S1E8 / Unequal: Race, Status, and COVID-19 / Greg Asbed & Jeneen Interlandi

I'm Dr. Celine Gounder, and I'm Ron Klain, and this is Epidemic. Today is Friday, April 3rd.

In this episode, we'll talk about how this coronavirus pandemic, which affects all what affects all of us doesn't affect all of us equally. We'll speak with New York Times journalist Janine Interlandi, a key member of the Times' 1619 Project, about how issues of race have historically and in the present day impacted access to healthcare in America.

You'll also hear from Gregg Asbed. Gregg is the co-founder of the Fair Food Program, the worker-driven social responsibility model, and a longtime human rights advocate. He'll be talking to us about how the COVID-19 pandemic is affecting farmworkers as well as our food supply.

And as always, we'll wrap up with some listener questions. Joining us now on the podcast is Janine Erntelandy. Janine's been a member of the New York Times editorial board since 2018 and was a contributor to the New York Times Magazine since 2006. She's written about health and science and education. She also was a key member of the team that put together the 1619 Project for the Times, which was a pathbreaking project that exposed the role that slavery has played in so many aspects of American life. We had a conversation with Janine about the role that race is playing right now and historically in access to healthcare. So Janine, thanks for joining us. We're really delighted to have you on the podcast. And grateful for your time to talk about these really important issues.

Thanks so much for having me.

So let's start at the 50,000-foot level here. Uh, we're facing a pandemic. Why is it so important for everyone to have access to key pieces of medical care at a time when we face this kind of pandemic?

People who don't have access to medical care, people who don't have access to the healthcare system in general, are going to be much more vulnerable they're not going to be treated, they're going to get sick, they're going to be more likely to die, and they're also going to be much more likely to spread the virus to other people. And for that to happen, those people have to be able to go to a doctor and get medicine and get care and even get advice and guidance about how to quarantine themselves, how to isolate themselves, whether they do or don't need to go to the hospital. Those are really crucial decisions right now. People who don't have access to doctors and to medicine can't make them by themselves. So, and to the extent that they can't, this thing goes on a lot longer and many more people get sick.

So, Jeanine, will we see a difference in the states that did or didn't expand Medicaid in terms of how coronavirus plays out in those states?

I'd say there's two things. I think one is that people that don't have access to healthcare are going to be less likely to seek out testing as it becomes more available. Someone that doesn't have access to healthcare is going to be much less likely to flip those switches and actually engage with the system. And I think it's going to be harder to reach patients in general that don't have any history of accessing the system at all. That's one thing. And then the other thing I would say is, to some extent, in states that haven't expanded access, that haven't done Medicaid expansion, you have potentially a less healthy population overall. You have a lot more underlying medical conditions that aren't being addressed in low-income communities. They've done some studies where you've seen shrinkages of racial health gaps in communities where they have Medicaid expansion, and those shrinkages have not happened in places where they have not done Medicaid expansion. So you have worse underlying health is one, and you have less likelihood that those populations are going to access healthcare in the first place is two.

So Jeanine, I want to go back in time a little bit. There's really some interesting history involving smallpox among freed slaves How did our control of smallpox differ based on race at the time, and why?

During the Civil War, there were certainly outbreaks of smallpox, particularly among the military. And so for the sake of maintaining the military and probably the white communities, we did certain sensible things. And you certainly quarantined the sick, you know, as humanely as you could. And then after the war, you saw smallpox kind of spread among the recently emancipated because they lived in conditions that made them very susceptible to illness. So because the newly emancipated, you know, were released without being provided any of the essentials to being healthy, and they— as they fell prey to these diseases and the death toll rose, white leaders, instead of addressing it with public health measures, they developed this theory. And it went like this. It was called extinction theory, and it said that Black Americans were so ill-suited to freedom that the entire race was basically going to go extinct and that there was nothing we could do to prevent that. So, you know, in the Union Army, we knew exactly what to do to stop smallpox from spreading. But among the emancipated Black Americans, there was just nothing we could do. And that was the mindset that they adopted. And it led, you know, as we talk about in the piece I wrote for the Times Magazine, it led to great health disparities that persist up to the present day.

In this current conversation we're having as a country about kind of going back to work, maybe it's a little less about race, maybe race is lurking in the background. But in the foreground, the conversation is really about the elderly. And you had the Lieutenant Governor of Texas recently say, basically, if a bunch of old people have to die so that young people can go back to work, that's kind of the way it should be. And some kind of implication that, you know, there just are large segments of the population that are vulnerable and that's just too bad. Do you see echoes of this kind of mentality you were talking about from, you know, 150 years ago Yeah, I do.

