Health Disparities of Pandemic Proportions: A Review of Health Disparities in the COVID-19 Pandemic (Sidhu, 5/27/2020)

Many thanks to Dr. Navee Sidhu, who gave a disturbing and thought-provoking presentation on Health Disparities in the COVID-19 Pandemic.

Dr. Sidhu described how health and social disparities permeate the COVID-19 Pandemic, examined the impact of racism on COVID-19, discussed how long-existing institutional and structural factors put communities of color at particular risk, and challenged us to consider how this impacts everyone.

Five questions from Dr. Sidhu for you to consider:
1) What will it take to create a more equitable society post COVID-19?
2) How do we center disenfranchised communities in the recovery process?
3) How does the health care system (at all levels) need to change to better support the health and well-being of its workers, patients and the society it serves?
4) What does it take to become healthy and maintain health?
5) What does quarantine look like for different people?

Part 1: Historical context for events in the present pandemic
"Any time we talk about historical context in the US, it is important to acknowledge where we have come from. . .a history of colonialism, genocide, slavery, oppression, exploitation, and capitalism."

• Social undesirability has long been associated with increased risk of "contagion" and "sickness"
• We have a history of protection of whiteness to ensure that power remains in white hands in our socialized system (xenophobic scapegoating)
• Immigrants have always been associated with disease: Irish immigrants=>Typhoid, Italian immigrants=>TB and smallpox, European Jews=>Cholera, 1900s Chinese immigrants=>Bubonic plaque
• 1980s AIDS=>gay men and Haitians, 2002 SARS=>Chinese, 2000s Ebola=>African
• This lens reinforces well-established misconceptions that individual biological differences are based in race, e.g: 
• non-truth that African Americans were "immune" to yellow fever (1890s)
• undertreatment of black patients  in ER for pain, different lab values for African Americans (NOW)
• Decreased COVID testing for black patients (NOW)

Part 2: COVID-19 Disparities in SoCo, SF, CA and USA

• In Sonoma County, Latinx currently comprise 67% of COVID cases while only making up 27% of total population. (see image) 
• This is a case rate of 104/100,000 in Latinx vs. 24/100,000 in whites
• In SF, 95% of COVID positive patients in the Mission District are Latinx (Latinx population comprises 44% of total population)
• only 10% of Latinx reported being able to work from home
• majority earn <$50K/year (poverty)
• majority household size >3 people
• In California, Latinx make up disproportionate number of cases and deaths from COVID-19 compared to proportion of the population-- across ALL age spectrums
• In the US, there is a paucity of data reported based on race, however  with the data we DO have, we know that 
• Black people account for 25% of US deaths (while only comprising 13% of US population), and are tested at lower proportional rates
• In Arizona, Native Americans comprise 20% of cases, and 21% of deaths (but only 4% of the state's population)
• In Illinois, African Americans account for 38% of COVID deaths and 24% of confirmed cases (while making up 15% of the state's population)
• In Kansas, Latinx comprise 51% of cases (and only 12% of the population)
• You can find more of this data on https://covidtracking.com/
• In summary, people of color experience lower testing rates, higher infection rates, and greater mortality rates. People who test positive more likely to live in poverty and live in multi-person households

Part 3: Impact of systemic racism and capitalism on the pandemic

• Black and brown communities are set up by our society to suffer greater health consequences during a national health emergency
• American capitalism is born from slavery
• Profit as motivation that reinforces oppressive conditions 
• Billionaires gaining wealth at expense of workers
• Large corporations getting bail-outs
• Recovery focused on GDP rather than health and well-being of human beings
• Racism (from Camara Phyllis Jones, MD, MPH, PhD)
• A system of structuring opportunity and assigning value based on the interpretation of how one looks, which we call 'race'
• Structural and institutionalized racism are "differential access to the goods, services and opportunities by race. . . [it is] normative, sometimes legalized, and often manifests as inherited disadvantage
• Predominant white bodies shelter in place, while black and brown bodies continue to work, sacrificing more to return to economic baseline
• Long-standing health and opportunity disparities in housing, finance, judicial system and healthcare correlate with increased covid-19 exposure, hospitalization. and death


• Housing: significant disparities between house ownership between races (home ownership is an important marker of social mobility in this country) (see image)
• Finance/accumulation of wealth is racially discordant (see image below)
• Justice system: disproportionate incarceration of black and brown bodies make people more susceptible to the pandemic (see image below)
• Healthcare: private entities value profit over people. Access to healthcare is paramount to a successful pandemic response, inevitably distributes the response along racial and class lines

