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.

 

 

 

Biden: Not Medicare for All, but leadership on COVID

The defeat of Donald Trump in the 2020 election was a wonderful thing, despite the less-good news: that the “blue wave” did not appear, that the Senate (barring two unlikely upsets in Georgia) will continue to be controlled by Mitch McConnell, that the GOP gained seats in the House, and especially that 70 million Americans voted to re-elect the worst president in American history, thus supporting racist, misogynist, anti-environment, anti-union, pro-corporate and pro-billionaire policies, and bellicose macho authoritarian bluster. The election of a Black (and Asian) woman as Vice-President is historic and great. While it is possible that Biden’s uninspiring “centrist” (read “center-right”) positions gained him votes, the division in America has never been more dramatic. Cities like, most highly featured in the days following the election, Philadelphia and Atlanta (as well as New York, Los Angeles, Chicago, etc.) went 70-80%+ for Biden, while rural counties went for Trump by the same margins.

My purpose here is not to be a political commentator, but to discuss what this might mean for health care under a Biden administration. Certainly not a supporter of any kind of single payer universal health insurance, including Medicare for All, Biden further has to contend with a (probably) Republican Senate and a newly strengthened rightist Supreme Court that even as this is being written is hearing another challenge to the ACA, President Obama’s signature domestic achievement, and the scaffold on which Biden hoped to build his own health care plan by adding a “public option”.

Assuming that, despite Senate and possible SCOTUS opposition, the ACA survives and even that the “public option” becomes law, it would be a great advance in the number of Americans who had access to decent health insurance (which, in itself, may doom its chances in those two “august” bodies!) Indeed, the arguments that many, including myself, have made for the savings that could be achieved by government single-payer program (extension of an improved Medicare to everyone) would likely be somewhat achieved by a well-designed public option, since better coverage would cost less money than it does under the private, for-profit, insurance sector. Not nearly as much as would be achieved by single-payer, but enough to have a good chance of eroding the base of those who hang on to excessively costly, poor-quality private insurance.

And yet, ”Medicare for All” continues to enjoy wide public support, certainly in those “blue” cities and counties, but also within the US as a whole, including some of the “reddest” areas. People know that their health insurance is costly and that the coverage is inadequate, and that not only their lives and health are at great risk, but so (to the extent that they have any) is their “treasure”. Democrats who supported M4A were all re-elected, while many opponents were defeated. Indeed, this illustrates the difference between those in power, members of the Senate and the House (and SCOTUS) who serve the wealthy and are mostly wealthy themselves, for whom tax cuts for their patrons and corporations (under the umbrella of the scandalous SCOTUS decision in Citizens United that declared money to be speech and corporations to be people!) are the main agenda, and their constituents. The latter have poor and costly health insurance, benefit little if at all from tax cuts, and are losing their jobs right and left as US companies push more and more money to the top. For the former, Medicare for All is a bugbear; for the latter it may be a lifeline.

The most important healthcare issue in which the election of Joe Biden is likely to make a big difference, however, is the most important healthcare issue currently facing America, and the world – the COVID-19 pandemic. This second (or maybe third) wave is breaking all kinds of records for new cases, new hospitalizations, and new deaths. In my state, Arizona, we have the highest rates since July. The nation has had well over 100,000 new cases a day recently, in some of the “reddest’ counties, with rates over 200/100,000 residents in some. The reason is that the virus does not care about what you want, and apparently what we have wanted is greater opening, an end to social isolation and not going out to restaurants and bars, not having parties and funerals and visits with our relatives. We want businesses to open, we want our jobs back, we want our personal economy (not just the stock market) to improve. We bristle at the “discomfort” of masks (like the “discomfort” of seatbelts). We want to rush, en masse, onto the football field to celebrate a huge victory for Notre Dame over Clemson (oh, wait, we did that!)

The problem, of course, is that each of those things spreads the virus, and the spread of the virus means more people will die. I have often said REOPENING=DEATH and it remains true, however much we want it not to be; there is nearly a linear relationship between the degree of reopening in any city or state and the increase in the rate of cases of “the rona”. Now, as we look toward all those college students, including those from Notre Dame, returning home for the holidays, we hold our breaths as we worry about how many of their parents and grandparents will become infected and die, putting a damper on the celebrations.

