Empathy for the Elderly: LetterWriting in a Pandemic

Reading letters from my sister’s eighty-something year old best friend— let’s call her Susan— always brings up an unanswerable question: is isolation an illness? On one hand, loneliness is linked to severe health conditions including increased risk of heart disease, stroke, depression, and a plethora of others. But in today’s uniquely challenging and unforgiving times, isolation is a safety measure— a way to stay away from the COVID virus we fear the most, we would think. Think again.

Social isolation is associated with about a 50% increased risk of dementia [1]. And while the past year has arguably been one of isolation for everyone, the past year has been a grueling year for nursing home residents. According to a study performed by Carla Perissinotto, M.D., a geriatrician and associate professor of medicine at the UCSF School of Medicine, found that seniors in long-term near the San Francisco Bay Area said that they would rather risk catching COVID than remain alone and isolated [2]. With the reduced ability to platforms such as Zoom to converse with their loved ones as well as the obvious restrictions on visits from loved ones, the elderly people in nursing are drowned in ragged steadiness of their own breathing.

So, what can be done? Western culture already neglects our elders more than we care to admit. Nursing homes have become a necessary evil for working parents who appease their conscience by sending their own parents to a “safe place to live out their years”. After all, it’s the perfect way to “visit when you want”. Sealed, shut, decision well done. But with this pandemic, “visit when you want” is not an option either.

Susan writes to my sister saying that she’ll never know when she’ll see her grandson next, when she’ll be able to spoil him with gifts and see him wear his new pajamas while he holds her hand. She’s dying from three different infections and he doesn’t even know it. It’s not her place to tell him and it’s not in her power to stop it. But what she can do is write to him, hoping he’ll write back. And he does. He sends her a picture in pajamas and Susan is so elated, she photocopies that picture and attaches it in a letter to my sister.

Write. That is something we can all do. Write to an elder during this pandemic. There will never be an answer to the question of whether nursing homes are ethical, whether they achieve the purpose they sought to achieve and whether they are the best solution for the elderly. But there will be an answer to whether you’re an empathetic person. One letter doesn’t take more than a couple of minutes to write. When the seniors in our society open them, they are overjoyed and treasure them. I hope that whoever reads this will take the time to write a letter to any elder in their life, shining a light in the isolation they face by giving them something to look forward to. And perhaps, something to live for.

References

1. National Academies of Sciences, Engineering, and Medicine. 2020. Social Isolation and Loneliness in Older Adults: Opportunities for the Health Care System. Washington, DC: The National Academies Press. https://doi.org/10.17226/25663.

2. Kotwal AA, Holt-Lunstad J, Newmark RL, Cenzer I, Smith AK, Covinsky KE, Escueta DP, Lee JM, Perissinotto CM. Social Isolation and Loneliness Among San Francisco Bay Area Older Adults During the COVID-19 Shelter-in-Place Orders. J Am Geriatr Soc. 2021 Jan;69(1):20-29. doi: 10.1111/jgs.16865. Epub 2020 Oct 9. PMID: 32965024; PMCID: PMC7536935.

COVID-19: An Environmental Justice Crisis

“The nation is sick, trouble is in the land, confusion all around,” said Martin Luther King Junior in his final speech encouraging sanitation workers to continue fighting for better working conditions and wages. King realized that social justice could not be achieved without healthy living environments. He was fighting to end segregation, stop massive industries from harming vulnerable communities, and ensure everyone has a safe place to live, work, and play [1]. Although King made this statement in 1968, his description of the nation continues to ring true in 2021. As the coronavirus has shown us, disparities in health continue to persist. These disparities are due to the lack of healthy living conditions in black, brown, and low-income communities. As King alluded to in his quote, health and the environment are linked. This direct correlation must factor into healthcare, pandemic prevention, and other public health policies.

