The COVID-19 pandemic laid bare the inequities built into the U.S. healthcare system. In this episode of the podcast we continue our conversation with UW Tacoma Assistant Professor Sharon Laing and UW Associate Profesor Wendy Barrington. We talk specifically about how the pandemic has disproportionately impacted communities of color. Laing and Barrington also discuss the health impacts of racism and why racism should be deemed a public health crisis.
Listen to Part I: https://www.buzzsprout.com/265902/4900661-racism-is-a-public-health-crisis-part-i
The COVID-19 pandemic laid bare the inequities built into the U.S. healthcare system. In this episode of the podcast we continue our conversation with UW Tacoma Assistant Professor Sharon Laing and UW Associate Profesor Wendy Barrington. We talk specifically about how the pandemic has disproportionately impacted communities of color. Laing and Barrington also discuss the health impacts of racism and why racism should be deemed a public health crisis.
Listen to Part I: https://www.buzzsprout.com/265902/4900661-racism-is-a-public-health-crisis-part-i
Sharon:
Racism is a stressor that causes wounds to the individuals who are exposed to this and these wounds, it takes a while for these wounds to heal. It is a public health crisis, and it can devastate a community.
Voice over:
From UW Tacoma, this is Paw'd defiance.
Eric:
Welcome to Paw'd defiance, where we don't lecture, but we do educate. I'm your host, Eric Wilson-Edge. Today on the Paw'd, part two of our conversation about the social determinants of health with UW Tacoma assistant professor Sharon Lang, and UW associate professor Wendy Barrington.
Eric:
In this episode, we'll talk about COVID-19 and its impact on communities of color. We'll also talk about the link between racism and stress, as well as why racism should be considered a public health crisis
Eric:
In terms of the pandemic. How has that sort of exposed these issues that you're talking about? And what ways are we seeing those things pop up in the midst of this pandemic?
Sharon:
It's funny because history really is a teacher for us. And unfortunately we haven't learned from history. We've had natural disasters before, and these natural disasters really demonstrate a very strong relationship between social economic status and health status.
Sharon:
So we look at say Katrina back in 2005, over 1800 people died in that disaster. The question that we ask, well, who died during this thing? These people were mostly unemployed or underemployed, they were low income people, they were socially isolated people, and they were people with chronic medical conditions. So we see the parallels to what's going on today.
Sharon:
If we look 10 years even before that, the Chicago heat wave in 1995, where you had for three full days the sweltering temperatures that ran over 100 degrees, 104, 106 for three days. Yet 739 people that died. Who died? Mostly elderly. These individuals lived in the course neighborhoods in Chicago, these individuals had underlying medical conditions like asthma and cardiovascular problems, these individuals were immobile.
Sharon:
In fact, the worst cases that we see for individuals here were individuals who were asthmatic or older individuals with cardiac problems who suffered these heat strokes. Some of these individuals in terms of poverty, they had no working air condition. Some of these individuals in terms where they lived, they lived in communities where perhaps there was some violence. And so the windows are boarded up and they couldn't get out of their homes because of that.
Sharon:
So again the question is, well when disaster occur, who dies? The poor, the sick and the elderly. This is exactly what we're seeing here with COVID-19, except now we have the worst disaster that we could possibly have perhaps in our lifetimes. And which means that these are individuals that have been identified as the ones who are victimized by natural disasters, the numbers are thousandfold or over 150,000 deaths in the United States. And that's very sad.
Sharon:
So let's start with COVID-19. In December of 2019, when this came out, we felt that well no one is immune to this virus, it's an equal opportunity virus. I mean when we looked to Europe, when we looked to East Asia, when we look to Southeast Asia, we saw that everybody pretty much were likely to acquire this awful virus.
Sharon:
Yet as the body started to pile up here in the United States, where we have the diversity, it's not a homogeneous communities. You see the identification of these bodies, they're black bodies, they're brown bodies, and they are indigenous bodies. These are the bodies are piling up here.
Sharon:
Who's most likely to die from COVID-19? A recent reports on this indicated that the infection rate for COVID-19 is three times higher in predominantly black counties than predominantly white counties in the United States. The same report indicated that mortality rate for COVID-19 might be as high as six times higher in black counties in the US than white counties. So these are the things that we must consider.
Sharon:
As far as looking at the specific social determinants of health factors and how they really link back to COVID 19. Let's put those three factors here, socioeconomic status, health access, and bias in our healthcare system. Let's look at those three factors.
