In the spring of 2020, the coronavirus pandemic first gripped the world by the throat and its deadly menace continues to unfurl with renewed ferocity. In the United States, medical and scientific experts issued a series of early recommendations to slow or halt the spread of the virus that causes the disease COVID-19. Such public health measures are clearly warranted. As of this writing, over 285,000 Americans have perished from COVID-19 and the infection numbers are soaring across much of the country. Recommendations to combat the virus spread include handwashing, covering the face when coughing and sneezing, wearing a mask when in public spaces, and social distancing. The most challenging anti-virus measure was the lockdown or stay-at-home orders issued by state and local governments. In many communities, people rushed out to stock up on food, water, and household supplies before they began sheltering in place. The lockdown preparations and implementation clearly highlighted the pervasive and persistent inequalities impacting every aspect of American life that are attributable to social determinants of health (SDH). The World Health Organization defines SDH as “the non-medical factors that influence health outcomes. They are the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies and systems, development agendas, social norms, social policies and political systems.” During the current public health crisis one key question for researchers, policymakers, and clinical providers alike to ask is: Which populations in the U.S. are most likely to experience adverse effects from SDH?
As an academic nurse researcher with expertise in health disparities, I closely monitored news about how the spring lockdowns were impacting various population groups. I paid special attention to the dramatically different experiences of white-collar employees, many of whom had the privilege of safely sheltering in place while working from home, and front-line essential workers who had no such option. This later group, often employed in grocery stores, meat-packing plants, bus stations, and other crowded environments, had higher risk of exposure to the coronavirus. Many of these essential workers are people of color and the devastating consequence of this reality was all too predictable. According to the U.S. Centers for Disease Control and Prevention, communities of color have experienced considerably higher rates of infection, severe illness, and death from COVID-19. This population includes approximately 100,000 individuals, largely African American, with sickle cell disease (SCD), an inherited red blood disorder. The major symptom of this disease is persistent, disabling pain, including excruciating episodes known as a pain crisis. SCD is a lifelong illness with a life expectancy of 48 years for women and 42 years for men.
With a primary research focus on pain management disparities experienced by SCD patients, I worry how coronavirus-related stressors are exacerbating the considerable pain already endured by these individuals. My research indicates that systematic stressors such as healthcare injustice—defined as unfair treatment an individual receives from important medical figures such as healthcare providers — predicts increased pain in patients with SCD. They are particularly vulnerable at this time because the coronavirus pandemic can magnify the negative SDH already experienced due to their race and disease trajectory.
I am concerned about how SCD patients are coping with today’s magnified societal stressors, particularly when trying to avoid a stress-related pain crisis that would require hospitalization and potential exposure to the coronavirus. Given the comprised hematologic profile of patients with SCD, which reduces oxygen circulation, these individuals are at elevated risk for both COVID-19 severity and mortality. Statistics from early in the pandemic document this grim reality. A recent study found that between March and May 2020, 178 infected individuals were entered into the SCD-coronavirus disease case registry. Of these, 122 (69%) were hospitalized and 13 (7%) died. (These hospitalization and death rates are much higher than for infected individuals in the general population.) Healthy stress management techniques that decrease emotion-triggered pain crises could greatly improve the well-being of SCD patients and potentially reduce their hospitalizations and deaths. Healthcare professionals can play a key role in encouraging patients to consistently utilize non-drug coping strategies to complement medication regimens for pain management.
Our research team found that patients with SCD who experienced healthcare injustice from nurses reacted to this psychological stressor by isolating themselves. Meanwhile, those who experienced healthcare injustice from doctors reacted by both isolating and pain catastrophizing. These negative coping strategies are associated with poor health outcomes. For example, pain catastrophizing corresponds to lower health-related quality of life for patients with SCD. On a more positive note, patients who experience healthcare justice also cope with prayer and hopeful thinking. These healthy strategies have long been endorsed within African American communities, where deep spiritual beliefs and regular religious practices have helped them deal with the harsh realities of slavery and the systemic racial discrimination and injustice that sadly remains a powerful force in American culture.
Another coping strategy for SCD patients dealing with stress and pain is guided relaxation. This can include deep breathing and counting backwards from 10 to 1 while focusing on a specific spot within an object. This technique has been shown to effectively reduce stress and pain for adults with SCD. Another recent study found that music therapy also reduces pain and improves mood. It is important that these vulnerable patients know there are a number evidence-based drug-free strategies they can utilize during this unprecedented and pressure-filled coronavirus pandemic.
Unfortunately, SCD patients in the United States, like other citizens the world over, cannot individually control the course of the pandemic and the havoc it is wrecking. However, these patients do wield tremendous control over how they choose to cope with coronavirus-related stressors that can intensify their SCD pain. In addition to the non-drug options described above, individuals can explore and try other safe coping strategies to better manage their physical and emotional health challenges. It is vital that patients are proactive on an ongoing basis to reduce their stress and pain and improve their overall well-being as the world awaits better coronavirus treatments and an effective vaccine.