S1E13 / A Black Plague / Helene Gayle & Aletha Maybank

I'm Dr. Celine Gounder.

And I'm Ron Klain.

And this is Epidemic.

Today is Tuesday, April 21st.

Over the weekend, the U.S. passed a grim milestone. More than 40,000 Americans have died from COVID at the time I'm recording this. One thing's clear, people of color, Latinx people, indigenous people, and particularly African Americans have made up a disproportionate number of those deaths. White House coronavirus response coordinator, Dr. Deborah Birx, spoke about this a few weeks back.

We don't wanna give the impression that the African American community is more susceptible to the virus. We don't have any data that suggests that. What our data suggests is they're more susceptible to more difficult and severe disease and poor outcomes.

Today, we're going to look at why that is, why this disease that affects all of us has affected some of us so much more than others.

Dr. Helene Gayle is the CEO of the Chicago Community Trust. Before that, she led the global humanitarian organization, CARE. Launched the McKinsey Social Initiative, and directed global health programs at the Gates Foundation, and before that spent 20 years at the CDC working on infectious diseases like HIV and tuberculosis.

I grew up in, in the '60s and early '70s during the time when our nation was going through a lot of social change, whether it was the civil rights movement or the women's movement or, you know, I looked at what was going on in Africa, anti-apartheid and other anti-colonial movements. And so, you know, I grew up with that sense of wanting to be part of something bigger than myself.

For Helene, that sense of mission took her to medicine. She became a pediatrician, but once she started to see patients, she realized that their problems weren't always so clear-cut.

Oftentimes what brought people in and out of the emergency room or in and out of my primary care clinic had less to do with the tools that we had in our health toolkit, but had a lot to do with systems and society and how people were able to have other aspects of their lives that allowed them to live healthy lives.

Helene saw these connections between class, race, and disease in her own family.

A lot of my extended family who had a lot of the sort of diseases that often run in parallel to to low socioeconomic status, diabetes, hypertension, chronic lung disease, et cetera. And so, you know, all around me, I saw how this kind of health and economic situations were also very much interchanged.

Helene kept treating her patients, but she started to wonder if there was a better way. What if she could address some of the bigger factors that were making people sick in the first place? So she went back to school to study public health, and then she joined the Centers for Disease Control.

Thinking that I would go for 2 years to do training in the Epidemic Intelligence Service, went for 2 years and stayed for 20.

Helene's family and professional life showed her how social determinants impact health. Today, she's working to improve those conditions by closing the wealth gap between rich and poor in Chicago. In the age of COVID the diseases that follow low socioeconomic status are hitting African Americans and other people of color especially hard.

The economic factors, the social factors kind of conspire with the already existing health comorbidities. And I think it explains a lot of why we're seeing what we're seeing in terms of Black and brown communities and the impact on COVID.

These underlying conditions don't exist in a vacuum. They're often the result of bad or even malicious public policies that target people of color.

They don't have the same resources, they don't have the same power, and they don't have the same conditions in order to achieve optimal health.

This is Dr. Aletha Maybank. She's the American Medical Association's chief health equity officer.

So when I say conditions, I mean they don't have the same opportunities of having affordable and quality housing in many neighborhoods, either in the South or in our urban areas or even in rural communities as well. All of our systems are all influenced and created by our historical context and connection to structural racism. And so we have to be able to name it. We have to be able to name racism as a fundamental cause of why these health inequities exist. It takes a shift in heartsets and mindsets about what produces not only the inequities, but what creates health overall.

There's no clearer example of this than redlining, the practice that blocked African Americans in particular from being able to buy homes in certain neighborhoods. That kept African Americans from being able to get federal support and loans to buy a house. It segregated our communities along color lines, and it robbed people of color of the chance to accumulate and pass down wealth to future generations through home ownership.

And so now you have this overcrowding, hyper-segregated communities that still last until this day. So when you have an infection such as COVID and you're in an overcrowded community and where people are living very closely together, they're more likely to spread from person to person.

These conditions have real consequences.

I'll take Chicago as an example. Streeterville, which is downtown Chicago, and you compare it to Englewood, which is South Chicago, there's a 30-year life difference. Downtown Chicago is predominantly white and South Side Chicago is predominantly Black.

This is before COVID These dramatic disparities impact people's living conditions, their access to healthcare, and their ability to pay their bills during quarantine.

We know the wealth gap between Blacks and whites is 10 times higher wealth in the white community. And that has tremendous impact in a person's ability to be able to kind of rebound and thrive and survive during times of COVID As we've said many times on this show, the pandemic affects everyone, but it doesn't affect everyone equally. There are folks who have to go to work. A lot of Black and brown communities, they're working the jobs. Of the janitorial jobs, many of the frontline jobs, and they have to go to work. There are several epidemics going on, you know, that were already existing, but they're kind of getting amplified at this point in time. And for communities of color, lower-income communities, they're experiencing it all. They don't have the privilege to social distance and physical distance in the way that people with money and privilege and have stay-at-home jobs do.

