‘Because we are trusted’: Managing COVID in disadvantaged groups

‘[T]here’s increased prevalence [of COVID-19] in disadvantaged communities all over the world, and we certainly have noticed that in Melbourne and in Australia the high prevalence areas of COVID are also in the areas of socioeconomic disadvantage.’
 
That is Dr Kate Walker, Chair of the RACGP Specific Interests Refugee Health network, speaking on an on-demand presentation for the RACGP’s annual conference GP20.
 
As one of the GPs who volunteered at a public housing tower in Melbourne’s inner-west during the hard lockdown in July, Dr Walker knows firsthand the challenges that can arise.
 
‘[That] was a very interesting experience as a GP. My role was very different in that people were quite suspicious because there was a lot of police around,’ Dr Walker said.
 
‘The challenge was building rapport, and working with the communities was very difficult in this situation.’
 
In the presentation, Dr Walker presents a case study to her fellow GP panellists of a refugee family in her care who came into contact with coronavirus.
 
The family of seven had already been impacted by overcrowding, unemployment, chronic disease, substance abuse, domestic violence and had dealings with the criminal justice system. This, to Dr Walker, demonstrates the complexities GPs need to consider when caring for and supporting their patients.
 
During the wider Melbourne lockdown, Dr Walker noted an increase in mental health issues among her patient cohort, with lockdown measures for some triggering traumatic memories of war and persecution. The challenges experienced by some in navigating telehealth made clear the barriers such as low health literacy and language.
 
‘People were having decreased access to their care, afraid to go out … sometimes the messages of “you can still attend your GP” are not getting out there and people are staying home and not accessing their GP for their regular healthcare,’ she said.
 
Panellist Dr Libby Hindmarsh, Chair of the RACGP Specific Interests Abuse and Violence in Families network and editor of the RACGP’s White Book, raised concerns over financial hardship and overcrowding in the home as triggers for violence within the home.
 
‘We have good evidence that domestic abuse and violence has increased in our patient population over this period of the COVID pandemic,’ she said.
 
‘But half of these people said police or other services hadn’t been notified and one of the reasons they said it hadn’t happened was because they had safety concerns.’
 
Dr Hindmarsh said this highlights the importance of GPs being mindful, particularly during a telehealth consultation, about whether a patient has a safe space in the home to have a confidential conversation.
 
Meanwhile, Dr Hester Wilson, Chair of the RACGP Specific Interests Addiction Medicine network, discussed the need for GPs to be aware of any substance dependencies patients may have, and their ability to access these substances. 
 
‘You need to make an assessment – does this person have alcohol dependence? Are they at risk of withdrawal? Are they at risk of a complicated withdrawal? How do you manage that, supporting them with medication to go through that withdrawal period?’ she said.
 
While it may seem counterintuitive, Dr Wilson said if patients decline treatment that GPs also have a role to play in ensuring they have access.  
 
‘[I]f you have someone who is dependent on alcohol, you don’t want them withdrawing without support,’ she said.
 
‘If they don’t wish to do that [have treatment] you provide them with alcohol, you provide their cigarettes for them. Now for me as a doctor, it’s like oh my god – I’m providing this stuff, which just has no nutritional value, [when] I spend my whole life trying to get people to stop. But in this situation we do need to continue to help people access the legal substances that they use.’
 
Caring for people in prison was raised by Dr Penny Abbott, Chair of the RACGP Specific Interests Custodial Health network, who pointed out that though Australia has not experienced the severe caseload of COVID in US prisons, lockdown restrictions had put a significant strain on people in prison and their families.

‘[As] the person comes into prison … they’re put into isolation for 14 days, which you can imagine is quite hard when you’re very distressed at your incarceration and then you’re in a room by yourself with very little contact,’ she said. ‘Then after that … there’ve been no visits in prison.’
 
For those released from prison, Dr Abbott said GPs play a critical role in ensuring a smooth transition.
 
‘[T]hat first week after release is a time when things can go belly up because you have so many stresses,’ she said.
 
‘There are so many factors that mean that you really need so much [help] post-release, and GPs are well placed to provide that and to be part of that detection system.’
 
While state health departments have continued to work with socioeconomically disadvantaged communities during the pandemic, Dr Walker said some people fall through the cracks.
 
‘[I’m] not saying GPs have to take this role with every individual, but having a mindful proactive approach to looking out for what might be missing is important,’ she said.
 
‘Making appointments for people who don’t turn up or haven’t turned up in a while, making sure our recall systems are in place, and working with interpreters is really critical through telehealth.
 
‘It’s [also] quite a good proactive thing to discuss with patients who are in high risk groups – how would they manage [COVID] in their family? Where would they go for testing? Is there a room where one member of the family could isolate? How would they manage the bathroom situation?’
 
Dr Wilson said it is crucial that GPs broach sensitive topics if necessary.
 
‘These conversations can be hard, they can be shameful … or it may not be safe or it may not be private. So continue to offer to support people to ensure that you can assist them in terms of helping them to manage their substance use [for example] throughout this time,’ she said.
 
‘Say “it is a part of my role as a GP to ask this because I want to ensure I can support you in any way you need”.
 
‘[W]e as GPs have this incredible place because we are trusted … [It’s] known that we can support people to access that specialist care should they need it.’
 
‘Caring for disadvantaged communities in the pandemic: Stories from the frontline’ is now available to access as part of GP20’s on-demand program. To view the full program, visit the GP20 website.
 
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