COVID-19 Shines a Spotlight on Healthcare Disparities

Measuring Health Disparities Across Greater Boston

When COVID-19 precautions began, the logistics of cancer treatment became more complicated. Restrictions limited the number of visitors who could accompany patients and changed the way that appointments worked. Patients were confronted with a more complicated healthcare system, and many canceled their cancer screenings.

"Our charge right now is to show up in the community and to make sure that people who have lapsed in screenings because of the pandemic get back on track."

"COVID-19 has created serious barriers for patients to get cancer screenings," explains Magnolia Contreras, MSW, MBA, vice president of Dana-Farber's Community Health and Benefits program.

Contreras is intimately familiar with health disparities in Boston. Every three years, her department conducts a thorough investigation of priority neighborhoods, including Dorchester, Jamaica Plain, Mattapan, Mission Hill, and Roxbury — places that face more socioeconomic issues than other Boston neighborhoods — to generate a Community Health Needs Assessment (CHNA) report. These reports analyze data from local, state, and national sources to help determine where there are significant health disparities caused by social determinants of health, such as race and income. Dana-Farber staff members in the Community Health and Benefits program also conduct interviews with community leaders, and hold wide-ranging focus groups with individuals from historically underrepresented groups.

Median income average in Boston is $62,021, but in Roxbury it is $27,721. Roxbury, Fenway, and Mission Hill had the highest proportions of households with incomes below $25,000 from 2013 to 2017. According to other data from 2013 to 2017, residents making less than $25,000 were less likely to undergo pap smears and colonoscopies, important cancer screening tests.

Contreras and her team also found that people in neighborhoods like Roxbury, Mattapan, Jamaica Plain, and Dorchester reported limited access to groceries, such as fruit and vegetables, and were disproportionately burdened by social determinants of health and behavioral risk factors like smoking.

"Historically, marginalized communities have had poor outcomes in cancer for a long time, and when you start to layer aspects of criminology, economics, and the effects of COVID-19, the burden becomes heavier, more complicated, and harder to quantify," Contreras says. "Our charge right now is to show up in the community and to make sure that people who have lapsed in screenings because of the pandemic get back on track."

Her team is currently working on a new needs assessment.

"We are taking what we've learned from the information we collected in 2019 and taking it into this current environment with more comprehensive questions," Contreras notes.

A study led by Dana-Farber researcher and physician Toni Choueiri, MD, also found that the rate of cancer screening procedures like colonoscopy and mammograms plummeted in early 2020 as a result of COVID-19. The report, published in Cancer Cell in June 2021, states that even though those rates recovered overall by the end of 2020, the proportion of Black and Hispanic American patients undergoing these procedures had decreased significantly. The study also found that Asian, Black, and Latino women were all significantly less likely to receive pap smears than white women.

"In light of previously established low screening rates in ethnic minorities, these findings are concerning and suggest the pandemic may accentuate racial disparities related to cancer screening," the study team concludes.

Strategies for Expanding Access

Today, Dana-Farber is working with community advocacy groups and implementing internal department strategies to address these inequities that have only been further illuminated by COVID-19.

Expanding access to patients within historically marginalized groups, and providing them with resources they need, is the main goal for Contreras's team. A new pilot program called Patient Navigation, part of the Cancer Care Equity Program, aims to proactively engage vulnerable patients across Institute sites at the point of cancer detection and screening — eliminating barriers that might slow down care. This pilot program launched in October 2021 in the gastrointestinal treatment centers at two Dana-Farber locations.

"The Institute has had a patient navigator program for more than two decades," Contreras says. "Building on that foundation, we've been able to develop a program to specifically address the needs of marginalized patients and patients with other access barriers. We want marginalized people to have the same positive outcomes that many of our patients at Dana-Farber experience."

