Blacks and whites traded places in Ky. coronavirus statistics as the pandemic became less urban and more rural

Graph by Bruce Maples (click to enlarge); dashed lines show races' share of state population.

By Bruce Maples

Kentucky Health News

As the coronavirus pandemic took off, there was a striking anomaly in the data: African Americans were being infected, and dying, at a rate much greater than their share of the population.

The difference was so great, and so striking, that it drew frequent comment from Gov. Andy Beshear in his daily press conferences. A month into the pandemic, on April 11, he announced that Kentucky Blacks were dying of Covid-19 at a rate two and a half times their 8.4% population share; they were 21% of the deaths in which the person's race was known (81% of cases at the time).

Graph by Bruce Maples; dashed lines are races' share of state's population.

Over the past year, however, the proportion of Blacks in the daily case and death numbers have steadily declined, to the point that they are now roughly the same, or less than, their share of the population.

At the same time, white Kentuckians' shares of Covid-19 deaths have steadily climbed and are now greater than their share of the state's population. Whites' share of cases also rose.

Meanwhile, Asian Americans' share of Covid-19 deaths in Kentucky is now less than their share of the population, reversing the pattern from early in the pandemic, when they were affected by some of the same factors as African Americans, one health expert said.

Dr. Sarah Moyer, director of the Louisville Metro Department of Public Health and Wellness, said many persons of color are "essential workers," often in customer-facing industries such as restaurants and grocery stores, and thus could not work from home. So in the early days, while many people were able to be "healthy at home," the Black and Asian populations in the state had to go into work, and thus were more at risk.

But as things began opening up, white institutions have been more aggressive about doing so, Moyer said: "More white churches went to in-person services. Black churches tended to stay remote. More whites started traveling. And, it's been largely white-majority schools that have pushed to get back into the classroom.

"And, it's just anecdotal, but it seems to me that whites are more willing to take risks."

State's latest report on cases and deaths by race and ethnicity

Donna Arnett, dean of public health at the University of Kentucky, said she suspects the early infection rate among people of color led to some "acquired immunity."

"I don't want to use the term 'herd immunity,' because we aren't clear on just where that line is," Arnett said. "But I do think that the large number of infections could have led to acquired immunity in that population."

She added, "An Indiana study showed that for every reported case, there are about 10 more cases that are not reported and not counted. So, that early spike we see on the graphs actually represents an even larger spike of cases, which may have affected later infections."

In Louisville, Moyer noted most of the people under 60 who are dying of Covid who are under 60 are Black or Hispanic.

One thing that has seemed clear over the past few months is that the rate of infection has dropped in the urban areas in the state, and increased in the rural areas.

The pandemic was later in getting to rural areas, but when it did, it found a vulnerable population that was sicker, older, and has less access to health care, several reports have noted.

WFPL graph shows higher rates of new coronavirus cases in rural counties and one health district.

For example, Louisville's WFPL reported Dec. 23 that the November death rate in the Kentucky River Health District was 107% higher than the statewide rate, so deaths there were 4% of the state total though the district has only 2% of the state's population. Out of 120 counties in Kentucky, only 18 had higher death rates in November than those comprising the Kentucky River district, based in Hazard.

Daily Yonder graph

This trend is national. The Daily Yonder does a weekly look at coronavirus cases and Covid-19 deaths in the rural U.S. Its latest graph clearly shows that the pandemic went from being an urban issue to a rural issue in August of last year, and that the divergence only grew as time went on, until recently.

Now vaccines are widely available, but public-health experts worry that rural residents will be more hesitant to get them, or outright resistant to the idea. They say the same sort of targeted communication that has been directed at communities of color needs to be designed to overcome rural reluctance.

Norton Healthcare announces five-step plan to address health and racial inequalities in Louisville and in its own house

Norton Healthcare has announced a five-step plan to address health care and racial inequalities in its own organization and the Louisville communities it serves:

• Establishing the Norton Healthcare Institute for Health Equity, which will identify and remove obstacles that prevent people in under-served areas from getting care.
• Ensuring access to primary care for everyone by providing more convenient and geographically accessible care. 
• Making a commitment that Norton's leadership will mirror the community, and taking initiatives to create an equal opportunity for growth, development and advancement for all team members.  
• Providing more education and advocacy on health-policy issues to help its workforce make more informed choices, while advocating for vital safety-net programs such as Medicaid, the Supplemental Nutrition Assistance Program and Temporary Assistance for Needy Families. 
• Investing an additional $20 million in permanent facilities and equipment over five years to address health needs in under-served areas. 

