Mathematics. Engineering. Nursing. Supply-chain management. This is not a list of required courses for a college degree, but rather the skills necessary for families taking care of a child with type 1 diabetes. In the face of COVID-19, many families are struggling to maintain the complex daily routines that keep their child with type 1 diabetes safe.
Caring for a child with type 1 diabetes is a team effort among families, schools, and health-care teams. Parents constantly monitor their child’s blood sugars and give multiple shots of insulin each day. Many children depend on school for meals and on the expertise of school nurses to help manage their diabetes. During school hours, school nurses take over the parents’ job of blood sugar checks and administering insulin shots. COVID-19 has upended these routines and threatens the delicate balancing act that keeps at-risk children healthy and out of the hospital.
Who is at greatest risk? Type 1 diabetes affects close to 200,000 children under age 18 in the United States, with well-known disparities by race and income. Studies in Philadelphia and throughout the country have repeatedly shown that black and Hispanic children, as well as children who live in poverty, suffer from higher rates of childhood diabetes complications. These disparities persist into adulthood, leading to higher rates of heart disease, kidney disease, and blindness.
As members of a pediatric diabetes health-care team, we are worried that COVID-19 is increasing the disparities that already exist. Without attending school, children are at risk of being without meals and lifesaving insulin shots. Parents who work in lower-income jobs are both more likely to have lost their jobs during the pandemic and more likely to be essential workers, risking their own health to serve others. Who is supervising a child’s diabetes care while parents are at work and there are restrictions on who can safely enter the home? And how are families affording insulin and diabetes supplies?
The way we are providing health care has changed. Social distancing now requires that we only see urgent patients in clinic. As a result, telemedicine has replaced most in-person diabetes care. These visits require patients to have cell phones with data plans or a broadband internet connection, and work best when patients are able to upload their diabetes data through a computer before their visit. Many of us take this technology for granted. While the digital divide between lower- and higher-income Americans is shrinking, there are still stark differences in access to technology for low-income families.
Some of our patients are lucky enough to have an extra member on their team to address racial and economic disparities: a community health worker. Community health workers are nonmedical, lay members of the community who help break down barriers that prevent families from being able to adequately care for their child’s diabetes. They link families to community resources and act as a liaison between families and their health-care teams. Community health workers live in the same communities as their patients and often have faced similar challenges to the families they serve.
During this period of economic and social instability, community health workers’ personal connection with families, and on-the-ground experience of dealing with social assistance programs, have proven invaluable. They are helping families to connect with their health-care teams through technology, applying for economic relief, finding local food pantries, strategizing childcare, and providing a virtual shoulder to lean on during these difficult times.
There is a growing interest in the addition of community health workers to the health-care team as an innovative, cost-effective way to improve health outcomes. But securing funding for their work remains a challenge. Despite the increasing evidence that addressing unmet social needs improves health and reduces costs, insurance reimbursement for community health workers varies widely by state. The addition of community health workers to pediatric diabetes care teams is still in its beginning stages, and our program is funded solely by grants and institutional support.
We must address the challenges faced by marginalized families and prevent the widening of existing health disparities in children with diabetes during the COVID-19 pandemic. It is time for insurance companies and health systems nationwide to embrace community health workers as valuable resources and vital members of the health care team.