FEMALE SPEAKER: Welcome to Mayo Clinic COVID-19 Expert Insights and Strategies. The following activity is supported in part by an independent medical education grant from Pfizer Inc, and is in accordance with ACCME guidelines.

MALE SPEAKER: Hello, everyone. Welcome again to our Grand Rounds. We have a really important topic today. As you know, 2020 is going down as potentially one of the most important years probably in this century. This century, it depends how you define it. But certainly from the last century and probably for the next century.

And that's not just because of the COVID, but also the emphasis from the George Floyd events recently that have come on racial disparities. And I think the Grand Rounds today is really a marriage of these two, because we know how COVID is affecting certain segments of our population in disproportionate ways.

And Mayo and in the Department of Medicine, we really want this to be a tipping point for the way that we address these issues. And we are working in a number of different ways. We'll hear more about it next week. But ways that we'll be looking for our interfaces with patients, ways that we'll be looking within our staff, and then ways we're looking with our community in terms of racial disparities and how we can be part of the solution here.

And part of those actions, the first steps before the actions is the communications, and the conversations, and the listening. And that's really what this is about today, is listening and learning. For many, they may have been living this their whole life. And for others, this is new to them.

But the amazing thing that I'm finding at Mayo is everybody's curious, and that's really what we need is a curious mindset. So I'm going to turn things to Carna to introduce our panel today, and I look forward to more conversations on this topic over the coming weeks. So thanks, Carna.

CARNA: Thank you, Dr. Shaw, and good afternoon, everyone. It's my privilege to introduce our speakers. Dr. Sharonne Hayes is a Professor of Medicine and Cardiovascular Diseases and founded the Woman's Heart Clinic at Mayo Clinic Rochester. She was appointed as Mayo Clinic's first Director of Diversity and Inclusion in 2010, and is the founder of TIME'S UP Healthcare.

Dr. Hayes has led efforts to enhance the development and mentorship of women and minority physicians, and to mitigate unconscious bias in order to promote a more diverse workplace and workforce at Mayo and in the field of medicine.

Dr. Irene Sia is an Associate Professor of Medicine and a Consultant in Infectious Diseases at Mayo Clinic Rochester. She is a founding member of the Rochester Healthy Community Partnership. Since 2004, this partnership has established an infective, community-based research infrastructure and implemented several projects aimed at improving the health of the community, including difficult to reach minority and disadvantaged populations.

Dr. Rahma Warsame is an Assistant Professor of Oncology and Medicine and is a hematologist at Mayo Clinic Rochester. Dr. Warsame is a Kern scholar in the Kern Center for the Science of Healthcare Delivery at Mayo Clinic. She is the diversity leader in hematology and the American Society of Hematology Ambassador for Mayo Clinic in promoting future minority hematologists.

Her research focuses on patient reported outcomes. So welcome to our speakers. We're delighted and grateful for your presence, and we'll start with Dr. Hayes.

SHARONNE HAYES: Thank you for this opportunity and for the commitment of the Department of Medicine as we go forward to have these conversations. I will say we were invited to present on this topic before the police killing in Minneapolis, and so for us, it seems all the more timely.

I looked at this-- to set the stage, why are we here? Well, one of the reasons that we are here is I looked, right before I came to the room, to see what today's Minnesota Department of Health numbers by race and ethnicity for COVID-19 testing positive.

There are approximately 10,000 white people that have tested positive and about 6,200 Black or African-Americans who have. Which, if it was evenly distributed for our population, would represent that we would have 62% of Black African-Americans in Minnesota. That number is actually about 6%, so they are represented at 10 times the number of positive cases compared to whites.

So I think how we can frame this is that COVID-19 is really a magnifying glass that is heightened this larger pandemic of racial and ethnic disparities. And for some, this has been a relative surprise. But for many others, it's not.

And this quote from colleagues Dr. Essein and Youmans, this pandemic is unfolding exactly as we might have imagined. And the unfortunate element of surprise is that the response to this disease has enjoyed belies a deeply entrenched failure to recognize the scourge of systemic racism.

We often use a bit of shorthand when talking about risk for diseases. For instance, we might say being an African-American is a risk factor for hypertension or for other cardiovascular diseases. [AUDIO OUT] Native American has been called out as an important risk factor for COVID-19 death.

