Over the past two decades with increasing life expectancy and better access to healthcare, there has been a rise in the population of adults above age 65 years in India. There has also been a significant increase in speciality and super speciality doctors. Many elderly persons suffer from a myriad of health conditions that require  consults with many specialists. Also, access to over the counter (OTC) medications and supplements has never been easier with online pharmacies and home delivery of pills. Multiple prescriptions from different practitioners along with self medication by patients themselves has created a  problem of polypharmacy or too many drugs taken by patients. In the current COVID 19 scenario, with elderly persons missing their regular appointments this problem has compounded.

There is no strict definition for polypharmacy. Some studies have arbitrarily defined it as four or more medications.  But patients with multiple serious conditions may genuinely require them. A better way to define polypharmacy would be the use of more drugs than which are medically necessary. This can be seen in patients of all ages but is commonly encountered in the elderly. There are many consequences of this on the health of older adults. Some of them are:

Adverse drug reactions – With advancing age, there is a decline in the function and reserve of organs like liver and kidneys. These organs are important for the breakdown and elimination of drugs. The gastrointestinal motility may be reduced in old age affecting the absorption of oral drugs. Thus the higher chance of adverse drug reactions in the elderly. In a recent study it was found that nearly 10% of emergency room visits by elderly was attributed to adverse drug events.

Drug Interactions – People may suffer from minor illnesses from time to time. This increases in old age. These may not be related to the area of expertise of the specialist they may be consulting already and thereby they are forced to meet a different doctor. Even though it might be just a minor illness, the drugs prescribed for it can have a serious drug interaction with the patient’s regular medications resulting in dangerous consequences.

One common example of this is with the drug warfarin which is given for prevention of  blood clots in patients who have had a heart valve surgery, stroke or venous thrombosis in the past. This drug can interact with many medicines. To quote a few, cotrimoxazole a common antibiotic, fluconazole given for fungal infections or even over the counter pain medications can increase the effect of warfarin putting the patient under high risk of bleeding. Some other common drugs implicated in drug interactions in the elderly are NSAIDs, antibiotics like fluoroquinolones, anti-epileptic drugs, anti-diabetic drugs, sildenafil, anti-arrhythmics and diuretics.

Cognitive impairment – Several studies have found polypharmacy to be associated with cognitive decline in elderly . Anticholinergics are notorious for this. These are used in urinary incontinence, prostate enlargement and Parkinson’s disease which are all diseases of the elderly.

Frequent Falls – Elderly patients have a high risk of falls. A fall can cause significant distress by hip fracture, head injury or blood loss in the already frail individual. Use of 4 or more medications has been found to be a risk factor in older patients for falls.

Apart from these other consequences of polypharmacy are worsening dementia, poor drug adherence and increasing healthcare costs. Elderly patients with many co-morbid health conditions, older adults living alone, the uneducated and those living in old age homes are particularly at high risk for the negative consequences of polypharmacy. We have elderly people running to multiple specialists often in different hospitals and clinics. Patients are in dire need of a medical contact who can filter through and manage their multiple medications on a regular basis. One who is within the community, easily accessible and relatively light on the pocket. The Family Physician or General Practitioner (GP) can fill this need.

About two decades ago the concept of the friendly neighbourhood family doctor was commonplace in India. Every family had their own doctor. He/She would know the medical history including any  adverse health events which have happened over the years and have an idea about the medications taken by each family member. They would be consulted regularly and their words were considered trustworthy by the patients. The family doctor was more like a family friend, invited for family events and part of the family’s joys and sorrows.

Today this concept has diminished. Various factors are responsible for this. Firstly, the commercialisation of healthcare with multiple private hospitals, New advances in healthcare, high-end diagnostics and treatment options with growth of many specialists and super-specialist doctors. The failure of government policies and medical education system in strengthening grassroot level healthcare personnel and lack of awareness among the patients themselves about the benefits of having regular follow up with a qualified primary care physician. So, how does a family physician help in avoiding the problems of polypharmacy?

• Intimate knowledge about the patient lifestyle and medical history – Sometimes medications may require adjustment during festivals, family functions or other life events in the older patients. For example, a diabetic patient may require guidance and drug adjustment during festivals like Diwali where his diet will change drastically or during travel. What about a diabetic who chooses to fast during the month of Ramadan?  An elderly patient on treatment for dementia,  Parkinson’s disease or a cardiac illness may need extra attention and change of drugs in times of bereavement or other stress. A family physician is in a position to do this because he/she has an intimate knowledge about the patient’s lifestyle. It saves the patient visits to multiple doctors and gives him the opportunity to clarify all his doubts and concerns in a single visit.
• Accessible and Inexpensive – A family physician usually has his clinic within the community. He sees patients of all ages. His fees are lesser than that of a specialist and does not need prior appointments.
• Routine Follow up – After the required intervention by a specialist, like an angioplasty by a cardiologist or a prostate removal by a urologist, patients can follow up with a GP at regular intervals. This gives an opportunity for the family doctor to connect with the patient at a personal level and motivate them to follow a healthy lifestyle and other precautions that the specialist may have advised. He can monitor the patient’s health closely, thereby deescalating or stopping certain medications as and when necessary.
• Coordinate with specialists – A common reason for polypharmacy is drug duplication. When consulting different specialists, some drugs could overlap. For example a patient consulting a neurologist for peripheral neuropathy and an endocrinologist for diabetes might be prescribed a vitamin supplement by both having different trade names. This could lead to unnecessary extra drug consumed by the patient. The patient probably visits the specialist once a year or even lesser. So lot of times it is years before such a drug duplication is recognised. This could easily be prevented by a family physician who would be able to coordinate professionally with the various specialists that the patient consults, acting as a single point of care. He can consolidate the prescriptions, do a drug review at every visit and avoid such duplication.