• Historically disadvantaged communities have higher rates of comorbidities:
• African Americans have higher rates of hypertension, 2x rates of heart failure, 3x risk of dying from asthma, 3x rates of chronic kidney disease, and 2x prostate and colon cancer, also comprise 44% of HIV+ population
• Latinx are twice as likely to have and die from diabetes, and twice as likely to have chronic liver disease (than non hispanic whites)
• During a crisis, people of color present sicker at baseline, while also in crisis, hospitals are allocating resources in time of scarcity to those who are "less sick"
• Although disparities have improved slightly, 40% of quality measure still worse for blacks than whites (2017)

Part 4: Life in Quarantine

• The Essential Worker 
• "You (meatpacking worker) are giving a great service to the people of the US, and we need you to continue as a part of critical infrastructure, to show up and do your job" (VP Pence)
• With inadequate education, few resources for workers, people of color being asked to make a sacrifices at great risk to their own health
• Who are our essential workers?
• 64% women, 41% people of color, 34% over age 50, 16% live with someone >65, 36% have minor at home, 24% live in families with incomes <200% poverty level
• Ongoing outbreaks at meat processing, UPS, amazon distribution centers
• Essentially these bodies expendable, at great financial benefit to their employers
• Essential workers are being told to return to hazardous work environments, sites with very high exposure risk
• What does life for folks who can effectively work at home and remain safe look like compared to continuation of life for "essential workers"?
• Normalizes sacrifice of health and body
• Only 10% of white americans know someone who has died from COVID
• Pre-exiting stress from minority taxes
• The "myth of individual accountability"
• The US Surgeon general asked African American people to stop drinking, smoking or doing drugs to protect them during COVID-19 (blames black people without explaining larger forces at play, which all people of color more vulnerable to this pandemic)
• Only 18% of white adults are worried they will get covid, while 43% of Latinx and 31% of black adults say they are concerned
• Racialization of comorbid disease focuses on a group; while true health disparities exist, these are actually markers of racial inequality (not biological). In fact, systemic racism results in comorbidities and increased infection and death from COVID-19

Part 5: Ideas for individuals how to move forward, where do we go from here?
Will the system stretched to its limits snap back to its original state of inequity? OR Will the system stretch exacerbate states of oppression and make things worse? OR Will the system morph completely and focus on equity, reconciliation and appreciation of the sacrifices people have made historically and in the present?

What individuals can do now?
Here are a few concrete action items:

• Understand your implicit biases: Harvard Implicit Bias Test
• Also know your biases can be exacerbated by stress
• Watch these Right to Health Web-in: 
• https://www.youtube.com/channel/UCz6VafF5GzIuCmqdF9yFb4A
• https://www.youtube.com/watch?v=xoXA8QFlC7s
• Read this article: https://journals.sagepub.com/doi/full/10.1177/1090198120922942
• Connect with HPEACE, volunteer with IsoCare, Petaluma People Services
• Talk to local governments: write letters to SoCo Board of Supervisors, state and national representatives using your clout as healthcare provider (www.5calls.org)
• Donate to Undocufund (or ask your wealthy friends to)
• Talk to your employer to hold them accountable for workplace safety for everyone

Primary Care of Alcohol Use Disorder (Lund 5/20/2020)

Thanks to Dr. Erin Lund, who gave an excellent Grand Rounds presentation this week on the Primary Care of Patients with Alcohol Use Disorder. Dr. Lund encouraged primary care providers to be forward thinking and proactive about diagnosing and treating alcohol use disorder.

Here's the quick and dirty: 1) AUD is super common 2) Screen for AUD 3) Start with brief interventions, and 4) Offer medications when indicated. Keep reading, you'll feel much more comfortable once you have a few of Dr. Lund's tools in your toolbox.

Alcohol use disorder (AUD) is SUPER common in the US with a 12-month overall prevalence of almost 14% of adults (7% mild, 3% moderate and 3.4% severe).