Masks and reasonable social distancing will not prevent this entirely, but will help a lot; masks really decrease transmission. Having a President who wears a mask, who encourages safer behaviors, who does not encourage total irresponsibility as has the current incumbent, is likely to make a big difference. Something has to, and certainly it needs to happen soon. Most encouraging, Biden is not only willing to, but enthusiastic about accepting science as the guiding principle of the response to the epidemic. He has already named members to his COVID “panel”. It could use some more epidemiologists, some nurses, but the intent and direction are good. The increase possibility of a vaccine, especially the recent news from Pfizer, is very encouraging. With a new administration committed to making a difference by using strategies that might actually make a difference, the trajectory of the virus might be turned around.

There are, and will continue to be, great obstacles. The most vulnerable populations will continue to be the most vulnerable – including people in prison, and those immigrants in federal detention, whose rates of infection are staggering. The Pfizer vaccine requires shipping and storing at temperatures of -80 degrees, which is very difficult in many places, particularly in less developed countries where the pandemic is raging.

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But leadership from the US President can go a long way. Whatever else we might wish from him that we are unlikely to get, we can hope that Biden will provide this.

Institutionalized racism and violence and the impact on people's health

I recently wrote about the confluence of the COVID-19 pandemic and its greatly disproportionate impact upon poor and minority communities, and the increasing awareness of the overall oppression of minority communities that has come to a head in the aftermath of the murder of George Floyd by the police in Minneapolis, along with the huge protests (and police repression of those protests) around the country (‘Structural racism, structural violence and COVID-19: We must fight both epidemics’). This incredibly important and deserves not only further discussion here but ceaseless discussion in all venues until the US really changes.

Minority communities in the US (and for the rest of this piece, “in the US” will be implicit) have always suffered a much great burden of chronic disease, much more limited treatment options, and worse health outcomes. It is not new with COVID-19. In addition, minorities have always suffered more police brutality, more incarceration and involvement in the criminal “justice” system, and more violent death. We live in a nation and a society that was built upon and perpetuates not just racist bias but a structure in which repression of minority people, especially people of color, and most especially African-Americans, is an intrinsic component. Police violence against Black people is not (solely) a result of the individual racism of the police officers inflicting it; it is the purposeful enforcement mechanism of institutional racism, which has always existed in the US: slavery, Jim Crow, mass incarceration. The White-run police state in apartheid South Africa was odious and obvious, and most Americans correctly identified its purpose, but our own similar structures seem to have been harder for many to see. This is partly because they have been less clearly stated in law (for at least a few decades), and in part because in South Africa, Whites are a small minority whereas here they are the majority (so far). But, if perhaps less obvious and to some degree less severely violent, our own society has always had racism built into its fabric.

Facts that must be acknowledged: Black people are victims of police violence, and are killed by police way out of proportion to their percentage of the population. Black men are involved in the “criminal justice” system at, at least, 3x the rate of White men. Black families have a net wealth of about 10% of White families. For years, decades, centuries, official policies, laws and de facto practices have relegated Black people to the back of the line, kept them from good jobs, housing, and education. Black men, even if they have money, or are doctors, or are off-duty police officers, are more likely to be stopped, harassed, arrested, injured or killed.[1]

Racism can take many forms; Dr. Camara Jones, a professor at the Morehouse School of Medicine and former President of the American Public Health Association (APHA), describes three broad types: institutionalized (which is what I am mainly discussing here), personalized (that expressed by individuals toward others), and internalized (the “self-hate” that victims of racism may begin to believe about themselves, in part at least)[2]. They are all important, and all affect the health of the victims, and all need to be addressed. We have increasingly seen campaigns aimed at raising (White) people’s awareness of unconscious (as well as conscious) bias.  This is good, and important, but our analysis needs to go far beyond the idea of individual bias, and understand WHY people have grown up with and maintain such bias.