In conclusion, polypharmacy is a fairly recent health problem with a greater incidence in the elderly population.  A well qualified, dedicated family physician can have a positive impact in the routine care and follow up of elderly persons. Along with monitoring their health and preventing inappropriate drug consumption, He/she can contribute to a safer, healthier and more comfortable life in old age.

Dr Krithika Ganesh is doctor by profession and currently have her own private clinic in Bangalore.She is passionate about the field of family medicine and believe that dedicated family physicians in every community are the need of the hour in India.

This question usually pops up in every mind while talking about any digital health intervention. This thought makes everyone think several times before implementing any new digital initiative. “Adoption” is a major challenge that everyone should take up in the limelight for the current digital revolutionary journey coming ahead. 

Discussing India’s healthcare access and quality index according to the Lancet journal it holds its position at 145 out of 195 countries. Front line healthcare workers are the first line of contact in India’s healthcare system. The Active social health activists (ASHAs), Auxiliary nurse midwives (ANMs) and Anganwadi workers (AWWs) usually fall under the cadre of frontline health care workers in India. Most of the FHWs in India are using m-health interventions as one of the tools in providing quality access to healthcare services in India. On the other hand, most of the m-health platforms are aligned towards mother and child health. There are several m-health platforms in India that are being used at frontline level. Not only this they are embedded with various tools and clinical decision support systems that help in tracking high-risk pregnancies, record management, antenatal care visits, scheduling, generating referrals, training, monitoring and end-to-end patient management. 

In India the major challenge in providing health care service is mostly confined to the rural areas and maternal and child health is one of those concerns that needs to be tackled. Various states has leveraged these m-health platforms in the tracking of mother and child health-related issues and providing training as well as front line level. But the biggest dilemma is are they being implemented well? Are they helping out in bringing the potential of these m-health interventions? Answering these questions will always remain as difficult till we come out with the solutions to overcome the major deterrent that is “Adoption”. 

Talking About Challenges

If we articulate about some of the challenges in adoption it can be broadly portrayed in terms of:

1. Technical issues
2. Healthcare worker readiness 
3. Healthcare system readiness 

Technical issues: Technical issues are one of the major deterrents that can lead to the failure in the whole system further leading to less or no adoption towards these online platforms. Complex designing of these health platforms that may influence them to take a back step towards the usage. Other issues may depend upon the features, how it is operated and up to what extent it is easier for them to update the fields in the system. There may be several other concerns like the phone getting heated up, or the phone freezing up, technical presentation (mobile friendly), touch screen etc.

Healthcare worker readiness: This may be understood well in terms of the perceived usefulness and perceived ease of use with some of the examples. 

Perceived usefulness: They usually think that what is the purpose of updating the same field electronically while they are already doing by writing in the paper? Will it be beneficial for them in improving their service delivery if yes then how? And how much do they believe that using these systems would require less comfort and up to what extent?

Perceived ease of use: Due to the complex functionality of the device or system they may not appreciate using it. Is the device developed in alignment with their workflow? Or this may be the result of technical issues also they are facing while using it.

Apart from this lack of understanding, education, attitude towards the technology proficiency and self-efficacy in utilizing these tools. While working in rural and confined settings, they can suffer from low self-confidence and motivation and equally the perception of target communities towards them can also have an impact towards adoption.

Healthcare system readiness: This comes as an overall backend support for the FHWs in adopting these tools. Current health care policies and various health care institutions are not into the enforcement of these mhealth interventions. This may be due to the lack of standardised protocols for the usage of these tools. On the other hand, the poor network access in remote areas, poor access to electricity and lack of proper infrastructure or maintenance cost of the online platforms comes under the impoverished healthcare system. For example, the majority of FHWs also faced problems with the network, internet when it came towards synchronizing the data entered with the servers. Further, most did not have access to electricity sources in their centres to charge their phones. One of the studies stated that the AWWS usually work in AWCs and reported they don’t have ports or electricity sources from where they can charge their mobile phones.

Heading Towards Solution

Now the discussion lands up towards the solution on how we can make FHWs geared up with the revolutionary digital health practices. If we talk about the solutions we need to think accordingly and specifically at each level.

1. Strategic level (at the time of planning)
2. Operational level (requirements before the implementation)
3. Frontline level (during implementation)

Strategic level: It is the first step that must be taken into consideration while implementing any of the interventions into the field. This usually includes planning and organizing of all the tasks and resources accordingly. Prerequisites during the planning must be clear in terms of value and workflow. Value usually encompasses the scope and how the usage of health intervention will benefit them. The aim of the overall process must be well communicated with the users as well. In terms of workflow the interventions that are being subjected to the users must align with what they usually undergo in providing services to the population. Healthcare policy acts as a lever in forming overall strategies. Therefore, standardised policy and regulations must be followed to maintain the main aspects of digital ecosystem i.e.; interoperability, data privacy and data management. Various other factors must also be considered like demographic, social, economic, etc. while formulating out the strategies.

Operational level:  Before the intervention gets implemented at the ground level some of the key operational factors must be taken into the concern. For example, while implementing the mHealth intervention in any low-resource setting one must have adequate resources at the backend. Proper infrastructure, adequate supply of electricity, internet coverage with sufficient speedy networks and resources for providing training and technical support. We should also look into the fact that the tool they will be using should be user friendly and with not very complex functionality.