But ascribing this risk to a race or group of people is really a shortcut for a much more complex pattern of risk that actually includes racism, which we're going to talk about today. We want to shine a light on how we need to reframe this conversation and how we consider race, which is a social construct, and explore racism as one of the more important risk factors for Black, indigenous, and people of color, BIPOC.

And show that, if we talk about the clinical risk factors, like hypertension and obesity, it's really too simplistic and were not the sole reasons for these COVID-19, and why it's hit these groups harder. And I also want to talk about how Mayo is currently and how we might, going forward, help address these.

So we all know what a sentinel event is. And I think my colleague and friend Dr. Keith Ferdinand has framed this current pandemic and its effect on African-Americans as a national sentinel event. The Joint Commission defines a sentinel event as an event that harms people or potential harm, such as falls and wrong site surgery.

And one could really argue that this has all of the features of a sentinel event, but very different root causes. For 100 years, we have been collecting data on various populations, and we know that Native Americans and African-Americans have, for years, had a shorter lifespan than white people, and more diseases.

We know, and as a cardiologist, I see every day that the US lifestyle isn't very healthy. But if you are a minority, it's even worse. And in fact, we've observed with the Honolulu Heart Study, and it found studying immigrants, Hispanic immigrants, that even generally healthy populations, the longer they live in the US, the less healthy they get by generation.

So some of the stark statistics are clearly that Black women-- I mean, in the US, we have one of the highest maternal mortality rates in the world. But if you are a Black woman, you are four times more likely to die when giving birth. And a Black child born in the US is twice as likely to die in the first year of life before their first birthday than a white child.

There is a higher death rate for virtually every type of disease. But in that includes death in the custody of law enforcement personnel, as we've seen in the past couple of weeks. So I want to talk a little bit about this term that you may have heard bantered around a bit more over the past couple of weeks, systemic or structural racism, so much that the meaning may be lost, or it's become politicized.

So we need to get back to the legacy of slavery and broken treaties to really understand our current state, and how some of those factors that are 400 or 600 years ago still are relevant today for the health of our people, and how they actually affect our patients and in COVID-19.

And that some of these comorbidities, like obesity, or asthma, or diabetes, that have been couched as risk factors for COVID-19, are really a result of unaddressed structural racism, the social drivers or determinants of health, and bias that's both conscious and unconscious.

So we've known, and certainly for cardiovascular disease, and that's what the little picture is, as you can see that deaths from cardiovascular disease are actually very much varied by zip code. And in fact, we can predict health and disease very closely by looking at where people live.

And people, by race, are not randomly distributed across the US. There are a number of factors, including where we took entire populations of native people and removed them from land that they could grow food or hunt, and moved them to places that were not sustainable. Redlining and the legacy of Jim Crow had led to people being concentrated in certain areas.

And in those concentrated areas, African-Americans tend to have more poverty, poor quality and higher density, which, obviously, both of those are connected to COVID-19. Inadequate built environment, meaning sidewalks and parks, and food deserts, where healthy food isn't available.

And then you layer that on top some of the chronic stressors, both psychosocial, living with unemployment or racism, but also environmental, where we know that, if you look at the Flint, Michigan story, pollution of air and water. And then we combine that with, actually, how health care can sometimes compound this.

So we know that many minority populations are overrepresented in the uninsured and underinsured status. They often have decreased access, as a result of that or because of lack of health care facilities, to primary and specialty care. And since, if you recall, especially early in the pandemic, you needed a referral from your primary care provider to get COVID-19 testing. You might not have that as available.

The locations, if we look at big cities, many of the locations for drive by, well, you have to have a car. So there is an additional barrier. But they're in suburban areas, which may not be accessible to some of those folks that live in the zip codes downtown.

And so-- and early in the pandemic, and it sort of looked at March and early April data in a number of states where they looked at administrative database, and Blacks and whites with identical symptoms, the whites were much more likely to be offered COVID-19 testing. And if they get sick, they are more likely, as we saw in some of the New York hospitals, to be cared for in under-resourced hospitals.

So there are other factors as well. And I think I framed this because we talk about why is, in Minnesota, 10 times the prevalence of positive testing. Well, think about who are essential workers are. Minorities, and particularly African-Americans, are much more likely to be represented in low wage, but essential service workers, often with no options for telework, and often dependent on getting to work with public transportation in a way that they can't be social distanced.

