Health Equity (Muodeme, 7/23/2020)

Special thanks to Dr. Ada Muodeme for her thoughtful and thought-provoking Grand Rounds this week on Health Equity. 

A friend and healthcare provider asked me this week, "Why are you hosting  so many Grand Rounds on race, racism, equity, and inequity?" My response is the following: "We bring you these topics because we-- the Sonoma County medical community-- need formal education on these topics. We need race discussions in our academic centers, in our hospitals, in our clinics, in our classrooms, break rooms and beyond. Grand Rounds is a natural place to start these conversations."  

And I am so grateful to our brave residents for being the leaders of this education!

While social justice was definitely integrated into my own medical training, race and racism in medicine were definitely not a part of any training. I did not get taught about how race and racism are structurally a part of medicine. I was not trained on allyship, anti-racism or white privilege. These are topics most white people (myself included) need to hear, read about, grapple with, and consider both personally and professionally. While many of our current residents come to us now with formal training in race and medicine, their teachers have little to none. 

And so we do this work.

This is another GR presentation by a BIPOC better listened-to than summarized by a white gal like me, but here are a few key points:

• Dr. Muodeme reminded us that healthcare comprises only 10% of an individual's health and well-being-- the remaining 90% includes behaviors, environment, societal factors, etc. She grounded her talk in the historical perspective of the African American citizenship status and health experience from 1616 to 2020-- slavery, Jim Crow, and Civil Rights. 

• Dr. Muodeme also shared with us a definition of health equity: "The attainment of the highest level of health for all people". Health equity-- she continued-- requires valuing everyone equally, societal efforts to address avoidable inequities and injustices, and the elimination of health and healthcare disparities.

• But what I appreciated most about Dr. Muodeme's presentation was her focus on the concept of unconscious bias, and the process of self-reflection and self work we all need to do to help mitigate those biases. "I don't know a doctor who comes to work thinking I don't want to right by my patients today," she said. "I don't know a doctor who thinks I am going to treat my black patients differently". And yet, we know we do. The system does. And we do. 

And so, pay attention, watch your thoughts, all. And see you next week!

Health Disparities of Pandemic Proportions: A Review of Health Disparities in the COVID-19 Pandemic (Sidhu, 5/27/2020)

Many thanks to Dr. Navee Sidhu, who gave a disturbing and thought-provoking presentation on Health Disparities in the COVID-19 Pandemic.

Dr. Sidhu described how health and social disparities permeate the COVID-19 Pandemic, examined the impact of racism on COVID-19, discussed how long-existing institutional and structural factors put communities of color at particular risk, and challenged us to consider how this impacts everyone.

Five questions from Dr. Sidhu for you to consider:
1) What will it take to create a more equitable society post COVID-19?
2) How do we center disenfranchised communities in the recovery process?
3) How does the health care system (at all levels) need to change to better support the health and well-being of its workers, patients and the society it serves?
4) What does it take to become healthy and maintain health?
5) What does quarantine look like for different people?

Part 1: Historical context for events in the present pandemic
"Any time we talk about historical context in the US, it is important to acknowledge where we have come from. . .a history of colonialism, genocide, slavery, oppression, exploitation, and capitalism."

• Social undesirability has long been associated with increased risk of "contagion" and "sickness"
• We have a history of protection of whiteness to ensure that power remains in white hands in our socialized system (xenophobic scapegoating)
• Immigrants have always been associated with disease: Irish immigrants=>Typhoid, Italian immigrants=>TB and smallpox, European Jews=>Cholera, 1900s Chinese immigrants=>Bubonic plaque
• 1980s AIDS=>gay men and Haitians, 2002 SARS=>Chinese, 2000s Ebola=>African
• This lens reinforces well-established misconceptions that individual biological differences are based in race, e.g: 
• non-truth that African Americans were "immune" to yellow fever (1890s)
• undertreatment of black patients  in ER for pain, different lab values for African Americans (NOW)
• Decreased COVID testing for black patients (NOW)