Sharon:
We know that socioeconomic status is impacted by obviously if you have a higher status, you have a higher paying job, federal job so to speak. And let's look at where the individuals who perish most, where are they working? These individuals are front line workers. Their jobs are deemed essential yet their pay does not make their job essential because it's low pay.
Sharon:
We're talking about individuals who are bus drivers, who are custodians, who are food preparation workers, supermarket clerks, medical assistants, restaurants, industry workers. These types of jobs, you will see that these jobs are segregated by race and socioeconomic status. Who occupy those jobs? Mostly people of color, African-American LatinX communities.
Sharon:
These types of jobs increases the exposure to this awful virus, hence likely to take the lives of individuals who are employed in these types of jobs. Let's think about where people live and how that also allows us to see the impact of COVID-19 an SDoH factor.
Sharon:
Well, in terms of where people live, communities of colors, particularly low income communities are more likely to live in more disadvantaged communities. You have multiple people who are dwelling within that community. Large number of individuals within a small confined space that encourages the movement of the virus, because there's more people who are likely to contract it.
Sharon:
When we talk about physical distancing in order to help mitigate the impact of COVID-19. When you look at it, physical distancing is really an issue of privilege. Isn't it? Because if you live in a community where you don't have overcrowding, if you live in a community or you live in ... If you have a job that allows you to telecommute, you can physically distance.
Sharon:
What about the communities who do not have the luxury of physically distancing? Because they are in a community whereby there so many of them in the household, because they can't afford to live on their own. And so this is where we see that these SDoH factors really expose or the COVID-19 pardon me, really expose the impact of SDoH factors. People cannot physically distance, people cannot stay away from their low income jobs that exposes them to the disease at a very, very high level.
Sharon:
We look at healthcare access and healthcare status. And again, we see how COVID-19 exposes the impact of SDoH factor and who is infected. Let's ask ourselves where are these testing centers that people can go test for the virus? For the most part, these testing centers are found in affluent communities. You don't see these testing centers in low resource communities.
Sharon:
In many situations in order to get tested, people require a doctor's note. Low income communities who do not have a primary care provider, do not have the doctor's note even if they can go to that testing center, and so they can't get tested.
Sharon:
So there you have again a situation based on healthcare access and income that limits the possibility to remediate the impact of this disease in this community. The final factor that we need to think about is underlying health conditions. As we said and we talked about earlier for many communities of color, because of insufficient income, if they have a particular condition early, they may not be able to take care of it because they just don't have the healthcare access to do that.
Sharon:
Then that means that if you don't, then you may have a severe expression of this particular condition. The recent research shows us that most of the patients who are coming in with COVID-19 have asthma at the highest level. Asthma is a big thing in the African American community. So these underlying conditions that were never remediated that involves even multiple conditions, comorbid conditions, then put certain communities at risk.
Sharon:
So this way you can see how, again access to health care, ability to address your healthcare needs really is a social determinant of health factor that COVID has exposed to show that certain communities are more likely to die from this particular disease because of these factors. The final thing that I want to talk about is bias in our healthcare system.
Sharon:
There's bias and who is referred for lifesaving interventions, there's bias in who is subjected to unnecessary treatments that can be life threatening. We know this from the unequal treatment report commissioned by the Institute of Medicine documenting bias, racism, prejudice, and stereotypes by healthcare professionals. These biases are confirmed in a number of studies since the original report back in 2002. Bias contributes to differences in health care treatment and bias has disproportionately negatively impacted African American communities.
Sharon:
So as far as COVID-19, it was noted early during the course of this pandemic, that due to insufficient resources like personal protective equipment or ICU beds, physicians can make a decision about who gets treated and who does not. So you may have a poor African American person who comes in to be treated, you may have a homeless African American person who comes in to be treated, you may have an overweight African American person who comes in to be treated. Medical doctors can make a decision about who gets treated and who does not.
Sharon:
And they're forced to do so based on the early lack of availability of medical resources. You will invariably have bias in who will be sent home because they are perceived to be far gone, too far gone to save. They may be sent home to die because resources are being saved for those who the doctors perceive as the ones who can be saved, and who are most likely to survive or who deserve to be saved.
Sharon:
Who makes that decision? Bias in our healthcare system, disproportionately affects communities of color leading to disparities in health outcomes. So I guess in wrapping up this particular section and thinking about this. Historically pandemics have exposed the impact of social determinants of health, and has linked as shown that certain communities will perish in these situations. The problem is that we haven't learned from history and yet history continues to repeat itself. Katrina, the heat wave of 1995, COVID 2020, and what else is forthcoming for us to learn our lessons.
