What are the practical steps that we in medicine can take against racism?

This is a guest post by Seiji Yamada, MD, MPH & Gregory Maskarinec PhD, colleagues from Hawai'i

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In this essay, we discuss what we in medicine in Hawaiʻi can do about racism.

This NY Times opinion piece "It’s Not Obesity. It’s Slavery" by Sabrina Strings, an associate professor of sociology at the University of California at Irvine, decries the victim-blaming attribution of the disproportionate coronavirus risk among blacks to their co-morbidities. The essay starts off as follows: 

About five years ago, I was invited to sit in on a meeting about health in the African-American community. Several important figures in the fields of public health and economics were present. A freshly minted Ph.D., I felt strangely like an interloper. I was also the only black person in the room.

One of the facilitators introduced me to the other participants and said something to the effect of “Sabrina, what do you think? Why are black people sick?”

It was a question asked in earnest. Some of the experts had devoted their entire careers to addressing questions surrounding racial health inequities. Years of research, and in some instances failed interventions, had left them baffled. Why are black people so sick?

My answer was swift and unequivocal.

“Slavery.”

What Sabrina Strings is pointing out here is the importance of history and its legacy of ongoing structural violence. Interviewed by Fareed Zakaria on "Why COVID-19 hit black Americans so hard," Harvard School of Public Health Prof. David Williams notes that for every dollar of income made by white households, black households make 59 cents. For every dollar of assets owned by white households, black households own 10 cents, and Latino households own 12 cents.

The Academic Medicine article "Changing How Race Is Portrayed in Medical Education: Recommendations From Medical Students," outlines how American medicine was historically steeped in racism. We also have the historical legacy of the Tuskegee, a United States Public Health Service study in which 399 black men were observed for decades with their syphilis infections untreated. Who was the first to object? Dr. Irwin "Irv" Schatz, former chair of the University of Hawai`i Dept. of Medicine, in 1965.

Closer to us in the Pacific, we have the legacy of the Marshall Islanders, deliberately exposed to fallout radiation Project 4.1 of the March 1, 1954 Castle Bravo thermonuclear test, then subsequently subjected to human radiation experiments for which they gave no consent. 

That the Marshallese had their human rights denied in this way reflects how they were viewed as less than human. With regard to Utrik Atoll, in a post-Bravo 1956 research planning meeting of the Atomic Energy Commission (AEC) Advisory Committee on Biology and Medicine, Merril Eisenbud, the director of the AEC Health and Safety Laboratory, noted (as quoted by Barbara Rose Johnston 2007, 25):

They had been living on that Island; now that Island is safe to live on but is by far the most contaminated place in the world and it will be very interesting to go back and get good environmental data, how many per square mile; what isotopes are involved and a sample of food changes in many humans through their urines, so as to get a measure of the human uptake when people live in a contaminated environment.

Now, data of this type has never been available. While it is true that these people do not live, I would say, the way Westerners do, civilized people, it is nevertheless also true that these people are more like us than mice. So that is something which will be done this winter.

[Photo: Holly Barker, Bravo for the Marshallese]

 That migrants from Micronesia continue to be denied participation in Medicaid (Med-QUEST) also reflects how they continue to be viewed as the "other" - not deserving of the access to health care as the rest of us. Micronesians also experience racism within Hawai`i's health care system. (See "Discrimination in Hawai‘i and the Health of Micronesians and Marshallese" and "Chuukese community experiences of racial discrimination and other barriers to healthcare.")

The public policy is complemented by more overt racism. One of my Chuukese patients (a man with two jobs, while his wife worked another, but living out of their car) reported to me that he was stopped by the police, told to exit his car, and was slammed against the hood of his car by the policeman.

What are the practical steps that we in medicine can take against racism?

We need to address the systemic racism against Native Hawaiians and Pacific Islanders.

We need to address the distrust that Native Hawaiians and Pacific Islanders have toward the health system and its practitioners to improve access.

We need a health insurance system that includes Micronesians.

We must address the economic marginalization of people who work full-time but cannot afford a home.

We must address the catastrophic on-going military occupation of these islands.

This is a broad outline of the steps that must be taken. We call upon all involved in medicine in Hawaiʻi to make it a reality.

#BlackLivesMatter

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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Rich hospitals get the bulk of government bailouts: It's the American way!

The world isn’t fair. The US isn’t fair. It isn’t equitable. It would be much better if things were more equitable, if everyone had the same starting line (or, to use a metaphor that might be more resonant with politicians and businessmen, started from the same tee), or if those who were starting from farther back got extra help to get them closer to being on a par. Par is another golf term, and actually in golf this is actually done. The “handicap” is an amount subtracted from the scores of weaker golfers (in golf, lower scores are better) to make the competition more fair. Unfortunately, it never occurs to the presidents and CEOs who play on the golf course to apply this same strategy to the actual world, to regular people and businesses.

In fact, it is those least in need benefit most from government policies. It has been clearly demonstrated that the 2018 tax cuts had little benefit for the middle class or working class, less yet for the poor whose incomes are so low they scarcely pay taxes, but was a bonanza for billionaires and mega-multi-national corporations. This is no less the case with the next multi-trillion-dollar coronavirus relief bills, where the richer you are the more you get. Nicholas Kristof points out that ‘a single mom juggling two jobs gets a maximum $1,200 stimulus check — and then pays taxes so that a real estate mogul can receive $1.6 million. This is dog-eat-dog capitalism for struggling workers, and socialism for the rich.' He is correct, and it is unconscionable. Franklin Roosevelt would certainly be appalled; I use a quotation from him that is inscribed in the FDR memorial in DC as the epigram for this blog.  By this measure we not only fall flat, we invert; you’d have to go back even before the “Roaring ‘20s”, at least to the “Gilded Age” of the 1890s to see such inequity enshrined. For a good, concrete, example of how MUCH a billion dollars is and how those who have multiples of it are so far from the rest of us, and how incomprehensible it is to expect working people to bear the brunt of need, Tom Lutz of the Los Angeles Review of Books writes:

In other culture news, The Atlantic laid off 68 people, and the LA Times made everyone take a 20% pay cut, which will save the paper $2 million in a year.

