In December 2019, doctors at Wuhan Central Hospital, the capital of China’s Hubei Province, were battling an unknown disease. A clinician, Li Wenliang, a 34-year-old Manchurian with an excellent academic record and a 2011 ophthalmologist graduate, was one of the first to alert his colleagues to this new ailment although at that time he had no clear idea of the nature and magnitude of the problem he was facing. It is common knowledge that in a message, on December 30, sent through a private chat, Li advised colleagues to be careful with this mysterious novel disease and recommended that they wore protective clothing to avoid getting infected.1 These concerns were well founded because a colleague, Dr. Ai Fen, chief of the emergency room at Wuhan Central Hospital, had reported a case that tested positive for SARS (severe acute respiratory syndrome) virus, the coronavirus that had spawned a pandemic in 2003. Li posted on the social network Weibo a document detailing the case, discussing the results of a CT scan and reporting that 7 workers at the Huanan seafood market had fallen ill with SARS, admitting that the exact viral strain involved was not known. Soon after Li made corrections to his original chat, clarifying that the virus was of a previously unidentified species. 2 Since then, over 170 million people have been infected and almost 3.8 million have died around the world.3 As SARS-CoV-2 spread both inside and outside of China, Public Housing Primary Care (PHPC) health centers started to prepare for a new health care era.
In the United States, low-income and racial and ethnic minority groups have been disproportionately affected by the COVID-19 pandemic. While the exact reasons for this remain unclear, they are likely due to a complex interplay of factors rather than a single cause. While the virus infects people regardless of wealth, exposure to infection is unequal. People in precarious, low-paid, manual jobs in the caring, retail, and service sectors have been more exposed to COVID-19 as their face-to-face jobs cannot be done from home.4 Overcrowded, poor-quality housing in densely populated areas have often added to the increased risk of SARS-CoV-2 infections.5 Poorer communities have also been more vulnerable to severe disease once infected because of crowding, higher levels of pre-existing conditions, and difficulties accessing health care.
Socioeconomic factors affecting public housing residents make this population more vulnerable to be infected by, have more complications from, and die of COVID-19 infections. There are over 1.1 million public housing units across our nation, and around 1.8 million people live in public housing developments.6 These public housing units are in highly dense, low-income neighborhoods located in big urban cities such as New York, Washington, D.C., Chicago, Philadelphia, etc., and are home of seniors and people with disabilities most of whom refer to have two or more chronic medical conditions such as diabetes, hypertension, asthma, chronic obstructive pulmonary disease, etc.7 The primary source of income for this population is through wages. Despite the efforts of this, working populations, ¼ of households fall into the HUD’s “very low-income” category. A large percentage of public housing residents also report being of a racial or ethnic minority group. All these sociodemographic characteristics and determinants of health play a role in increasing the likelihood of severe infections, hospitalization, and dead due to SARS-CoV-2.
The real impact of COVID 19 on public housing residents receiving services from health centers is difficult to determine, PHPC (Public Housing Primary Care) health centers provide aggregate public housing data and not all patients receiving services at these clinical locations are public housing residents. Thus, data provided by PHPC health centers misrepresent the overall picture of COVID-19 infections in public housing. Also, privacy laws and regulations protecting health information do not allow the release of case counts by place of residency. Despite these challenges, PHPC health centers have developed plans and strategies, which help them to assess, plan, and respond with specific activities and interventions aim at preventing COVID-19 infections and complications among public housing residents.
There are 108 HRSA-funded PHPC health centers located in or immediately accessible to public housing, providing services to over 850,000 every year.8 PHPC health centers have played an important role in national, state, and local responses to the coronavirus pandemic. These facilities have contributed to SARS-CoV-2 response efforts by providing testing and immunizations, triaging patients, and reducing the burden on hospitals in addition to playing a role in addressing social determinants of health and an increase in the demand of behavioral health services as a result of the pandemic. PHPC health centers have guaranteed continuity of care for low-income, public housing patients with chronic conditions many of whom identify themselves as being part of a racial and ethnic minority group. Between April 2020 to May 2021, PHPC health centers tested 1,367,534 patients, and approximately 59% of them were from racial and ethnic minorities. Between January 2021 to May 2021, almost 900,000 thousand COVID-19 vaccine series were initiated and 68% of those receiving at least one dose of the COVID-19 vaccine were from ethnic and racial minorities. Moreover, almost 700,000 patients have completed COVID-19 vaccinations, and 72% are from racial and ethnic minority groups. In-person visits to PHPC health centers decreased during the first months of the pandemic and have been fluctuating throughout the last year. However, primary care services have been provided at PHPC health centers in-person and virtually to make sure patients keep receiving all health and preventive services provided at their clinical sites. There have been challenges to offer some essential health services such as immunization, and screening for some cancers such as colorectal and cervical. Routine immunization numbers have been down during the pandemic but have started to level up since March of 2021.