And racial stereotypes are complicating people's ability to follow public health guidelines safely, like wearing face masks to prevent the spread of the virus.

Back in March, a video was posted to YouTube. You can see two young Black men wearing surgical-style masks.

Hey, so we were in Walmart in— what's this, Wood River? And Wood River, Illinois, this officer right here behind us Just told— just followed us in the store. You just video— he said that— he said we can't video, but he just told us we're on body cam. He just followed us from outside, told us that we cannot wear masks. There's a presidential order, there's a state order, and he's just— and he's following us right now out of the store. We're being asked to leave for being safe, and this is what we're doing right now.

We've seen multiple videos of violence towards Black people for next to nothing at the hands of police. And so to have the expectation that somebody who is already under kind of a heightened light for law enforcement to put a wrap around their face, that's just, that's almost, that's a setup for increased agitation and violence towards people who are doing absolutely nothing.

Wearing masks.

There he is.

We're getting kicked out of Walmart for wearing masks.

Are you serious?

Hey, so coronavirus is real. This police officer just put us out for wearing masks and trying to stay safe.

It's like this double-edged sword. You die one way or you die the other way. And this is all rooted in our historical context around racism, but also just the bias that exists. Now, I do believe a lot of it is also intentional as well, but sometimes people don't recognize their own biases and systems don't recognize their own biases.

Aletha says that if our public policies are going to move beyond these biases, we are going to need data, good data, on who's most affected by COVID. Aletha thinks it's likely that COVID cases are probably most underreported in communities of color.

Absolutely. There's just a mistrust for the healthcare system. So I read a quote yesterday by a woman who said, you know, I'm 72, I'm a woman, I'm Black, I have diabetes. And if I get symptoms, I'm not going into a healthcare setting because I know they're going to leave me in the hallway to die. Right? And so that is a sentiment not just among her, but among other people.

I've heard it not just in the recent time, but just even before COVID If better data could be collected, it could be an opportunity to get help where it's needed most. But that means authorities need to be willing to see the situation fully, warts and all.

What I've learned in doing racial justice work is there has to be accountability by leadership to say that this is important and critical for us to do and to elevate injustice, even if it is unpleasant. And even if, you know, it shows something that may not shed a great light upon our city, we need to show this data because our most marginalized potentially are not getting what they need to get. If we don't focus more upstream, as we call it, to why these conditions and why this situation exists in the first place, we will not solve or close the gaps around health equity. We will land completely in the wrong place when it comes to solutions down the line, and especially the policy solutions.

COVID-19 is exaggerating deep disparities in our society, but there could be an opportunity to rebuild and a better, more equitable way.

When there was an earthquake or a tsunami or Superstorm Sandy, how do you build back better so that the next time there is a shock, which inevitably there will be, people, institutions, environments are much more resilient? So I think we have the obligation and the ability to build back better after this.

Take how education is being impacted by coronavirus.

Example, here in Chicago, as a result of the fact that schools are closed and young people are having to do their work online, well, there was a true digital divide. A lot of poor kids who didn't have access. We've been able to get out thousands of computers to kids who never had them before and starting to work on getting more equitable broadband access so that they're actually much more able to be able to engage in online learning. We ought to be able to do that all the time. It shouldn't have to be for an emergency. Through the federal CARES Act and many other programs that have been launched, we're actually putting cash into people's hands so that they can pay their bills. Well, you know, the idea of giving poor people cash is something that's done all around the world, But we've always had an aversion to it, a sense that poor people won't know what to do with money if they get it. So couldn't we do that more consistently to give financial security? We're doing a lot to provide small businesses low-interest or no-interest loans with much more flexible terms than ever before. We could be doing this for small businesses and particularly businesses of color who have a hard time accessing capital. To be able to grow their businesses, which not only grows businesses and wealth for the individual but also provides jobs in neighborhoods where there's high rates of unemployment. I could go on, but I think there's a lot of things that we're doing during this emergency response that we should think about. What could we continue to do to create the kind of financial and economic resiliency so that when the next shock comes, people are better prepared and we don't have to always have to create an urgent response.

Helene says that many of these disparities were created by public policy, so we should be able to use public policy to address them as well.

As a nation, we've got to put in place a public health system that includes disease preparedness so that we're ready for whatever is the next shock and that all of us no matter who we are, what socioeconomic status, what race, ethnicity, what job we have, that we don't have to go through this again. It is within our reach to be able to end these sorts of unacceptable wealth and health disparities.

And Aletha remind us of something important. Public policy matters in fighting pandemics. You know, sometimes people ask us, why do you keep bringing policy and political matters into the podcast? Isn't this supposed to be about medicine and science? Well, of course, medicine and science come first, but public policy shapes how we deal with pandemics. And now we're going to answer a few listener questions. Our first question this episode comes from Dr. Jordan Winter.