Frontline level:  It becomes a very compelling factor in terms of adoption. One is directly in-contact with the healthcare workers. Continuous hand holding, motivating them through behaviour change communication (BCC), developing trust around the users act as the most important action point in addition in creating a sustained digital initiative on a large scale. Like the top leaders can be identified among them in terms of the beneficiaries they have updated so as to keep constantly engaged and motivated. Monitoring and evaluating their work outputs in terms of creating a daily scoreboard. Making them realize the scope, should be made clear to the Healthcare workers. When the users witness that online intervention can be taken as an encouraging means to accelerate the administrative processes, it is usually welcomed by them and easily adopted.

Delivery of services to citizens through “online mode” is at the core of the overall electronic health ecosystem being talked about. Major I.T. Initiatives by the Ministry include various health initiatives for improving efficiency and efficacy of public health care across the country under the Digital India Program. For example- Govt of India has initiated “The Integrated Government Online Training (I GOT) -Diksha platform is being used to conduct seamless training sessions for healthcare professionals across the country. ECHO India has partnered with premier government healthcare institutions in its efforts to strengthen the emergency response to COVID-19 with consistent capacity building programs for healthcare professionals, including doctors, nurses, ASHA workers and paramedics by conducting virtual training sessions with their partners. Thus, there are still limitations, despite the existence of theories on technology usage in the workplace, the evidence regarding these interventions in terms of how they usually affect performance of FWHs and the evaluation of efficiency of services delivered through this is still missing. 

Tamanna Sachdeva is presently associated with Tech Care for All as Business Analyst Healthcare. Her areas of interest are mainly in healthcare research and program management.

The field of Audiology is about 55 years old in India

Audiology is a branch of science that studies hearing, balance and related problems. Audiologists are healthcare professionals who use technology, create problem-solving and social skills to identify and treat hearing and balance problems and thus help people communicate and connect better with the world around them. The field of Audiology is about 55 years old in India and has grown exponentially in terms of manpower development, technological advancements and public awareness.

According to WHO (March 2020) around 466 million people worldwide have hearing disability and 34 million of these are children. The way we deal with hearing loss is in the midst of a revolution with enormous changes and new approaches to testing and more affordable and effective treatments are clearing the way for healthier hearing. For instance, in most of the developed countries, Universal Hearing Screening is mandatory for every new born child.On the other hand most of the developing countries are in the process of streamlining these programs. In India most of the public and private hospitals in bigger cities have already started the program and government is working to implement this at secondary and primary healthcare facilities.

These tests are simple, painless , easy to carry out and give immediate results. Early identification of hearing loss in children can help with timely intervention which may include surgery, hearing aids or cochlear implants etc. These children can be mainstreamed in schools and lead an absolutely normal life and thus preventing a lifelong burden on parents, caretakers and in turn on the society.

Studies have time and again proved that adolescents’ focus and priority in their teenage Without mandated routine hearing screenings in schools, students with unilateral, less severe or late-onset hearing loss may not be identified or will be misdiagnosed and managed

Moving forward, school-age hearing screenings are an integral tool in identifying children with hearing loss who were not identified at birth, lost to follow-up, or who developed hearing loss later. Without mandated routine hearing screenings in schools, students with unilateral, less severe or late onset hearing loss may not be identified or will be misdiagnosed and managed. Unfortunately, very few such programs are available in India at the moment and no guidelines are in place by policy makers.

Hence the role of pediatricians becomes vital, to identify any children who could have any degree of hearing loss across various age groups and refer them to audiologists for timely intervention. Most of the audiologists in our country are qualified and trained to conduct these advanced tests which not only tell us the degree but also the type of hearing loss. These objective tests are called electrophysiological tests like BERA, ASSR etc which can be carried out as an OPD procedure. Nonetheless, technical expertise is required to conduct and interpret the test findings and suggest an appropriate intervention. Also, there is an estimate that 1.1 billion young people (aged between 12–35 years) are at risk of hearing loss due to exposure to noise in recreational settings or as an occupational hazard. In particular, it’s due to the excessive use of headphones and earbuds that are perpetually on the heads of countless young people today.

Audiologists play a vital role in educating the masses about such lifestyle changes which can keep your ears safe and hearing intact.

Audiologists play a vital role in educating the masses about such lifestyle changes which can keep your ears safe and hearing intact. More and more work needs to be done in this area. Like other health conditions, hearing should also be checked periodically. Hearing tests are simple subjective tests done in a sound proof chamber and most of the hospitals have these facilities. In the last decade, we have seen a gradual increase in the number of young adults coming to get a routine hearing test for themselves but a lot needs to be done still.

Age-related hearing loss (presbycusis) is the loss of hearing that gradually occurs because of the natural aging process or as we grow older. It is one of the most common conditions affecting our senior citizens and elderly. Technology has come a long way for this age group. From diagnostic tests for intervention options there is a wide array of solutions available to address any kind of hearing loss.

Hearing aids over the last 10 years have undergone a big change … and have really started to meet the needs of people with hearing impairment far better.From atime when they were body worn, aesthetically unappealing with poor performance,working with AA batteries they are now small, discreet. Rechargeable and have smart phone connectivity directly.Further principles of artificial intelligence have also been incorporated in latest hearing aids.

In India we have access to all the latest technology and few of the places do offer international level of patient care.But still there is a long way to go in awareness and education of masses to avail these advancements. Similarly,when hearing aids do not benefit cochlear implants can be done for those individuals irrespective of the age.India has some fine surgeons and very well qualified audiologists to carry out these procedures with all international acceptable norms.

To conclude field of Audiology in India has come a long way,but still has a long journey ahead to reach at all levels of patient care.

