[Skip to Content]
[Skip to Content Landing]
Views 15,120
Citations 0
Viewpoint
May 8, 2020

The Disproportionate Burden of COVID-19 for Immigrants in the Bronx, New York

Author Affiliations
  • 1Division of General Internal Medicine, Montefiore Health System, Bronx, New York
  • 2Division of General Internal Medicine, Albert Einstein College of Medicine, Bronx, New York
JAMA Intern Med. Published online May 8, 2020. doi:10.1001/jamainternmed.2020.2131

As general internists who work in the hospitals and outpatient clinics of a large safety-net health system in the Bronx, we care for an ever-increasing number of patients with symptoms of coronavirus disease 2019 (COVID-19) who call our clinics to ask for guidance, seek care in our hospitals, and die in our wards. We are distressed by the disproportionate burden of the COVID-19 pandemic for immigrant patients.

The Bronx, a borough of New York City, is one of the most ethnically diverse urban areas in the US and ranked the least healthy of New York State’s 62 counties. It has rates of chronic diseases such as asthma, diabetes, hypertension, obesity, and tobacco use disorder—all factors that appear to increase the risk of complications from COVID-19—that are among the highest in the state.1 Poor health in the Bronx is due at least in part to decades of policies related to housing, education, environmental health, and criminal justice that have perpetuated racial and economic inequality. Unsurprisingly, the Bronx currently has the highest rate of COVID-19 diagnoses and deaths among New York City’s boroughs.2 More than half a million immigrants live in the borough, and most speak a language at home other than English. Immigrants in the Bronx are disproportionately represented in the essential workforce at risk for exposure to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), including physicians, nurses, nursing aides, home health aides, subway and bus drivers, grocery clerks, and others. The limited sociodemographic data available for COVID-19 cases in New York City show that Hispanic or Latinx individuals, who constitutemost immigrants in the Bronx, are considerably more likely to die of COVID-19 than white New York City residents.3

As we care for patients in the community and in the hospital during this crisis, we are deeply troubled by some of the ways in which COVID-19 uniquely affects low-income immigrant patients. In these communities, the combination of high levels of chronic diseases, chronic stress, and less access to preventive health services4 increases the risk of more severe SARS-CoV-2 infections. Many immigrant patients live in close quarters with multiple generations sharing bedrooms and bathrooms. In these families it is often impossible to isolate older family members, those with asthma or other comorbid conditions, or even those who are ill with COVID-19 from others in the household, including those who must continue to leave home to work.

When conducting telemedicine visits because our clinics are shuttered, we routinely ask about COVID-19 symptoms and answer patients’ questions. For immigrants with limited English proficiency, the lack of available translated information about the disease has meant relying on social media to obtain advice that may be erroneous. A man with fever, fatigue, and diarrhea was confident that he did not have COVID-19 because he had held his breath for 10 seconds and had not coughed, repeating a myth that has circulated online in many languages despite being refuted by the World Health Organization.5 Even with substantial symptoms of COVID-19, patients also fear the immigration-related consequences of going to the hospital. Immigrant patients are highly susceptible to the combination of elevated rates of exposure to SARS-CoV-2, misinformation about its transmission and disease course, and hesitancy to access care.

Caring for hospitalized patients has also revealed particular challenges for immigrants. Because visitors have been barred from hospitals, patients face their illness alone in a foreign space, without families who often serve as cultural mediators between them and the health system. Staff have reduced both the frequency and amount of time they spend in patients’ rooms to minimize exposure and conserve personal protective equipment, and doors to patients’ rooms are often kept closed. Trying to communicate with anyone while speaking through an N95 mask, plastic face shield, and full personal protective equipment is difficult; to do so via a telephone interpreter with a patient who is short of breath and speaks a different language feels particularly depersonalizing and inadequate. We can only begin to imagine how terrifying the experience is for patients. In addition, with outpatient practices closed, our posthospital discharge plans often seem tenuous for immigrant patients—particularly those who are undocumented, who already have difficulty navigating the health care system, and who may not have a regular source of outpatient care.

In both the outpatient and inpatient settings, COVID-19 has brought added complexity to the use of interpreter services, a crucial means of communication with immigrant patients. Owing to the high transmissibility of SARS-CoV-2, in-person interpreters at the bedside of hospitalized patients are now rarely used. Telephone interpreter services are challenging; we have observed clinical staff trying to avoid touching the room telephone to their face or contaminating their own device. In both inpatient and outpatient settings, it is critical to provide reassurance to patients who are ill or anxious about the pandemic. For those who do not speak English proficiently, using telephone interpreter services further strains our ability to express empathy, and we can only hope that it comes through.

Even before COVID-19, immigrant communities in the US faced numerous difficulties accessing health care, including language barriers, lack of health insurance based on legal status, and fear of accessing medical services related to immigration enforcement.6 Now COVID-19 has exacerbated these barriers and has starkly revealed the inequities of our health care system. Because they are less likely than nonimmigrants to have a primary care physician,7 immigrants may have more problems accessing medical care by telephone. Additionally, patients with fears about immigration enforcement may not be willing to risk a call to a physician’s office or a visit to an urgent care center or emergency department given the increased number of deportations by Immigration and Customs Enforcement during the past several years and the recently revised public charge rules.8,9 Implemented by the Department of Homeland Security in February 2020, the revised public charge rules have broadened the conditions under which the government can deny admission or visas to immigrants based on their use of public benefits. As a result, immigrants may wait too long to seek care for symptoms of COVID-19, putting themselves and their families at risk.

