THE DIAGNOSTIC PARTNER: ADDRESSING THE EQUITY IMPLICATIONS OF HEALTH DIAGNOSTICS

Wilbur Lam
M.D., PHD.

We recently spoke with Dr. Wilbur Lam, who will head up the ADJUST Center. Dr. Lam is a principal investigator at the Atlanta Center for Microsystems Engineered Point-of-Care Technologies (ACME-POCT), where he has been instrumental in testing the quality of COVID-19 diagnostics on behalf of the NIH’s Rapid Acceleration of Diagnostics (RADx) program through a collaborative initiative with Children’s Healthcare of Atlanta, Emory University, and Georgia Tech. He is also a pediatric hematologist/ oncologist at Children’s Healthcare of Atlanta’s Aflac Cancer and Blood Disorders Center, and an associate professor at Emory’s Department of Pediatrics and Georgia Tech’s Wallace H. Coulter Department of Biomedical Engineering.

Why is Emory launching the ADJUST Center?

The COVID-19 pandemic was the catalyst. We asked ourselves, what have we learned from our work with COVID-19 diagnostics, and what should we do next? Because people were able to test themselves for COVID-19, the medical community, the scientific community, and the public have learned that decentralized diagnostics work. But shifting the diagnosis of disease to the home raises many questions. How does this affect the practice and business of medicine? Who controls the resulting data? Who will pay for these tests? Who sets policy?

The other driver is the lack of health equity in diagnostic technology. What we saw with the pandemic is that, as usual, people with resources had access to testing first. Immunocompromised and chronic illness patients – who were likely to be from communities of color, of lower socioeconomic status (SES), and far from healthcare resources geographically – needed testing most but didn’t have access. Black and Latinx communities were hit particularly hard by the pandemic; Centers for Disease Control (CDC) data shows that people in these groups who contracted COVID-19 were roughly three times more likely to die from it than non-Hispanic white people. Asian Americans and Native Americans were also at higher risk.

The ADJUST Center has two missions: to help move diagnostic technologies towards the patient and the patient’s home, and to tackle the societal issues that hinder equity in diagnostics. We’ll tap resources across the Emory campus that can contribute to our mission – from the Goizueta Business School to the Rollins School of Public Health – as well as partner institutions like Georgia Tech and Children’s Healthcare Atlanta. Atlanta’s Grady Hospital is also part of our center and as such represents underserved populations whom we’ll focus on helping. We’ll also be developing technologies and helping technology developers to ensure that new solutions are designed to be accessible for underserved populations.

How can diagnostics impact health equity?

PHASE’s joint offering with Dr. B’ telehealth represents a more modern approach to test-to-treat education and facilitation.

You can’t just create a technology and expect it to be utilized by everyone in the same way. Healthcare is not one-size-fits-all; it has to be contextualized within communities and cultures. For example, telemedicine was meant to democratize healthcare. Of course, it grew by huge numbers during the pandemic, but not for those of low SES. Pre-COVID, studies showed that low SES communities had the highest adoption of telemedicine when it was offered in churches, because that was a trusted place for the people who lived there. Community centers like churches had the infrastructure which allowed people to access healthcare remotely even if they didn’t have the technical capabilities at home. Then those centers closed down during the pandemic and many didn’t reopen or opened with reduced capacity. The digital divide and issues of trust are both major factors, and those cultural insights need to be part of the plan.

Another significant issue is usability. In our ACME-POCT work with COVID-19 tests, the majority of those tests submitted for review actually failed, not because of technical issues with the tests, but because patients couldn’t use them. If a person in their home has to go through many complicated steps, or can’t see well enough to read the directions, or aren’t dexterous enough to use a pipette, they can’t successfully complete the test. It doesn’t matter how well a technology works; if the user can’t effectively implement the technology, it’s useless.

If we want to offer all people the same access to diagnostic testing, we have to understand each community, engage with them, and bring them the technology in a way that works for them.

With a lift in awareness from COVID of “test-to-treat” as a fast, effective response, do you see the approach being rekindled for other infectious diseases?

Yes. STIs are an important area of opportunity for test-to-treat, as is hepatitis C. There’s a big push for what we call point-of-care diagnostics where people can get a test result in less than 30 minutes. I think in the next few years we will see some STI or hepatitis C test-to-treat products, which means that you can get tested by a nurse or medical assistant in a storefront, jail setting, or in a community-based organization. Eventually, we’ll see over-the-counter products combining at home self-tests with treatment coupons or even tests co-packaged with medication.

What advice would you share with healthcare professionals around the test-to-treat approach?

I would encourage them to be raise awareness and promote the program to their patient population. Messages in their patient portals, patient education materials in the waiting room, quarterly wellness newsletters, and website videos. There are many ways to create awareness and educate your patient population.