Exacerbating the health care divide Transcript

Alex Schein:

In these times has been a handy turn of phrase in 2020, the varying adjectives you use to modify it, difficult, unique, strange. What started as a useful shorthand for the COVID-19 pandemic became used to describe worldwide protests and calls for racial justice. This fall, the Omnia podcast goes beyond the shorthand, using COVID-19 as a platform for a six episode series that explores the science, social science, and history that has shaped events in 2020. In these times, knowledge is more important than ever.

In this episode, we talk to a political scientist, a PhD student in history and sociology of science and a professor of sociology, Africana studies and law about the ways COVID-19 has shined a spotlight on disparities in the US healthcare system. This is episode four, Exacerbating the Healthcare Divide.

Julia Lynch:

One thing that people usually think of when trying to understand where health disparities come from, is access to healthcare. Seems to make sense that health and healthcare would be related, but it turns out that access to healthcare really only accounts for about a quarter of the disparities in population health that we observe. There's something else that's going on.

Alex Schein:

Julia Lynch is a professor of political science and co-director of the Joseph H Lauder Institute of Management and International Studies. She's the author of Regimes of Inequality, the Political Economy of Health and Wealth. When it comes to understanding disparities in health outcomes, Lynch says you need to dig deeper than individual choices.

Julia Lynch:

The next thing that people usually think of when they think about the causes of disparities in population health, across different population groups is people's behaviors. Things like what they eat, or how much they exercise, or whether they smoke or use illicit drugs. It's true that these kinds of behaviors can be said to explain a much bigger share of health disparities in a certain sense they are causes, but it's important to recognize that these disparities are often constrained. These behaviors are very often constrained by the circumstances that people live and work in. They're not really freely chosen. That brings us to our third category of causes of disparate outcomes in population health. That's what social epidemiologists call social determinants of health. This is the stuff that isn't about health care, and it's not about individual choices. It's not about sort of in human biology, for example, between men and women.

Instead it's about the conditions that people live and work in that affect their health. For example, can people afford to buy fresh vegetables? Is their workplace likely to be safe? Is their housing likely to be overcrowded? Are they subjected to the stresses of daily encounters with racism? All of these are things that sort of on average are likely to affect the health of different population groups, these social determinants of health.

Alex Schein:

Professor Lynch says governmental policies in the labor market and economy often compounds suffering in low income populations.

Julia Lynch:

As a political scientist who studies population health, I'm particularly interested in the political and policy determinants of health, which I think can sort of be said to come before the social determinants of health. These are the choices that governments make that affect how people live and work. Regulation of the labor market and the economy includes the policies that governments make regarding things like labor rights, minimum wages, income taxation, and even macro-economic policies that affect the level of employment. Governments do a lot to manage the labor market and the economy, and these policies feed really quite directly into population health outcomes. This is because first of all, they affect people's incomes. They affect how much people earn and how much of what they earn. They get to keep, which is really essential for securing goods that promote health. These policies also, though, affect the level of inequality in society, which social epidemiologists believe has an independent effect on health.

I think the most obvious example that's visible right now is meat packing workers, who are some of the most poorly protected workers, not only in the United States, but also in European countries. Meat packing plants, as I'm sure most of your listeners will know, have been the source of a number of sort of outbreaks within the broader COVID pandemic. Working conditions are actually really important and the way that governments regulate working conditions can feed directly into health.

Alex Schein:
Another area of policy that heavily contributes to disparate outcomes is the welfare state.

Julia Lynch:

The second area of government policy that I said is kind of where the big bang for your buck is in terms of, of population health is the welfare state. I'm not talking just about cash transfers for very poor people. I'm talking about social policies more broadly, that aim at social protection. Things like unemployment benefits, minimum income benefits in countries that have those old age pensions, subsidized housing, publicly provided childcare. These are all aspects of the welfare state. These are things that, broadly speaking, allow people to survive, even if they might not be able to be active participants in the labor market at any given point in time in their life. These policies have a direct impact on health again, because they free up financial resources for families to spend on things that keep them healthy. For example, if I have government subsidized housing or government subsidized childcare, it's going to be a lot easier for me to afford, to eat fresh vegetables and meat and fish rather than kind of empty calories.

Social policies are also important because a strong safety net prevents people from having to work when they're sick. Again, in the COVID pandemic, we've seen that having to go to work when you're sick is not good for population health, but this is true more broadly when people who work in fast food restaurants risk losing wages if they go in to work sick or they risk losing their job if they call in sick. We all get sick. These kinds of policies are important, not only for the health of people who might be direct beneficiaries, but also for the health of the population as a whole.

Alex Schein:

Lynch says that if we're going to improve health outcomes, we need to start shifting the policy focus and the public messaging.