Patrick Soon-Shiong, who owns the LA Times, has a net worth of $7 billion, so one year's 5% return on his wealth would cover that $2 million savings for 175 years. Or he could just cover for this year and have a net worth of $7,348,000,000, instead of $7,350,000,000. Laurene Jobs owns The Atlantic. Her net worth is $23 billion; 5% return on that in one year would pay those 68 fired staffers $100,000 a year each for 169 years. Or she could just pay for this year, and not kick 68 human beings to the curb to face the worst unemployment in 70 years. If she did that, at the end of the year, instead of $24,150,000,000, she would only have $24,143,200,000. That difference is surely worth ruining the lives of 68 people for. Her Apple stock alone went from $7 billion to $12 billion over the last 12 months. That appreciation could pay the fired 68 staffers $100,000 a year each for 735 years. and she still would be one of the 40 richest people in the world.

FDR was famous for the “New Deal”, a mixture of programs to put Americans back to work and to bring us out of the Great Depression. Congress and the executive branch have, in response to the coronavirus pandemic, trotted out literally trillions of dollars, but unlike Roosevelt have done their best to ensure that the most goes to the least needy. It is not just regular people who are affected; bailout money intended to offer relief to small businesses (already generously defined as fewer than 500 workers) went largely to much larger businesses. Some of this was blamed on administrative mistakes in a rush to get the money out, but huge corporations did in fact get lots of money, and didn’t give it back. And, in case you were wondering when I was going to get to health care, the same dynamic is playing out for hospitals.

The pandemic has hit hospitals hard, particularly those in high-prevalence places (like New York City) and particularly public hospitals and others that care for the poor in the best of times. Although most rural areas have not had as high an incidence of coronavirus infections, rural hospitals were teetering on the brink before the pandemic, because a hospital is an expensive operation to run and rural areas have, well, less dense populations. And populations, also that are more likely to be old and poor. Which are two risk factors for getting and dying from COVID-19, but are also risk factors for a lot of other health issue. This is why such hospitals – small rural hospitals, overwhelmed inner city hospitals, hospitals with true need, should be getting the bailout money to help them in this crisis. But – and I doubt this will come as a surprise – they are not getting most of the help, and most of the help is going to big, money-rich, hospital chains, the hospital equivalents of billionaires and multi-national corporations.

A recent article in the New York Times, ‘Wealthiest Hospitals Got Billions in Bailout for Struggling Health Providers’, with the subhead ‘Twenty large chains received more than $5 billion in federal grants even while sitting on more than $100 billion in cash’, begins

A multibillion-dollar institution in the Seattle area invests in hedge funds, runs a pair of venture capital funds and works with elite private equity firms like the Carlyle Group.

But it is not just another deep-pocketed investor hunting for high returns. It is the Providence Health System, one of the country’s largest and richest hospital chains. It is sitting on nearly $12 billion in cash, which it invests, Wall Street-style, in a good year generating more than $1 billion in profits.

And this spring, Providence received at least $509 million in government funds….

While all hospitals have taken a financial hit from the cancellation of high-profit elective procedures, some, like Providence (and there are many others) have big-to-huge cash reserves, while others can barely make payroll month-to-month. In the typical rich-get-richer scenario that characterizes the US all too often, those hospitals that have high profiles (read: take care of well-to-do people) not only do not have to make it on low-reimbursement uninsured and Medicaid (and even Medicare) patients, the get big donations, as detailed in “One rich NY hospital got Warren Buffett’s help. This one got duct tape”, NY Times April 26, 2020 (updated May 20). As all too often with “philanthropy”, the rich give to organizations that benefit the rich, and take a tax break for it. And so do the hospitals, most of which are organized as “non-profits” but act like for-profit businesses, but don’t pay taxes. Much of the data in the May 25 article comes from this Kaiser Family Foundation report. It documents that the biggest recipients of aid were for-profit and wealthy “non-profit” hospital systems. 

How does this happen? By intent or sloppiness? I don’t know.

While Health and Human Services also created separate pots of funding for rural hospitals and those hit especially hard by the coronavirus, the department did not take into account each hospital’s existing financial resources.

“This simple formula used the data we had on hand at that time to get relief funds to the largest number of health care facilities and providers as quickly as possible,” said Caitlin B. Oakley, a spokeswoman for the department. “While other approaches were considered, these would have taken much longer to implement.”

Most people are decent people; if a package is mistakenly delivered to your house but is addressed to someone down the street, you don’t keep it. If the person who was supposed to get it is aged, disabled, poor, or otherwise in need, and this package provides some relief – perhaps food, clothing, medicine, you are especially concerned to make sure they get it. This kind of morality does not apply to billionaires or to wealthy corporations, whose absolute greed to grab anything that they can get their hands on, no matter who else suffers, would make the highwaymen of yore, or Mafia dons, blush.

“If you ever hear a hospital complaining they don’t have enough money, see if they have a venture fund,” said Niall Brennan, president of the nonprofit Health Care Cost Institute and a former senior Medicare official. “If you’ve got play money, you’re fine.”’ Well, they’re fine. And I guess you’re fine if you can afford to go to one of them, not the hospitals that serve the people with the greatest need. And if you don’t think about it too much, you can probably sleep at night.

I don’t see how the CEOs and Boards of these hospitals do.