Dr. Raj Sharma is an alumni of Cornell Ivy League University, New York and Graduate from AIIMS, NewDelhi,India. He is an emblem of medical, allied medical and corporate entrepreneurship.His dynamic professional expertise is backed by over 12 years of entrepreneurial experience insteering initiatives towards achieving organizational goals and rendering responsibilities related toHealthcare Business Management.Raj Sharma is the director of Priority Hearing Care.

Adolescents are one of the vulnerable groups as they are experiencing this difficult time of transition along with their socio-emotional and physical changes.

The covid-19 pandemic has undoubtedly resulted in a deep psychological impact on individuals (Asmundson and Taylor, 2020; Li et al., 2020). It’s been over 6 months now that the schools have been shut in India and students are attending virtual classes. The uncertainty of COVID-19 has impacted the adults and children alike. Adolescents are one of the vulnerable groups as they are experiencing this difficult time of transition along with their socio-emotional and physical changes as per the study of Larsen and Luna, 2018 and Sturman and Moghaddam, 2011.

It is quite a known fact that schools provide an opportunity for holistic and overall development of children. To adolescents, school means interaction with peers, school means learning new perspectives and ideas, school means developing socio-emotional quotient, school means learning social skills, school means shaping their own identity and role and hence school means acquiring various life skills apart from academic knowledge.

Studies have time and again proved that adolescents’ focus and priority in their teenage years start revolving around their peers and social circles. This is the time when they are preoccupied with their self-image, need attention from peers, need to impress and please friends as well as wanting to be accepted in their social circles. Their formation of self-identity and self-esteem all are rooted in their transactions with their social circle.

The covid-19 outbreak and being quarantined at homes has resulted in various adverse consequences on lives of teenagers: worrying and uncertainty about future, sudden shutting down of school, increased time on their tech devices, home confinement with parents, no athletic/physical activity, acute stress, feelings of loneliness and anxiety. Odriozola-González et al., 2020 mentioned about studies conducted in Spain have established that large number of children experienced anxiety and depression during the initial weeks of the lockdown.

Studies have time and again proved that adolescents’ focus and priority in their teenage years start revolving around their peers and social circles.

Some of the major psychological impacts one can expect and see the teenagers experiencing are discussed below.

Loneliness and missing socialization: As defined in the work of Tomoya et al. 2020 he established how prolonged isolation and confinement could result in social craving which has brain craving activity very similar to neural responses to hunger. Social distancing and quarantine as a result of COVID-19 has made adolescents prevent hanging out with their friends which is one of the crucial markers of adolescence. This could result in frustration, irritability and even anger with the whole ongoing scenario.
One of my students expressed how she does make sure to catch up with her friends over video calls and texts but really misses hanging out, carrying out pranks and just whiling away time together in school.

Missing out on major events: The lockdown happened when it was just about time for the previous academic year to pass school and enter college. The sudden lockdown resulted in teens and young adults losing onto some major year-end events and celebrations for instance, farewell and spending some last days with friends. Isha Goswami (passed out year 12 in 2020) shared how she felt miserable on not being able to say a proper goodbye to her friends or even getting dressed up in a saree for her farewell (a big day for every adolescent student). Uncertainty around college admissions has also contributed to the stress, apprehension and anxiety in them.

Infact the current grade 12 is also on the verge of entering their board preparatory time in next couple of months. These students are spending last year of their school life sitting at home and unable to enjoy with friends, having fun and moreover, making memories!
I recently spoke to a few students in grade 12 and they expressed their apprehension, sadness and frustration about missing onto their last leg of school life. They clearly sounded hurt, upset and even irritated. No matter how much they socialize with their peers on calls, the feeling of spending last few days of school with your friends in person is priceless and irreplaceable.

Impact on self: Adolescents, as a result of all that discussed above have been reportedly undergoing a lot of uncomfortable experiences such as sleep disturbances, appetite changes and feelings of loneliness and isolation. With the lockdown, just like adults, teenagers too have experienced great amount of change in their routines.
Sri (Grade 9) shares, “Since the lockdown has begun, our whole routine has gone for a toss. We are sleeping late, eating junk and spending a large amount of time in front of the screens. The rules that my parents had laid down for me and my brother have all been forgotten because of this lockdown.”
It won’t be uncommon to see many teenagers experiencing a range of intense emotions from fear and anger to sadness and grief because of such mixed and major changes in their life suddenly.

 Confinement and struggle with parents: It is a well-known fact that during adolescence, teenagers prefer spending time alone or with friends and wanting more space from parents. Due to this lockdown and confinement where they have to forcibly stay with their parents 24×7 has made things tougher for them. Priya (pseudo name, grade 11) shared, “It is sometimes very frustrating to see that parents’ involvement has increased since we all have started staying at home. They want to know everything I am doing and they comment on everything like my clothes too”.

Some of the parents shared that the amount of disagreements, arguments and conflict has doubled between them and their teenage children during this pandemic.  They shared that more than ever, the adolescents are preferring to stay in their rooms and watching shows online or spending time on their phones.

 However, after considering all these psychological impact of COVID-19 on adolescents, we cannot not mention the amount of optimism, positivity and resilience one could expect from this age group. The ability to bounce back from a challenging, stressful and an uncertain situation could be best expected by these teenagers who also add a sense of hope and optimism for all of us for wishing this pandemic’s end soon.

Some of the parents shared that the amount of disagreements, arguments and conflict has doubled between them and their teenage children during this pandemic.

KashishBehl is a psychologist working with an International school in Gurugram as a counsellor. She has been working with children for 8 years now, first as a social worker and then as a psychologist.

Throughout the course of history, humans have lived through many pandemics like the Plague of Justinian (541-549 C.E.), the Black Death(1347-1351), and Spanish flu (1918-1920) which have taken numerous lives.