Julia Lynch:

The focus on health behaviors has a long standing tradition within the public health community, but there's also been a lot of research on it. One of the things that we know is that focusing on health

behaviors very often actually makes health disparities worse because the people who are most able to receive messages about improving diet or improving behavior or the danger of smoking or whatever. Those are the very same people who have the more resources. You find that paradoxically, health education campaigns, for example, very often do tend to increase rather than reduce health disparities. I look at that as a political scientist and I say, "Hmm, what's wrong with this picture? Why do we keep doing this thing that we know doesn't work?" We're making a big mistake if we try to reduce inequality by talking about it in terms of health, that in fact it's much more effective to reduce inequality, both health inequalities, and other kinds of inequalities.

It's much more effective to just bite the bullet and talk about the underlying socioeconomic inequalities and fix them. One reason for that is precisely what you said, which is that's a really hard sell to tell your constituency that you don't think they actually have what it takes to change their behavior. That's just a horrible message. At the same time, as it's a horrible message to tell them, "Look, I know your life sucks, but I'm going to take away some of the few pleasures that you have in your life like smoking and eating sweets." That's not a good message either. I think for a lot of reasons, and not only that, it's a much better idea to try to reduce inequality by reducing inequality, rather than by talking about it, in terms of reducing health inequality.

Alex Schein:

With her research, Rebecca Mueller is shining light on the unique challenges people with genetic vulnerabilities face during the pandemic.

Rebecca Mueller:

I have a long standing interest in what we call the ethical, legal and social implications of genetics and find that the history and sociology of science is a really useful approach for thinking through those complex issues.

Alex Schein:

The doctoral candidate in the department of history and sociology of sciences’ research came to be focused on the effect of microbes, like the coronavirus, on those within the cystic fibrosis community or CF. My colleague and Omnia writer, Jane Carroll spoke with Mueller earlier this fall.

Jane Carroll:
Could you briefly describe your research?

Rebecca Mueller:

I'm writing a history and ethnography of the cystic fibrosis community starting in the 1980s and bringing it up to the present. I became really interested in the ways in which the CF community that like many rare genetic conditions had formed support groups and conference opportunities and even camps for kids in the summertime, evolved in this really rich way in the 1970s and 1980s. Then was gradually disbanded because there was a bacterial epidemic of an opportunistic pathogen that impacted people with a condition. I study what the community was like before that risk was known and then compare it to the later chapters in the history of CF where the community migrated online and made efforts to mitigate the risk of infection.

One of the important things for me to emphasize is that CF is not really an infectious disease. It's a genetic condition, and people have a vulnerability to infection with opportunistic pathogens that do not

infect healthy people, and that are really everywhere in the environment. Because individuals with CF are susceptible to these microbes, they have similar vulnerabilities and it became clear over time that they could infect one another and that they should therefore be kept separate.

Alex Schein:
Mueller says the pandemic has created a unique set of circumstances for those with cystic fibrosis.

Rebecca Mueller:

What's been interesting about the impact of the pandemic on the CF community is that this is a community that is already somewhat accustomed to operating at a social distance and already has some of those sort of skills and infrastructure in place. There's a way in which the pandemic has sort of amplified the CF community because it has emphasized the ways in which people with CF are different in the sense that many are staying in quarantine for longer and therefore have different needs for social support that the community is already well-equipped to address. The other thing that's been really interesting to see in terms of the impact of the pandemic on the CF community is that, for quite some time, the biggest national scientific conference around CF that's for professionals, but that some patients have an interest in attending made a rule that because of infection control, they really only wanted to have one person with CF in attendance each year.

That was a guideline put in place in 2013 that I think was concerning to some CF advocates who felt as though it was really important to be able to attend and understand the science deeply. Because of the pandemic, the conference like many conferences has now moved online. I think that's really significant and shows the ways in which the pandemic is forcing organizations to consider doing things in a way that is more inclusive.

Alex Schein:

The world going virtual has opened up possibilities for people in the CF community, but the pandemic has also seen the frequent use of hurtful language.

Rebecca Mueller:

I think that the statements that are made and that's this pandemic about it, "only killing people who have preexisting conditions", are very offensive and concerning to people in the CF community and essentially devalue their lives and kind of other them in a way that is kind of intensified, because many people with CF can sort of pass as healthy under a lot of circumstances. This is bringing into relief, the fact that they are being advised to be more careful during the pandemic and the national discourse is really one that revolves around whether prioritizing their vulnerability is important or not.

Alex Schein:

One of the central issues affecting cystic fibrosis patients today is the lack of communication and partnership between the sciences.

