Protecting the community: Essential workers, nursing homes, and the incarcerated

The COVID-19 pandemic continues, resurging across the US and in many other places. Different strategies have been adopted in different places, with varying degrees of success in slowing the spread of infection and death. This should provide us with information on what works well, and what strategies we should be adopting. For one example, family medicine colleagues in São Paulo, Brazil, report on their experience in nursing homes in the Royal Australian Journal of General Practice. They used public health management techniques including no visitors, rigid use of testing, recommended PPE and isolation, and others, as well as medical management and psychosocial management working with families and patients to help them through this process. They have had only 4 cases in the last 90 days (as of the November publication date), no people in isolation, and a low death rate.

 In Arizona, as in the US, case rates and mortality continue to rise.  We have more cases than ever, and fewer hospital and ICU beds. The state has chosen to address this issue by lifting restrictions on businesses, opening restaurants, bars, salons and gyms. Based on all evidence from everywhere, this is likely to further increase infections and deaths (“Health chief changes benchmarks so no Arizona business will be shuttered in pandemic”.)

Thie new policy is clearly in response to business owners concerned about their livelihoods and the probability that they will even survive. This is a real problem for them, and for us, in the horrific economic downturn that has accompanied the pandemic for most people (for major investors, however, the stock market has done well). Pima County, where Tucson is, has taken a more aggressive and restrictive approach; after more than 320 cases reported among county employees, including the chief health officer, it has furloughed 20% of the work force for 3 weeks. Of course, this will be an economic hardship for those people’s families.

Thus we have the situation where we know what to do to prevent increased infections and deaths, but have to also address the serious financial impact on regular people who lose their jobs and businesses and incomes. Sadly, efforts to reopen have been almost linearly associated with increased infection rates and deaths. The efforts taken by our Brazilian colleagues were effective in an important and high-risk, but ultimately limited, venue, that of nursing homes. The fact that the increased infection and death rate in our communities will take its greatest toll on the elderly and those with chronic disease, not those whose exposure to others in workplaces, schools, and meetings (although they are also at risk, and not immune) makes it even more complicated. The leadership at the federal level, sometimes inaccurately described as “lack of leadership” when in fact it is actively leading us in entirely the wrong direction, is making things much worse, and creating and exacerbating an incorrect understanding of the disease among many people.

Those who work in high-risk occupations, who cannot “phone (or Zoom) it in” but rather have to be present, most often among the lowest paid, those who live in multi-generational and multi-family households, are paying the highest price. These people are not only members of racial and ethnic minority groups, but those groups are far over-represented in their numbers. A recent article in the New York Times again makes the point that Black and Latinx people are hardest hit, not because of any genetic or biologic reason but because of their social and economic situation resulting from centuries of structural racism. Race, it is clear but requires repeating, is a social, not a biological construct. The negative impacts on health, income, longevity, education, and everything else is not from “race” but from “racism”; indeed, the only significance of “race” is that it is the basis for racism.

Now there is a vaccine (actually, two, maybe soon three, vaccines) and administration of them is rolling out, especially in the wealthy countries that have acquired most of the doses (of course, in the US the Trump administration jeopardized this by passing on an opportunity to acquire more doses of the Pfizer vaccine, and this was certainly not to help out the poor parts of the world!) The debate now moves to who should get it first and in what order. In most places in the US, priority is going to health care workers and nursing home patients, which makes sense. They are, respectively, the most likely to contract and transmit the infection and the most likely to die from it. And then? Who? Those with the highest risk or those with the best connections? In many hospitals we hear reports of the C-suite executives (the “front office”) being at the front of the line for vaccine, despite the fact that they do no health care. Nice of them to want to “model” behavior, but the vaccine should go first to those who see patients. The priority should be those who not only interact with the public, but who cannot do their jobs if they don’t actually show up for work, and among those, people who would be the worst off if they lost their jobs (and those who have already been laid off but might be able to come back and begin working again). The last would be those who can continue to work from home, or are retired without major health risks, and can continue to isolate themselves.

