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Episode 3 – Structural Inequities and the Pandemic's Winter Surge

Learning Objectives
1. Understand the trajectory of the COVID-19 pandemic's unique impact on communities of color in the United States and its tie to historical discrimination and structural inequities
2. Describe the racialized and politicized national response to COVID-19
3. Recognize the crucial role that social interventions can and could have played in decreasing the burden of COVID-19
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The Clinical Problem Solvers Antiracism in Medicine Podcast Series aims to equip listeners with the consciousness and tools to practice antiracism in their health professions careers. Learn more.

Audio Transcript

Utibe Essien MD, MPH: This is Utibe Essien.

Dereck Paul, MS: This is Dereck Paul, and welcome back to the Anti-Racism in Medicine series of the Clinical Problem Solvers podcast. Where, as always, our goal is to equip our listeners at all levels of training with the consciousness and the tools to practice anti-racism in their health professions careers.

Paul: We have a very special guest today. Ed Yong is an award-winning journalist and science writer for The Atlantic. This year, Ed's reporting, including his cover story, "How the Pandemic Defeated America," has won several journalism awards. And there are surely many more awards to come. Ed Yong, welcome to the podcast.

Ed Yong: Hi. Thanks so much for having me.

Essien: Ed, again we're so grateful for your time here. Our show, as I mentioned, is about practicing anti-racism in medicine. And in our journey so far we've learned a lot about the importance of combating structural inequities. In your piece in August this year, you mentioned that the coronavirus found, exploited, and widened every inequity that the US has had to offer. You know with the second wave coming, or actually being here today, how can we have seen the structural inequities play out at this point? And what do you think we can expect to come?

Yong: Yeah. I think many of the people of color I know who work on infectious diseases and pandemic preparedness saw what has actually happened happening a mile away. It went from the earliest points of the pandemic. People recognized that Black, and indigenous, and Latino, and Pacific Islander groups were more likely to be disproportionately influenced and disproportionately infected and killed by the coronavirus. Even when policymakers and politicians were describing it as a great equalizer, I think it was clear to everyone who had studied inequities that was not going to be the case. That as a result of very long-standing inequities in American society, and in American medicine, that some groups were going to enter the pandemic with a slew of disadvantages that made them more likely to contract and die from COVID-19. And of course, I am not talking about biological disadvantages. There's nothing inherent in anyone's DNA - or anything like that - that accounts for these discrepancies. It's the result of discrimination and/or social factors that have been part of American history since the very beginning.

Paul: That's extremely helpful. And I appreciate you reinforcing that concept of race as a social construct and not a biological one. And so we're frontline workers. I think we see things up close. And one of the big benefits I think of your writing has been, I think it's allowed some of us to see some of that bigger picture. And COVID is, yes, revealing those existing structural inequities and the structural racism in the United States. But my question for you is, do you see racial injustice in the way that we've responded to COVID? To the national response to COVID?

Yong: Yeah, I think so. So, my colleagues Adam Serwer and Ibram Kendi have written beautifully about this at The Atlantic. And Adam wrote this searing piece in, I believe, either the late spring or early summer, about how the coronavirus was an emergency until Trump and his associates saw who was being infected. And I think there's some truth there. I think when you--I think the fact that it was clear quite early on that the virus was initially predominantly hitting blue states, coastal cities, and it was taking a disproportionate toll among indigenous and minority groups, that that contributed to some of the inaction. And to be clear, even if there wasn't malice involved, even if there wasn't a deliberate decision to let communities of color take the full brunt of the pandemic, then the administration's utter incompetence achieved much of the same effect. If you don't have policies that specifically address inequities at their core, not as some sort of sidebar, then you are just going to make those inequalities worse. If your policies are equal opportunity, then the virus is going to just slam into every inequity that the country had to offer.

And as we said, it had plenty to offer. I mean, just look at the most recent figures from APM Research. So, one in every 1,600 white Americans has died from COVID, one in every 875 Black Americans have died, and the per capita death rate is almost twice as high. And that's truly shocking. And that's the result of not just letting the virus run wild but also not putting in place the kinds of policies that would help people who came into this with a disadvantage.

Essien: Yeah. That's such a critical point, and I appreciate you also mentioning the APM Research Lab that's really been putting out critical data related to the disparities that we've been experiencing in COVID-19. And Dereck mentioned our role as frontline workers and one of the themes you've been especially reporting on more recently is that COVID-19 is not just releasing resource limitations as a barrier—you know you had this powerful story earlier this month titled "No One is Listening to Us," and it really emphasized that point, really touching on colleagues from across the country around their challenges with experiencing and managing and caring for COVID-19. Tell us a little bit more about what you've been hearing on the ground from our colleagues.

Yong: Yes. So healthcare workers around the country I've spoken to have just told me that they're feeling exhausted, that they're stretched to the very limit. And I feel a bit weird about telling both of you this since you are frontline healthcare workers. But certainly, I've heard from people in the Midwest especially where the current surge is particularly bad that--it's almost impossible to really convey the scope of what they're seeing.