Rebecca Mueller:

In the 1990s, when there was sort of a new opportunistic pathogen detected in the CF population, there was tremendous amounts of research to understand how patients were acquiring this infection. Initially, it led to epidemiological studies that determined that yes, patients were passing it between one another, but after efforts were made to control infection between people with CF, the foundation

looked at environmental sources of this pathogen and that made them gather the different scientists who were working on the pathogen. What that revealed is that medical microbiology was operating very much in a silo from agricultural microbiology and industrial microbiology. At the same time that CF scientists were concerned about this pathogen, agricultural scientists were very excited that this pathogen could actually serve as what's called a bio pesticide. A natural organism that can be protective in the process of growing plants.

You can just see that there was really a lot of excitement and enthusiasm for ways that the microbe could be used in the environment that were deeply problematic to the CF community. As the scientists started to get those people from siloed areas together at one table to talk about whether this was "friend or foe." That was the title of one of the conferences that was held during that period. As a result of that, the Cystic Fibrosis Foundation advocated to have the environmental protection agency regulate these microbes much more tightly in a way that really diminished their use in agriculture.

Alex Schein:

Mueller says that despite the challenges, the cystic fibrosis communities remain committed to discovering new opportunities for social engagement.

Rebecca Mueller:

The types of socializing that's happening online for people with CF in general, and then at kind of an increased rate during the pandemic are largely these types of sort of Zoom meetings and Zoom hangouts that I think are being organized both by organizations and also just by individuals who are using their own social networks to get people together, to check in and to talk more about life in general. It's the pandemic and also about other issues that are pertinent to the CF community and so much as many are quarantining for longer. What's interesting is that because of this longstanding concern about infection over time, the CF community prior to the pandemic had built different platforms for things like singing together through classes and choirs, and also exercise platforms tailored to people with CF where individuals can do dance and do yoga.

Those, again, I think are potentially more popular. It certainly seems as though more people are enrolling in getting involved as opportunities to do those things in the outside world have diminished. I know that beyond CF, certainly there has been an adoption of these platforms for exercise and for choir and for other activities. It is interesting that in CF, there was really a longstanding history of that prior to the pandemic that has really just increased.

Speaker 10:

From the moment the Corona virus outbreak began, health officials have preached that COVID-19 doesn't discriminate, that it's an equal opportunity killer, but new reports strongly suggest that race still matters. In Milwaukee County, Wisconsin, where black Americans are just 26% of the population, there are more than 70 of the deaths from the coronavirus. The reports are startling in North Carolina, Connecticut, and Michigan too.

Alex Schein:

COVID-19 has further exposed already dire health outcome inequalities. With the rates of diagnosis and death disproportionately affecting racial minorities and low income workers. We spoke about structural racism's impact on inequality with Dorothy Roberts, George A Weiss University Professor of Law and Sociology, Raymond Pace and Sadie Tanner Mossell Alexander Professor of Civil Rights and Professor of Africana Studies.

Dorothy Roberts:

Structural racism affects health outcomes because it makes people of color, especially black people and indigenous people or native Americans, especially vulnerable to bad health because of the way in which our society is structured to put them in less healthy living conditions. They are more susceptible to getting sick and to dying from illnesses. We could trace that structural racism back centuries and in every subsequent generation, there are new forms of organizing society in a way that disadvantages marginalized groups.

Alex Schein:
Professor Roberts says the biological concept of race was invented as a way to justify inequality.

Dorothy Roberts:

The biological concept of race plays into this because it was invented as a way to support and justify and manage racism as a way of governing society. If we go back to the 1600s, we could see the convergence of scientific concepts of race and the desire of Europeans to conquer other people, enslave slave Africans, dispossess indigenous people of their lands and launch a whole imperialistic approach to other peoples. This was both justified and managed through a system of classifying human beings into races. That was invented in a couple of ways. One, because the very idea of dividing human beings into races was made up. There's no natural division of human beings into these groups. This very concept of dividing human beings up into so-called races was an invention of Europeans. Then the idea that these groups were biologically distinct is a critical part of that invention. That idea that human beings are naturally divided into races and that races are biologically distinct from each other. People within races are biologically similar was a way of promoting the false concept that this was a natural division.

Also, a way of claiming that white people were naturally or biologically superior to all other groups of human beings with black people being placed at the bottom of this made up hierarchy. The false view that human beings are naturally divided into races, serves the purpose today of convincing some people that the reason for health inequities is because of natural biological innate differences between races instead of because of structural racism. It continues to function in the same way that the very people who are victims of structural racism and getting blamed for causing health disparities, either within their bodies innately or because of their behaviors.

Alex Schein:
Examples of medical practices that were directly influenced by racism, still exists today.