The US was built upon the free labor provided by chattel slavery of African-Americans. Many of our “Founding Fathers” (e.g., Washington, Jefferson, Madison) were not only slaveholders, but plantation owners with huge numbers of slaves. Thomas Jefferson’s “agrarian ideal”, that our nation would be best off if its people were farmers, was either ironic or hypocritical; it was not Jefferson but his slaves who did the farming at Monticello. Compromises with slaveowners led to a Constitution whose flaws are now obvious; that each state has two senators, regardless of population, was intended to help the South. Thus today small states are overrepresented in the Electoral College (e.g., Wyoming has one congressional district and thus 3 electors, 5.5% of California’s 55, but its entire population is less than any of California’s 53 congressional districts). Indeed, the South wanted to count each slave as a person for the sake of the census, although they had no intention of letting them vote; the ‘3/5’ rule was a compromise. Of course, today it is the “conservatives”(really, racists) who say no to counting everyone, especially undocumented immigrants (a category that did not exist at the time of the Constitution).

The “race” (pardon the pun) is fixed; we do not all start from the same place; Blacks start with one hand tied behind their back (or one leg shackled?). It is not just in health or in police violence; the story of government-sponsored racism in housing is amazing and scary (as portrayed in this video). What is amazing is how persistent this has been.  On the death of John Lewis, a true American hero, some have discussed the role that the violence perpetrated by police on nonviolent protestors in Selma, AL, had on helping push the Voting Rights Act of 1965 into law. Signing it, President Johnson noted that it had been over a century since the Emancipation Proclamation, but that in the South many Blacks still could not vote. Today, in 2020, it is more than half again as long and in the US – not only in the South – strategies continue to be implemented to keep minorities from voting.

The negative impact of our racist infrastructure on the health of minority people is tremendous. Woolf and colleagues estimated that in the decade 1991-2000, all medical advances averted 176,000 death, but if African-Americans had the same death rate as Whites, over 686,000 deaths would have been averted![3] Park and colleagues demonstrated that Leukocyte Telomere Length, a marker of cellular aging indicating cumulative biologic stress, which equates to shorter lives, is indeed shorter in those who perceive the neighborhood they live in as poor quality, compared to those who perceived their neighborhoods as good quality.[4]

Our medical schools, on the front lines of training new physicians, rarely overtly address the pervasive, not occasional or individually-mediated, racism of our health care system. We still train students to start presentations including race (and gender) -- “A 53-year old Black male” – although in the US “race” is a social construct and the genetic variation within any “racial group” is far greater than that between different groups. A recent article in the New England Journal of Medicine by medical student LaShrya Nolen uses the metaphor of the bulls-eye lesion of erythema migrans that characterizes early Lyme disease – in people with white skin. Because it is not as obvious in people with dark skin, the diagnosis is made later and complications are more common. She observes that we are “missing the bulls-eye” in addressing systemic racism in medical education.[5] In a New York Times Op-Ed, “Medical Schools Have Historically Been Wrong on Race” Dr. Damon Tweedy comments on the pervasive racism in patient care and education of physicians that is current as well as historical.

If we are to approach a system where there is truly health equity, we need to work simultaneously on many fronts. The health care delivery system, and its educational components, need to restructure from the ground up. Much more significantly, we need to address the Social Determinants of Health: access to safe housing, enough food, good jobs? Opportunity for a good education, not tied to the income of one’s parents through local school funding; all the things that make health worse and telomeres and lives shorter. We need to dismantle the police state that addresses protests against police brutality with more police brutality; to recognize that the police do not protect everyone equally, but primarily have the role of repression in some of our communities, and stop incarcerating such a high percent of Black males.

We are in a war for the soul of our nation. Will the racism of our history continue to dominate the reality of our lives, and continue to create and maintain inequity and poor health and death, or will we, finally, more than 150 years after the Emancipation Proclamation, really begin to address structural racism and its impact upon our health?

 

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[1] Derrick CB, “Sirens: 4 decades of harassment by the police”, Guernica, July 27, 2020

[2] Jones CP, “Levels of Racism: A Theoretic Framework and a Gardener’s Tale”, Am J Public Health. 2000;90:1212–1215.

[3] Woolf SH, Johnson RE,Fryer GE, Rust G, Satcher D, ‘The Health Impact of Resolving Racial Disparities: An Analysis

of US Mortality Data’,  American Journal of Public Health | December 2004, Vol 94, No. 12,2078-81.

[4] Park M, Verhoeven JE, Culjpers P, et al., “Where you live may make you old : The Association between Perceived Poor Neighborhood Quality and Leukocyte Telomere Length”, PLOS One, June, 17, 2015.

[5] Nolen, L, “How medical education is missing the bulls-eye”, N Engl J Med 382;26 nejm.org June 25, 2020