On the other hand, the virtual interactions be it personal or work space, have pushed us deeper into this simulation where society is an interconnection of dots demarcating our position in this virtual web.

Composed by: Nishan Chakrabartty

The author is currently working in NCERT at the Department of Education in Arts and Aesthetics as a Project fellow in developing teacher education books in the pedagogy of Art Integrated Learning. He has a masters degree from JNU in Arts and Aesthetics specialising in cinema and performance studies. His interest lies in the study of social anthropology via the lens of performance studies.

In Ayurveda it is known as Apasmara: Apa, meaning negation or loss of Smara, meaning recollection or consciousness.

Ayurveda and Yoga techniques may improve physical and mental health.

Composed by: Kusumika Krori Dutta

Kusumika Krori Dutta, Assistant Professor, Department of Electrical and Electronics Engineering, M.S.Ramaiah Institute of Technology, Bangalore.

During this wave of COVID-19 pandemic, the hospitals across the country are diverting resources from routine inpatient critical care and outpatient clinics to meet the surge in demand

the patients which were triaged at the OPD Centre will be grouped according to the speciality services required and then they will be sent to the respective hospital

Composed by: Hamza Perwaiz

Hamza is an aspiring MBA (Hospital & Health Management) student in Indian Institute of Health Management Research, Jaipur. Previously he has interned with various hospital organizations such as Columbia Asia Hospital Gurgaon, AMRI Hospital Kolkata, Medica Supespecialty Hospital Kolkata & Institute of Neuroscience, Kolkata.

Medical frontline warriors such as nursing staff and doctors are already receiving endless appreciation and gratitude from the citizens.

Fatigue isn’t just the physical exhaustion but also what we call ‘caregiver burnout’.

Composed by: Kashish Behl

Kashish Behl, MSc Clinical Psychology is a psychologist currently working with an International school in Gurugram as a counsellor. She has been working with children for 8 years now, first as a social worker and then as a psychologist.

Ultimately, racial and ethnic disparities that arise during public health emergencies like
COVID-19 are related to socioeconomic status deprivation and affluence.

Coronavirus Disease 2019 (COVID-19) is the new public health crisis threatening the globe. It is postulated to have erupted from Wuhan, Hubei, China in December 2019, and to have been transmitted from bats to an intermediate host to humans. The World Health Organization (WHO) announced COVID-19 as a pandemic on January 30th, 2020. It rapidly spread across the entire world, and as of April 29, 2020, 210 countries and territories have been affected with over 3,000,000 positive cases and over 200,000 deaths. As of April 29, 2020, The United States of America (USA) reported 983, 457 positive cases and 50, 492 deaths made it the most affected country in the world. The COVID-19 Associated Hospitalization Surveillance Network (COVID-NET) conducts population-based surveillance for COVID-19 positive patients who are admitted into the hospital across USA. It has been revealed that during the month of March 2020, 59% of the surveillance population was White Americans (WA), 18% were African Americans (AA), and 14% was Hispanic and Latino Americans (HLA); however, amongst the hospitalized patients, 45% was AA, 33% was AA, and 8% was HLA. This clearly indicates a disproportionate burden of the disease amongst racial and ethnic minority groups, specifically AA, possibly due to the genetic, environmental, and socioeconomic variabilities that exist. Currently, healthcare sectors worldwide are facing challenges in the diagnosis, treatment, and prevention of COVID-19. Healthcare professionals including Physicians, Scientists, and Professors are fighting to put an end to this disease. As an effort to aid in this fight, we have put together this review article discussing some of the racial and ethnic disparities and key epidemiological variables that exist in relation to COVID-19.

According to CDC, members of racial and ethnic minority groups are more likely to live in densely populated areas due to racial and ethnic residential segregation, which is a fundamental factor leading to health disparities.

The first human coronavirus was identified in the 1960s; since then, some of them have led to major human outbreaks such as severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS). Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the virus strain that causes COVID-19, and it is mainly transmitted through respiratory droplets via infected humans or surfaces. The estimated incubation period of the disease is 2 to 14 days from the time of exposure, and symptoms range from asymptomatic infection to death. The most common presenting symptoms include fever, dry cough, and shortness of breath (SOB); other symptoms include headache, dizziness, confusion, conjunctivitis, rhinorrhea, nasal congestion, anosmia, sore throat, sputum production, dysgeusia, anorexia, nausea, vomiting, abdominal pain, diarrhea, rashes, hives, lesions, myalgia, body chills, body ache, and fatigue. In patients with underlying comorbidities, the disease may progress to pneumonia, respiratory failure, kidney failure, septic shock, and death. Mild symptoms, from which a patient can easily recover, constitute 80% of the disease; severe symptoms such as shortness of breath and pneumonia constitute 14%; critical symptoms such as organ failure and septic shock constitute 5%; and fatal symptoms resulting in death constitute 2%. According to the World Health Organization (WHO), COVID-19 infects individuals of all ages; however, the two most vulnerable groups are the elderly (over the age of 60) and immunecompromised. Currently, COVID-19 positive patients are managed through supportive therapy, and the degree to this therapy is used depends on the severity of the symptoms.