And I think because, you know, now we're not talking explicitly about letting certain populations die along racial lines, but along age lines, but it's sort of convenient apathy where there's no one saying that these solutions won't work, but they're going to be really hard, time-consuming, expensive, and we don't want to do the work. So we say, oh, you know, for the greater good of saving the economy, we should just let these other groups die. And I mean, there's many problems with that, but one of the huge obvious holes in that argument is that it's not actually just the elderly that are susceptible to a bad outcome from COVID It's people with lots of underlying health conditions. And it's, you know, people with diabetes, people recovering from cancer, people with asthma, you know, all kinds of things can make you susceptible to dying from COVID And if you take all of those different things and add them up, it comes out to like 100 million people in America are more susceptible to a bad outcome.

I also think there's a point here about class that often gets ignored. There are a lot of people at work who aren't just doctors and nurses. They're the heroes, absolutely, but the delivery people, the people who are running laundromats, the people who are working at the cash register at the grocery store and the CVS, who are a large part of the economy. And I wonder how we think about those people and how they kind of as a class group are winding up getting treated quite differently as we try to manage the risk of the spread of this disease?

I mean, I think that's a huge point. You know, in my own family, my sister-in-law is a hairdresser. You know, I have family members that work in car dealerships, and those people are really going to struggle. And I think that's where Congress needs to step in and provide a recovery package and an aid package that doesn't just bail out industries, but actually saves average Americans. This mindset that can kind of take place among, I think, upper middle class workers who have the luxury of working from home. If you say, oh, this is great, I'm spending more time with family, or I'm learning to cook, or I'm doing this or that, there are— not everybody has that luxury. Some people need to go out to work, and some people live in really close living quarters with like more than one person, and it's not exactly a comfortable situation for them to just stay home the whole time and not earn any income. So I think that's a huge problem that both the federal government needs to engage with, and as this epidemic, this pandemic persists and spreads, that average folks need to kind of keep in mind.

So Jeanine, there's a history in terms of how farmworkers and other domestic workers are excluded from some of the same protections, and some of the people you're talking about very much fall into that category, you know, the nannies and the housekeepers and so on. Why are they treated differently, and what do those loopholes mean for people working in those sectors in the middle of this coronavirus pandemic?

You know, to answer that question from a historical perspective, you have to actually go back to sort of the creation of our healthcare system. Former slave states, they came to wield enormous congressional power, and they formed this voting bloc that was uniformly segregationist and overwhelmingly Democratic. And that voting bloc kind of preserved the nation's racial stratification. They did it by securing local control of federal programs, and they did it under a mantra of states' rights, which is something that we still see talked talked about very much today, and that is very much influencing the response to COVID. And one of the things that that bloc did was they added qualifications directly to federal laws, and those qualifications had very discriminatory intent. So it was at the behest of these Southern Democrats, farmworkers and domestic workers, you know, that was more than half the nation's Black workforce at the time. They were excluded from policies like Social Security, the right of workers to collective bargaining. They were excluded from fair labor standards, which set a minimum wage. They were excluded from all of these policies, basically the entire social safety net they were cut out of under this mantra of states' rights. And so how that worked was like states should determine how various social safety net programs are implemented. And then when you flash forward and you have the program of Medicaid, which is supposed to help low-income populations, like that became a state-run program. So states largely have the discretion still over how Medicaid is run.. And in a lot of states, it's run in a way that, that, that can be discriminatory and that can be difficult for people to access. So if you look at the states that didn't implement Medicaid expansion, it's a lot of the same states that were former slaveholding states. And so there's an echo there, basically. Yeah.

You know, Jeanine, I mean, just to continue on this thought for a second, there does seem to be a correlation between where Medicaid has been expanded after the passage of the Affordable Care Act. And some of the states where the expansion's most needed is some of the states where it hasn't happened. States with a lot of farm workers, states with a lot of poverty. And so how do we think about that? I mean, I think that we are having a big debate right now in the country about what kind of healthcare system we should have going forward. But in fact, 10 years ago, we did something, you know, quite important to expand healthcare coverage. And yet still some of the people who need it the most haven't really gotten it because of decisions of individual states.

Yeah, I mean, I think there's two things that need to happen without trying to get too political here. I think number one, the federal government would do a great service if they would drop the lawsuit right now that is trying to completely strike down the Affordable Care Act because that's gonna take healthcare away from people that already have it. Number two, they should really use their bully pulpit to press the states that have not enacted Medicaid expansion to do so because the best way to address it is to make sure that as many people as possible have access to healthcare, have access to the programs they're going to need to support them, and Medicaid is a huge part of that.

I think it's important for our listeners to know, as you mentioned, that Supreme Court has agreed to hear a case as soon as October to decide whether or not the Affordable Care Act is going to go away completely, and that's very much up for grabs with the Supreme Court.