Eric:
It's interesting hearing the two of you talk about this. It all seems to fit together into some sort of kind of cleanly and just in kind of like a horrible puzzle. Like once you take the separate pieces and you can kind of see how it all works once it's combined.
Eric:
So this really interesting, also a little depressing but I think we have to get that information and be a little depressed if we hope to do anything about it. In my mind, not talking about it is kind of how we got here. So talking about it, it seems like the first step to doing actually something to change all of this.
Wendy:
If I may I want to kind of step back to something that you just said, because I think it's really important to kind of emphasize. You were mentioning about how this discussion that we've been having has been almost ... Well, it is depressing, it can be overwhelming and that that can instill a sense of inaction.
Wendy:
And I'm kind of going to move us more into talking about next steps and really discussing anti racism and efforts that are anti-racist, and what do I mean by that? So the way that this country has operated since as you mentioned earlier about teaching that racism no longer exists, I don't see color, everything's fine by not being racist, that has contributed to the perpetuation of our systemic racist processes that we are continuing to experience to this day.
Wendy:
So the need to really ... I think we're really at this amazing moment where everyone's eyes, specifically white people's eyes are opening up to the fact that no, no, it's not that I am not racist, it's that I need to be anti-racist. And what do I mean by that? Anti-racism is making intentional change. So action to actually undo the processes of racism.
Wendy:
So not just kind of letting things go as they are, but actually dialing in, pushing up your sleeves, working shoulder to shoulder, and really quite frankly having black indigenous and people of color kind of lead that process of interrogating how racism is working in systems, and identifying and designing solutions to be able to put into practice, to be able to undo the effects, and the perpetrating kind of nature of those racist mechanisms.
Wendy:
So how can we do this? Earlier I spoke of racism really as a social determinant of equity. So given that inequity is a threat to our very notion of a democratic and just society, I'm just going to go ahead and say why don't we see systemic inequity as a symptom of disease, disease of systems. And how can we come together to start to rectify, to treat and cure the disease in our systems?
Wendy:
So essentially our systems need a wellness checkup quite frankly. We need to diagnose systemic racism by evaluating policies, practices, and norms to see if communities are disproportionately experiencing harm or disadvantage. And if they are, we have to make changes to not only stop that from happening, but to actually make reparations or to actually repair the actual harm that's already been inflicted.
Wendy:
So that's one thing. So these treatments can include revising existing policies, developing new policies, and as well as this needing to be done across levels of society. So at the national level, at the state level, at the community level, at the school level, at the organizational level, within our own places of work and worship and play, however we want to kind of define these different spaces that we move in.
Wendy:
Now, this talk especially talking in terms of reparations makes people really nervous because quite frankly adopting and perpetuating whiteness, this concept I described earlier as a state of being which allows systemic racism to continue. It is inherently exclusionary. I kind of talked before about this idea which I really kind of characterize whiteness and thinking that well, if you have something, then that means that I don't have something. Needing to just cut that out, excise it, remove it, amputate that from our consciousness and think more collectively.
Wendy:
So where does nurses come into this? So 2020 has been declared by the World Health Organization as the year of the nurse. And I've been really quite blessed to be able to kind of work with nurses and learn about the profession, especially within my position in the school of nursing at the UW. And I see the profession as having very specific expertise to contribute to actually diagnosing systems and working with stakeholders in those systems to come up with a holistic treatment plan, because that's what nurses do.
Wendy:
I'm learning so much from my nursing students, how nurses are known for thinking through with patients about how to prioritize action to address and facilitate health, respecting and fostering patient autonomy even when countered to Western expectations of health and wellness.
Wendy:
Now, if we can translate that to diagnosing racism and fostering communities of color and empowerment, even when countered to Western status quo notions of how operations have been, we're at a really kind of exciting point to be able to have activated actors be able to start to dismantle and disrupt and transform healthcare, but also this could serve as models for other systems as well.
Wendy:
Because quite frankly, this needs to be done, whether it's in education, whether it's in healthcare, whether it's in law enforcement and criminal justice, whether it's within mortgage lending, whatever, it has to be done across the board. Because racism has seeped into so many of our systems and to all of our systems, because it really, again has been the bedrock that has served to create and perpetuate our nation, which has been founded on white supremacy.