King’s fight for healthy living environments was one of the sparks that ignited the environmental justice movement of the 1980s [7]. Environmental justice advocates for the fair treatment of all people, regardless of color, race, and income in respect to environmental laws and policies [3]. This movement has been championed by minority and low-income communities who are disproportionately exposed to environmental pollutants. The individuals living in America’s most polluted areas are those who are people of color or little wealth [5]. Environmental regulations in America are “not color blind,” as communities with weaker political voices are exposed to more harmful living conditions [6]. White, high-income communities have economic power, which directly ties to political power. As a result, these communities have the ability to dictate zoning rules, keeping factories, landfills, refineries, etc. out of their backyards [6]. In contrast, low-income and black and brown communities have little economic capital and political influence. As a result, corporate decision-makers take advantage of these communities and build facilities with negative environmental impacts in these neighborhoods [7].

This zoning is especially unjust because these vulnerable communities experience significantly worse health as a result of being exposed to environmental toxins [4]. Zip code is an important indicator of life outcomes [1]. For example, the Sierra Club mapped polluting industries, medical waste incinerators, superfund sites, and railroad tracks transporting dangerous cargo in Memphis, Tennessee. They found that these sites were primarily located in African American neighborhoods. This is because African American neighborhoods are built on cheap and undesirable land due to segregation laws, and these communities lack the political power to demand change [3]. As a result, they have worse health. For example, these communities experience an infant mortality rate twice that of the national average, and lead poisoning is the leading cause of illness among the children of Black Memphis [3]. Furthermore, low-income and minority communities living in impoverished neighborhoods in Chicago and Detroit, where economic inequality and pollution have persisted, experience some of the highest mortality rates in America [6]. As Fatemeh Shafiei, director of environmental studies at Spelman College, said, “Geography is destiny” [1]. Racial and economic disparities are reinforced by environmental regulation, residential segregation, and differences in exposure to environmental toxins.

Health is directly tied to the environment, and the COVID-19 pandemic has underscored this point. The communities most affected by the pandemic, people of color and low-income neighborhoods, are those exposed to the most environmental toxins, such as air pollution around manufacturing plants, buried waste, contaminated water walls, etc. For example, although African Americans comprise 30 percent of the population in Chicago, they represent 60 percent of the COVID deaths in the area [1]. Further, Latino communities are disproportionately affected by COVID, which is only exacerbated due to overcrowding, workplace exposure, and lack of health insurance in these communities [1]. The Navajo Nation is another example of this inequity, as the community has a positive COVID test rate nine times higher than that of the rest of Arizona. These high rates are directly related to the poor living conditions, underfunded health system, and contaminated wells experienced by this population, as a poor environment leads to increased disease spread and severity [1]. All three examples of COVID inequities are directly tied to the environment these populations live in.

However, the importance of understanding context and environment when examining health disparities is often ignored. For example, the U.S. Surgeon General essentially blamed the smoking and drinking habits of African American and Latino communities for the severity of COVID in these populations [8]. However, this statement forgets the history of structural inequities that leads to higher rates of unhealthy habits in these groups. For example, African Americans and Latinos are disproportionately affected by COVID due, in part, to high rates of underlying health conditions in these populations, such as heart disease, diabetes, and asthma. Minority populations have a higher rate of experiencing these health conditions because of the context they live in. These communities tend to be oversaturated with unhealthy, fast foods and are far from affordable grocery stores [6]. Diet and behavior are driven by context, and it is important not to overlook the environment when thinking about health.

The government’s pandemic policies have also severely ignored the environmental disparities experienced by vulnerable populations. The populations hardest hit by COVID live in overcrowded communities with immense air pollution and harmful living conditions. The government’s stay-at-home orders only exacerbate health disparities, as they force these individuals to retreat to toxicity, not safety [1]. Furthermore, during COVID, the Trump administration has relaxed environmental restrictions due to worker shortages, social distancing, and travel restrictions [2]. Polluters no longer have to monitor and report air and water emissions during the pandemic, likely leading to a spike in air pollution and more chemical spills [2]. This decision blatantly disregards the harmful effects of the environment on vulnerable communities, especially since studies have linked exposure to air pollution to an increased risk of COVID deaths [6]. These practices to stop the spread of COVID prioritize white, middle/high-income communities while increasing harm to minority and low-income neighborhoods.

