One More Question

“Actually, there is one more question.” My elderly patient paused at the doorway. Because he was hard of hearing, rarely answered his flip phone, and had no close relatives, getting him connected to my clinic for cirrhosis management had felt like a miracle. He had a deep mistrust of the healthcare system as an African-American and it took multiple visits for us to forge a therapeutic alliance.

Though we both wore masks, I knew his expression well. I had seen it many times from patients who, often due to embarrassment, wait until the very end of a visit to bring up the issue that matters most to them.

I sat back down. “Yes, of course?”

“Can you help me make an appointment for the vaccine? I don’t have internet.”

We had often discussed the benefits of the COVID-19 vaccine, always ending with his saying, “I’ll think about it.” Despite knowing his difficulties with his flip phone, I still took a moment to process that he did not have internet. Nonetheless, this was a win. I wanted to share my excitement about his decision but my smile faded.

He was 67-years-old and lived an hour outside Boston in New Bedford, a coastal town with a large minority population and high unemployment. Massachusetts just entered phase 2 of the vaccine rollout, meaning only patients over 75 qualified. Because he only had one qualifying co-morbidity, my patient could not get the vaccine even when it became available to patients over 65 with two qualifying co-morbidities.

In New Bedford, the average life expectancy is 68 years old, 12 years younger than the Massachusetts average.¹ Statistically speaking, residents of New Bedford did not live to long enough to qualify for vaccination. My patient was trapped in a vicious circle—the same factors that led to high COVID-19 rates in his town also prevented him from obtaining the life-saving vaccine.

Despite their efficacy, Blacks and Latinos have far lower rates of vaccination compared to Whites.² Vaccine hesitancy alone doesn’t fully explain this. Rather, social determinants and the lack of diversity and inclusion in clinical trials and policy-making drives these disparities. The initial vaccine trials grossly under-represented minorities based on COVID-19 rates, much less based on population proportions.³ Without this key factor, frequently missing in medical studies,^4,5 we are left to speculate about specific safety and efficacy for these already wary populations. Furthermore, our distribution models assume characteristics of patients that are disproportionately untrue for minorities: a working knowledge of the internet and English, easy access to medical centers, and an expectation of survival to reach the qualifying age.

Of all the lessons I learned this pandemic, the most important is that scientific innovation is only as powerful as the people it helps. For what good is the greatest scientific achievement if it never benefits the most vulnerable? What is the point of disease prevention if the patient in front of you has no path to reach it? During all those long hours working on the COVID-19 units, I yearned for this day when I could see my regular outpatients in clinic once again. Now that it was here, it took my patient asking just one question to make me realize this was far from over.

This moment in history also prompted me to look inward within my own field of gastroenterology. I became aware of our grave health inequities from colorectal cancer screening⁶ to evaluation of functional gastrointestinal disorders.⁷ I intend to be part of the solution by devoting my career to race-conscious scientific inquiry. In my research, I plan to integrate knowledge of the whole patient—by asking about their backgrounds, their barriers, and their beliefs—and basing my design upon this foundation.

“I would be glad to help you,” I said slowly. “But you don’t qualify for the vaccine yet. As soon as you do, we can try to make that appointment together.”

“Oh, I see,” my patient nodded and turned to the door. “Thanks anyway, doc.”

The work ahead starts by not just looking for answers, but by asking the right questions. The next time a patient asks me one more question, I aim to have a better answer.

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