When Paula Houston, EdD, her team and leaders from Harborview Medical Center started reviewing demographic data on who was getting — and being hospitalized for — COVID-19 in the UW Medicine system, they were deeply troubled. The pandemic had been described as a “great equalizer.” But the truth was that there was nothing equal about the burden of the novel coronavirus. Some vulnerable groups were much more likely to test positive — and to become seriously ill.

“We first became concerned when we saw the disproportionate numbers of limited English proficient (LEP) patients who had tested positive and were being hospitalized,” says Houston, the chief equity officer for UW Medicine and associate vice president for medical affairs for the University of Washington. “This led us to begin capturing all race, ethnicity and language data, along with information on housing security.”

“It was no surprise that we began seeing the highest burden of disease in our Black, Latinx and LEP patients, as we already have data that tells us these communities experience higher rates of conditions, such as diabetes and heart disease, which exacerbate the effects of COVID-19. This put a magnifying glass on the structural inequities in our healthcare system that contribute to these disparities,” says Houston.

The discovery accelerated the creation of a new Office of Healthcare Equity at UW Medicine — led by Houston — and a strengthened commitment to addressing the root causes of health disparities, both in our own health system and across the region.

Their findings have also helped to shape COVID-19 public health strategies for three communities that are at a much higher risk from the pandemic: people experiencing homelessness, people of color and our elders.

Providing shelter from COVID-19

On any given night, about 12,500 people in Seattle are living on the streets, in encampments or in shelters — communal places where social distancing is difficult.

For people who are homeless, COVID-19 creates an especially heavy burden. Many of them have underlying health conditions and other stressors that make them vulnerable to becoming seriously ill. And living outside makes it harder to recover from an illness or to follow medical advice.

“The consequences could be very serious if the homeless community is hit hard by COVID-19 — not only for those who become sick, but also for the larger community and our health system,” says Paul Hayes, RN, chief executive officer at Harborview Medical Center.

To help lessen the danger to people facing homelessness, UW Medicine’s Pioneer Square Clinic launched a mobile testing program in April, with support from the Paul G. Allen Family Foundation and hundreds of individual supporters. The van traveled to homeless shelters and downtown emergency services, with stops in South Seattle two days a week, offering free COVID-19 testing and guidance on next steps.

For those who became sick, Harborview Hall, on the Harborview Medical Center campus, was transformed into a 50-bed facility to care for homeless people who tested positive for COVID-19. The facility, staffed with UW Medicine healthcare professionals based at Harborview, offered 24/7 care until patients recovered.

So far, these efforts have prevented a widespread COVID-19 outbreak among people facing homelessness. But UW Medicine leaders say the health of this population must remain a priority.

It was no surprise that we began seeing the highest burden of disease in our Black, Latinx and LEP patients, as we already have data that tells us these communities experience higher rates of conditions, such as diabetes and heart disease, which exacerbate the effects of COVID-19. This put a magnifying glass on the structural inequities in our healthcare system that contribute to these disparities.
– Paula Houston, Chief Equity Officer

Reaching out to communities of color

A UW Medicine mobile COVID-19 testing van
Since April, UW Medicine’s two mobile testing vans have conducted more than 20,000 tests in downtown Seattle and South King County neighborhoods, thanks to generous funding from the community.

In Washington state and nationwide, people of color are at much higher risk from COVID-19. In the first months of the pandemic, Public Health – Seattle & King County data showed that rates of confirmed COVID-19 cases for Latinx, Native Hawaiians and Pacific Islanders were four times that of whites. The rate of confirmed cases for Blacks was twice that of whites. And higher rates were found in south Seattle and south King County, in locations that overlapped with communities of color.

Several factors are responsible. First, people in these communities have higher rates of the underlying conditions that are linked to serious cases of COVID-19. This is because of a long history of structural racism, including racist housing policies, employment discrimination and lack of access to healthy foods and neighborhoods. Second, they may have limited access to healthcare or experience discrimination in the healthcare they receive. Third, many people of color are essential service workers — such as grocery store cashiers, delivery workers or cleaners — who can’t work from home and whose jobs increase their exposure. These jobs are also less likely to provide healthcare or sick leave.