According to the WHO, COVID-19 positive neonates and young children must be admitted into an isolation unit with constant heart rate, respiration, and blood oxygenation monitoring; adults showing mild symptoms must isolate for self-quarantine, intaking sufficient fluids, and using symptom relieving medications. Adults showing severe to critical symptoms must be admitted into an isolation unit with intravenous fluids and corticosteroids, and oxygen therapy. In terms of medical management of COVID-19, there are some medications that deserve recognition. Currently, one of the most promising drugs being investigated by the National Institute of Allergy and Infectious Diseases is Remdesivir. This drug is a broad spectrum antiviral agent that blocks viral replication by interrupting the nascent viral ribonucleic acid chains leading to premature termination; it was earlier used to treat Ebola virus disease and Marburg virus disease. Another drug also showing promising results is Chloroquine, which is an anti-malarial agent that increases late endosomal and lysosomal pH above the level that is required for the virus and cell fusion while interrupting the glycosylation of cellular receptors; it was used to treat SARS. Cancer drugs such as Baricitinib, Ruxolitinib, and Fedratinib are also being investigated. They may work in COVID-19 by inhibiting the Janus kinases, and signal transducers and activators of transcription proteins reducing viral infectivity, viral replication, and the associated host inflammatory response.

Due to pressure from civil rights groups and public health advocates, many of the states across USA have started reporting demographic data for COVID-19. According to Ronald J Daniels, the President of John Hopkins University, and Marc H Morial, the President and CEO of the National Urban League, COIVD-19 showed prominence in individuals belonging to racial and ethnic minority groups, especially AA, at a dramatically disproportionate rate.

Another barrier to healthcare access faced by AA and HLA is the lack of health insurance..

COVID-NET has revealed that during the month of March 2020, 59% of the surveillance population was WA amongst which 45% was hospitalized due to COVID-19, 18% was AA amongst which 45% was hospitalized, and 14% was HLA amongst which 8% was hospitalized. Furthermore, the New York City Health Department has revealed that till April 19, 2020, the COVID-19 death rate amongst AA was 92.3 per 100,000 people and in HLA was 74.3 per 100, 000 people; this was significantly higher than the death rate of WA, which was 45.2 per 100, 000 people. The disproportionate infection rate and death rate amongst racial and ethnic minority groups, especially AA, may be due to genetic difference such as genetic variations and pre-existing comorbidities, environmental distinction such as habitats, socioeconomic prominence such as occupations, living conditions, and access to healthcare. Ultimately, racial and ethnic disparities that arise during public health emergencies like COVID-19 are related to socioeconomic status deprivation and affluence. In this review article, we discussed some of the disparities to better understand COVID-19 and aid in the fight against it, as well as to inform the general public about skewed population outbreaks and prevent it in the future.

Genetic Variabilities Leading to COVID-19 Disparities

Genetic variations impact certain individuals’ predisposition to COVID-19 – genetic polymorphism plays an important role in the likelihood of being infected by the disease, severity of symptoms, and immunological response towards the disease. COVID-19’s transmission and dissemination into host cells is mediated by angiotensin-converting enzyme 2 (ACE2) and transmembrane serine protease 2 (TMPRSS2). ACE2 is an enzyme found on the host cells’ surfaces, and is currently postulated to be the primary receptor to which the virus attaches; TMPRSS2 is a protein that facilitates viral fusion through the cell membrane. Researchers at the University of Pittsburgh conducted a study in April 2020 to learn about how genetic variations play a role in COVID-19’s epidemiological variability. They assessed the effects of ACE2 and TMPRSS2’s genetic expressions in over 2000 individuals from varying populations, and concluded that AA have lower expressions of both. This suggests that genetic variations may lead to lower susceptibility for COVID-19 infection amongst AA, and host genetics may explain the infection rate, severity of symptoms, and death rate on a personal level.

Certain health conditions such as obesity, hypertension (HTN), diabetes mellitus (DM), and cardiovascular disease (CVD) are common amongst AA due to their genetic variations, and such predisposing factors put them at an increased risk for COVID-19.

The Journal of the American Medical Association published a study analyzing 5700 COVID-19 positive patients hospitalized in various hospitals across New York City during March 2020; this study showed that the most common comorbidities amongst these patients were HTN at 56.5%, obesity at 41.7%, and DM at 33.8%. While information is still limited at this time, recent studies conducted in China point towards a positive correlation between existing comorbidities and COVID-19 mortalities. For example, the European Respiratory Journal published a study that analyzed 1590 COVID-19 positive patients,who were hospitalized across China from December 11, 2019 to January 31, 2020. They stated that 25.1% of them had at-least one comorbidity with HTN, DM, and CVD being the most common. Other health conditions such as hepatitis B, immunodeficiencies, chronic kidney disease (CKD), and malignancies were also presents, but at a lower rate. These patients presented with shortness of breath, loss of consciousness, and chest abnormal x-ray results.

According to the Centers for Disease Control and Prevention (CDC) in 2016, the prevalence of HTN in USA was 29% in which AA contributed to 40.3% and HLA contributed to 27.8%. AA has a T594M variant polymorphism on the betasubunit of the sodium epithelial channel, which may increase their prevalence to HTN. The increased rate may also be due to various physiological factors such as increased alpha receptor sensitivity, decreased beta receptor sensitivity, increased sympathetic nervous system activity due to stress, increased endothelin, increased transforming growth factor beta, decreased prostaglandin E2, decreased urinary dopamine after salt loading, and decreased atrial natriuretic peptide after salt loading.

The American Journal of Hypertension published a study in April 2020 stating that the prevalence of obesity is 51% higher in AA and 21% higher in HLA than WA, and AA have the highest correlation between body mass index and salt retention than any other race. Obesity may lead to sodium and fluid retention as well as vascular damage, which in turn may lead to the exacerbation of HTN. The Cleveland Clinic Journal of Medicine published a study in 2013 stating that AA have a higher rate and an earlier onset of HTN and DM as well as increased complications associated with CKD and CVD. The higher rate of HTN and associated lower rate of blood pressure control contributed to a higher rate of DM; the higher rates of HTN and DM contributed to a higher rate of CKD. Such increased rates in AA were due genetic variations, exposure to air pollution, limited food resources, and limited access to healthcare.

