November 23, 2020

Coronavirus and Health Inequities

hello and welcome to JAMA Medical News I'm Jennifer Abbasi and I'm excited to be joined by dr.

Linda ray Murray dr.

Murray is an adjunct assistant professor at the University of Illinois at Chicago School of Public Health she retired from clinical practice in 2018 after 40 years as a general internist until 2014 dr.

Murray was the chief medical officer for the Cook County Department of Public Health she was also formerly the bureau chief for the Chicago Department of Health under Mayor hell Harold Washington and she worked as medical director of the federally funded health center serving the cabrini-green public housing project in Chicago she is also a past president of the American Public Health Association we are so honored to have you with us dr.

Murray thank you well it's wonderful to be here so today is Juneteenth it is the day that we commemorate the ending of slavery in the United States so as we grapple with the corona virus pandemic which we know is disproportionately affecting people of color we are simultaneously speaking out as a nation against systemic racism and police brutality against african-american men and women so it is truly a historic moment in our nation's history I was hoping we could start with koba 19 and the health inequities the long-standing health inequities it has exposed so in the u.

s.

black people account for 13% of the population but 24% of koba 19 deaths where race is known and blacks Latinos and American Indians also represent a disproportionate number of cases in Illinois where we both live Latinos by far represent the most cases so can you talk to us about some of the many factors that are driving these numbers right I think this global pandemic gives us an opportunity to really look carefully at health inequities a lot of people blame the differences in health status on people's personal health behaviors and certainly as a clinical physician those are critically important and like most positions I spent time with my patients working on those difficult things stopping smoking watching your diet all those things but really what we understand more and more is that the conditions in which people live the structural factors we call them how the country votes whether or not people have medical insurance whether or not people are able to get sick days these are all things that influence individual health and helper populations in profound ways certainly more than just their individual personal habits so with this particular pandemic when the numbers first came out and let me first congratulate those states Illinois was one of them that began to publish the data early by race and ethnicity when those numbers first started to come out some people reflexively said well that's what you expect with a population that's poor with a population with challenges but there's more to it than simply that yes if you have a comorbidity that's an issue but in our area and in most of our urban areas the essential workers and let me be clear who that is yes there are doctors and nurses and people that are working in health care but they're also people that are stocking in grocery stores and delivering the Amazon packages and you know running the the subways of the bus lines these east-central workers in the main are underpaid low wage workers often don't have sick time and so they have a special pressure to go to work and if we know in the Chicago area the parts of our area that have high numbers of these Center workers are the south side the south west side the western suburbs and they match very well with working-class low-income working-class communities and black and brown communities so I would argue that all of these structural factors the things that force people to have hypertension like racism the the jobs that people are forced to have the fact that if a member of the family gets sick they don't have a guest house or a basement for someone to stay in that you have multi-generational households in relatively small spaces all of these structural factors really help account for these horrible differences in case rates in death rates okay something that has been discussed is that the idea of working from home which is something that I have the opportunity to do is a privilege for a lot of people and the privilege that a lot of people don't have absolutely if you have a low-wage job at your time is restocking grocery stage shelves or checking people out with their food you don't you can't do that from home there are other realities to it we've seen with our kids in school is the issue of digital divide it's very real you know I'm a physician and a retired physician I live at Hyde Park the community of the University of Chicago but my Wi-Fi is not as good it's other places in the city and further on in black communities at brown communities so even if you could afford Wi-Fi it's not always there this is gonna be a big problem so yes working from home is a privilege most people cannot really do it and also the tools if they have you to when they can or force work it oh my god for kids in school there's a real problem with doing it what if you have three kids you know maybe if you're lucky you might have one computer so I think the notion that we've solved everything just by doing everything to zoom is a mistake that that's not a reality and people are going to be suffering because of that what do you think about air pollution as a potential factor I know that researchers are looking into possible associations between air pollution which we know communities of color have higher exposures to and Cova 19 susceptibility severity do you think it could be a factor I wouldn't be surprised if it's clinicians we're used to thinking about a number of different factors as ideological causes for diseases we don't always know exactly what percent might come from air pollution or something else and we don't often know the pathways the physiological pathways through which these factors impact the human body so do I think air pollution is unhealthy for people absolutely as an occupational environmental specialist I know that that's the truth do we have a clue about what impact that may have on Kovan 19 no probably not in a definitive way yet but fortunately for us coping the challenges with coal mid-nineteen we do know what we need to do we do know from basic public health that we need to contain the disease we need to search for decent therapeutic measures why we can while we're waiting for hopefully a vaccine so I don't think it's critically important how much air pollution might impact Tobit 19 in a negative way I wouldn't be surprised if it did I think we have to concentrate on as clinicians is what do we need to do to minimize people having morbidity and mortality from this from this virus back in April a young man on Chicago's northwest side held a house party to memorialize two friends who were killed by gun violence and this is when the city was on full lockdown and he was very publicly shamed he went on to apologize and to say that he hadn't seen much information on the dangers of the corona virus and this to me seems like a major failure of public health messaging so do you feel that Chicago and for the nation that the nation for that matter did enough to get the message out to minority communities including the african-american community I think the question becomes what message and how does it compare to what other people have to do I happen to have two young women three young women too in Chicago who are my granddaughters and believe me one just turned 21 and one just graduated high school so the fact that they would be on lockdown doing these momentous events is like mind-boggling I think we have to do two things one is when we give messages as the medical community we have to try to be clear not only clear about what we know but also clear about things that we don't know so to the extent that the advice that has come to public changes without full understanding of why it's changing to the extent that our political leaders cause more confusion then shed light on what's going on I think it it confuses people the other thing I have to say is young people are young people and so I know myself that while basketball rims were pulled down on the south side on our basketball courts on the north side basketball rims are still up in white communities so I think we have to be a little careful about the shaming I think it's horrible that that party took place and I feel sorry for those young people and they clearly didn't fully understand what's going on and so we have to find ways to talk to each generation and in the way that they're not gonna be watching the evening news or seeing in there on social media and other things and I think since that event as a pandemic has gone on that we've seen lots of people common and one of our local rappers and other media stars both sports and music have come out to try to help explain this I thought it was really important that doctor foul to you for example came on Trevor Noah's program had a session with Stefan curry so I picked you have to form your message so that it reaches the audience's you need to reach so we had one message for old people like me and another message for young people like him do you think that the messaging has improved and that more people are being reached now I think more people are being reached only because you know this is going on for three months now but I think our messaging is not improved as much as it needs to so people people unfortunately expect to come to the doctor's office to know right away what's wrong with them they don't even understand how tentative the regular tests we do are they don't understand differences in that realm and they expect to get a pill or a shot and everything to be fine now obviously we're not able to do that with Kovac 19:00 we're not able to do that with most diseases so I think to reassure people that were working on a vaccine to be to be clear so we've seen well maybe a vaccine will be ready if the vaccine is ready in 2021 I think it'll be close to a miracle especially if you actually in people's arms so I think we have to tell people this is how normally we approach these issues this is how long Maxine's usually take even if we discover one or two effective vaccines by 2021 it'll take another length of time before we have enough supply and distributed around the world that message has to go out and it has to go out repeatedly all of the time so that people have realistic expectations and they can make adjustments for that so that means we have to ask positions be willing to say we don't really understand this pandemic completely yet we don't understand everything this virus does these are the things that we're trying to do around the world to understand it and here's what we could do collectively as a community in this present time so we have to be willing to admit about what we know and what we don't know yeah so transparency honesty managing expectations not over promising right so dr.

