In this special edition of Ethics Talk, Dr Uché Blackstock joins us to discuss COVID-19 morbidity and mortality outcomes inequity by race and what needs to change now and postpandemic.
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Tim Hoff: Welcome to another special edition of Ethics Talk the American Medical Association Journal of Ethics podcast on ethics and health and health care. I'm your host Tim Hoff.
As data begins to emerge about patient mortality from COVID19, stark trends are beginning to take shape. In Milwaukee, Wisconsin, where 26% of the population is black, 66% of people who have died from COVID19 are black. In Louisiana, black residents make up 32% of the population and account for 70% of the deaths from COVID19 in the state. The story is the same all over the country. Patients who are members of minoritized racial or ethnic groups are dying at disproportionately high rates. The reason for this is not a mystery. We know what's happening. Entrenched health inequities translate to increase disease burden, lack of access to care and ultimately to worse outcomes. The questions these inequities raise demand that we look not only back understand how we got here but forward to understand where to go.
With me today is Dr. Uché Blackstock. Dr. Blackstock is an emergency medicine physician and the founder of the Advancing Health Equity, an organization whose mission is to help close the gap of persistent health care inequities through speaking engagements, workshops and consulting services. She joined us to discuss racial and ethnic inequities being expressed through COVID19 and how we should address these inequities moving forward.
Dr. Blackstock thank you very much for joining me.
Uché Blackstock: Thank you for having me.
Hoff: COVID19 health outcomes data coming out across the country demonstrates racial and ethnic inequity particularly in disproportionately high mortality rates. Given what we already know about the pervasiveness in centuries-old persistence of social and health inequity this is not new, and it's not surprising. But we should be asking what the current pandemic illuminates about racial and ethnic health inequities that we might not see as clearly in so-called normal times. What should we be paying attention to about inequity in this COVID19 pandemic that can then guide us about how to address health inequity even after we get through this crisis?
Blackstock: That's a great question, and as you alluded to we had preexisting racialized health disparities and inequities before this pandemic. So, we had black and brown communities carry very high chronic disease burdens, black women have the highest maternal mortality rate, black men have the shortest life expectancy, so this pandemic is essential putting a crisis on top of a crisis. But, I do think there are additional factors that have been illuminated in the recent weeks that makes these communities even more vulnerable. So, many of the black and brown communities are low-income, they have low wage, um, low-wage workers and many of them are essential workers and service workers. Interestingly in this pandemic many of them are the frontline workers, so they often still have to go to work, and they are exposed to the public and they are also exposed to sick colleagues. They often do not have the luxury of working from home. And so, I think that what we've seen is that these communities which are already vulnerable in terms of their health status due to manifestations of structural racism, in this pandemic situation are made even further vulnerable by other factors.
Hoff: In a recent interview with Slate you describe a difficult conversation that you had to have with so many of your patients lately specifically about the fact that they should be tested but won't be due to scarcity of test kits and limited organizational resources. How do you have these conversations?
Blackstock: As we see with the pandemic as it's an evolving and dynamic situation, my conversations with my patients have also been evolving and dynamic. I noticed this week in particular which is the apex of the pandemic here in New York City, I've just seen the volumes increase of patients presenting COVID19 symptoms and had to have these conversations more and more often, and they don't get any easier. I tell patients that I acknowledge that we're in very, very scary times. I acknowledge that their symptoms are concerning to them and to their family. But, I also tell them that we are in a situation where we have very limited resources, and I try not to go into the reasons why but we know the reasons why, and that we have to save those tests for the people who are the highest risks for developing serious complications from COVID19. So, the elderly and people with chronic medical problems like diabetes, high blood pressure, obesity, and asthma that make them more prone to becoming really very, very ill with the disease. And so, I acknowledge their frustrations. I tell them in an ideal world we would have the ability to test everybody. And sometimes patients they get it, sometimes they say, “I understand I'm having relatively mild symptoms I know what to look out for if I were to get sicker.” And then other people I've had some very uncomfortable even sometimes awkward situations. Even one patient got very upset and he actually just stood up while I was talking to him and for a second I actually felt a little scared because he was so upset. Um, but, I just try to make my patients understand that I do get it, I get their frustrations. But I also tell them that right now in terms of whether they are tested or not that really wouldn't change what I tell them to do.
