “and since those patients are being seen more often, the quality measures for the facilities rise.”
Parity Health Information & Technology, located in northern Alabama, is a consultancy firm just under a year old, founded by Iris P. Frye. She previously worked at United Healthcare before striking out on her own; clients range from universities to businesses.
Frye thinks that telehealth was underutilized until COVID hit and a broader spectrum of patients and healthcare workers are now seeing it as a viable option to help overlooked communities. The COVID crisis also forced there to be more flexibility in Medicare and Medicaid reimbursements for telehealth visits. “The reimbursement rates are the same as an office visit,” notes Frye, which had previously been a barrier.
When Frye talks to healthcare clients, she often has to explain particular aspects of life in underserved communities that healthcare professionals might not be aware of. “You cannot prescribe $100 medication when there’s a $5 generic,” Frye says.. And this person might receive $400 a month, or $700 a month to live off of for the whole month!” She says that no one should have to choose between eating and their medication.
She also has to explain that many would-be patients who skip or avoid doctor visits, simply might not have anyone to watch their kids, or money for gas or public transportation. “All of these factors that you have to take in consideration when you’re dealing with this community,” says Frye, “telehealth and remote patient monitoring helps 100% in my opinion.”
This story was produced as part of the Arkansas Reporting Project, focusing on entrepreneurship in Northwest Arkansas and the Arkansas-Mississippi Delta, sponsored by the Walton Family Foundation.