“When we announced our $5 million investment with the Louisville Urban League last fall, I said the investment was just the beginning and that we will be fully engaged in eliminating health care disparities in our community,” Norton President and CEO Russell F. Cox said in a news release. “Since then, we have opened a primary care office in the West End YMCA building and tested nearly 1,000 people in under-served neighborhoods for covid-19.

“Now we must collectively work harder and faster than ever to embrace and understand our differences, be more inclusive, create a sense of belonging, build a genuine welcoming environment for everyone, and ensure that all people have an equal chance to live a healthy life.”

Randomized coronavirus and antibody testing in Louisville will determine 'true extent' of virus, could be extended to rest of Ky.

By Melissa Patrick
Kentucky Health News

A project aimed at finding out the true extent of the coronavirus in Louisville has moved into its second phase after receiving a $1.5 million donation from the James Graham Brown Foundation, with hopes that it will be replicated across the state and nation, and even the world.

"The project is a national model, and we hope the rest of the country will follow in the coming months," Aruni Bhatnagar, director of the University of Louisville Christina Lee Brown Envirome Institute, said at a news conference Monday, June 8.

The Co-Immunity Project is a collaboration of the Envirome Institute and the Louisville Healthcare CEO Council, along with Louisville’s three major health systems, Baptist Health, Norton Healthcare and UofL Health.

Bhatnagar said invitations bearing a U of L seal have been sent to 13,000 households in all parts of Louisville asking them to participate in free testing for both the coronavirus and its antibodies. Participants will be selected based on age, race, sex, background and location to create a sample that matches Jefferson County's demographics.

Illustration from UC Davis Health

The first phase of the project involved testing nearly 1,500 health care workers for the virus and its antibodies. Tests of the public began with 2,400 people. They will be followed by random tests every eight weeks, with about 22,000 being tested when the project is finished. The first round will be completed by June 20, with the results to be released 10 to 12 days later.

"It is our hope that through this type of regular, representative [testing] is that we will be able to calibrate a response with greater precision in risk group, in timing and in location," he said. "But to succeed, it will depend on the participation of our community."

Initial results from statewide testing in Indiana released in May found that the number of infections was about 11 times higher than had been reported at the time of the tests, and that about 45% of those who tested positive had no symptoms, Marcus Green reports for WDRB.

Bhatnagar explained that while testing capacity has greatly expanded across the state, these results are not representative of the entire population, because they only include people who choose to be tested and this type of testing does "not tell us about the true extent of the virus in our community."

"We need not only expanded testing, but smart and consistent testing," said Bhatnagar "We need to test a random sample of people who are representative of the entire community. Much like a well-designed political poll, we have to be careful to ensure that the  test results from a group of people mirror that of the larger population. Only this can give us a real picture of who has the virus, and who has had the virus."

Bhatnagar said the data from this study will best represent an urban setting, and that he hopes to eventually extend this project to the rest of the state: "It would be somewhat precarious to extrapolate the results from urban areas to rural areas, so I think if this model could be followed in the entire state of Kentucky, then we would in the future like to include both urban and rural locations."

The news release says scientists from around the world can use the data to study effectiveness of antibody therapies and to identify types of individuals who are better able to fight off the virus.

Free webinar Friday on actions against health disparities, limiting covid-19 impact on marginalized and vulnerable populations

A free webinar on Friday, June 12, will highlight actions that some organizations are taking to address inequities and disparities and to minimize the disproportionate impact of coivd-19 on marginalized and vulnerable populations. The webinar is sponsored by the Foundation for a Healthy Kentucky.

Speakers include Heather Howard, program director at State Health and Value Strategies, Fran Feltner of the Center of Excellence in Rural Health at the University of Kentucky, Anita Fernander of the UK College of Medicine and Sadiqa Reynolds of the Louisville Urban League.

Vivian Lasley-Bibbs, vice chair of the foundation's board of directors and director of the Office of Health Equity for the Kentucky Department for Public Health, will moderate.

The webinar will run from 10 to 11:30 a.m. It is free but participants must register here.