It took just 2 months for us to go from 1 COVID case in the United States to 350,000. By the end of the current crisis phase, past the peak, maybe 99% of the country will still be unexposed. So how can we reopen the country for business before herd immunity takes over, which could take years, or a vaccine is developed, which could take a year and a half? How would it be safe to do so, and why aren't we discussing this difficult point? It seems that the subsequently continuous run of peaks, which would be inevitable, until this happens would occur at a price of thousands of lives?

Jordan, this is a really important question. First of all, I think it's important that we understand that when we lift social distancing restrictions, the virus will start spreading again. People will get sick. Some people will get really sick and die. The point of those social restrictions was to slow transmission, not to stop it, and to give us time to prepare. There are two key pieces to that preparedness. We need time to prepare our public health system and time to prepare our healthcare system. The healthcare system needs to be able to test everyone who has symptoms and safely care for everyone with COVID as well as other medical conditions, and not in an unsustainable crisis kind of way. The public health system needs to be able to trace the contacts of people with COVID and to test those contacts. It needs to do antibody testing to figure out who's been infected with the virus and whether those people are indeed immune to reinfection again or not. And surveillance data from both the healthcare and public health systems will serve as a speedometer of sorts to let us know when the transmission of the virus is starting to accelerate again and when we may need to step on the brakes again and tighten social distancing measures.

And our next question comes from Dr. Mark Duncan.

Hi, my name is Mark Duncan. I'm a hospitalist based in Denver, Colorado. My question is about the second wave of cases that a lot of people are predicting will happen months from now. Let's say that lockdown and social distancing is effective and we see a big reduction in cases, but not a lot of the population is immune. So months from now, if we see an you know, city by city, an outbreak of new cases, what can we expect from that? Will it be a more optimistic outcome since we've already prepared in some sense? What can prior pandemics teach us about this?

Mark, we know that when we lift social distancing measures, transmission of the virus will increase again. The question is, how big will that second peak be and when will that hit? Much of that depends on how we use the time now while social distancing restrictions remain in place to prepare. As for lessons from prior pandemics, if we go back and look at how different cities took action during the 1918 flu pandemic, we can see that cities that started social distancing earlier had lower rates of death during their first wave of infection, but they were at higher risk for a bigger second wave. And that second wave hit more quickly after restrictions were lifted. And this speaks to the need to be vigilant, to have monitoring systems in place before we lift social distancing restrictions. And the fact that we've already complied with social distancing for an extended period of time shouldn't give us a false sense of security. We're not out of the woods yet.

You know, I'd add, Celine, that, you know, I've often said that there are 3 preconditions to ramping up levels of activity. The first one is we have to get the incidence of the disease down. We have to have testing and contact tracing in place, and we have to be able to have our healthcare system well enough staffed and well enough equipped to deal with reemergences of the cases. We are never going to be 100% safe until there's a vaccine that's widely available and widely used, but I think we all know realistically we are going to start to go back to work to school, to other activities before we get to that 100% safe point. So as a society, as we do that, we need to make sure these preconditions are in place: lowering incidence, more testing, contact tracing, better-equipped medical system. And then we put conditions in place. We say to people, as you're going back to work, we're going to spread people further apart, we're going to try to observe social distancing in the workplace, we're going to give those workers on the front lines— not just doctors, nurses, and first responders, but everyone dealing with customers, the right protective gear. We're going to clean our workplaces frequently in our schools. We're going to take steps to reduce the risk as much as possible. That has to be part of moving forward. If you'd like us to answer your question, record an audio file on your phone with your question and email that to us at hello@justhumanproductions.org. That's hello@justhumanproductions.org.

Epidemic is brought to you by Just Human Productions. Today's episode was produced by Zach Dyer and me. Our music is by the Blue Dot Sessions. Our interns are Sonia Baradwa, Isabel Rickey, and Claire Halverson. If you enjoy the show, please tell a friend about it today. And if you haven't already done so, leave us a review on Apple Podcasts. It helps more people find out about the show. You can learn more about this podcast, how to engage with us on social media, and how to support the podcast at epidemic.fm. That's epidemic.fm. Just Human Productions is a 501(c)(3) nonprofit organization, so your donations to support our podcasts are tax deductible. Acceptable. Go to epidemic.fm to make a donation. We release Epidemic twice a week on Tuesdays and Fridays, but producing a podcast costs money. We've got to pay Zach, so please make a donation to help us keep this going. Check out our sister podcast, American Diagnosis. You can find it wherever you listen to podcasts or at americandiagnosis.fm. On American Diagnosis, we cover some of the biggest public health challenges affecting the nation today. In season 1, we covered youth and mental health. In season 2, the opioid overdose crisis. And in season 3, gun violence in America. I'm Dr. Celine Gounder.

And I'm Ron Klain.

Thanks for listening to Epidemic.