According to the Hawaii Department of Health, non-Hawaiian Pacific Islanders, who make up 4% of the population, account for 30% of the COVID-19 cases. What are reasons for this tremendous disparity? More importantly, what can be done about it?
In their recent perspective article entitled “Racial Health Disparities and COVID-19 — Caution and Context” published in the New England Journal of Medicine, Chowkwanyun and Reed argue that disproportionate COVID-19 infection in certain racial or ethnic groups in the U.S. do not exist in a vacuum. Instead, they are often better explained by socio-economic factors, such as housing instability, food insecurity, occupational risk and lack of access to preventive services.
Many of our Pacific Islander friends and neighbors have jobs that cannot be done from home on a computer, such as in fast food, dishwashing or security. In addition, many are not eligible for federal coronavirus assistance funds. They often work jobs that do not include paid sick leave. The bottom line: If you don’t show up, you don’t get paid. When there are bills to pay, you might get on the bus and go to work with a minor scratchy throat or runny nose. It is clear that many people with coronavirus do not develop any symptoms, and those who become sick may spread the virus before they develop symptoms.
In addition, many in our Pacific Islander community are uninsured. Our federal and state government revoked Med-QUEST for Compact of Free Association (COFA) citizens, and in the years since, we have failed to provide an adequate alternative. Those who are uninsured are wary of receiving a big medical bill and are less likely to seek care.
The most efficient way to spread the virus is living together in close proximity in the same household. Because of the lack of affordable housing and economic opportunity, many in our community share two or three bedrooms with a dozen other family members. For someone who is concerned they may have COVID-19 or are positive for the virus, it is nearly impossible to keep others from getting infected. If we want to keep COVID-19 from spreading in a household, the infected person has to be in their own room, with their own bathroom, and food and water has to be left on a tray for them outside their room — a luxury that is unimaginable for these families.
The disproportionate COVID-19 infection in our non-Hawaiian Pacific Islander population is the end result of years of socio-economic and housing vulnerability, as well as our state and federal government’s unwillingness to meet the health and economic needs of COFA citizens. We must resist blaming groups for the rise in COVID-19 infections in Honolulu because they failed to adhere to physical distancing protocols, and instead, focus on socioeconomic factors that drive continued COVID-19 infection.
We need to think creatively about identifying and isolating individuals sick with COVID-19 and find ways to support those who cannot afford to quarantine. In addition to language accessible and culturally sensitive contact tracing efforts, can we better support and learn from our community health centers? Can we procure more hotel rooms, and make sure that there are support services for those who are infected, no matter their social status?
In many ways, we are not in this fight together. Some of us are more vulnerable to getting COVID-19 and suffering its complications. Yet when the vulnerable get sick, we are all more vulnerable. The COVID-19 pandemic shows us that we are all interconnected. How we approach the health and well-being of the vulnerable in our community will have consequences for all of us.
Kalei R.J. Hosaka is a fourth-year medical student at the University of Hawaii’s John A. Burns School of Medicine; and Seiji Yamada, M.D., M.P.H., is a family physician practicing and teaching on Oahu.