Wendy:
So I think part of this is assessing and addressing social determinants of health and equity. Nurses do this at the bedside, they do this in communities, but really quite frankly, population health nurses need to do this for systems. We need more population health nurses.
Eric:
So, Sharon I'm wondering if you could talk to us about what it means when we say that racism is a public health crisis.
Sharon:
Yes. Thank you, Eric. Now racism is indeed a public health crisis and we need to address it in this way as a nation. I'd like to present as part of the discussion by first conceptualizing what public health is and what racism is. Public health is designed to protect the health of individuals within their communities. Public health promotes and protects individuals where they live, work, play and worship.
Sharon:
Racism on the other hand is a system of power that assigns some type of value to individuals based on a social interpretation of what race is supposed to be. Now, when we think about the impact of racism, it is that it unfairly disadvantages some individuals and communities while advantages other individuals and communities. Therefore, racism leads to inequities.
Sharon:
So racism is indeed a public health concern because it creates inequities, and social and economic inequities cause disease and death to those who are the victims of this virulent effects. What this means is that race matters.
Sharon:
So I'll just look at this from a purely biological perspective, Eric, in terms of looking at the impact of racism on the health of communities. If you look at this from say the activation of our system, the activation of our sympathetic nervous system. You experience a stressful event, you're walking down the street, it's dark, you hear something, you're the only one walking down.
Sharon:
There's an excitation of your system, your heart races, your galvanic skin response, or your sweat gland activity is activated, your pupils dilate. It gets wider to deal with things. So your body is designed to deal with a stressor. And so it's designed to either fight that stressor and remove it from you or to flee from that stressor. But there are changes in your body that's designed to do that.
Sharon:
Well, think about what those changes are. You have cardiovascular reactivity, increase in heart rate, increase in blood pressure. So you have this area of the sympathetic system that is kind of tapped to address this issue. Well, here's the thing. If you experience chronic stress, you are always activating that system, which is a protective device to protect you from the effects of something pernicious.
Sharon:
And you have situations whereby and the research has borne this out whereby African American men seems to have a higher baseline level of heart rate variability. Why? The explanation for that is that the exposure to chronic stress in this case, chronic racism raises or elevates the action of that system and puts this community at risk.
Sharon:
And hence you will see higher levels of cardiovascular reactivity, or cardiovascular diseases in communities of color, particularly black communities than you will see in white communities. That's one way in thinking about how the exposure to stress, racism being a stressor can cause poor health outcome in a community that's exposed to this for sustained periods.
Sharon:
The other thing, the other way I'd like to look at this is research that address wound healing. So it's looking at the time it takes to heal from a wound when you are distressed. And there's research that looked at undergraduate students that show that wound healing for students who study for an exam is shown to be 40% longer than those not studying for an exam. Stress therefore lowers our immune system, lowers the T cell activity, reduces inflammation.
Sharon:
And so the time it takes to recover from an insult to the system is much longer when you are experiencing stress and distress than if you're not experiencing stress. So here's the problem that we have here. Not only do you have the various systems that are being galvanized like heart rate activity, that puts you at risk because it compromises the system, but you have a situation where you're laid bare because anti-inflammation is happening, and you're unable to respond to an insult that is trying to penetrate your system. A cold, a flu, a virus, COVID-19.
Sharon:
So this is how when we speak about racism being a public health crisis, racism is a stressor that causes wounds to the individuals who are exposed to this. And these wounds, it takes a while for these wounds to heal. It is a public health crisis and it can devastate a community.
Wendy:
Sharon, I think that's a really great point and how you have centered the conversation not on racial differences in health outcomes, but the actual impact of racism on physiologic processes that put people at risk for disease.
Wendy:
The evidence is growing about the impact of racism and Sharon has shared with us about that. But up until this point, the academy really, and researchers have really wanted to focus on trying to explain differences in health outcomes because of these racial categorizations, instead of recognizing that it's the experiences of racism that are contributing to these differences in health outcomes.
Wendy:
So how is anti-racism playing out now? And quite frankly this is a fairly new, I mean calls for anti-racist approaches are not new but actual political will, and when I say political I mean that's going to vary. We're not seeing that at the federal level, but within more local levels, whether it be state or county or organizational, we are seeing changes such that people and organizations are willing to implement these approaches.