Currently, information regarding the risks of taking antihypertensive medications such as angiotensin-converting enzyme inhibitors (ACEI) or angiotensin II receptor blockers (ARBs) in COVID-19 is limited. As stated earlier, SARS-CoV-2 binds to ACE2 receptors as the initial step in viral infection, and these antihypertensive medications may potentially increase ACE2 receptor expression increasing the risk for COVID-19. However, abrupt withdrawal of these medications may result in adverse outcomes; as a result, they should be continued in patients who are at risk or positive for COVID-19.

In March 2020, the Louisiana State University Health Sciences Center stated that patients with HTN taking ACEI or ARBs may be at a greater risk for COVID-19. On the other hand, the New England Journal of Medicine published a report in April 2020 analyzing ACE2 receptor expression in 617 COVID-19 positive patients, taking antihypertensive medications in Japan.

It concluded that ACE2 receptor expression has increased in patients taking Olmesartan, but not in patients taking other ARBs such as Losartan, Candesartan, Valsartan, or Telmisartan, or ACEI. Another study published by the Journal of American Heart Association in April 2020 once again stated differing information where COVID-19 positive patients taking antihypertensive medications when hospitalized had a lower risk of all-cause mortality compared to patients who were not taking these medications.

Although the information above is conflicting, it indicates a potential benefit of taking antihypertensive medications in COVID-19. SARS-CoV-2 not only binds to ACE2 receptors initiating the viral infection, but it also down-regulates ACE2 receptor expression therefore preventing it from exerting its protective effects in various organs which may potentially lead to acute respiratory failure and CVD. Furthermore, the down-regulation of ACE2 receptor expression leads to the accumulation of angiotensin II, a peptide hormone in the renin-angiotensinaldosterone-system (RAAS) causing vasoconstriction and increasing blood pressure, and RAAS activation; it has been postulated that angiotensin II may also play a role in organ injury in COVID-19 positive patients. A report published by the New England Journal of Medicine in April 2020 discussed the results of various studies: 1) In experimental mouse models, exposure to SARS-CoV-1 spike protein resulted in the down-regulation of ACE2 receptor expression, and acute lung injury or acute respiratory distress syndrome (ARDS); 2) In experimental mouse models, exposure to SARSCoV-1 spike protein induced acute lung injury or ARDS, which was limited by RAAS blockade; 3) In COVID-19 positive patients, elevated levels of plasma angiotensin II induced some degree of lung injury. In all of these studies, the up-regulation of ACE2 receptor expression, restoration of angiotensin II, and RAAS blockade were reversed with antihypertensive medications thereby preventing acute respiratory failure and CVD.

Environmental Variabilities Leading to COVID-19 Disparities

According to the Max Planck Institute for Chemistry and Mainz University Medical Center in 2015, air pollution was responsible for 8.8 million premature deaths worldwide. In USA, air pollution is considered the largest environmental risk factor for disease. Currently, air pollution has decreased across the country as vehicle emissions have reduced due to social distancing and lockdown orders in place. However, decades of air pollution such as particulate matter, ozone, nitrogen dioxide, and sulphur dioxide have had negative impacts on people’s health. Millions of Americans are currently diagnosed with asthma and HTN due to air pollution, and these conditions increase their risk for COVID-19. The Harvard TH Chan School of Public Health released a study in April 2020 stating that long-term air pollutions directly linked to an increased COVID-19 death rate.

According to CDC, members of racial and ethnic minority groups are more likely to live in densely populated areas due to racial and ethnic residential segregation, which is a fundamental factor leading to health disparities. As a result, they may find it hard to practice the social distancing measures required for the prevention of COVID-19. Many of them live in multi-generational households where it is difficult to protect the elderly or immunocompromised individuals from COVID-19 transmission in confined spaces. In addition, grocery stores and medical facilities tend to be placed far away from these areas making it tough for the members to stock up on products in order to prevent going out often and receive treatment for COVID-19 if needed respectively. Also, members of racial and ethnic minority groups are overrepresented in detention centres, jails, and prisons where congregate living increases the risk of exposure to COVID-19. These racial and ethnic disparities are evident in Michigan where AA represents 12% of the state population, yet 40% of the state’s COVID-19 deaths as of April 2020 according to Metro Times.

In Wisconsin, where AA represent 6% of the population, yet 50% of the deaths as of April 2020 according to The Washington Post; and in Louisiana where AA represent 32% of the population, yet 70% of the deaths as of April 2020 according to Newsweek.

Socioeconomic Variabilities Leading to COVID-19 Disparities

As COVID-19 positive cases continue to increase across USA, AA and HLA have been affected at a disproportionate rate. According to the Brookings Institute, AA represent 15% of Michigan’s population, yet 35% of its COVID-19 positive cases as of April 2020; this shows that they are 133% more likely to be infected by the virus. In addition, the COVID-19 death rate in Michigan is currently 4% in which AA is once again over-represented at 40%. In contrast, WA represents 75% of the population, and only 25% of its positive cases and 26% of deaths. According to the New York Times, AA have COVID-19 death rate of 20 per 100, 000 people and HLA of 22 per 100, 000 people in New York as of April 2020. According to the WBEZ radio station, AA represent 16% of Illinois’ population, yet 30% of its COVID-19 positive cases. North Carolina and South Carolina show similar patterns with a slightly smaller gap.