Community health workers help Kentuckians deal with the multitude of obstacles between them and better health

By Melissa Patrick
Kentucky Health News

BEATTYVILLE, Ky. – Fannie Callahan, a 62-year-old woman from Lee County, worked at the local nursing home for 38 years before retiring, has insurance, and pays her bills on time. But a six-day hospital stay in 2013 left her thousands of dollars in debt and wondering how to pay it and also cover her basic needs – until a co-worker told her about Kentucky Homeplace.

Samantha Bowman, CHW

Samantha Bowman, a community health worker at Homeplace, said she was able to call Fannie's bill collectors and get the debts written off or reduced, then helped her create a payment plan within her budget.

"I was in distress and really didn't know which way to turn," Callahan said. "I don't know what I would do without Kentucky Homeplace."

For more than 20 years, Kentucky Homeplace has used community health workers to get thousands of Kentuckians the services they need. Most of its clients are either at or near the poverty level, but the program is free to anyone in the 30 Eastern Kentucky counties it serves.

CHWs aren't medically trained, but come from the communities they serve and are trained patient advocates who help coordinate their clients' care, provide access to medical, social and environmental services, and deliver education on prevention and disease self- management.

Homeplace is part of the University of Kentucky's Center of Excellence in Rural Health. CERH Director Fran Feltner said preventive screening rates are higher for Homeplace clients than state and national averages "because the CHWs really work with them to make sure they get screened." The mammogram rate is 89 percent, far above the state's 58 percent and the nation's 60 percent.

Bowman said the greatest needs for her clients are medical, and she often helps them get medical supplies.

Counties served by Kentucky Homeplace are in blue

"We see those working-poor individuals or even middle-income individuals that come in here that have tried other avenues without success," she said. "They are working 40, 50, 60 hours a week, but the income is not enough for them to be able to afford to access the care they need, whether it's glasses, dentures, hearing aides, medications, or even diabetic shoes -- they can't afford to get them."

Bowman said she also helps her clients become better health consumers, noting that many leave their doctor's office without a real understanding of their diagnosis or what they need to do about it.

"The majority of them can't work through the medical system, it's too difficult. They don't understand, most of the time, even the medications they take," Bowman said.

"So Homeplace makes a huge difference in looking at the person as a whole and starting from that beginning screening to know what the person really needs. Is it that they need food? Is it that they need shelter? And then when you get those goals met, then you can talk to them about preventive care," Feltner said. "The success is that holistic approach that we take to take care of the people."

CHW and similar programs vary across the state

The Montgomery County Health Department's CHW program, called "The Bridge" (or "El Puente" for Latino clients) is clinic-based and focuses on chronic-disease management.

Gina Brien, director of the agency's Community Department, said surveys of clients show that they are more able to manage their at-risk or chronic conditions, have better health status and have reduced emergency-room visits and overnight hospital stays.

The Barren River District Health Department uses CHWs and registered nurses in a "self-management program" and only accepts clients who have heart failure, diabetes and chronic obstructive pulmonary disease.

Cara Castleberry, manager of the Community Health Management Program, said one of its program's many successes in the past year has been an average drop of 2.15 percent in their patients' A1C, a test for blood sugar.

The Mountain Comprehensive Health Corp. in Whitesburg uses registered nurses as quality care managers to coordinate care and improve patients' health behaviors. The program requires patients to have two chronic health conditions and is covered by Medicaid. Care managers provide many of the same services as CHWs, but are also able to manage their patients' health conditions.

"We've seen A1Cs go down. We've seen patients who never come in for preventive exams who have come in for preventives. I had a patient who hadn't had a pap[smear for cervical cancer] in 15 years . . . and she was just too scared to talk to somebody about the fact that she was afraid that she couldn't step up on that bed," said manager Chalena Williams.

Most CHW programs in Kentucky are rural, but the Louisville Urban League recently launched a CHW program, "It Starts with Me," in four neighborhoods in west Louisville, which have some of the greatest health disparities in the city.

"What we are finding with many of our clients is that there is a gap between what a medical provider -- or really any type of organization that they are interfacing with -- is asking them to do and then what they are understanding," said Lyndon Pryor, the league's health program manager.

Pryor said providers think they are being straightforward about recommending medications, but fail to realize patients don't know how to get them through their insurance, or don't have transportation to get to the pharmacy, or that work conflicts keep them from complying with the instructions.

"CHWs are able to sift through all of the different nuances of a person's life and figure out how to get to the best solution possible for the individual," Pryor said.

The future of CHWs in Kentucky

CHWs are becoming an integral part of a health system that is increasingly focused on outcomes and the social determinants of health.