Wendy:
Currently I'm working with the Washington Department of Health and federally qualified health centers to increase preventative cancer screening rates. Screening for breast, cervical, and colorectal cancer can save lives by finding cancer earlier when it's easier to treat.
Wendy:
There are two federally funded screening programs that provide screening opportunities for low income and on or under insured populations seen at Federally Qualified Health Centers or SQHCs. And we are now discussing how to make the work that we're doing, this partnership, how we can actually implement anti-racist strategies.
Sharon:
As we think about the applications of this work, my research appears relevant to this discussion. I conduct research on the applicability of mobile health technology, smartphones, mobile health apps and sensors to support health outcomes for communities disproportionately affected by chronic diseases including diabetes, cardiovascular diseases and some cancers.
Sharon:
What we have learned is that many low income communities, particularly low income African Americans have access to smartphones and use them regularly to address a number of social and economic needs. These communities also may not have regular access to healthcare support.
Sharon:
Now, mobile health technology leverages smartphones and health apps such as glucose monitoring and mental health tracking apps to support health and wellness for communities that may not have access to immediate healthcare. However, what we have noted recently is that many of these tools are not usable for all intended users.
Sharon:
To illustrate, a recent study reported on the usability of very common health apps addressing diabetes, depression and caregiving. In this study, respondents were asked to one, enter the names of medications that they were taking for specific health concerns, enter their blood sugar level to monitor diabetic status, and enter mood status to track mental health and wellbeing.
Sharon:
Respondents included a variety of individuals such as whites, African Americans and Latinos. And the respondents presented with multiple chronic health conditions including diabetes and depression. Now when we look at the results of the study, surprisingly, the participants in the studies were only able to complete 43% of the tasks involved in monitoring their health concerns without assistance.
Sharon:
And this was across 11 popular health apps. These tasks involved manual entry of their health data, moving through multiple screens and steps and with treating their data from the applications. So we see usability barriers for patients with chronic health conditions. We can surmise that for communities encompassing different social, economic and cultural needs, the challenges might be stronger.
Sharon:
As we move to incorporate technology into healthcare delivery, designers of the technology must consider whether the different tools such as mobile health apps are easy to understand, easy to access, and easy to be used by the different end users who will engage with this technology. Considerations might include cultural differences in interpreting presented information, language differences of the end users and differences in educational level of respondents.
Sharon:
Therefore, a one size does not fit all. To surmise therefore, existing systems might disadvantage one group over the other by not considering and incorporating the unique and specific needs of all groups, especially groups that might be historically disenfranchised.
Wendy:
So just to kind of piggyback on what Sharon was talking about. I mentioned earlier about the need to examine and value kind of alternative ways of knowing. So this speaks directly to what Sharon was just sharing, how we must be able to consider other ways of doing and being essentially when we're generating knowledge and creating innovations.
Wendy:
And there's a rich and robust line of scholarship that explores quite frankly how white supremacy has lifted the ideologies of white Europeans while invalidating and stamping out alternative ways of knowing of other peoples. Now I'm an epidemiologist and my training has prepared me to study the distribution and determinants of diseases in human populations.
Wendy:
And even that very definition should clue you into the fact that my discipline is very steeped in Western conceptions of health. So only by ... And by using this very limited perspective, we may be missing key health innovations. So I think that's a really great point.
Wendy:
Most of what we know about human health is from studying white populations. This omits the experiences of people of color, specifically with respect to how those experiences shape health and wellbeing, both beneficial and harmful elements of experience including racism.
Wendy:
So in my research, I've begun to ask myself how scientific questions, how my scientific questions potentially align or contribute to racist or hegemonic ideas, methods or approaches. So traditionally we've been taught that those ideas, methods and approaches are valid or are the gold standard. Through our conversation, I think we can arrive that these ways of knowing are not valid or beneficial even for everyone.
Wendy:
And because of this, I've also started to ask myself how I incorporate ways of thinking and doing that is grounded in the experiences or priorities of peoples who have been oppressed, marginalized or excluded by hegemonic and racist ways of knowing.
Wendy:
So I think this kind of ... It's essentially a reflection, it's almost like running an internal conflict of interest statement and thinking about how am I thinking about this and how is this perpetuating systemic racism? And what am I doing to disrupt that? I think that's really the key to what we all need to do, and quite frankly in all domains of our life.
Voice over:
Thank you to our guests, and thank you for listening. Be sure to like and subscribe. You can find us on Spotify, Google Podcasts, Pocket Cast, Stitcher and Apple podcasts.