They are overrepresented among the homeless and incarcerated. And then we layer implicit and unconscious biases that affect both in our population, but also in health care. And finally, I wanted to talk about a few things, other things that contribute and that are historical, or things that we might want to consider.

One is wealth. So we know there is an income gap. But it's really important to talk about generational wealth. And for every dollar that a white family or generation has, a Black family has $0.05 to $0.10. So 5% to 10% of wealth.

The exposure actually, and it's beyond the scope of this talk, but actually, the exposure to racism or discrimination is associated with adverse-- with more hypertension, with more diabetes, with more obesity. I think generally, perhaps until the past couple of weeks, there was an overestimation by our optimistic population that we'd made more progress than this.

And that's why the numbers and data are so important. And there is an empathy gap. And by that I mean, we all are able, as human beings, to be more empathetic with those who are like us. Women to women, white people to white people. And so sometimes it makes it easier to other somebody when they are not doing as well and to almost blame the victim. And I think that's what one of the purposes of this talk today.

So as we go forward, and in the words-- and I'd encourage you to read this essay by Dr. Lauren Powell, who is a public health expert, used to be a state public health expert and is now Executive Director for TIME'S UP Healthcare, that it's racism and not race that's the culprit.

The causes of our current issues are complex, systemic, and many. And honestly, the solutions will be too. I think we have to come out and talk about how race-- because I've heard my colleagues and women bristle when they say, well, being Black is a higher risk for getting COVID or dying having a baby.

And I think it's important to realize that it's just not that simple. We need more data to better understand our history and this legacy, and I'm going to turn it over to Dr. Warsame to help us with that.

RAHMA WARSAME: Thank you, Dr. Hayes. So in God we trust, and to all others, we bring data. So here's the numbers. And I have data as of June 8. So globally, there were 7.1 million cases, 406,000 deaths thus far, and 3.4 million that have recovered.

If we look at the United States as of June 8, they were 1.9 million cases, 118,000 deaths, and 526,000 who've recovered. So now we get closer to home in our state of Minnesota, and now we get a little bit more granular data. There have been 344,000 tests that have been done.

27,886 that have been positive, a little under 1,200 deaths, and a little under 23,000 who've recovered. And now even closer to home, Olmsted County. There have been 711 cases, 12 deaths, and 562 that have recovered. And I really applaud Mayo Clinic for creating that COVID-19 dashboard, which has given us up to date information on those that are admitted, those that are in the ICU, and positive cases.

But what we don't have but we are collecting is race, ethnicity, gender data, which I encourage us to start reporting as well, which will be a theme of my discussion. Now, before we talk about disparities, we need important definitions. So what's health equity?

Health equity is when everyone has equal opportunity to be as healthy as possible. Whereas health disparity is when differences in health outcomes and their causes among groups of people differ not as a result of biology, but because of inherent other issues.

For example, African-American children are more likely to die from asthma compared to their non-Hispanic white children. But another important definition is health differences. There are sex and racial differences in biology, and that is not a disparity.

I'm a hematologist. I treat multiple myeloma. Multiple myeloma is twice as common in African-Americans than it is in Caucasians. That is not a disparity. That is a difference. However, the lower survival that African-Americans have compared to every other population, the less transplants, novel drugs, and enrollment in trials, that's a disparity.

So that'll be important to understand. Now, reporting. Reporting data is critical. It has been sluggish to start. And once we did start, currently 39 states and the District of Columbia are reporting race ethnicity data. There are still 11 states here in Orange that are not reporting.

And I think this graph really, it says it all. So if you look here in the olive green, that is the Black people in America who are dying at the highest rates per 100,000. And then the next closest groups are the Asian and the Latinx groups. What you don't see here is the indigenous groups, because there's such little data, unfortunately, that we cannot even provide any comparable data.

So let's dig into this a little bit deeper. So disparity in death rate among the Black Americans. So Black Americans make up about 13% of the US population, but have suffered 25% of the deaths of COVID-19. And in the jurisdictions that are available to study, they are overrepresented in deaths in 20 out of the 41.

