In March, just weeks into the COVID-19 pandemic, the incident command center at Brigham and Women’s Hospital was scrambling to understand this deadly new disease. It appeared to be killing more Black and brown patients than whites. For Latino patients, there was an additional warning sign.
The warning came from clinicians who couldn’t communicate clearly with patients in the hospital’s COVID units. And it showed up on Brigham patient safety reports that flag concerns about unequal access to care.
“We had an inkling that language was going to be an issue early on,” said Dr. Karthik Sivashanker, Brigham’s medical director for quality, safety and equity. “We were getting safety reports saying language is a problem.”
Sivashanker dove into the records, isolating and layering the unique characteristics of each of the patients who died: their race, age, gender and whether they spoke English.
“That’s where we started to really discover some deeper, previously invisible inequities,” he said.
Inequities that weren’t about race alone.
Hospitals across the country are reporting higher hospitalizations and deaths for Black and Latino patients as compared to whites. Black and brown patients may be more susceptible because they are more likely to have a chronic illness that increases the risk of a more severe case of COVID. But when Sivashanker’s team at the Brigham compared Black and brown patients to white patients with similar chronic illnesses, they found no difference in the risk of death from COVID.
A difference did emerge for Latino patients who don’t speak English. They had a 35% greater chance of death.
That sobering realization defined a specific health disparity, some possible solutions and a commitment to change.
“That’s the future,” Sivashanker said.
But first, the Brigham had to unravel this latest example of a life-threatening health disparity. It started outside the hospital, in communities like East Boston, Chelsea and Revere, where the coronavirus spread quickly among many native Spanish speakers who live in close quarters and work jobs they can't do from home.
Some of those residents avoided coming to the hospital until they were very sick because they didn’t trust the care provided in big hospitals or feared detection by immigration authorities. But just weeks into the pandemic, COVID patients who spoke little English began surging Brigham and Women’s and other Boston hospitals.
“And we were frankly not fully prepared for that surge,” Sivashanker said. “We have really amazing interpreter services, but they were starting to get overwhelmed.”
“In the beginning, we didn’t know how to act. We were panicking,” said Ana Maria Rios-Velez, a Spanish-language interpreter at the Brigham.
Rios-Velez remembers searching for words to translate this new disease and experience for patients. When called to a COVID patient’s room, interpreters were confused about whether they could go in, and how close they should get to a patient. Some interpreters have said they felt disposable in the early days of the pandemic when they weren’t given adequate personal protective equipment (PPE).
"I want them to see the compassion in me.”Translator Ana Maria Rios-Velez
When she did have PPE, Rios-Velez said, she struggled to gain a patient’s trust from behind a mask, face shield and gown. For safety, many interpreters were urged to work from home. Speaking to patients over the phone created new problems.
“It was extremely difficult, extremely difficult,” she said. “The patients were having breathing issues. They were coughing. Their voices were muffled.”
And Rios-Velez couldn’t look her patients in the eye to put them at ease and try to build a connection.
“It’s not only the voice, sometimes I need to see the lips, if smiling,” she said. “I want them to see the compassion in me.”
The Brigham responded by adding interpreters and providing more iPads so that remote workers could see patients. The hospital purchased amplifiers to raise the volume of the patient’s voice above the beeps and hums of machines in an ICU. The Mass General Brigham network is also making interpreters available via video in primary care offices. An MGB study found lower use of telemedicine visits by Spanish-speaking patients as compared to white patients during the pandemic.
The goal is that every patient who needs an interpreter will get one. Sivashanker said that happens now for most patients who make the request. The bigger challenge, he said, is including an interpreter in the care of patients who may need the help but don’t ask for it.
In the midst of the first surge, interpreters also became translators for the hospital’s website, information kiosks, COVID safety signs and brochures.
“It was really tough. I got sick and had to take a week off,” said Yilu Ma, Brigham’s director of interpreter services.
Mass General Brigham is now expanding centralized translation services for the hospital network.
The Brigham's analytics team uncovered other disparities. Lower-paid employees were getting COVID more often than nurses and doctors. Sivashanker said there were dozens of small group meetings with medical assistants, transport workers, the security team and the environmental services staff where he shared the higher positive test rates and encouraged everyone to get tested.