Part 2: COVID-19 Disparities in SoCo, SF, CA and USA

• In Sonoma County, Latinx currently comprise 67% of COVID cases while only making up 27% of total population. (see image) 
• This is a case rate of 104/100,000 in Latinx vs. 24/100,000 in whites
• In SF, 95% of COVID positive patients in the Mission District are Latinx (Latinx population comprises 44% of total population)
• only 10% of Latinx reported being able to work from home
• majority earn <$50K/year (poverty)
• majority household size >3 people
• In California, Latinx make up disproportionate number of cases and deaths from COVID-19 compared to proportion of the population-- across ALL age spectrums
• In the US, there is a paucity of data reported based on race, however  with the data we DO have, we know that 
• Black people account for 25% of US deaths (while only comprising 13% of US population), and are tested at lower proportional rates
• In Arizona, Native Americans comprise 20% of cases, and 21% of deaths (but only 4% of the state's population)
• In Illinois, African Americans account for 38% of COVID deaths and 24% of confirmed cases (while making up 15% of the state's population)
• In Kansas, Latinx comprise 51% of cases (and only 12% of the population)
• You can find more of this data on https://covidtracking.com/
• In summary, people of color experience lower testing rates, higher infection rates, and greater mortality rates. People who test positive more likely to live in poverty and live in multi-person households

Part 3: Impact of systemic racism and capitalism on the pandemic

• Black and brown communities are set up by our society to suffer greater health consequences during a national health emergency
• American capitalism is born from slavery
• Profit as motivation that reinforces oppressive conditions 
• Billionaires gaining wealth at expense of workers
• Large corporations getting bail-outs
• Recovery focused on GDP rather than health and well-being of human beings
• Racism (from Camara Phyllis Jones, MD, MPH, PhD)
• A system of structuring opportunity and assigning value based on the interpretation of how one looks, which we call 'race'
• Structural and institutionalized racism are "differential access to the goods, services and opportunities by race. . . [it is] normative, sometimes legalized, and often manifests as inherited disadvantage
• Predominant white bodies shelter in place, while black and brown bodies continue to work, sacrificing more to return to economic baseline
• Long-standing health and opportunity disparities in housing, finance, judicial system and healthcare correlate with increased covid-19 exposure, hospitalization. and death


• Housing: significant disparities between house ownership between races (home ownership is an important marker of social mobility in this country) (see image)
• Finance/accumulation of wealth is racially discordant (see image below)
• Justice system: disproportionate incarceration of black and brown bodies make people more susceptible to the pandemic (see image below)
• Healthcare: private entities value profit over people. Access to healthcare is paramount to a successful pandemic response, inevitably distributes the response along racial and class lines

• Historically disadvantaged communities have higher rates of comorbidities:
• African Americans have higher rates of hypertension, 2x rates of heart failure, 3x risk of dying from asthma, 3x rates of chronic kidney disease, and 2x prostate and colon cancer, also comprise 44% of HIV+ population
• Latinx are twice as likely to have and die from diabetes, and twice as likely to have chronic liver disease (than non hispanic whites)
• During a crisis, people of color present sicker at baseline, while also in crisis, hospitals are allocating resources in time of scarcity to those who are "less sick"
• Although disparities have improved slightly, 40% of quality measure still worse for blacks than whites (2017)

Part 4: Life in Quarantine

• The Essential Worker 
• "You (meatpacking worker) are giving a great service to the people of the US, and we need you to continue as a part of critical infrastructure, to show up and do your job" (VP Pence)
• With inadequate education, few resources for workers, people of color being asked to make a sacrifices at great risk to their own health
• Who are our essential workers?
• 64% women, 41% people of color, 34% over age 50, 16% live with someone >65, 36% have minor at home, 24% live in families with incomes <200% poverty level
• Ongoing outbreaks at meat processing, UPS, amazon distribution centers
• Essentially these bodies expendable, at great financial benefit to their employers
• Essential workers are being told to return to hazardous work environments, sites with very high exposure risk
• What does life for folks who can effectively work at home and remain safe look like compared to continuation of life for "essential workers"?
• Normalizes sacrifice of health and body
• Only 10% of white americans know someone who has died from COVID
• Pre-exiting stress from minority taxes
• The "myth of individual accountability"
• The US Surgeon general asked African American people to stop drinking, smoking or doing drugs to protect them during COVID-19 (blames black people without explaining larger forces at play, which all people of color more vulnerable to this pandemic)
• Only 18% of white adults are worried they will get covid, while 43% of Latinx and 31% of black adults say they are concerned
• Racialization of comorbid disease focuses on a group; while true health disparities exist, these are actually markers of racial inequality (not biological). In fact, systemic racism results in comorbidities and increased infection and death from COVID-19

Part 5: Ideas for individuals how to move forward, where do we go from here?
Will the system stretched to its limits snap back to its original state of inequity? OR Will the system stretch exacerbate states of oppression and make things worse? OR Will the system morph completely and focus on equity, reconciliation and appreciation of the sacrifices people have made historically and in the present?