“These are community members who have been marginalized and oppressed,” says Houston. “We have a moral obligation to make sure that all members of our public have the same opportunity for good health.”

Mobile testing was an early priority, but Houston’s team knew they couldn’t simply park a van in communities of color and expect people to show up. Instead, they partnered with the Seattle Department of Neighborhoods, meeting online with community organizations to explain what they were doing — and, crucially, to listen to their concerns.

“We dispelled myths that we would be reporting their data or reporting them to immigration,” says Houston. “This was an opportunity to build relationships and trust. We made sure they understood that we intend to continue to do the work to help their communities stay safe and healthy.”

COVID-19 has really accelerated the way UW Medicine is doing community outreach and engagement.
– Paula Houston, Chief Equity Officer

Protecting our elders

Washington’s first major COVID-19 outbreak — and the country’s first confirmed coronavirus-related death — occurred at a nursing home in Kirkland, a suburb of Seattle. Not only did that outbreak highlight the vulnerability of both patients and staff, but it also revealed a gap in critical clinical support that made national headlines.

Skilled nursing facilities are home to perhaps the highest-risk group of all: older people. About 2.1 million Americans live in long-term care facilities, less than 1% of the population. Yet 42% of all COVID-related deaths in the U.S. have taken place in these facilities.

UW Medicine’s Post‐Acute Care Network stepped in to help address the gap by developing guidance for skilled nursing facilities, rehabilitation centers, assisted living and long-term care facilities to follow in monitoring, slowing disease spread and managing COVID-19 outbreaks. By following the recommendations, skilled nursing facilities can help reduce cases and decrease the burden on hospitals, clinics and emergency medical services.

With the possibility of recurring or seasonal COVID-19 outbreaks — and until vaccines are available — future recommendations for facilities could include broad-based testing of residents and staff, increased use of telemedicine and better communication between facilities and local public health officials.

UW Medicine, in collaboration with county and state health officials, is sending “drop teams” to conduct universal COVID-19 testing at long-term care facilities.

An urgent call for action

For Houston, who has been working to advance health equity at UW Medicine for three years, the increased public consciousness and outrage over the inequitable impact of COVID-19 on marginalized communities — and the outcry to improve racial equity that spread nationwide following the murder of George Floyd in May — is an opportunity for change. Houston and other UW Medicine leaders are prioritizing the message that racism and police violence are public-health issues.

“COVID-19 and the most recent incidences of police violence against Black people have shined a spotlight on the systemic racism in all of our societal institutions,” says Houston. “Healthcare is just one of the systems — along with housing, transportation, education and economic conditions — that intersect to influence the overall health of people in our communities. Now is the time to be activists as an institution, partnering with other sectors to truly begin to dismantle oppressive systems and rebuild them to ensure all can thrive.”

Houston will collaborate with leaders across UW Medicine to improve healthcare equity. The UW Medicine Healthcare Equity Blueprint, created in 2017, outlined a multi-year plan to increase staff diversity to better represent those we serve and promote advancement in the healthcare workforce, reduce bias, engage the communities served and better meet the needs of marginalized populations. Now, a new equity charter will formalize the work currently being done and create guidelines for continuing to partner with marginalized communities. Future efforts include improving data collection on demographics, creating more inclusive policies and reducing systemic barriers to healthcare.

“The vision of the Office of Healthcare Equity is to deliver on UW Medicine’s mission to improve the health of the public by ensuring that policies and practices focus on equity, social and health justice as we strive to become an anti-racist organization,” says Houston.

COVID-19 likely won’t be eradicated anytime soon. But with more support, we can work to reduce its harmful effects on groups with elevated levels of risk.

“When the people in the community are healthy and educated, we have a healthier community,” says Houston. “That’s what we all want.”

By Stephanie Perry
Photography: Dennis Wise

Video: UW Medicine Harborview Medical Center COVID-19 mobile testing program Watch