As part of this pilot, Dana-Farber patient navigators call new patients before their first appointment to complete an assessment in order to understand any barriers that patient may be facing, particularly those that would prevent them from attending that initial appointment. During the phone call, patients can ask questions about their upcoming appointment, and the navigator can begin connecting them with relevant Dana-Farber services. That might include resource specialists who can help find accommodation and transportation for the patient, as well as social workers who can provide clinical psychosocial assessments for patients and loved ones. A patient that may have a history of alcohol or drug abuse, for example, may be put in touch with a member of Dana-Farber's social work team, who can assist in monitoring their needs.

Persons in Massachusetts looking to come to Dana-Farber without insurance are also connected to the financial team to coordinate enrollment in MassHealth, the state's Medicaid program. Other resources include interpreter ambassadors.

Patient navigators will also meet patients at Dana-Farber for their first appointments to serve as a guide before, during, and especially after their consultation.

"Ideally, they will be there to help make sure that there is open communication between the care team and the patient," Contreras explains. "This will help to ensure that patients not only begin their care here, but also that they won't fall through the cracks and be lost to follow-up."

Using Legislative Advocacy

Through work led by Kate Audette, MSW, MBA, director of the Government Affairs program, Dana-Farber is also committed to making change through legislative action.

When she joined the team in 2019, one of Audette's first priorities was making telehealth (virtual) appointments available to residents of Massachusetts. Before then, telehealth appointments were not allowed in the state of Massachusetts. Advocates like Audette sought to change that.

"Everything that I do takes on an equity lens," Audette says. "Telehealth is an important tool to drive equity in healthcare access. For example, it improves access to care for hourly wage workers, who might normally forgo care due to an inability to take the time off work, or time away from their family to be able to commute to an in-person appointment," Audette said. "That is not even to mention that scenario that we are facing today with the pandemic which required innovation solutions to addressing healthcare access for everyone."

Setting a legislative agenda in 2019 that was centered on equity meant that Audette was prepared to advocate for policy solutions that addressed the longstanding inequities that were exacerbated by the pandemic, like promoting housing stability by ensuring that Massachusetts residents had access to legal counsel when facing eviction.

"If our patients are unhoused, how can we expect them to come to appointments?" Audette notes. "Landlords almost always have a lawyer during the eviction process, and many tenants simply can't afford legal representation. Since the onset of COVID-19, longstanding economic inequities have been exacerbated which has resulted in greater rates of housing instability, especially in BIPOC communities across the Commonwealth We can alleviate that by making sure tenants facing eviction have a right to counsel."

People who are unhoused, or face housing insecurity, experience high levels of economic and emotional stress. Cancer outcomes can be significantly harmed as a result: Multiples studies conducted under the direction of Dana-Farber pediatric physician and researcher Kira Bona, MD, MPH, have shown that exposure to material economic hardship can significantly affect outcomes for children with cancer even when they receive care at large academic facilities like Dana-Farber.

Dana-Farber's Legislative Action Network (LAN) is a grassroots community of volunteer advocates working to advance equity-focused policy solutions. In addition to advocating for improved access to care and social determinants of health, the LAN advocates for improved cancer prevention and early detection, strengthening funding for cancer research, and eliminating disparities in cancer care and clinical trials.

Investing in Communities

Dana-Farber's Community Health and Benefits program has used its analyses to invest in areas of Boston hit hardest by health inequities. In November 2021, Dana-Farber committed $4 million to support long-lasting community health improvement and help make existing health and support services more accessible.

It also provided grants to 12 community organizations, such as GreenRoots, which is measuring air quality in Chelsea and East Boston to attempt to address air pollution, and FamilyAid Boston, which supports families and children facing homelessness.

"Funding these innovative projects in Greater Boston is consistent with our mission, as Dana-Farber seeks to address the root causes of cancer and other chronic conditions, while helping to advance health equity," Contreras notes. "By partnering with local community organizations and working upstream together, we will increase access to services and create the conditions that promote health for everyone.

"We have a unique understanding of how individuals and communities are affected by healthcare," she says. "Our goal is not only to improve care for the individual patient, but also for the greater society."