And in 16 states and the District of Columbia, that overrepresentation can exceed by 10% to 31% of the population, which is simply too much. And it all boils down to this. COVID-19 is killing Black Americans at 2.4 times the rate of white Americans and 2.2 times the rate for Asians and Latinos.

Now, what limited indigenous data that does exist is here. We only have six states, and I applaud Minnesota as one of them, are including and reporting data on the indigenous people. Most of the times, they're included in this other category, and it's impossible to be able to rate what's going on in those populations.

For the six states that are there, three of them, the proportion of death to population is about right. However, if you look at Mississippi, Arizona, and then most staggeringly, New Mexico, the proportion of death relative to the population is significantly different.

And then I would be remiss not to mention the Navajo. The Navajo Nation, which spans parts of Arizona, New Mexico, and Utah, the entire population of this people is about 170,000, and they now have 4,002 cases. This Native American group now has the highest number of cases per 100,000 in this country, 2,300.

And for some comparison and understanding, New York and New Jersey, which were the epicenters of this disease in the United States, have 1,800 1,660 respectively. And that is a significant issue. The Navajo are being decimated by COVID-19.

Now let's look at our Latinx population. This may look a little bit small, but it's because there's great data. There is reporting on the Latino population in all 39 of those states and the District of Columbia. And for the most part, there aren't striking differences between proportions of population and the percentages of death.

Overall, the Latinx people are dying at the rates proportion to their population overall. However, this fails to mention the much higher rates of infection of the Latinx group. And more importantly, in four states it is significantly overrepresented in death. And those are in New York, Illinois, Wisconsin, and New Jersey, where their increased representation of death is significantly higher.

Now let's compare this to white Americans. Across all the reporting jurisdictions, white Americans are less likely to die from COVID-19 given their share of the population. And if we look at those of the white Americans who represent COVID-19, they're 61.7% of the combined population, but have only experienced 49.7% of the deaths.

And that's only where race and ethnicity is known, which is why reporting is key. This may be an underestimation, and maybe even an underestimation of the disparity that we do know. Now, great news. As of August 1, all US laboratories will be required to collect demographic data on anyone who receives a coronavirus test. That is age, sex, race, ethnicity, and location.

Without data, we are unable to know where our gaps are and how to intervene. So this is a huge success. Now, Dr. Hayes referred to some of the reasons why these disparities exist, entrenched in a lot of systemic racism. The first thing most people think is higher comorbidities means higher severity means more risk for death.

And that is true. There are higher comorbidities. Hypertension, heart disease, those that were mentioned. But these same diseases are simply a reflection due to systemic inequities that have accumulated over time, such as redlining, access to health care, food insecurity, et cetera.

Now, if we look at-- there have been many strategies as to how to not get COVID now that we know what we can do. Getting tested, Dr. Hayes outlined that. Getting tested was sluggish, to be fair, to the entire nation when we started. But once adequate testing was available, it was not really available to these populations.

It was either not in their areas or the innovations which, for safety, such as drive-through, were simply not an option and a privilege. Wear masks. We all wear masks. I have my mask. Now, unfortunately, for Black Americans, particularly Black men, the perception of their threat or being threatening makes wearing a mask a decision between the risk of getting infection and the risk of unrest and potential police brutality.

And that is a big decision. As Dr. Hayes mentioned, they are overrepresented in vulnerable populations. Over a third of incarcerated people are Black. Another 25% are Latinx. More vulnerable, there are 40% of the homeless population is Black, and those are simply more susceptible to infection.

Socially distance. We hear it all the time. Six feet. We really need to keep that part, that distance. But that is simply a privilege of those who can keep that distance. In these densely populated areas, it is simply not an option.

I grew up in a household with seven people, three bedrooms, and one bathroom. You couldn't get away from each other if you wanted. And if there was a disease, we certainly couldn't get away with it. And so understanding that these opportunities or recommendations are also privileges that many of these people do not have.

Work remotely when possible. That is an excellent idea. Except that most of these populations are unable to work remotely. I'll get that into a little bit more detail. Here in the McKinsey report, they looked at all the essential jobs.

These were the heroes, the people who kept working and had to to allow our societies to continue to function. Now, Black Americans were overrepresented in 9 out of the 10 lowest wage jobs considered high contact and essential services. And as we know, PPE was not available for all. It was barely available for health care workers.