Dorothy Roberts:

The idea that people of different races have different diseases and experienced common diseases differently, which was really developed during the slavery era to justify enslaving black people on grounds, that slavery was good for their health. That idea continues to profoundly and fundamentally shape medicine today. Doctors, when they're trained, are still taught to notice right away the race of their patients, and they're taught to diagnose patients diseases according to race. They're taught to prescribe medications according to race. They're taught to figure out the right dose of medications according to race and other kinds of therapies according to race. It's so embedded in today's medical practice, that there are a number of instruments that diagnose disease, where the algorithms have race as a key variable with lung function. We can trace this directly back to Samuel Cartwright's view that black people had weaker lungs.

Then therefore it had to be forced to work by white people in order to be healthy. Today, there are still some spirometers that measure lung capacity that have an adjustment for race. Just the other day, it was revealed that in the national football league concussion settlement, there is a separate test for black players to determine whether or not they are suffering from dementia as a result of concussion suffered while playing football, so that black players have to show greater damage to their brains than white players with the built-in assumption that the black players entered football with lower functioning brain capacity. That's just three examples. I could give you many, many more that categorically and automatically treat black patients differently as if their bodies function differently based solely on their race.

Alex Schein:

Robert says that racist governmental policies that existed in the past, impact current day access to quality health care.

Dorothy Roberts:

The lack of access to high quality healthcare is an important factor in explaining disparities in mortality and illness in the United States. Black people have always experienced less access to high quality healthcare beginning during the slavery era, but also during the Jim Crow era, where there was segregated healthcare facilities and black people were relegated to colored wards in hospitals or to black hospitals that did not have the resources that white hospitals and other healthcare facilities had. Today, there are still is because of residential segregation, segregated health care in the sense that black people are more likely to have in their communities, healthcare facilities that have fewer resources, less high tech health resources, or medical care within their communities. Even if we have universal healthcare, we still have to be concerned about biased decision-making by healthcare providers that give to black patients lower quality healthcare. There are studies that show that even when black Americans have equal health insurance, as white Americans, they get lower quality healthcare. That's another piece of it that's really important.

Alex Schein:

Professor Roberts' research is especially focused on the wellbeing of marginalized women, her seminal book on this topic, “Killing the Black Body, Race, Reproduction, and the Meaning of Liberty,” is taught in classrooms across the U.S.

Dorothy Roberts:

The U.S. is the only developed advanced nation where the maternal mortality rate is going up and it even is an outlier among all nations, because in most nations, even developing nations, the maternal mortality rate is decreasing. That tells you something about the United States overall and the inferior quality of healthcare for everybody. We can also see this in the fact that the US has the highest rate of COVID deaths in the world. It's not a coincidence the US also has the highest rate of incarceration in the world. The United States has very unhealthy public health policies, whether we're looking at law enforcement or at the provision of healthcare, black women are three to four times more likely to die from pregnancy related causes than white women in the US. In some parts of the United States are just astoundingly deplorable in terms of the care that pregnant women get. In the Mississippi Delta, black women are more likely to die from pregnancy related causes than black women in Rwanda or Kenya, are.

The higher rates of death among black women cuts across socioeconomic lines. Even college educated black women are more likely to die from pregnancy related causes than high school educated white women in the US. Why is that? Now this goes back to the question of, is the reason for these health inequities some innate cause, or is it because of structural forces? Here are some researchers are looking for some innate reason why black women would be predisposed to die from pregnancy, which is kind of an implausible hypothesis to begin with. We can point to so many structural reasons why lack of access to prenatal care, growing up in segregated black neighborhoods, where there are fewer resources that support health.

Also, there's evidence of racial bias on the part of healthcare providers with many black women reporting that their calls for attention either before or after giving birth have been ignored by healthcare providers, even Serena Williams. One of the most famous black women in the world wrote an article about how she was devalued in her experience of giving birth. I think we have to look at all of these aspects of health inequities are structural forces that make black people vulnerable to poor health, lack of access to healthcare and racism within the healthcare system.

Alex Schein:

That wraps up the fourth episode in our six part series, In These Times. We'll be back with episode five, Racial Justice and Repair, in which we speak to a PhD student who combines the study of philosophy at law and a college alum who returned to Penn as a chaplain, about this summer's protests, which dominated the 2020 headlines along with COVID-19.

The Omnia podcast is a production of Penn arts and sciences. Special thanks professors, Julian Lynch, and Dorothy Roberts, and to Rebecca Mueller. I'm Alex Schein. Thanks for listening.

Be sure to subscribe to the Omnia podcast by Penn arts and sciences on Apple iTunes, or wherever you listen to your podcasts. To listen to all six episodes of, In These Times.