• Lifetime prevalence of AUD is is 29% (13% lifetime prevalence of severe AUD)
• Men>>women, Young>old
• Alcohol is the 3rd leading cause of death from modifiable risk factors (behind smoking and obesity/poor diet)
• Genetics definitely play a role: 5-10% of women and 25% of men have a relative with AUD

A little reminder about what is considered "one drink" when you ask a patient how much they drink:

Remember, however  that different beers and wines have different alcohol contents, so it's not uncommon that people are drinking 'more' than they realize.

How much is too much?

• Binge Drinking: at least 1 day in the past 30 days with >4 drinks for a woman, >5 for man on one occasion
• Heavy Alcohol Use: binge drinking more than 5 days (in the past 30 days)
• Drinking limits (cut offs for low risk vs. high risk drinking) are based on both gender AND age. 

**Note: for people over 65, limits are the same for men and women: no more than 3 drinks/day or 7 drinks/week.

**Note also that many people you know and love meet criteria for at least a mild AUD; this may be particularly true in this land of wine country and craft beers.

DSM-5 criteria for Alcohol Use Disorder : a maladaptive pattern of substance use with 2 or more of the following 11 criteria within past 12 months (Mild 2-3 criteria, moderate 4-5, severe ≥ 6)

1. Drinking larger amounts/longer periods than intended
2. Effort/desire to cut down
3. Great deal of time spent obtaining, using, and recovering
4. Craving
5. Recurrent failure to fulfill role
6. Continued use despite social/interpersonal problems related to drinking.
7. Activities given up (social, occupational, recreational)
8. Recurrent physically hazardous behavior.
9. Continued use despite physical or psychological problems
10. Tolerance
11. Withdrawal

Why screen for risky drinking?

• It's a USPSTF Grade B recommendation 
• AUD is really common; harmful drinking is estimated at 30% in primary care practices 
• Patients with AUD have a higher risk of death by ALL causes
• Plus, they die years earlier, increased automobile crashes, accidental and intentional injury, social and legal problems
• AUD affects every organ and system in the body: from brain (sleep, mentation) to gut (gastritis, cancers) to heart (cardiomyopathy, CAD)

How to screen? Two options;
1) Single question alcohol screening test (NIAAA): How many times in the past year have you had more than  X or more drinks/day? (X=4 for a woman and X=5 for a man) (>1 is a positive screen, 82% sens, 79% specificity)
2) AUDIT-C

Addiction medicine specialists use a format called SBIRT when talking about how to intervene. (SBIRT stands for Screening, Brief Intervention, Referral to Treatment)Brief Intervention:

You can use the AUDIT C to screen, but also to guide treatment ad your intervention:

0-3: health promotion (great job, keep it up! you are drinking responsible)

4-5: moderate risk drinking, brief intervention

6-7: high risk drinking, brief intervention +/- meds +/- specialty care mgt

8-9: severe risk drinking: start meds, psychosocial intervention, specialty mgt

10-12: specialty management

Here is an example of a brief intervention called FRAMES: 

Treatment for AUD includes 1) acute treatment of AUD (intoxication and withdrawal) AND 2) chronic treatment (abstinence initiation, use reduction, and relapse prevention)

• Psychosocial: formal therapy, self/help 12-step (There are LOTS, including AA, SMART Recovery, Rescue Recovery, and more). Each have varying levels evidence and should be tailored to patient's preferences
• Local resources available HERE, click to explore what is available in Sonoma County
• Medications???

Okay, what about the meds, do they actually work? 

• Pharmacologic management of AUD is underutilized in primary care
• AUD is one of only 3 substances with THREE FDA-approved medications
• Disulfiram (aka Antabuse)
• Acamprosate
• Naltrexone (oral vs. extended release injectable)
• Only 8% of adults with AUD in the US are treated with medications!
• There are also LOTS of medications with varying degrees of evidence used (off label) for AUD, including topiramate, baclofen, gabapentin, ondansetron and sertraline (more below)

Acute Alcohol Withdrawal (AWS):

• Look for signs of sympathetic nervous system hyperactivity: HR, BP, pupils, diaphoresis, tremor
• Use the CIWA vs. Short Alcohol Withdrawal Scale (SAWS) to characterize severity of the AWS: patient scores symptoms, <12 mild AWS, >12 moderate to severe AWS
• CIWA takes 2 minutes, assess 10 (mostly subjective) symptoms
• SAWS is completed by patient, validated in the outpatient setting



SAWS, AAFP 2013

Inpatient vs. outpatient management of AWS?