And so these people were going to work without adequate coverage, and did not have appropriate sick leave, and had lower wage incomes, and were mandated to continue work. That is one of the reasons, including the aforementioned things I discussed earlier, as to why they have higher risk of infection and why they are dying at higher rates.

There may be something that may be related to viral load. But more study is simply necessary. Now, the COVID-19 vaccine. I think we're all waiting for it, breath abated for this coveted vaccine. But once it is available, we're going to have to make some critical decision as to who gets it first.

And there is a wonderful study published in 2018 that's looked at quantifying the impact of social groups in vaccination on inequalities of infectious disease. It's like they were prophetic. And what they found is that if we equally vaccinated everyone, we would exacerbate the risk of infection in high risk groups by seven times.

That's bad for all of us, because that means the continued propagation of this deadly disease can delay our ability to return to a realm of normalcy. Now, equitable vaccination, on the other hand, in this study, did show better infection control and faster infection control. And I think that's what we all want.

So when this coveted vaccine is available, my hope is that it would first go to health care workers, essential workers, elderly, immune compromised, and minorities. Now, what can we do? Report demographic data. And I'm going to go ahead and check this box. Thank you, legislature that is mandating this.

But we need to do more. Reporting allows us to understand and understand what we need to. Do we need to report demographic data in clinical trials. We need to analyze demographic data in clinical trials to understand whether there is a differential benefit, or worse, harm to certain groups of people.

We need to increase the enrollment of minorities in clinical trials. And that's something I'm very proud to say, at Mayo Clinic, they have been actively removing barriers to increase enrollment, that the languages of the consent forms are available in our most commonly spoken languages, the fact that people are able to go get testing without primary care. And with that, I will transition to Dr. Sia, who will talk more about what we have done and can do.

IRENE SIA: Good afternoon. So we have heard from Dr. Hayes and Dr. Warsame about some of the COVID-related health disparities. And in this section of the talk, I'm going to describe some of the initiatives that we at Mayo Clinic have done to address some of these disparities and lift up some of the things that we have done.

So when COVID started to spread throughout the country in early March and data started to emerge about health disparities, we were beginning to realize that, although there were a lot of credible messages around COVID-19, these messages were not reaching immigrant and minority populations.

But before I describe what we have done, who are we? Well, I am describing a partnership in Rochester called Rochester Healthy Community Partnership, which was formed in 2004 in response to another infectious disease that disproportionately affect racial and ethnic minorities, and that was tuberculosis.

So RHCP was formed with a mission to promote health, and equity, and well-being among the population through community-based participatory research, education, and civic engagement to achieve health equity. And if you would like to know more about who we are, what we do, and how we work together, I would refer you to our website, which is www.rochesterhealthy.org.

So as this partnership started to pass some of our studies and clinical trials, we decided to focus our efforts toward disseminating COVID-19 information to immigrant, and refugee, and minority communities in Rochester. With that, we decided to adopt CDC's Crisis and Emergency Risk Communication framework, which encourages public participation in disease prevention and containment.

The six principles of this framework are be first, be right, be credible, express empathy, promote action, and show respect. But the effective application of these principles indicate that we need to be able to reach vulnerable populations.

And one of the ways to reach vulnerable populations, and this is supported by data and by our experience, is community engagement. Because community engagement engages communities, empower them with decision making, and adds a component of evaluation.

And specifically, community engaged research partnerships are uniquely positioned to operationalize this framework effectively. And why is that? There are several reasons for that. Community engaged research partnerships have already laid the foundation for engagement through prior work.

In the case of RHCP, we have worked with the community for over 15 years now. Partnerships have access to large networks of vulnerable populations. Community partners have organizational and technical capacity, therefore interfacing with vulnerable populations, and partnerships empower community decision making.

So we cocreated what we call message maps around COVID-19 prevention and containment, coronavirus-2 testing, and the socioeconomic impacts of COVID-19. And the same process was used to create updates and weekly messages that have been translated and continue to be translated into six different languages.

How is this operationalized? Communication leaders who either self identified themselves or were identified by community leaders representing six language groups were disseminating the information within their social networks. These communication leaders were trained during a single teleconference to deliver messages, and participated in daily teleconferences during the first two weeks of this implementation.