patrice harris the immediate past president of the American Medical Association has said that she has been trying to dispel a misconception among the African American community that black people can't get co19 do you have any idea where this myth arose what it's all about and how pervasive it's been and potentially how detrimental it's it's interesting these are Street myths are always a source of amusement and joy for me as a physician I think today most black communities no longer think that fortunately but in the very beginning when this was advertised as a virus which started in China so you have to think about who from America and Europe goes to China not not working-class people black people on the southside of Chicago so in the very beginning people who were working in China people that were tourists in China people that were engaged in world travel were the first few people in the United States that get the disease and so then it gets in people's mind or I don't know anybody with the disease so it must not be happening in community today surgeries have been done and more black people know someone who has been sick or in the hospital or died then white Americans so I think today that myth is not a problem in the black community certainly here in Chicago I know in little village Pilsen little village of predominantly Mexican community in the early days they said well you know Mexicans can't get this that's something that's happening to black people but it's not happening to Mexicans and obviously we know today in Chicago that the Latin X had the highest rate that highest rate the highest number of people with copic 19 so communities without information without accurate information they invent explanations from what's going on there are also conspiratorial theories about working just like we saw with HIV they're conspiracy theories about where things come from and what the motive is and as physicians we have to deal with that honestly and openly I remember early in HIV there were lots of problems in minority communities about why HIV existed who invented it etc so this is something that always happens with pandemics and we have an obligation as clinicians to give the information as accurately as we have it and again to imitate people's questions and not just dismiss them what about distrust of the medical establishment in the black community can you talk to us about whether you feel like that's had a bearing on the Cova 19 pandemic you know that's always a problem it is real and it's hard to say that people are wrong for having a level of distrust I both of my parents had been dead for a few years but I remember when they were still here sitting at their table trying to help them figure out what what Medicare planning to sign up for trying to convince them to get certain preventive things you know flu shots etc and they stopped at one point I'm their eldest child I'm the only child that's a physician they stopped and looked at me and they said Linda we don't trust doctors and we haven't forgotten that you're one of them so this is from your proud parents I think that african-americans have every right to dis stress clinical medicine not just for Tuskegee that people often refer to but for how the structural racism in medicine as an institution in our hospitals and our health clinics and our insurance plans and how we talk about and think about people of color and black bodies it's a constant source of irritation it's a constant reminder that we are viewed lesser than and then perhaps we're not quite human so that reality that historical reality is here it's reinforced everyday and so I understand completely the distrust that people have for forces for physicians as a group fortunately I can say as a practicing physician people tend to like their own physician if they keep going to them so they may in fact really like their own clinical positions no matter what race they are but that doesn't mean they stress the institution and that's why I think it's so important that we not have higher than thou attitude on how we deal with people we shouldn't we really have to not be judgmental we really have to try to understand the real world struggles that people have in following instructions and thinking about how to make themselves healthier so yes we have some distrust there's distrust in the white population too most of the anti-vaxxers tend to be people in who are white Americans so we really have to find a better way to communicate with people that live in this country and gain their trust and I think that starts by admitting what we know and what we don't know and having a reason conversation on what people need to be concerned about and what not it's always interesting to me that even though every year I struggle and struggle to get my patients to take a flu vaccine when cold in nineteen hit people were calling me up they said COBIT 19th vaccine so again people's attitude toward disease depends on so much else in terms of how society talks about it are you concerned about when we do have a vaccine if it will be available for minority communities absolutely so I support the single-payer health system I think it's it's a moral problem that this country doesn't provide medicine medical care at the point a service free for everyone you should not be restricted from seeking medical care when you need it it should come out of our basic tax system that's my firm belief and I think this pandemic makes it even more obvious we can't have people hesitate in getting it test when they need one because they're afraid of a bill even people that have been hospitalized and sent home being told that they don't have to worry about that particular coded 19:00 hospitalization they go home they need oxygen and all of a sudden they have a giant bill it may not seem giant to someone who is a physician but to $300 is a huge bill for many many working-class families so they go home they're supposed to have home oxygen but they can't afford to pay for the oxygen it is a crime that this the richest country in the world can not provide medical care for everyone in our borders so I do think that this is going to continue to be a problem and getting vaccine as part of that there should be no barriers to getting the vaccine we have to make sure that the highest priority the people that are causing the most there are most in danger of spreading the virus get the vaccine first health care workers first responders and we have to make sure there's a global approach because we shouldn't think we can vaccinate the United States or even vaccinate North America and ignore the global side because the virus will just be back here again so this does require a global cooperative effort not only in just trying to discover a good vaccine but also implementing I read this great article in ProPublica about the first hundred people to die from cover 19 in Chicago and 70 of them were black and what the article pointed out is that a lot of people in the black community in Chicago waited for a couple different reasons to go to the hospital and one of them being that they didn't have faith in some of the lower resource safety net hospitals in their neighborhoods and so they waited and by the time they got to the hospital it was too late for them what are your thoughts on that I think people know intuitively that we are at under source community and they may not know clinically when somebody might need to be an ICU or when somebody might need a ventilator but they intuitively know that all the resources one would like to have are not