What individuals can do now?
Here are a few concrete action items:

• Understand your implicit biases: Harvard Implicit Bias Test
• Also know your biases can be exacerbated by stress
• Watch these Right to Health Web-in: 
• https://www.youtube.com/channel/UCz6VafF5GzIuCmqdF9yFb4A
• https://www.youtube.com/watch?v=xoXA8QFlC7s
• Read this article: https://journals.sagepub.com/doi/full/10.1177/1090198120922942
• Connect with HPEACE, volunteer with IsoCare, Petaluma People Services
• Talk to local governments: write letters to SoCo Board of Supervisors, state and national representatives using your clout as healthcare provider (www.5calls.org)
• Donate to Undocufund (or ask your wealthy friends to)
• Talk to your employer to hold them accountable for workplace safety for everyone

Reflections on Inequity and Solidarity in the Pandemic Present (Holmes, 4/8/2020)

Many thanks to Dr. Seth Holmes, who jumped in late to present a terrific and timely Grand Rounds this week on Inequity and Solidarity in the Pandemic Present.

As a great thinker and scholar, Dr. Holmes took us through history, sociology, anthropology, philosophy, and breaking news to challenge the lens we use to view our current state of the COVID-19 Pandemic. And to insist that while we comply with physical distancing, we should simultaneously be striving toward social solidarity.

Some questions to start us off:

• How does the novel Coronavirus pandemic follow the fault lines that already existed in our society-- particularly the inequalities and the discrimination?  How does this pandemic force us to look anew at these fault lines?
• Is this an historic opportunity to think about what kind of society we want to be-- to remedy those inequalities so that our health system and our social system can be more healthy, more safe, more truly democratic, and more inclusive for all people? 
• While we undoubtedly need to adhere to physical distancing recommendations, how can social solidarity help us survive this and any future pandemics?

In his presentation Dr. Holmes invoked several scholars' work on the notion of SOLIDARITY:

• French sociologist Emil Durkheim, who studied societies and asked the question: How do societies hold together despite social differences and increasing division of labor? His answer: Social solidarity: the sentiment and practice or feeling and action of interdependence between individuals and groups in a society

• Physician and scholar from Martinique, Frantz Fanon: Solidarity can and must transpire in the midst of social difference, including solidarity across national lines (against colonial powers) and between people within the countries against colonization, as well as solidarity across racial lines (against racist social systems)

• Educator and theorist Paolo Freire: Solidarity is a collective project. .  capable of changing not only the ways in which society is structured but also has to change everyone who is involved (people with less and more power) . . .Liberation brings about transformation of the exploited and the exploiter.

• Combahee River Collective (Robin D. G. Kelley, Angela Davis): Solidarity as coalition building recognizes connections between different forms of inequity, different forces of exploitation, and highlights the need to stand together for the good of everyone. . .this is difficult to achieve in the US in which individualistic models of health are most common.

And as we ponder our place in this pandemic and many of us work on the front lines in hospitals, clinics, and facilities across Sonoma County and beyond, Dr. Holmes challenged us to ask ourselves the following.

How might we use social solidarity during this pandemic to. . .

• protect our mental health? 
• avoid social constructs of stigmatization?
• build systems that benefit the health of all?
• protect the health of everyone, including (and especially) those who have been most marginalized our society?

As former US Secretary of Labor Robert Reich pointed out in a recent opinion piece,  "In many senses, our country doesn't have a fully functional public health system. Instead we work in a for profit health care system that is disjointed and ill-prepared for this crises and future crises. . .If we want to survive this and future pandemics we must understand how critical our public systems are for everyone in our society.

Let us not overlook the effect of this pandemic our most vulnerable, those who are

• incarcerated
• detained
• homeless
• poor
• people of color
• Recent Atlantic article by Ibram X. Kendi: inordinate numbers of people of color dying at roughly twice the rate of white people in the US (histories of institutional and structural racism) (Ref: What the Racial Data Show: the pandemic seems to be hitting people of color the hardest)

We are all in this together. We must stay connected. We must confront racism, xenophobia, and stigmatization. We must fund our public health and social systems. We must support those most marginalized, stop incarcerating and detaining those on whom our system relies.

With social solidarity, we can change our system.