So here's a screenshot of what this teleconference might look like. And I would just like to take a moment to acknowledge some of the people in this screenshot. Dr. Mark Whelan with Community Internal Medicine is my kind of academic partner and colead in RHCP.

These are some of our community partners. These are representatives from the local public health department. Dr. Jane Njeru is also in Community Internal Medicine, who is also an academic partner in RHCP. RHCP also encourages and have mentored learners, and two of them are here.

Dr. Natalia Castillo is an infectious disease fellow, and Dr. Shafi Mohammed is also in Community Internal Medicine. Dr. Mohammed started working with RHCP when he was in high school, and he is soon to be a Mayo Clinic staff in the next few weeks. So congratulations, Shafi.

So how does this work? So messages were created by community academic partners, and communication leaders then disseminated this information to their communities. And in addition to disseminating information, communication leaders were soliciting and listening to community members lift up their concerns about COVID as far as with relates to health and socioeconomic impacts.

So this bi-directional communication allows us in the partnership to rapidly refine messaging according to changing facts and community concerns. This bi-directional communication also allowed us to provide timely answers to questions and concerns from the community, allowed us to leverage resources, and allowed us to lift up the voices of these vulnerable community members to decision makers.

We conducted a participatory evaluation of our intervention during the first two weeks of the implementation to assess what our intervention reach was to assess acceptability and feasibility. So we use qualitative data from tracking sheets, from summary notes, and semistructured interviews, and mapped it to the CDC CEIC framework.

So how did we do? In the first two weeks of implementation, we reached almost 10,000 individuals in the community across six ethnic and language groups. And the communication was done through a number of different communication mediums, mindful of the physical or social distancing guidelines that were and are still in place.

Our evaluation showed that by adopting this risk communication framework by cocreating messages, by modifying messages later that the communication leaders felt that they were supported in disseminating accurate COVID-19 messages. The evaluation also indicated that the bi-directional communication allowed the team to adapt the messages and connect community members to resources in real time. And community concerns were used to influence local testing policies and practices.

So this is the RHCP COVID-19 Task Force, which is now composed of over 30 individuals, with various community organizations represented. But this is not the only initiative that Mayo Clinic and Mayo Clinic providers have been doing in the community.

So I have the privilege today to share some of the efforts that are done by our colleagues who are not here today. So the Fostering African-American Improvement in Total Health is under the leadership of Dr. LaPrincess Brewer in the Department of Cardiovascular Medicine.

And when this all started, Dr. Brewer conducted a neat survey of several churches that serve African-Americans in Rochester in the Twin Cities, and found out that the majority of these churches had no emergency preparedness team or plan.

And she also identified the top three church needs that included trusted health information, financial support, and food and utilities. And in response to this, Dr. Brewer has since distributed emergency preparedness planning manual to over 100 churches and has also created a Facebook page to distribute accurate COVID-19 health information, and I'll come back to that in a moment here.

Extending her work with a federally qualified health center, the Open Cities Health Center in the Twin Cities, Dr. Brewer has now pilot testing rapid testing strategies using the Mayo Clinic laboratory's diagnostic processing to see if that testing can be facilitated and with a rapid turnaround time.

So as of the moment, over 100 tests have been performed. And out of those, approximately 30 positive, COVID positive cases, have been detected. Not only is this important, but this process has also allowed the reduction of the turnaround time of results, which has significant impact not only to the health center, but to the patient and the community.

And Dr. Brewer is currently testing the effectiveness of a community-driven, culturally tailored messaging to see if this might increase the uptake of COVID testing among this population. In Florida, Dr. Richard White has also adopted RHCPC, our framework to disseminate and develop culturally appropriate messages to the Hispanic community.

They have established a communication leaders forum, have biweekly Zoom calls. Messages are posted on social media forums. They have had radio appearances as well as town halls. In all of these three examples of what we have done, the important thing to remember is that COVID-19 messaging has been culturally and linguistically tailored.

The example here on the top is an example from the FAITH project with the African-American community. The example in the middle is for the Hispanic community in Florida. And the two examples at both ends of this slide are examples from Rochester Healthy Community Partnership.

In Arizona, several town halls with African-American and Hispanic communities have been convened by Mayo Clinic staff, and there has been a cross sectoral participation in these town halls and Q&As, including physicians, researchers, policymakers, community leaders, as well as local health officials.