Another major group that is finally getting some media attention, even if it is unlikely to get much vaccine, is the incarcerated population. The AP reports that “1 in 5 prisoners in the US has had COVID-19, 1,700 have died”. This could be predicted; it is a group crowded together, unable to isolate, often with pre-existing conditions, and essentially without agency – they have to do what they are told. There are, broadly, two reasons for immunizing them. The first is human – they are human, and they are at very high risk, and they are already being punished; they should not be further punished by getting this disease. The second is practical; prisoners are not, actually, entirely separate from the rest of the population. In addition to guards and others who move between the inside and the outside, many prisoners are released; this is most especially true for jails, where the length of stay is short (usually awaiting a court appearance for those who cannot post bond), and thus is really part of the community from which inmates come – and go back to. Nathaniel Lash makes this case convincingly in the New York Times Sunday Review, “The coronavirus has found a safe harbor”. For example,

Cook County Jail was the site of the largest detected outbreak in the country early in the pandemic. In recent weeks, it has exceeded that — there were 340 active cases among inmates on Dec. 16. The population, meanwhile, has returned to levels typical before the pandemic, about 5,500 people.

We should have fewer people in jail.  It is outrageous that people are incarcerated because they cannot pay bond, overt discrimination against the poor, and cannot afford to support the very politically powerful bail-bond industry. This was true before COVID, and is more true now. ‘“There’s no question with a new peak in infections that we have to be decarcerating now,” said Dr. Emily Wang, the director of Yale School of Medicine’s Health Justice Lab. “If we don’t have larger-scale decarceration efforts, we won’t control Covid.”’ The answer is bail reform that corrects these inequities – vicious inequities with frequently fatal outcomes. But the opposition continues to cloak itself in the mantle of morality rather than greed, public safety rather than racism. ‘“We’re seeing the extent of the opposition to bail reform: They so strongly oppose it they will do it in the face of a pandemic,” said Andre Segura, legal director for the American Civil Liberties Union in Texas.’

The US incarcerates more people than anywhere in the world, a lot for relatively minor drug offenses. This does not prevent crime, especially violent crime, and it continues to rise even as crime rates decrease. In 2020 it is out of control, it is inhumane, and it is a significant cause of the spread of COVID. 

We need to get the vaccine out there soon, especially to those at highest risk of both dying and transmitting it to others. Clearly, the incarcerated population must be included.

 

 

 

Structural racism, structural violence and COVID-19: We must fight both epidemics

The novel coronavirus which causes COVID-19 does not discriminate. Despite the common human error of teleologically imputing motivation to organisms – or even inanimate objects – this virus, like other viruses, like other microorganisms, does not choose its victims by conscious intention. Like other microorganisms, it is opportunistic, attacking people who are available and do not mount an immune resistance against it. In the case of COVID-19, that was, at least initially, everyone who was exposed, so that while it began in China it was brought to other countries by international air travelers, generally among the more economically privileged.

But it didn’t stay that way. While the virus does not discriminate, human societies do, and poor people always suffer more. In many countries, including the US, the UK and Brazil it is minority populations, people of color, and especially Black people who have borne the brunt of the epidemic. This disparity is particularly dramatic in countries with long histories of racism that have vicious right wing leaders. The Guardian describes Enormous disparities': coronavirus death rates expose Brazil's deep racial inequalities. In the US, another country with these two characteristics, the disparities are so large that they should be shocking, except we are used to them now. This graph from the NY Times shows the disparity in COVID cases based on income, (the graphic shows NYC and Chicago, and clicking on the interactive link lets you look at the specific but similar patterns in many major cities), but the disparity based upon race is layered on top of that.

Study after study demonstrates this disparity.  They are revealed in hearings in the House of Representatives, and have been demonstrated for many chronic diseases. The cause is Structural Racism, which systemically has placed Black people in lower-paying jobs with much less hope for advancement and the accumulation of wealth, more blighted and polluted neighborhoods where access to basic services (food, transportation, recreation) is worse, segregation of schools either by law (de jure) or de facto in which education is worse, and more limited, and the incredible chronic stress of racist practices in society. This clearly manifests in the fantastically high rate of police brutality against Black and other people of color in the US, as has been demonstrated again and again, and with the murder of George Floyd has led to what (we hope) will be sustained and sustainable demands for change, and in the psychological stress that the ever-present danger of such acts along with less lethal racist treatment wreaks on the people experiencing it. All of us are worn and depleted by acute stress situations (“fight or flight”, with the exhausting secretion of adrenergic hormones) and need to rest to recover, but the chronic condition of stress experienced by oppressed and repressed people leaves no room for recovery, weakens resistance, increases chronic disease and shortens lives. Medical students (at least that large majority who are white) sometimes find this the “soft” stuff, not like the cellular level biochemistry and physiology, that sounds more “real”, but this is not so. There are studies that demonstrate, concretely, cellular level indicators of longevity (leukocyte telomere length) are shorted in people undergoing chronic stress, overall,[1] and in many specific conditions, including PTSD, chronic lung disease, Alzheimer’s disease, and chronic racism.