The COVID-19 pandemic is not just a health crisis – it is also an environmental justice issue. Health and the environment are one and the same. As King stated, “the nation is sick. Trouble is in the land” [1]. Current environmental restrictions and practices, such as unfair zoning laws placing vulnerable communities near landfills, factories, etc., stay-at-home orders, and EPA relaxations, are disproportionately harming the health of vulnerable communities, making them more susceptible to pandemics, such as COVID. These current practices are ethically unjust. The right to a healthy living environment is a key part of the American dream, and it is tied to the right to health. COVID has exposed how years of housing segregation and zoning laws have put minority communities at risk [1]. This cycle must end. To address and treat COVID and other health disparities, the environment must be examined, and structural disparities must be acknowledged.

References

[1] Cabrera Y. Coronavirus is not just a health crisis - it's an environmental justice crisis. Grist. https://grist.org/justice/coronavirus-is-not-just-a-health-crisis-its-an-environmental-justice-crisis/. Published April 24, 2020. Accessed March 12, 2021.

[2] Duong T. States Sue Trump EPA for Suspending Environmental Regulations During Pandemic. EcoWatch. https://www.ecowatch.com/states-sue-trump-epa-suspending-regulations-coronavirus-2646004668.html?rebelltitem=3#rebelltitem3. Published May 15, 2020. Accessed March 12, 2021.

[3] Environmental Justice. EPA. https://www.epa.gov/environmentaljustice. Published March 4, 2021. Accessed March 12, 2021.

[4] Harris RT. Environmental Justice and COVID-19: Some are Living in a Syndemic " NCRC. NCRC. https://ncrc.org/environmental-justice-and-covid-19-some-are-living-in-a-syndemic/. Published September 10, 2020. Accessed March 12, 2021.

[5] History of Environmental Justice. Sierra Club. https://www.sierraclub.org/environmental-justice/history-environmental-justice#:~:text=The%20environmental%20justice%20movement%20emerged,minority%20and%20low%2Dincome%20communities. Published November 1, 2019. Accessed March 12, 2021.

[6] Katherine Bagley, et al. Connecting the Dots Between Environmental Injustice and the Coronavirus. Yale E360. https://e360.yale.edu/features/connecting-the-dots-between-environmental-injustice-and-the-coronavirus. Accessed March 12, 2021.

[7] March 17 2016 RSVM. The Environmental Justice Movement. NRDC. https://www.nrdc.org/stories/environmental-justice-movement. Published February 24, 2021. Accessed March 12, 2021.

[8] Summers J. U.S. Surgeon General: People Of Color 'Socially Predisposed' To Coronavirus Exposure. NPR. https://www.npr.org/sections/coronavirus-live-updates/2020/04/10/832026070/u-s-surgeon-jealt-people-of-color-socially-predisposed-to-coronavirus-exposure. Published April 10, 2020. Accessed March 12, 2021.

Closing the LGBTQ+ Gap in Health Care

Access to health care has been a notoriously controversial topic in political and legal systems, and many inequities within health care are pervasive. In this instance, we are going to explore the relationship between healthcare and the LGBTQ+ community. There has been an extensive history of anti-LGBT discrimination within healthcare that continues to shape access to healthcare for members of this community as well as exacerbating disparities in health conditions. In fact, homosexuality was categorized as a disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM) until 1973 and transgender identity was recently changed to “gender dysphoria” in the latest edition from 2013. Even more recently, the Trump-Pence administration sought to make it easier for health care providers to discriminate against members of the LGBTQ+ community using religious exemptions, despite the Obama administration and several court rulings explicitly protecting against discrimination in health care based on gender identity and sex stereotypes [1]. Furthermore, for patients who are turned away by providers, it is difficult to find alternatives, especially given a shortage of medical providers in rural communities as well as in critical fields such as mental health care [1]. Members of the LGBTQ+ community may face legal discrimination in access to health insurance, housing, employment, marriage, and adoption, and there are a lack of laws protecting against bullying in school and fostering social programs for this community [3]. As a result, many LGBTQ+ individuals are unable to find medical services or forego care, and are more likely to face numerous health disparities, such as increased risk of depression and chronic conditions, as a result of discrimination [2].