And recommendations from these town halls and Q&A have been lifted up to local officials and decision makers. There have been other community engagement activities that have been supported by the Center for Health Equity and Community Engagement Research, one of which is to facilitate testing among or for the Native Americans, American Indians, through the Native American Research Outreach.

A lot of these efforts have been facilitated by Ms. Jenny Weiss, who also happens to be a cofounder of the Rochester Healthy Community Partnership. So thank you, Jenny. The Mayo Clinic employees in Arizona has coordinated an emergency relief drive for essential needs that they have distributed for the Navajo Nation.

So in summary, community engaged partnerships are really uniquely poised to respond to pandemic risk communication needs, including COVID-19 with at-risk communities. And with that, I turn it over to Dr. Hayes.

SHARONNE HAYES: So before we move in to our Q&A, and I hope there are some good discussions. I think to wrap this up, the necessity for us to better collect and analyze these data related to race, ethnicity, and gender, and for those of you who know, my life's work has been heart disease in women.

And the fact that we were not analyzing data about heart disease by gender or by sex meant that we missed the boat for women with heart disease. We don't want to repeat this here. We need to look toward culturally tailored resources for this disease, as outlined by Dr. Sia.

We need to-- not discussed here, but so important because it's so pervasive, is looking at the effects of implicit bias that affects health care workers. It affects all of us. And if we think about when implicit bias is most likely to be co-opting our brain, it's when we are stressed. It's when are fearful, when we are busy.

And that has been the chronic state for the past few months in this COVID-19 impact. And I think finally acknowledging the impact of racism on US health care, on health care in Minnesota, Arizona, and Florida, and look to ways that we individually, and as an organization and through our community, can work to limit the effects on this.

We really live in two Americas, where access, and wealth, and power are really unevenly distributed and have led to some of these differences in COVID-19. And so as this pandemic has pulled the veil, or the bedsheet, off of some of these disparities, I think looking how Mayo and we individually can be part of the solution is really what we hope to convey today. Thanks, and we'll take questions.

CARNA: Well, thank you for the presentation. And we do have time for questions. As a reminder, the Slido code is MGR, all caps, 20, MGR20. I'll start with a few questions that came in during the presentation. One is a question, or rather a comment, regarding disparities between rural and urban America. What do we know? What can be done if they do exist?

SHARONNE HAYES: So I'll start, just because broadly, some of the biggest disparities are, if you look at cardiovascular disease and others, are between rural and urban. So we often think of disparities as being the inner city. But in fact, the health outcomes, the poverty, there is little to no data as of yet on COVID-19. And I will look to Dr. Warsame, because she's looked at the data most closely.

RAHMA WARSAME: So until August 1, we have not had specific locations that have been released. So they will tell you per county. And so the data has been limited. I think it will be very interesting. I suspect, much like everything else, the rural communities will be hard hit, and we're going to see a significant disparity there.

CARNA: Do you-- I just am kind of discussing why do we think it could be related to multigenerational households' access to care. Probably too soon to know. But any ideas regarding that distinction?

RAHMA WARSAME: I suspect that a lot of it is access to health care and access to credible knowledge. Because initially, you really did need a referral. And there are areas in rural America where the closest health care facility is over 100 miles. And If you're already ill and there's mixed messaging, it's difficult to get credible messaging. But I suspect it's about access to health care.

SHARONNE HAYES: I think it also is it appears that the spread of COVID-19 has been delayed. So there may be some complacency in terms of-- and that's why some of the communication has been upped, that these small towns or farm towns, it maybe hasn't hit somebody that they know yet. But when it does because of lack of social distancing, it may well be a worse hit.

CARNA: Thank you. We have a couple questions related to next steps. One person mentioned, wonderful presentation. I notice that my primary care patients receive messages during COVID-19. Did non-English speaking patients receive messages as well?

SHARONNE HAYES: So you mean the message that went out from Community Health?

CARNA: I believe so, Yeah. Yeah. And then kind of a follow up question. So recognizing Mayo Clinic as a leader in health care and human care, kind of future directions and immediate next steps. And I might open that up to the panel for comment. I think they're excellent questions.