Blackstock: Do you know what I mean? It wouldn't change …
Hoff: Because it's standard advice of…
Hoff: Quarantine yourself.
Blackstock: Yes, exactly, exactly.
Hoff: Conditions of scarcity are not unique to pandemics. These conditions do draw more attention however when they influence how well positioned health care systems are to respond to illness affecting the white and wealthy and privileged among us. A commonly heard phrase during this current pandemic is that “COVID19 does not discriminate.” While this is somewhat true it's also a little bit misleading since both conditions of scarcity and urgency prompt us to think differently about who deserves what and when and why. Put in another way, wealthy white people of the global north and global west are not as practiced to dealing with life under conditions of scarcity and urgency. So, what are the lessens here for how we should orient ourselves to racial and ethnic inequities after COVID19 has given some of us a “baptism by fire” exposure to scarcity and urgency that we might never have had to navigate before?
Blackstock: In thinking about our current situation and thinking about how even within the health care system this idea of just being aware of social determinants of health is not something that most clinicians are really in tune with, probably more for in the public health sphere. I think what we need to realize is that our one-on-one interaction with our patients are so much more than just this interpersonal relationship, that we really need to think about: what are the individual resources of this patient in terms of educational level, income, wealth? What are their neighborhood resources in terms of housing, food choices, public safety? What are their opportunity structures? So how are the schools in their neighborhoods, are they disinvested in? Is there lack of jobs? How does the criminal injustice system play a part? And so, I think that what this pandemic has shown a light on in so many different ways is how really social determinants of health and even more so structural racism which is a fundamental factor that influences social determinants of health. What's a large role it plays in health outcomes, and how as not only as clinicians but as a health care system, we really need to be more proactive about how our interventions influence those social determinants. And so, I know that Jonathon Metzel and Helena Henson have talked about this idea for years of structural competency – of how policies and economic systems and social hierarchies like structural racism can influence poverty and inequality which then influence downstream health outcomes. I think that this pandemic just sort of emphasizes even more how we really need to understand how that process works. And think about proactively about ways and interventions to improve health outcomes downstream.
Hoff: During a daily White House briefing on April 7, Dr. Anthony Fauci acknowledged the racial disparities and COVID19 related outcomes while suggesting “there's nothing we can do about it right now except to treat patients as they come.” A common response to that statement seems to be to ask, “well when is the time to address these disparities” and “why can't health equity work be integrated into current pandemic response.” I just wanted to get your thoughts on that.
Blackstock: What we do know is that those inequities exists before, they are being magnified and amplified now and they are going to exist after this, right? And so one of the reasons why we are calling for the release of statewide racial, ethnic, and demographic data about who is being tested for COVID19, how many cases are there, and who's is dying from this is because right now in this moment dynamically we need to be able to act equitably allocate resources to communities that need them most. So, if we're seeing from this preliminary data that there are certain communities, black communities that are being more harshly impacted by COVID19, then those are the communities that are going to need more testing that are going to need more health care workers especially like, so New York City for example is issuing a request for health care workers from other states to come and help given that we are the epicenter and our resources are overwhelmed, right? So, we need to make sure if health care workers are coming to New York City – and we have the data that was released yesterday that black and Latino communities or people who develop COVID19 are more likely, 2 times more likely, than white New Yorkers of dying – then we need to send those health care workers to those hospital in those communities. We need to make sure that ventilators that are being sent to New York City are sent to communities that need them most. While we definitely will need to address health inequities continually after this, we need to address inequities dynamically in real time as well.
Hoff: Dr. Blackstock thank you very much for joining us and sharing your expertise on this.
Blackstock: Thank you so much for having me and giving a platform for discussing this important issue.
Hoff: That was Dr. Uché Blackstock, an emergency medicine physician working in New York City and the founder of Advancing Health Equity.
Thank you for listening to this special edition of Ethics Talk. Fact checking was performed by the journal's senior research associate Shaun Rouser and music was by the Blue Dot Sessions. For more information on the ethical challenges of pandemics, please visit our site, journalofethics.org, where we have curated content relevant to the current outbreak in our COVID19 Ethics Resource Center. Be sure to rate, review and share and follow us on Twitter @journalofethics for the latest news and updates. That's all for this episode, talk to you next time.
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