By Jaimy Lee
MarketWatch photo illustration/OHSU School of Medicine, iStockphoto
This interview is part of a series of conversations MarketWatch is conducting with some of the leading voices in the U.S. on the COVID-19 pandemic.
Dr. Esther Choo, an emergency room physician who studies racism and sexism in medicine, says there should be a disproportionate representation of people of color in the COVID-19 vaccine studies.
, Moderna Inc.
, and Pfizer Inc.
have publicly said they’re pushing to enroll a more diverse group of participants in the pivotal Phase 3 trials of their coronavirus vaccine candidates. But Choo, who practices at Oregon Health & Science University in Portland, isn’t quite sure that’s good enough.
According to the Centers for Disease Control and Prevention , Native Americans are 2.8 times more likely to contract the virus and 5.3 more times likely to be hospitalized; Black Americans are 4.7 more times likely to be hospitalized and 2.1 times more likely to die; and Hispanic people in the U.S. are 2.8 times more likely to contract the virus and 4.6 times more likely to end up in the hospital.
“Balanced representation should be disproportionate representation of black and brown people, because they’re more affected by the disease,” she said. “Investors should be really asking them, what are your plans so that this is as widely disseminated as possible.”
It’s not totally clear why COVID-19 has had an uneven impact on people of color in the U.S. It could be the prevalence of pre-existing conditions like hypertension or obesity that are common among certain groups of people, a lack of a medical safety net that may drive lower-income people to seek care later, or having to work in higher-risk service environments like grocery stores or nursing homes during the pandemic. “Every single factor about exposure has a differential that favors people who are not brown or black,” Choo said.
But even before there was a pandemic, there have long been problems with adequate representation of people of color in clinical trials that have been acknowledged by both the Food and Drug Administration and drug makers. Research from 2011 found that Black Americans and Hispanic Americans made up 12% and 16% of the population, respectively, but less than 6% of clinical trial enrollment. A study published earlier this year concluded that information about race for six potential COVID-19 treatment studies was inconsistently collected and reported, and the number of Black patients who were included in the trials were under-represented, compared with the percentage of the Black population who have been sickened by the virus.
MarketWatch: Why are black and Hispanic Americans, in particular, being so hard hit by COVID-19?
Dr. Esther Choo: In terms of exposure, who are the frontline health care workers? Who has the luxury of work-from-home options and sick leave and financial reserve to take time out for work? Who has dual-family households? Who has adequate [personal protective equipment] when they do work? Who is taking public transportation to their jobs? Who has autonomy at their workplace to say, this doesn’t feel safe and I’m not going to do this?
Every single factor about exposure has a differential that favors people who are not brown or black. Who has a greater burden of risk because of all the pre-existing social disadvantage? It’s black and brown people — [who have] more chronic disease and more poorly controlled chronic disease, because of all the systemic factors that make people unhealthy if they don’t have access to healthy environments and education and wealth and insurance and good quality health care.
There have been two big studies, one in [published in the American Journal of Preventative Medicine in September] New York City and one [conducted by NPR in May] in Texas , looking at where testing occurred. If you are in a community that has a larger nonwhite population, less testing happened even though more testing was needed. There’s a big study out of Sutter Health system that showed that black patients who ultimately were diagnosed with COVID got diagnosed in the hospital, compared with Asian or white patients, who were diagnosed in the outpatient setting. In other words, if you were black, you had to get sick or go to the hospital, potentially even get admitted to the hospital before you got your test. That is really devastating, because if you look at the protocols for receiving medications — remdesivir and dexamethasone — you have to have a documented positive COVID test in order to get access to those treatments.
You also are less likely to be enrolled in clinical trials, which I think is the reason that clinical trials are having a really hard time with balanced representation. [The latest figures for two vaccine candidates show that about 29% of the participants enrolled in the U.S. arm of the clinical trial of the BioNTech/Pfizer vaccine candidate and roughly 34% of the participants in Moderna’s trial are people of color.] Balanced representation should be disproportionate representation of black and brown people, because they’re more affected by the disease. They should be over-represented. Instead they’re under-represented.
MarketWatch: What is the concern about remdesivir if someone doesn’t get tested until they are in the hospital? [Gilead Sciences Inc.’s /zigman2/quotes/210293917/composite GILD -0.55% remdesivir is an antiviral that has received emergency authorization as a treatment for some very sick COVID-19 patients.]
Choo: The concern is that you wouldn’t even qualify to receive it until that test is positive. Some of these treatments have a treatment window, where it’s best started within a certain number of days. Say you finally get diagnosed, and it’s day 12. But the protocol says you have to be in the first 10 days of symptoms.
MarketWatch: I read your piece in The Lancet about Indigenous people and COVID, and I was pretty shocked that the number of positive cases in Navajo Nation had surpassed New York per capita. What’s the first step in addressing this? Is it a matter of having access to data? Is it about expanding access to care?