I had a nurse in Nebraska in what is--in the University of Nebraska Medical Center, arguably the best-prepared hospital in the country for infectious diseases and for emerging infectious diseases in particular, tell me that she thought…she used to work in oncology, so she's no stranger to death and suffering. But the amount of death that she has had to deal with in the last two days is almost beyond her comprehension. She just can't process it. Hospitals have had to open up…so this hospital, in particular, has opened up 10 COVID units, each of which is an entire hospital floor. One of those units is entirely for patients to die. In Iowa, the state is out of staffed beds. One of the nurses I spoke to said she's just had to emotionally shut down. There are only so many body bags that she can zip. COVID patients are some of the sickest patients that many healthcare workers have ever had to treat. They require twice as much attention from an ICU nurse for three times the length of the hospital stay. They just sap a huge amount of resources and attention and a lot of them won't make it. I think it's a really bad situation.

And look, again, I don't want to--I don't want to be telling both of you what the experiences of Black physicians are at the moment. But I think one thing I've heard from a lot of physicians and scientists of color is that they--for all the horror and stress that people in medicine and science are experiencing right now--people of color are experiencing that plus extra. So not only are they dealing with all the same problems that their white colleagues are dealing with, but they are also having to deal with a huge amount of personal grief. Black people, Latino people, Indigenous people are much more likely to know someone personally who's died from COVID. So they're adding mourning on top of all their normal duties. Also, they're having to deal with institutions like hospitals and universities that seem to have only just this year discovered that racism is a thing. And are now asking them for help, and advice, and consultation on how to be anti-racist. And that's coming at a time when they have all this other stuff to do. So I think it's very much the case that people of color in professions that are stretched to the limit are really stretched to the limit right now.

Paul: It's true. And I want to shout out folks like Dr Uché Blackstock, folks like Dr Esther Choo, who have actually been representing our profession to the country and to the world, and have I think done just a great service in representing us and those concerns too. And then, just to add another piece of context for folks who might not be familiar with the University of Nebraska. Really arguably the leader in infectious disease, and really led us in terms of how the US related to the Ebola pandemic. And what I'd ask you is--one thing that I've been thinking about and we've been talking about is, we hear some of our national leaders come back and forth and calling this the China virus, right? And I think there's something underneath that that I think maybe isn't quite obvious. I'm wondering how you think about it? Why are folks doing that, and what's the utility of it to them? And do you see it relating to this conversation we have about racism and structural inequities?

Yong: Yeah, definitely. I think in all epidemics there is always a move by bad actors to shift the blame on to specific groups of people. Often marginalized communities who make convenient scapegoats, or who can be sort of analyzed and dismissed even further. So, with HIV obviously, we had gay people, sex workers, people who used drugs. There was no shortage of marginalized communities to stigmatize in terms of HIV. With Ebola, we saw a huge amount of anti-Black racism.

And with SARS, the original SARS and this current coronavirus, we're seeing a lot of anti-Asian racism. It is true, of course, that the virus originated somewhere in China. And I think it is also clear that the Chinese government delayed in releasing information about this new epidemic early on. I think those delays made a major difference of a week, maybe a few. And that's not unimportant, but that also doesn't explain why so many countries around the world, the US almost first among them, have done such a poor job and wasted every possible lead and advantage that they had. Because I think you can put that on China's door, but I think that by doing that, and by deflecting blame to anyone, to China, the WHO, to the CDC to Tony Fauci, what have you. It allows the administration to distract from just how badly its own incompetence has hampered the nation's ability to deal with a virus that so many other countries have been able to control. Not once, but twice. So I think it's part of that. I think it's sort of this mix of trying to distract from the current crisis, plus also this very, very old historical tendency in the case of an epidemic to try and find a group to blame or to dismiss.

Essien: Yeah. That's such a great point. An important point, Ed. I think the shift blaming is- blame-shifting rather is what we're experiencing right now with the vaccine. It's trust in minority communities that's going to be the reason why they take it or don’t as opposed to the actual equitable policies around ensuring that access...

Yong: But…

Essien: Oh, go ahead.

Yong: Sorry. Just on that point, I think it's interesting that you see the types of blame changing over the course of a pandemic. Right? So at the start, I believe there was a lot of rhetoric around, oh, maybe Black folks aren't just taking this seriously or they don't believe that-- when in fact it-- I think the evidence suggests that they were clearly taking it much more seriously than white communities. And then when it becomes clear that they're disproportionately being infected, then the rhetoric shifts to, oh it's because they're more likely to have chronic diseases and be unhealthy or eat unhealthy diets. As if that was an explanation in itself, rather than another pattern that just demanded further explanation. So you can just say-- you can just blame higher rates of heart disease and diabetes without asking, why is it that communities that have been saddled with poverty and segregation and discrimination and all the rest for decades, if not centuries, why is it that they might have higher rates of chronic diseases that then predispose to covid. And then you have people looking at things like, oh maybe it's because of vitamin D or-- it's almost like people will grasp for every possible explanation under the sun except for systemic racism which just comes last.

