In the heart of Denver, on Champa Street, weathered chairs have been dug out of dumpsters. They stand near tent houses whose polyester walls shake. Inside are partners, possessions, and pets. Beacon lights glint on the polished glass of a hospital, well within reach. Yet, medical care seems light-years away in one of the wealthiest nations whose poor are among the poorest in the world.
I practice medicine in the US. I am also an infectious diseases expert. Many of my patients have problems I can’t treat; they face structural racism, immigration barriers, homelessness, poverty, underinsurance. But they have two diseases that I can treat: covid-19 and tuberculosis (TB). Both these diseases breed on inequities brought by these problems.
Earlier this year in Denver County, Hispanic/ Latinx comprised 29% of the population, yet 40% of covid-19 patients in the entire population were Hispanics/Latinx. Similar trends were observed in Black neighborhoods. Higher median household income correlated with lower test positivity for covid-19 in a neighbourhood. But it does not have to continue this way.
Before covid became prevalent, I worked in India. I saw how effective a community-based prevention programme could be against infectious diseases. Active models bring care to patients’ own environment and change misaligned perceptions in marginalized populations.
In a district of Uttar Pradesh, which has the highest burden of TB, I shadowed a trained community volunteer. Each morning, we went knocking on doors of houses. The residents glanced at me with suspicion, but offered an ear to the volunteer who spoke in their language and understood their perspective. She educated people about symptoms of TB, addressed stigma, and screened the entire family. Specimens collected for testing were transported to the nearest lab. Contacts were traced. Street plays, free medical camps, and mass media tools were utilized to create awareness about TB.
Training volunteers among communities reduced delays in diagnosis and treatment initiation. Active delivery of care worked better than traditional, passive care, where the onus was on the patients to seek care. Bringing care to neighborhoods built trust and empowered them as a whole. It sent a strong message: they too, could make a difference. They too, could bring value.
In present day US, this means training a Black volunteer to work closely on his community’s healthcare needs, or a Hispanic volunteer to screen for covid-19 and other infections in Hispanic populations where language and immigration can be huge barriers to care. People who were once homeless can be trained and incentivised to work as volunteers and help reach homeless populations.
A few months ago, Michelle Haas’ team built a similar programme in Denver. It leveraged the skills of experienced TB outreach workers, many bilingual Spanish speakers. This increased awareness of contagious respiratory diseases like TB helped identify patients with covid-19 who needed escalation of care. Patients were taught self-monitoring by pulse oximeter. Financial and nutritional services were provided by partnering organisations in the community.
Most of the experienced TB workforce has been diverted to provide essential covid-19 care in the community over the past year. This diversion, including a lack of funding, has caused serious setbacks to advances made in global TB elimination by at least five to seven years. Be it loss of lives or economy, covid is a disaster. Still, there is another pandemic on the horizon: tuberculosis, the world’s deadliest infectious disease. It is estimated that the disruption brought on by covid-19 will cause an additional 1.4 million deaths from TB in the next 5 years.
Globally, there is a 25% decrease in reported TB cases. In the US, case notification rates have decreased by 20% in 2020 compared to 2019. This does not reflect better control of the disease, but rather missed opportunities from our inability to detect cases. Many patients hesitate to seek care for the prolonged isolation or quarantine is not sustainable for daily wage earners. Early signs of impending crisis are evident in many states.
Control of TB and covid-19 does not need to be antagonistic. The care could be integrated in parallel as the risk factors, symptoms, and modes of spread of these two diseases are similar. This would require capacity building, but more importantly, strong will by policymakers and key stakeholders who can ramp up investments in such programmes.
Among wealthy nations, America spends the most on healthcare, but fares worst when it comes to the perception of care. It is crucial to understand that access to care is driven by a community’s receptivity to care. Active models of care eliminate biases brought on by social inequities. Reaching out to these hotspots—the pandemic’s seismic zones—will have long-term payoffs by bridging disparities in America.
As the next phase continues with widespread vaccination, the care philosophy must evolve to one of equity. This would include paying careful attention to the twin pandemics of covid and tuberculosis.
Aakriti Pandita, is an assistant professor of medicine at the University of Colorado School of Medicine. Her research is focused on TB, covid-19, and healthcare disparities.
Competing interests: none declared.