“We let them know they wouldn’t lose their jobs,” if they had to miss work, Sivashanker said. And he along with managers told these employees “that we realize you’re risking your life, just like any other doctor of nurse is, every single day you come to work.”
Some employees complained of favoritism in the distribution of PPE, which the hospital investigated. To make sure all employees were receiving timely updates as pandemic guidance changed, the Brigham started translating all coronavirus messages and sending them via text, which people on the move all day are more likely to read. The Mass General Brigham system offered hardship grants of up to $1,000 for employees with added financial pressures, such as additional child care costs.
Angelina German, a hospital housekeeper with limited English, said she appreciates getting updates via text in Spanish, as well as in-person COVID briefings from her bosses.
“Now they’re more aware of us all,” German said through an interpreter, “making sure people are taking care of themselves.”
And the hospital set up testing sites in some Boston neighborhoods with high coronavirus infection rates, where many employees live and were getting infected.
“No one has to be scheduled, you don’t need insurance, you just walk up and we can test you,” said Dr. Christin Price as she looked across the parking lot at the Brookside Community Health Center in Jamaica Plain, where tents offered more than testing during warmer months.
Nancy Santiago left one of the tents with a 10-pound bag of fruits and vegetables she said she'd share with her mother.
“I had to leave my job because of daycare, and it’s been pretty tough,” she said, “but you know, we gotta keep staying strong and hopefully this is over sooner rather than later.”
The Brigham recently opened a similar indoor operation at the Strand Theater in Dorchester. Everyone who comes for a coronavirus test is asked if they have enough to eat, if they can afford their medications, whether they need housing assistance and if they’re registered to vote.
The bags of food and social support are elements of the debate about the role hospitals will play outside their walls, to curb health disparities rooted in racism.
“Poverty and social determinants of health needs are not going away any time soon and so if there’s a way to continue to serve the communities, I think that would be tremendous,” said Price, who helped organize the Brigham’s community testing program.
Mass General Brigham leaders say they’ll take what they’ve learned by dissecting disparities during COVID and expand remedies across the hospital network.
“Many of the issues that were identified during the COVID equity response are unfortunately pretty universal issues that we need to address if we’re going to be an anti-racist organization and one that promotes equity strongly as one of our core strategies,” said Tom Sequist, chief of patient experience and equity for MGB.
The Brigham’s work on health disparities comes, in part, out of a collaboration with the Institute for Healthcare Improvement (IHI) that included a focus on gathering, analyzing and tracking data.
“If we don’t name and start to talk about racism and how we intend to dismantle it or undo it, we’ll continue to place Band-Aids on the problem and not actually tackle the underlying causes."Dr. Kedar Mate
“There’s a lot of defensive routines into which we slip as clinicians that the data can help cut through and reveal that there are some biases in your own practice,” said IHI President and CEO Dr. Kedar Mate.
Once hospitals identify race-based bias or discrimination, they have to name it, Mate said.
“If we don’t name and start to talk about racism and how we intend to dismantle it or undo it, we’ll continue to place Band-Aids on the problem and not actually tackle the underlying causes," he said.
Which is why Mate said he’s pleased to see the Brigham’s effort to address health disparities for non-English speaking patients within the framework of Mass General Brigham’s anti-racism plans.
Will Brigham’s work lower the risk of death from COVID for Spanish-speaking patients? Sivashanker said that will be hard to prove.
“It’s never going to be as simple as we just didn’t give them enough iPads or translators and that was the only problem, and now that we’ve given that, we’ve shown that the mortality difference has gone away,” he said.
That's because health disparities are complex problems tied to poor education, housing and the criminal justice system.
“So until we get to that more foundational approach, it’s going to be hard to show improvement on these downstream clinical measures,” he said.
But Sivashankar said more interpreters and iPads, better messaging to non-English speaking employees, and all the other steps the Brigham has taken during COVID have improved both the patient and employee experience. That, he said, counts as a success while work on the next layer of discrimination continues.
This article was originally published on January 29, 2021.
This segment aired on January 29, 2021.