The overall impact of the pandemic on public housing residents is uncertain, and how it has affected PHPC health centers clinical performance measures will not be known until 2020 health center data is made public. Nevertheless, PHPC health center have adapted, learned to live with the pandemic, and come up with promising practices to provide COVID-19 immunizations and testing as well as other essential and routine health services for this vulnerable population. To increase COVID-19 vaccination rates, PHPC health centers have been working with community organizations, especially with their natural partners: public housing agencies. Through these partnerships, PHPC health centers have been able to vaccinate public housing residents on public housing premises and make sure that seniors and residents with disabilities can be immunized without going to any of the health center clinical sites. In collaboration with public housing agencies, PHPC health centers have conducted PHPC community forums where they have educated patients on, tested for, and reinforce prevention against COVID-19. Clinicians have adopted approaches like “talk to the doc” sessions where they respond to questions on vaccine safety and address vaccine hesitancy and confidence. Some PHPC health centers are also working with the Federal Emergency Management Agency (FEMA) to set up large outreach events. PHPC health centers have worked with municipalities and local governments to secure safe and open places in the communities and close to the housing developments to offer COVID-19 immunizations and other essential services. A PHPC health center in Texas recently conducted a “Vax – A – Thon” and opened its clinical site for uninterrupted 24 hours to offer COVID-19 testing and immunizations. The use of mobile clinics has been fundamental to reach out to patients in remote and nontraditional areas in the communities. Alongside in- person visits to assure continuity of care, PHPC health center programs have adopted a menu of new remote service options: tele visit platforms, texts, emails, patient portals, telephone applications, and the list is growing. PHPC health centers have the appropriate community collaborations in place, the outreach network, the staff, and the technology to ameliorate the impact of COVID-19 on public housing residents.
SARS-CoV-2 has shown that the battle against novel diseases may require novel approaches and technology. The novel coronavirus is unlikely to be the last pandemic or emergency will face, and PHPC health centers agree that COVID-19 is going nowhere. As stated by a PHPC health center CEO, “we are just learning to live with it as a new endemic condition.” As PHPC health centers seek to continue serving their patients, numerous difficulties remain, and other challenges could appear. PHPC health centers leadership highlights the need to gear efforts towards the pandemic aftermath. Bringing back effective preventive and primary care services that were set aside in order to mount the pandemic response is imperative. In addition to restoring services, PHPC health centers are also working on updating their emergency management plans and designing and implementing long-term recovery policies to make sure they are prepared for the post-pandemic era and beyond.
References:
1 Hegarty, Stephanie. (2020, February 4). Coronavirus in China: who was Li Wenliang, the doctor who tried to alert about the outbreak and whose death is one year old. BBC News.
2 Deng, Chao., & Chin, Josh. (2020, February 7). Chinese doctor who issued early warning on virus dies. The Wall Street Journal.
3 Johns Hopkins University & Medicine. (2021). COVID-19 dashboard by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University (JHU). Coronavirus Resource Center
4 Whitehead, M., Taylor-Robinson, D., Barr, B. (2020, May 22). Covid-19: we are not “all in it together”—less privileged in society are suffering the brunt of the damage. The BMJ Opinion.
5 Daras, K., Alexiou, A., Rose, T. C., Buchan, I., Taylor-Robinson, D., & Barr, B. (2021, February 4). How does vulnerability to covid-19 vary between communities in England? Developing a small area vulnerability index (SAVI). Journal of Epidemiology & Community Health.
6 U. S. Department of Housing and Urban Development (HUD). (n.d). Resident Characteristics Report.
7 U. S. Department of Housing and Urban Development (HUD). (2017, March 16). A health picture of HUD-assisted adults, 2006-2012. Office of Policy Development and Research (PD&R).
8 Health Resources and Services Administration (HRSA). (2019). National health center data.