As COVID-19 continues to spread across the nation, it will continue to exacerbate socioeconomic inequalities along the racial and ethnic lines. Firstly, according to the Brookings Institute in April 2020, AA and HLA are more likely to live in areas of with socioeconomic statuses lacking green space, healthy food options, recreational facilities, and safety; these inefficient neighbourhoods are rooted in the historical legacy of redlining. Secondly, according to McKinsey & Company in October 2019, AA and HLA are less likely to work in business and professional sectors, and more likely to be part of the COVID-19 essential workforce. For example, they represented 20% of the nation’s food service workers, stockers, cashiers, and janitors according to McKinsey & Company in October 2019, and 30% of the nation’s bus drivers according to DATA USA in 2017. During a pandemic like COVID-19, AA and HLA workers, and consequently their families, are at increased risk of exposure to the disease.

Furthermore, many AA lack access to healthcare due to racial and ethnic residential segregation as mentioned in our Environmental Variabilities Leading to COVID-19 Disparities section. As stated above, they live in areas with low socioeconomic statuses where adequate healthcare resources are not available leading to poor health. The Journal of American Medical Association published a study in 2017 analyzing the blood pressure of 2280 AA; it concluded that living in racially and ethnically segregated areas is associated with increased systolic blood pressure. Living in these areas during a pandemic like COVID-19 prevents the residents from being able to protect themselves efficiently from the disease. For example, on April 9, 2020, La Shawn K Ford, a Democratic member of the Illinois House of Representatives, stated that 10 million face masks were retrieved from the federal government, but none of them were provided to Chicago’s West side neighbourhoods, which are predominated by AA.

Another barrier to healthcare access faced by AA and HLA is the lack of health insurance. According to a study published by Health Affairs in 2005, AA and HLA are less likely to be insured than WA based on their mortality gaps, which were analyzed from 1960 to 2000. This disparity was largely evident before the advent of Medicaid and Medicare; for example, in the 1960s, AA infant mortality rate was 44.3 per 1000 children and WA was 29.2 per 1000 children. Over the years, the overall American infant mortality rate including the AA rate has decreased; however, the gap between the AA infant mortality rate and WA rate has increased. A study published by Cancer Detection and Prevention in 2002 stated that AA women are 2 times more likely to be diagnosed with uterine cancer than WA women, and 2.5 times more likely to die from it; it also stated that AA women are less likely to be diagnosed with breast cancer than WA women, but 36% more likely to die from it. The death rate is higher amongst AA women because they lack health insurance, and as a result get screened for and diagnosed with cancer at later stages compared to WA women. According to a study published by Urologic Oncology in 2014, having health insurance was associated with decreased racial and ethnic disparities in disease treatment. The study analyzed 70, 006 men, and concluded that uninsured AA men with prostate cancer were 62% less likely to receive treatment compared to WA men while insured AA men were 38% less likely. In 2018, the Affordable Care Act stated that 41.2% of AA was enrolled in public health insurances such as Medicaid or Medicare, which have limited coverages and additional costs; as a result, these individuals’ finances were affected, as they had to spend a portion of their income for out of pocket expenses and premiums.

During this COVID-19 pandemic, uninsured or publicly insured individuals are less likely to be tested and therefore treated for the disease due to the perceived costs. Although the Federal government announced that COVID-19 testing and treatment will be free for all American residents regardless of insurance status and type in April 2020, there are gaps in these mandates, which may potentially lead to unexpected medical expenses. As a result, many individuals, specifically members of racial and ethnic minority groups who lack health insurance, may unknowingly be infected by COVID-19 disease, and eventually succumb to is complications or transmit it to other individuals.

Moreover, micro-level factors also enhance COVID-19’s racial and ethnic disparities. According to the Brookings Institute in April 2020, racial and ethnic empathy gaps exist in perceived pain tolerance, and racial and ethnic biases exist in medical treatments. This report discusses a study that analyzed 60 million patients who were admitted to the emergency room across USA from 2007 to 2011, and concluded that AA patients had half the odds of being prescribed opioid medications compared to WA patients. In addition, PubMed Central published a study in 2017 analyzing 39 primary care physicians and 227 AA and WA patients with HTN. The study concluded that AA patients’ interactions with their Physicians involved greater Physician verbal dominance, less patient-centred care, and shorter visits compared to WA patients; this was because Physicians strongly believed that AA patients will not comply with recommendations. Furthermore, an article published by BBC News in April 2020 stated that Dr JeanPaul Mira, the Intensive Care Unit Head at Cochin Hospital in France, and Dr Camille Lochthave, the Head of Research at Inserm Health Research Group in France, suggested that COVID-19 vaccines should be tested in Africa. Such incidents have occurred due to existing stereotypes that AA lack education achievement and medical knowledge.

This review article clearly illustrates that COVID-19 involves varying degrees of infection rate, severity, and mortality rate amongst individuals due to racial and ethnic disparities, and members of racial and ethnic minority groups, specifically AA, are disproportionately affected. The underlying environmental, structural, and socioeconomic variabilities have existed for years, and become exacerbated in this pandemic. As COVID-19 continues to spread across USA, the understanding of the disease has increased and more information is now available. We must use this information to manage and eventually end this pandemic. And in the meantime, we must strike a balance between protecting public health and safety, and respecting human rights, equality, and dignity

Composed by Prathayini Paramanathan, Muhammad Abbas, Winifred Iklaki, Priscilla Itua, Mehran Mortazavi, Parastoo Taravati, Ayobamidele Ayisat Tiamiyu.

Prathayini Paramanathan, based in Illinois, USA, is a final year medical student currently sub-interning in cardiology, and a Clinical Research Assistant working in numerous cardiovascular studies. In addition to medicine and research, she has completed certifications in Public Health at Harvard University in Massachusetts, USA. She also contributes her time to numerous humanitarian organizations such as the American Red Cross and World Vision.