As of late April 2020, the rate of SARS-CoV-2 infections and deaths was beginning to slow in New York City. Some of the trauma caused by this pandemic was unavoidable given its scale and speed. A more equitable health care system, however, would not have failed immigrants and other vulnerable groups in the ways that we have seen. As the immediate crisis lessens and the country begins to address longer-term pandemic-related goals, a comprehensive and equitable response is necessary. To address the ongoing outbreak, COVID-19 testing and treatment should be accessible to all patients and targeted as needed toward populations, such as immigrant communities, with elevated risk. Testing and treatment will only be effective if immigrants can receive communications in their own languages and can access services without fear of immigration enforcement. One of the legacies of the COVID-19 pandemic should be a health care system that provides access to comprehensive care for all patients in the Bronx and beyond.

Back to top
Article Information

Corresponding Author: Jonathan Ross, MD, MS, Montefiore Health System, Albert Einstein College of Medicine, 111 E 210th St, Bronx, NY 10467 (joross@montefiore.org).

Published Online: May 8, 2020. doi:10.1001/jamainternmed.2020.2131

Conflict of Interest Disclosures: Dr Ross has received grants from the National Institute of Mental Health. Dr Starrels has received grants from the National Institute on Drug Abuse, consulting fees from Venebio Group, LLC, research support from the Opioid Post-Marketing Requirement Consortium, and royalties from Wolters Kluwer Health. No other disclosures were reported.

Additional Contributions: We thank Chinazo O. Cunningham, MD, and Shadi Nahvi, MD, for their critical reading and editing of this manuscript. They were not compensated for their contributions.

References
1.
University of Wisconsin Population Health Institute. 2020 County health rankings report: New York. Accessed April 13, 2020. https://www.countyhealthrankings.org/reports/state-reports/2020-new-york-report.
2.
New York City Department of Health and Mental Hygiene. COVID-19: data. Accessed April 20, 2020. https://www1.nyc.gov/site/doh/covid/covid-19-data.page.
3.
New York City Department of Health and Mental Hygiene. Age-adjusted rates of lab-confirmed COVID-19 non-hospitalized cases, estimated non-fatal hospitalized cases, and patients known to have died 100,000 by race/ethnicity group as of April 16, 2020. Accessed April 20, 2020. https://www1.nyc.gov/assets/doh/downloads/pdf/imm/covid-19-deaths-race-ethnicity-04162020-1.pdf.
4.
New York City Department of Health and Mental Hygiene. New York City community health profiles. Accessed April 20, 2020. https://a816-health.nyc.gov/hdi/profiles/.
5.
Dupuy  B. Ability to hold your breath 10 seconds is not a test for coronavirus. Associated Press News. March 12, 2020. Accessed April 13, 2020. https://apnews.com/afs:Content:8635070312.
6.
Khullar  D, Chokshi  DA.  Challenges for immigrant health in the USA: the road to crisis.   Lancet. 2019;393(10186):2168-2174. doi:10.1016/S0140-6736(19)30035-2PubMedGoogle ScholarCrossref
7.
Derose  KP, Escarce  JJ, Lurie  N.  Immigrants and health care: sources of vulnerability.   Health Aff (Millwood). 2007;26(5):1258-1268. doi:10.1377/hlthaff.26.5.1258PubMedGoogle ScholarCrossref
8.
Perreira  KM, Yoshikawa  H, Oberlander  J.  A new threat to immigrants’ health: the public charge rule.   N Engl J Med. 2018;379(10):901-903. doi:10.1056/NEJMp1808020PubMedGoogle ScholarCrossref
9.
Cantor  G, Ryo  E, Humphrey  R. Changing patterns of interior immigration enforcement in the United States, 2016-2018. American Immigration Council; July 1, 2019. Accessed April 20, 2020. https://www.americanimmigrationcouncil.org/research/interior-immigration-enforcement-united-states-2016-2018.
Limit 200 characters
Limit 25 characters
Conflicts of Interest Disclosure

Identify all potential conflicts of interest that might be relevant to your comment.

Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.

Err on the side of full disclosure.

If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.

Not all submitted comments are published. Please see our commenting policy for details.

Limit 140 characters
Limit 3600 characters or approximately 600 words
    1 Comment for this article
    EXPAND ALL
    The Challenges of the Bronx
    Joseph Bottino, MD | Retired Bronx Physician
    I was born in a Bronx tenement, did not speak English until I started public school, spent most of my medical career in the Bronx, and can say that I never turned away a patient for financial reasons. True: poverty, race, and immigration status can make rendering medical care challenging. False: the disproportionate burden of illness in residents, particularly immigrants, in the Bronx is a failure of our social welfare systems and structural racism. The level and amount of care afforded to the occupants of Jonas Bronck's Park, considering the lack of resources, is amazing. No comparison to what I experienced during my years as a physician in sub-Saharan Africa and briefer times in South and Central America.

    For sure, our medical system has lots of room for improvement, both in the Bronx and everywhere in the US. I personally support instituting a universal, no questions asked, single payor system, but meanwhile I'm not crying about what we already have.
    CONFLICT OF INTEREST: None Reported
    READ MORE
    ×