• 90% of patients with AWS can be managed outpatient
• Must be able to take oral meds, return for frequent follow-up visits, have a friend/relative/caregiver to watch for red flags
• Contraindications to outpatient management: serious lab abnormalities (e.g. profound anemia), hx of withdrawal seizures or DTs, serious medical or psychiatric comorbidity, current polysubstance use
• FYI: Supervised detox (with meds rx'd by YOU for symptom management) is available at Orenda Center. Call: 707-565-7460
• There is evolving evidence for the use of both anticonvulsants (e.g. valproic acid, carbamazepine, and more, see table) and gabapentin to treat AWS

Oral medications to treat AWS (AAFP 2013)

 A little more on the FDA approved meds to treat AUD. While none have great evidence at abstinence, they all have varying evidence for reducing quantity, frequency, etc. They are worth offering in shared decision-making conversations:

• Disulfiram (Antabuse): not really recommended by Dr. Lund because it doesn't really work
• oldest med around for AUD (approved in 1949)
• makes you sick when you drink, inhibition can last for days (up to 14)
• Two blinded studies in 2014 showed no better than placebo in reducing overall ETOH consumption
• Acamprosate,  2 tabs TID (1998 mg/day), covered by PHP
• short half life: has to be dosed so frequently
• NNT 12 to return to "any drinking", can use in people who are still drinking
• may be more effective in women, particularly women with anxiety
• Naltrexone (oral vs. injectable), covered by PHP
• oral tabs 50mg daily, injectable 380 mg IM/month
• oral NNT 20 to prevent return to 'any drinking', NNT 12 to prevent return to 'heavy drinking'
• injectable: reduces number of drinking days
• cannot be combined with opiates, cannot use in cirrhosis

Other meds (non FDA approved) with emerging data for AUD

• Topiramate: A 2014 meta-analysis found it more effective than naltrexone and acamprosate, particularly for increasing abstinence and reducing heavy drinking. Dosing: start with 25mg/day titrate up slowly by 25-50mg per week. Goal: 100-300 mg/day, divided BID
• Gabapentin: 2014 RCT found reduced craving and increased abstinence. Effective dose for relapse prevention: 600 mg TID, small abuse potential (esp in opiate use disorder), can be combined with naltrexone to increase efficacy. Can be sedating.

Okay, don't you feel braver!? Go out and heal, and remember: screen, intervene, and offer meds (when appropriate).

Abnormal Uterine Bleeding (Bartlett, 5/6/2020)

Thanks to Dr. Bartlett for her Grand Rounds this week on The Surgical Management of Abnormal Uterine Bleeding (AUB).

Here are some summary points:

Typical presentations of AUB:

• irregular periods, heavy periods
• abdominal cramping or dysmenorrhea
• fatigue
• dizziness
• pelvic pain or pressure
• missing work or school

AUB is subjective-- normal uterine bleeding is a 28 to 30 day cycle but definitions of "normal blood flow" is really based on a woman's "normal" menstrual cycle is.

Women should be treated for AUB if/when they request treatment and/or if it is adversely affecting their life--i.e. missing work or school. Unless a woman has symptomatic anemia due to her AUB, surgery is an elective procedure.

Diagnostic work-up AUB:

• medical, surgical, and OB history
• pelvic exam
• pelvic ultrasound (BEST imaging for gyn organs)
• CBC, TSH, pregnancy test (+coagulopathy workup particularly if young/teenage)
• up to date pap smear
• Endometrial biopsy advised (if >45 and/or risk factors)

Ddx:

PALM (structural)-COIEN (non-structural)

polyp, adnenomyosis, leiomyoma, malignancy or hyperplasia

coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, not-yet-classified

Treatment options for AUB:

• Combined oral contraceptives (birth control pills)
• Tranexemic acid (TXA), used only during menses (slight increase risk of VTE)
• Progesterone IUD (Mirena, skyla)
• Hysteroscopy D&C
• Uterine ablation
• Myomectomy
• Hysterectomy

Recovery from surgical intervention:

• Hysteroscopy: outpatient surgery, bleeding and cramping, nothing vaginally x2 weeks
• Uterine ablation: outpatient surgery, discolored vaginal discharge, nothing vaginally x 2 weeks
• Myomectomy: depends on location (hysteroscopy vs. mini-laparotomy)
• Hysterectomy: can be done outpatient (or overnight stay), most done laparascopically/robotically, pelvic organs removed through vagina IF cervix also removed