How these forces intersect at a community hospital focused on the underserved …
A year into the global pandemic, we are grappling with the scale of its impact and the conditions that created, permitted and exacerbated it. For those of us in the mental health field, tentative strides toward telepsychiatry pivoted to a sudden semi-permanent virtual healthcare delivery system. Questions of efficacy, equity and risk management have been raised, particularly for underserved and immigrant populations. The structures of our work and its pillars (physical proximity, co-regulation, confidentiality, in-person crisis assessment) have shifted, leading to other unexpected proximities and perhaps intimacies—seeing into patients’ homes, seeing how they interact with their children, speaking with patients with their abusive partners in the room, listening to the conversation, and patients seeing into our lives.
As the pandemic crisis morphs, it is unclear if we are at the point to do meaningful reflective work, but for now, I offer some thoughts through the lens of my work at Cambridge Health Alliance (CHA), an academic healthcare system serving about 140,000 patients in the Boston Metro North region.
CHA is a unique system: a teaching hospital of Harvard Medical School, which operates the Cambridge Public Health Department and articulates as “core to the mission,” health equity and social justice to underserved, medically indigent populations with a special focus on underserved people in our communities. Within the hospital’s Department of Psychiatry, four linguistic minority mental health teams serve Haitian, Latinx, Portuguese-speaking (including Portugal, Cape Verde and Brazil) and Asian patients.
While we endeavour to gather data on this across CHA, anecdotal evidence from the minority linguistic teams supports the existing research suggesting that immigrant and communities of color are bearing the disappropriate impact of COVID-19 in multiple intersecting and devastating ways: higher burden of disease and mortality rates, poorer care and access to care, overrepresentation in poorly reimbursed and “front-facing” vulnerable jobs such as cleaning services in hospitals and assisted care facilities, personal care attendants and home health aides, and overrepresentation in industries that have been hardest hit by the pandemic such as food service, thereby facing catastrophic loss of income.
These patients also face crowded multigenerational living conditions and unregulated and crowded work conditions. These “collapsing effects” are further exacerbated by reports from our patients that they are also being targeted by hateful rhetoric such as “the China virus” and larger anti-immigrant sentiment stoked by the Trump administration and the accompanying narrative of “economic anxiety” that has masked the racialized targeting of immigrants at their workplaces and beyond.
Telehealth. As we provide services, we have also observed that, despite privacy concerns, access to and use of our care has expanded due to the flexibility of telehealth. Patients tell us that they no longer have to take the day off from work to come to a therapy appointment and have found care more accessible and understanding of the demands of their material lives.
Some immigrant patients report that since they use phone and video applications to stay in touch with family members, using these tools for psychiatric care feels normative and familiar. For deeply traumatized individuals, despite the loss of face-to-face contact, the fact that they do not have to encounter the stresses inherent in being in contact with others out in the world has made it more possible for them to consistently engage in care with reduced fear as relates to their anxiety and/or PTSD. These are interesting observations as we try to tailor care and understand “what works for whom.”
Immigrant service providers. Another theme in the dynamics of care during the pandemic is found in the experiences of immigrant service providers whose work has been stretched in previously unrecognizable ways—and remains often invisible.
Prior to the pandemic, for example, CHA had established the Volunteer Health Advisors program, which trains respected community health workers, often individuals who were healthcare providers in their home country, who have a close understanding of the community they serve. They participate in community events such as health fairs to facilitate health education and access to services and can serve as a trusted link to health and social services and underserved communities.
What we have seen during the pandemic is even greater strain on immigrant and refugee services providers who are often the front line of contact. We have provided various “care for the caregiver” workshops that address secondary or vicarious trauma to such groups such as medical interpreters often in the position of giving grave or devastating news to families about COVID-19-related deaths as well as school liaisons and school personnel, working with children who may have lost multiple family members to the virus, often the primary breadwinners, leaving them in economic peril.
While such supportive efforts are not negligible, a public system like ours is vulnerable to operating within crisis-driven discourse and decision making. With the pandemic exacerbating inequities, organizational scholars have noted in various contexts that a state of crisis can become institutionalized. This can foreclose efforts at equity that includes both patient care as well as care for those providing it. The challenge going forward will involve keeping these issues at the forefront of decisions regarding catalyzing technology and the resulting demands on our workforce.
Diya Kallivayalil is the director of training at the Victims of Violence Program at the Cambridge Health Alliance and a faculty member in the Department of Psychiatry at Harvard Medical School.