in our communities also they understand what co-pays etc means and I think people also have other realities if I go to the doctor and I can't work for a week what does that mean so I think especially early before some of the unemployment stipends itself were put in place this was a real problem it will continue to be a problem and so people have lots of real-world reasons who's gonna take care of my mother if I go in the hospital who's gonna take care of my children if I go in the hospital so we have to as a society we're gonna address this pandemic appropriately we have to put those structural supports there to support people you can't ask someone to isolate for two weeks because they're infected and you don't provide them with a way to do that you don't provide them with food and you don't provide them with the way to protect their family members you can't ask people to be in quarantine without those social supports so we are really teetering on the edge I'm very concerned as we enter the fall with K through 12 schools about to open we really have not spun through what we need to really support families and individuals in this time this is not gonna be a return to normal anytime soon and we have to put those societal things in place in an organized way to allow all of us to survive what do you think about the lack of demographic data that we've been experiencing this is something that hurts me to my heart as a public health person we have allowed over the past 25 years the public health infrastructure that existed in this country to crumble in the past 20 years we've lost a quarter of a million of public health workers in governmental Public Health and so the reality is for example that most health a big health departments like the city of Chicago or the county of Cook they have under 30 contact tracers how is that possible that shouldn't be possible and so yes we have major problems and deficits in our public health infrastructure our laboratory system has been decimated when I first did my residency we most places mostly health departments and mobile health large health department's had lamps at their own lamps most of those are gone now we're fortunate in Illinois to still have state lamps functioning we've lost many of our public health nurses that really were entrenched in the community that went door to door talk to people knew about the communities there are many countries in the world where every child is born gets a visit from a public health nurse whether you're the daughter and son of a millionaire or whether you live in a poor community we don't we have not kept up with the computer and data management infrastructure that we really need today in public health we're behind in some of these phone apps in terms of contact tracing so we have a system it's like a rusty bridge with holes in it that we're trying to combat this is pandemic with and I hope one of the things that we learn from this is we cannot allow our public health infrastructure to decay like this this is critical to survival of the nation our we do but doing better in collecting demographic data data uncover 19 at this point we start about 15 percent of people the test having race and ethnicity like another another problem again it's not a surprise but it's just a question of the infrastructure to do it we know this is spread and workplaces look at our meatpacking plants look at the nursing homes the way we collect that it makes it more difficult to easily quickly see those areas where we have spread going on all right jails prisons nursing homes college dorms there's some that you would normally think of but we don't actively do it and the other thing we're missing critically is what what we're taught in school were supposed to do is active surveillance it's not enough to know a year from now where these the disease happen we want to know right now so that we can respond immediately there's a problem at this plant there's a problem at this there's a problem over here so that really requires a system of active surveillance with rapid turnaround with staff that know what they're doing less than a third their 3, 000 health departments in this country less than a third of them have even one epidemiologist on staff that's criminal and that's because we've decided to cut government workers and we decided not to invest in public health we have to change that because that's what that's like we have a fire going on and we defunded the fire department that's what's going on now we have a global pandemic we've defunded our fire department to put out the fire okay so with the response to the killing of George Floyd and other unarmed black men and women in the United States we are at another reckoning over race and racism in this country an estimated one in 1, 000 black men in the US will be killed by police over the course of their lifetimes according to data and the risk is also greater for other people of color as a physician how do you think about this in the context of keeping communities healthy this is this is an emotional problem for me Native Americans have always and still today are killed at the highest rate from police killings I am a mother of a black man and he's 49 years old now but I still have terror in my heart if I know he's going out to a party or and when he was younger it was true terror and I would not feel any relief until he came back in the house and was physically alright there is no way to overstate the terror that lives in the hearts of black mothers all over the country and to see George Floyd murdered in front of you on TV it's something that I intellectually understand happens every day in this country before cellphones I knew it happened but now when it can be visibly take and when police can know they're being filled and still continue to murder people I can't even describe the kind of range that I feel it is impossible for a family a black or brown family a Native American family or community not to be terrorized by that reality and there is no way you can protect your your loved ones by that there's no way you can be protected black physicians especially male physicians when they go out in the street to the cops they're just another black man so the fact that this reality is now obvious and being notice to most Americans is a good thing but for me as a 71 year old black woman this has been here all my life and I'm glad that the young people are glad that my granddaughter's and their generation are out in the streets protesting again this when I was their age I was out on the streets protesting police brutality we've had this problem in our country for centuries and I hope that Americans come to grips with what we mean by structural racism in medicine for example I can't tell you the surprise I felt in 2008 when the American Medical Association apologized to the black community and black physicians but we have to go beyond just an apology we have to really work together to change how we educate our physicians and other health care workers we have to work together to change the face of our profession we have to work together to change how we think about and diagnose disease we have a lot of power and authority and respect as physicians and we know what we need to do they have healthy communities and we need to speak out forcefully and strongly and say no this is what we need to do to have healthy children in our schools this is what we need to do they have healthy seniors in our communities we know what to do we just have to come to the other and begin to do it so you have said dr.