SHARONNE HAYES: I actually don't know the answer to how ECH, Employee Community Health, did that. Obviously, I got my message in English because that is my preferred language. So I think that's a great question and one to consider.

And to push on that, because sometimes we assume that-- you know, the people who are preparing those messages and sending them out may not be cross checking the preferred language box that has been checked. And I think upping our game in that regard, particularly when there is urgency.

CARNA: Thank you.

SHARONNE HAYES: Dr. Sia, did you want to comment on that? And you would know, because you're connected with that population.

IRENE SIA: I guess my answer was in response to what do we need to do next. From our standpoint is that I showed the data on our performance the first two weeks. But we have actually not gathered data on the effectiveness of the messaging.

And so that would be, to us, the next step, evaluating how effective or messaging has been, and what are the barriers to some of the things that people are still not following. So we see people still not physical distancing, people in the community still not wearing face masks or face coverings. So what are the barriers to those? Those are some of the things that, for us, we should be able to do and we're planning to do.

SHARONNE HAYES: I would just comment directly to what are some of the barriers. So one of the things when the Twin Cities was so hard hit after the riots and sort of the pillaging, some of which were some of the clinics that were critical access clinics. So you had a disadvantaged population that, now their only source of health care was not open anymore.

And we reached out to some of those, including the Broadway Clinic and Smiley's Clinic, which are University of Minnesota affiliated. And one of things they said, you know, our community, they don't have masks. And we don't have little ladies in basements who are flipping them out 100 a day either.

So that would be a need. And I think it gets back to what you said, Irene, in terms of asking what is needed. So I think we assumed, well, maybe they need some medical supplies. They need PPE for their health care providers. No, the University of Minnesota was doing fine with that.

They were more concerned about how do we get and protect our population. And to do that, you have to have people who can talk to them, like you. And we have to listen.

RAHMA WARSAME: I would add about-- answering to the question of what can we do next. And I may be a broken record, but I think transparency in reporting. Like, we should have weekly notifications of who we're enrolling in trials, and if there is a clear distinction, and who is getting into trials, who's being offered trials, and who we have that's positive and sick.

I think that holds us accountable to recognize that we may need to do something different. Reporting allows us to shine the light as to the areas that we then need to then figure out a way to intervene. And I hope that that comes through, so that our dashboard afterwards includes all the trials, what trials are enrolled by race, gender, ethnicity. And I would hope that this would be nationwide, but that's what we can do locally.

CARNA: Thank you. Next question. How many of the regional variances in outcomes do we think are related to the known disparities?

SHARONNE HAYES: I would answer that that we don't know. And I think it goes back to the point is, we're so early in this pandemic, and there's so much we don't even know about the virus. And I will defer to my infectious disease expert.

But the actual knowledge, and so, to take it to that, I think we know that there is, just by the numbers that we have now, that there has to be certainly some impact to quantify it. But I think we must.

I think, to the person who asked the question is, if we say it's 20% race differences, not disparities, and 40% disparity, then we have different targets of treatment. Then we say, well, let's try to understand differences in responses to a drug as opposed to addressing social determinants of health.

CARNA: Thank you. The next two questions relate to telemedicine and technology. In the era of telemedicine, how will we address the gap, or what are some ideas for addressing the gap in access to the services provided via technology?

SHARONNE HAYES: [INAUDIBLE] Irene, because--

IRENE SIA: That's a good question, and I don't know that I have the answer for that right now. But I think telemedicine, certainly, is something that we need to-- it's one of the things that we as an institution can really look at, is that how is telemedicine being utilized or do these populations have access to the technology that will allow them to be involved in that kind of thing.

RAHMA WARSAME: I suspect if we use schools as an example, it has clearly resulted in exacerbating the privilege and disparity. So I think telehealth, which has been fantastic, and important, and safe way to give care, mandates that we require a way to provide either a place where people can go safely and be able to access it.

We need to then look at internet opportunities. And a lot of this hit the educational realm. So I think we need to partner with groups so that we can come up with solutions that would affect and be helpful for all of us.

SHARONNE HAYES: I think one thing we know is many minority populations actually have bigger uptake of smartphones and cell technology and less so-- but they may not have Wi-Fi. And so recognizing that we need to not assume that everybody has a laptop that can interact with us and be ready with that.