One of the most dangerous results of discrimination against the LGTBQ+ community in health care is the delay or denial of necessary medical care, which may result in members of this community avoiding medical care as a whole. There have been instances of physicians refusing to provide HIV medications, misgendering transgender patients, or even turning away pediatric patients with same-sex parents, which are just some examples of the discrimination that this community faces [1]. Data from a 2017 survey found that 8% of LGBTQ+ respondents had a healthcare provider refuse to see them because of their sexual orientation and 7% had a provider who refused to recognize their family, including a child or a same-sex partner [1]. On the same survey, it was found that 29% of transgender respondents had a healthcare provider refuse to see them and 23% were intentionally misgendered or dead-named [1]. This type of discrimination deters individuals from this community. As a result, 1 in 4 transgender people and 8% of LGBQ patients avoided seeking essential health care due to fear of discrimination [1].

Furthermore, there are marked disparities in health within the LGBTQ+ community, such as high rates of psychiatric disorders, substance abuse, and suicide, with LGBTQ+ youth being 2 to 3 times more likely to attempt suicide [3][4]. LGBTQ+ youth are also more likely to be homeless, less likely to get preventative screenings for cancer, and are at higher risk of HIV and other STDs [3]. One of the major health concerns in the LGBTQ+ community is sexually transmitted infections. In particular, almost half of the incidences of all sexually transmitted infections in the United States affect MSM (men who have sex with men), despite the fact that MSM constitute 2% of the U.S. population [3]. It is also important to note the even larger disparities among black and other non-white members of the LGBTQ+ community who are at a larger risk for HIV/STDs and other health conditions. Ultimately, it is essential for healthcare providers to understand these disparities and become knowledgeable in the history of discrimination against the LGBTQ+ community that has led to such concerning disparities, so that these individuals can access the health care that they deserve.

Protections for the LGBTQ+ community are uneven despite the federal protections from the Obama administration, with 37 states in just July of 2018 not having an explicit ban against health insurance discrimination on the basis of sexual orientation or gender identity [2]. Much effort is still needed to ensure these protections and to eliminate medical disparities, including providing medical students with proper training to increase culturally competent care, implementing anti-bullying policies in schools, providing accessible social services to reduce suicide and homelessness among youth, and treating HIV and STIs with effective interventions [3]. Until all these needs are met, it is important to shed light on these disparities and talk about critical issues among the LGBTQ+ community so that one day every patient can get the help they need, no matter who they are or who they love.

References

[1] Shabab Ahmed Mirza and Caitlin Rooney. “Discrimination Prevents LGBTQ People From

Accessing Health Care.” Center for American Progress, 5 Mar. 2021, www.americanprogress.org/issues/lgbtq-rights/news/2018/01/18/445130/discrimination-prevents-lgbtq-people-accessing-health-care/.

[2]“US: LGBT People Face Healthcare Barriers.” Human Rights Watch, 28 Oct. 2020,

www.hrw.org/news/2018/07/23/us-lgbt-people-face-healthcare-barriers.

[3] “Lesbian, Gay, Bisexual, and Transgender Health.” Lesbian, Gay, Bisexual, and Transgender

Health | Healthy People 2020,

www.healthypeople.gov/2020/topics-objectives/topic/lesbian-gay-bisexual-and-transgender-health.

[4] Ard, Kevin L, and Harvey J Makadon. “IMPROVING THE HEALTH CARE OF LESBIAN,

GAY, BISEXUAL AND TRANSGENDER PEOPLE: Understanding and Eliminating Health Disparities.” Improving the Health of LGBT People, The Fenway Institute, www.lgbtqiahealtheducation.org/wp-content/uploads/Improving-the-Health-of-LGBT-People.pdf.