Our healthcare system is responding, but much of it not in a way that will help stem the epidemic. Recently, I wrote about ‘Rich hospitals get the bulk of government bailouts: It's the American way!’ (May 26, 2020), and more recently information comes to light that shows many systems are doing even less to help America confront the virus, laying off thousands of actual healthcare workers, and more to line the pockets of their C-suite executives! While these egregious and unforgiveable abuses are worst in for-profit hospital systems such as HCA, they are also occurring in many large and prosperous “non-profit” systems.

The NY Times comments on Anthony Fauci, the NIH’s top virologist:

He described the pandemic as “shining a very bright light on something we’ve known for a very long time” — the health disparities and the harder impact of many illnesses on people of color, particularly African-Americans.

The coronavirus has been a “double whammy” for black people, he said, first because they are more likely to be exposed to the disease by way of their employment in jobs that cannot be done remotely. Second, they are more vulnerable to severe illness from the coronavirus because they have higher rates of underlying conditions like diabetes, high blood pressure, obesity and chronic lung disease.

Philip Ozuah, the CEO of Montefiore Medical Center in the Bronx, very hard hit by the virus, writes of the deadly combination of racism and COVID-19 writes that “I fought two plagues and beat only one”,

America has changed its behavior in such profound and fundamental ways to mitigate the coronavirus, from self-quarantining and working from home to wearing masks and literally risking our lives to care for the sick. As our streets fill every night with protesters demanding a change that has been too long in coming, I dare to hope that we as a people can summon the same selfless courage and determination to change our behavior to address the endemic racism and brutality that plagues our country.

Then finally we may rid ourselves of that deadly virus as well.

For a clear, angry, and cogent description of the roots, causes, current manifestations of, and discussion of what we might do, a recent entire episode of John Oliver’s ‘Last Week Tonight’ is  a must-view.  He starts with the horrific and (finally) increasingly known statistics – such as that in Minneapolis, people of color are 7 times as likely to be arrested as whites, and the incredible fact that in the US 1 in 1000 Black men can expect to be killed by the police! Toward the end he quotes Kenneth Clark commenting on uprisings in the 1960s. Clark describes how after each previous crisis, from 1919 on, the powers-that-be say the same things and nothing really changed. The stark reality that this is still true 50 years later is unavoidable. Oliver insists that things must change, that we need to direct address and change the way that police to their jobs, and indeed redefine what the role of the police should be. He states that ‘It’s about a structure built on systemic racism that this country built intentionally and now needs to dismantle intentionally.’

Some have suggested that the risk of spreading the coronavirus from people gathering in mass demonstrations is high. These demonstrations have even been compared to the right-wing “anti-mask” demonstrations.  The risk of infection is likely heightened, but care can be taken; the important point is that whatever is necessary to finally confront and end racist violence in this country, particularly by the police, must happen and must happen now. Bassett, Buckee, and Krieger from the Harvard T.H. Chan School of Public Health take this on directly and strongly in a recent Op-Ed in the NY Daily News, ‘Racism is a deadly virus too: a public health defense of these mass protests’. They contrast the risk of COVID-19 infection by demonstrators consciously and purposely not wearing masks to the anti-racist demonstrators who are doing their best to wear masks and practice physical distancing.  They conclude that:

Protesters are in the streets demonstrating against police brutality and white supremacy not because they are indifferent to the risk of COVID-19. They are doing what they can to protect themselves and their communities precisely because the institutions that are supposed to protect and serve them have been killing black people in this country far longer than the coronavirus has.

The evidence is in and is clear. Indeed, it has been in and clear for many generations. Racism exists, not merely in the beliefs and attitudes of some or many people, but in the intrinsic structure of American society. It is structural racism and structural violence. It continues to kill and harm people at intolerable rates. In the midst of a terrible global pandemic caused by the SARS-CoV-2 virus, we finally and thoroughly must fight and erase the epidemic of structural racism in the US.

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[1] Olveira BS, et al., Systematic Review of the Association Between Chronic Social Stress and Telomere Length: A Life Course Perspective, Aging Res Rev. 2016 Mar;26:37-52. doi: 10.1016/j.arr.2015.12.006. Epub 2015 Dec 28.

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