Murray that you are devoting the rest of your career to be an enthusiastic full-time troublemaker so what is that so what does that mean for you well first thing it means is talking to young people you know we've been through this before when I was young when I was a child I listened to my elders I listened to my great-grandmother who explained to me as a child Linda white people are always going to knock you down and what you have to decide to do is how often you're gonna stand up and that's really something that I'd carry with me my whole life so I've spent time with young people and talk to them about what I did when I was done what my grandmother did what my great-grandmother did and answer their questions and help them figure out how to lead in this time period I think it means making sure that I continue to speak out about problems in our profession I spend a lot of time trying to make sure that the number of black and brown students that get into medical schools increases it means being politically active and working in the area where I have some expertise medical care and public health it means working very hard to make sure that no physician has to hesitate Oh what x-rayed order or what lab tests to order or what medicines order simply because our patients can't afford it we shouldn't be hamstrung like that positions we should be allowed to practice our crap with some dignity and respect and not worry about all these regulations in a million insurance forms we need to have a single-payer health care system so in whatever years I have left that's what I'm trying to do to work with other people and make sure that when I'm gone I've left people behind that have learned a little something about how to cost trouble for me wonderful we look forward to seeing what else you have to show us thank you so much dr.

Murray we really appreciate you being here today thank you as a pleasure take care you you.

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