Essien: Yeah. It sounds like the talks that I've been giving around the country around this topic, you know, the shifting and not focusing on the preventable, but rather developing these ideas or stories based on these unexplained and untrue biological facts like you stated at the beginning of your remarks. In your writing, you say that some of this was preventable. What aspects of this do you think were preventable? As we're about to hit the second wave or again as we're speaking perhaps we're in it, there are some places that are really getting hit hard. There are others that perhaps still have some room to go. Is there anything we can do to try and prevent some of the deepening of the inequities we've been seeing?

Yong: Yeah, I think America has this very strong bias towards biomedical countermeasures. We always look for drugs and vaccines as this silver bullet panacea that's going to solve problems of disease. And the vaccine is obviously a big thing, but we could have done stuff before the vaccine. We could've rolled out any number of social interventions like paid sick leave, hazard pay, support for poorer and disadvantaged communities who couldn't isolate themselves, who couldn't take time off work, who couldn't stop earning the hourly wages that they are currently earning and they keep their families fed. I think those social interventions could do a huge amount of good. So why is it that when we look at things like masks and distancing, we call them non-pharmaceutical interventions rather than what they actually were for most of this year, which were the only interventions on offer?

I have a piece coming out soon about how the pandemic is affecting science as a whole. And one of the points I'm going to make in it is that medicine wasn't always this way. Right? So in the mid-19th century, we had folks like Rudolf Virchow writing, going to European typhus epidemics, and saying regardless of how this disease spreads, it's only an epidemic because of things like poor education, bad housing, bad sanitation, incompetent civil servants, aristocrats who have saddled people in poverty. So he's talking about political and social factors. And he specifically writes, "Medicine is a social science," and we've lost that. We've lost that understanding that medicine has this core social component to it. Medicine over the course of the 20th century was split into the biomedical and the social. The biomedical focused on germ theory, on vaccines, on drugs. And the social one was the part of-- the social side was taken up by sociologists and anthropologists whose views we absolutely need right now. Many of those folks, people I've talked to like the ones you mentioned already: Esther Choo, Uché Blackstock, sociologists like Rashawn Ray, Elaine Hernandez, Cody Bowen, they've been invaluable to me in understanding what we need in this pandemic. I really hope that the lesson we take away once the vaccine arises isn’t just, "Oh, look science saved the day," we could have done so much before that vaccine arrived to save lives that wasn't done.

Paul: And as we bring this conversation to a close, one of the stories that hasn't been covered as much as the others in this pandemic is how COVID-19 has affected indigenous and American Indian communities and nations. In some ways, they have faced incredible challenges from the pandemic, and then in other ways, there have been triumphs and incredible successes in terms of response to COVID-19. Can you tell us a little bit about what you've learned?

Yong: Yeah. So a lot of indigenous communities, I think most famously, the Navajo Nation, early on really struggled with COVID-19. A lot of them live without running water, so washing hands and basic hygiene that everyone else was told to take up just wasn't an option. A lot of them have lung problems because of this history of colonialism and uranium mining on their lands and they're pushed out away from their lands. A lot of them have very poor access to healthcare facilities again because of this long history of colonialism and genocide and discrimination. And then more recently, there was an incredible piece on Stat by Usha Lee McFarling, a journalist who has really made her goal to spotlight marginalized communities throughout the pandemic, about how the Cherokee Nation has done wonders listening to the science and resisting the kind of lax policies that surrounding Oklahoma has taken up. I don't want to do that story for her. I think I would recommend listeners of this to read Usha's piece. Her work in particular throughout this pandemic has been exceptional. And I feel like if anyone--or any listeners of this podcast would find tremendous value in the stories that she's written.

Essien: Ed, thank you again so much for sharing with us today. You provided such a powerful overview of all that you've been writing over this past year. We'll obviously be providing in our show notes links to your articles and some of the articles of the works of colleagues we reference, which as you've been doing on social media where we met, has been so wonderful to see you collaborating and citing other people's work. Again, if there are any parting words for us as physicians, we always love to end our episodes with words of advice for what we can be doing tomorrow.

[music]

Yong: Stay safe, guys. I appreciate you. I hope you weather the coming weeks with your health and your family's health intact, and I hope everyone else does their part.

Paul: Ed Yong, thank you for being on the podcast.

Yong: Yeah, thanks. Take care.

Audio Information

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Disclaimer: The CPSolvers provides information for educational purposes only. It is not intended to be medical advice.

View show notes for each episode at https://clinicalproblemsolving.com/antiracism-in-medicine/.

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