Kentucky's CHW Workgroup, led by the state Department for Public Health, and the state's Community Health Worker Association are working on a certification process for CHWs, in hopes of increasing funding options, which would allow the program to expand.

Insurance rarely covers CHW services. Kentucky's CHW programs are funded by various sources, including the state's general fund, grants and local taxes.

Brien, a member of the workgroup, said it started meeting in 2012 and made progress, but last year's change in administrations has required them to educate the new health officials. Nationally, a formal task force is working on a framework for sustainable, effective CHW programs.

The Bureau of Labor Statistics says Kentucky had between 390 and 560 CHWs in May 2015, the latest data available. Nationally, there were about 48,000.

Feltner said Kentucky needs more CHW programs because there are areas all over the state with great health disparities that would benefit from them: "If you don't remove those barriers and those social determinants of health, you have a sick population."

This article was produced as part of the Health Care Workforce Media Fellowship, run by the Center for Health, Media & Policy, New York, N.Y. The fellowship is supported by a grant from the Johnson & Johnson Foundation. Kentucky Health News is an independent news service of the Institute for Rural Journalism and Community Issues, based in the School of Journalism and Media at the University of Kentucky, with support from the Foundation for a Healthy Kentucky.

More Kentucky patients are recuperating in their local, rural hospitals after surgery in an urban hospital

By Melissa Patrick
Kentucky Health News

Rural residents are increasingly being transferred out of big urban hospitals to recuperate in rural hospitals, many of which are struggling financially and can use the business.

"We have seen trends of this around the state," said Elizabeth Cobb, vice president of health policy for the Kentucky Hospital Association, said in an interview.

Oregon's legislature voted recently to encourage the trend in that state, by appropriating $10 million for rural health-care improvements, with the largest part encouraging such transfers.

In Kentucky, Cobb said the transfers would have to make sense from procedural, convenience and financial perspectives, but when it works out it is great for both the urban and rural hospitals, and also for the families.

"Certainly when there is a treatment or procedure that will take a significant amount of recovery, it is a wonderful thing for rural Kentuckians to be able to transfer back to their community facility to finish off their recuperation," she said.

Oregon's program aims to create a more consistent patient population in its rural hospitals, which will help stabilize their funding. At the same time, the program will relieve pressure on strained urban hospitals, Chris Gray reports for The Lund Report.

Rural hospitals are struggling financially all over the country and often have inconsistent patient volumes, while urban hospitals struggle with reaching capacity, and often worry they might have to expand, Gray notes.

A state report by then-Auditor Adam Edelen last year found that one in three of Kentucky's rural hospitals were in poor financial condition and suggested that to survive, they might have to adapt to new business models, such as merging with larger hospitals or hiring them as managers, forming coalitions with other hospitals, or finding a health-care niche that hasn't been served, such as creating a partnership with urban hospitals to allow rural patients the ability to recuperate closer to home.

While it sounds like a "common-sense system," Gray reports that the program is costly to set up, between $4 and $7 million, but once it is up and running, and the hospitals learn how to coordinate, "it should be self-sustaining, since money from insurers, Medicaid and Medicare will follow the patient," according to an interim workgroup of rural health officials from Oregon.

A rural health physician told Gray that "local hospitals and healthcare access, along with good public schools, provide the backbone for a viable community when employers are looking to invest in a community," he writes.

Louisville comes in third to last in fitness and health ranking of 50 largest cities

Rowing under California's Bay Bridge (Photo by City Kayak)

In a fitness ranking of the country's 50 largest cities, Louisville ranked an abysmal 48th, sitting just above Detroit and Oklahoma City.

These were some of the results of the American College of Sports Medicine's 2012 Fitness Index. Cities were assessed on preventive health behaviors; levels of chronic disease; health care access; and community resources and policies that support physical activity such as bike lanes and parks.

Minneapolis-St. Paul was ranked first for the second year in a row, scoring 77.2 out of a possible 100 points. Louisville got just 32.1 points, but it did climb up one ranking slot over 2011's assessment.

The index is gaining notoriety and "might well become the scorecard for cities looking to attract health-conscious companies and people to settle in for a spell," reports Melissa Healy for the Los Angeles Times. "It draws on parks and recreation data from the Trust for Public Land, on nutrition and health behavior collected by the Centers for Disease Control and Prevention, and on federally tallied school report cards to learn about school policies that promote fitness." (Read more)