There's another point, I think, to make here in terms of the lessons that we should be learning about healthcare and healthcare policy in light of the pandemic. You know, there are other things the Trump administration and, you know, that Republicans in Congress have done that have undermined the Affordable Care Act. And we can be generous and say that wasn't their intent. But I'm thinking about things like allowing these kind of skimpy plans that the Affordable Care Act struck down because they didn't provide enough protection for people. You know, these things are going to come back to haunt us. One of the things I'm thinking of is like, you know, CMS changed provisions such that every COVID test is now a thing that has to be covered by your health insurance. Like, that's a great thing. CMS absolutely should do that. But they also allowed these other plans on the market that are no longer required to cover everything that CMS says are, you know, things that absolutely have to be covered. It's this thing where it's like we do one good thing, but then we're kind of shooting ourselves in the foot on the other side of it. I think that's something that we're going to see and we're going to learn really hard lessons about in the months ahead.

So much of the debate currently is pitting the economy versus public health, and that seems to be grounded in large part, at least in my opinion, as to whether we believe health care is a basic human right.

So I think most Americans would say, if you ask them point blank, that health care is absolutely a right and everybody should have access to health care. But then we get into questions quickly of like, well, what does that mean? What level of health care should people have? And I think sometimes when we're answering that question, we tend to like ration it. It's not just every single person's equally entitled to the same thing. It's we feel like some people are entitled to more than others depending on how well they take care of themselves or how hard they work. And there's this tendency to blame people sometimes for their own illnesses in ways that don't really make sense to me. And I think the lesson right now and the lesson I think we're going to learn from the COVID outbreak or from the COVID pandemic is that all of those debates kind of don't matter. We're really only as safe and as healthy as our most vulnerable neighbor is. So you can say what you want about who you think does or doesn't deserve good healthcare, but if you say certain people don't deserve it, those people are going to get sick. And when they infect somebody that you love, you might feel differently. So I feel like we can have all of these debates that we've been having about how to ration healthcare, who's entitled to what and why and how, and you can maybe create an algorithm. But at the end of the day, you know, you should learn from this moment that you have to protect everybody or you yourself are always going to be at risk.

Jeanine, thank you so much for joining us.

Oh, thanks so much for having me.

Next, we'd like to welcome Greg Asbed. Greg has spent much of his life fighting labor abuses, and he co-founded the Coalition of Immokalee Workers, a group that's been fighting brutal conditions in American agriculture. The Coalition for Immokalee Workers got started by organizing tomato pickers in the fields of Immokalee, Florida. Greg, we're honored to have you join us on the show today.

Thank you for having us on.

So, Greg, who are our nation's farmworkers today?

The vast majority are immigrant workers. They come mainly from Mexico, from Guatemala and the Caribbean, mainly Haiti. They do some of the hardest, most dangerous, least protected, least well-paid work in this country, and they have for generations. And, you know, these moments of crisis lay bare a lot of things about our society. Suddenly farmworkers are considered essential workers and can't be allowed to shelter at home because their work is so important to the country. Now, people in Immokalee knew that, people who work in the fields knew that, but they were never given the kind of respect or treatment or recognition of the importance of their work until now. We all see the healthcare workers and other food workers and first responders who are absolutely— should be praised. There's no limit to the praise that should be given to people who just a couple weeks ago didn't consider themselves to be heroes. They were just doing work. And now they are throwing themselves essentially in front of live ammunition for the rest of us. But that same thing should be said of the farmworkers who are doing their work every day. And exposing themselves to danger to do so.

What are some of those specific dangers that farmworkers face which might be different from somebody working in the service industry in New York City, for example?

It's two things. Part of it is rooted in farmworker existence always in this country, and then part of it has to do with this crisis. And farmworker communities across the country, there are no medical facilities or medical personnel. You know, in Immokalee, there's no hospital beds, no ICU, no people trained to run them, to staff them. There's just none of that, right? The closest hospital is 45 minutes away, an hour away. But nobody has a car either, because nobody has enough money to buy a car. And people don't have insurance. So healthcare is on an emergency need basis, essentially, for farmworkers. Also, Farmworkers have lived for generations in dilapidated, overcrowded housing. You'll have 10, 12, or more people living in a single-wide trailer. So you have kind of a dorm setting, but an overcrowded dorm setting. And those are the conditions that people came into, as well as extreme poverty. So that was how farmworkers were before this happened. When you put that in the context of this crisis, of this pandemic, what are the two things that doctors tell us we must do in order to survive. Social distancing before you get sick. And then once you do test positive for the virus or have symptoms, it's self-isolation. Take a room to yourself, have people bring you food, hopefully you have a bathroom to yourself, and close yourself off for 2 weeks. Farmworkers simply can't do that. And so the 2 most important things you can do to survive this horrible existential threat aren't even available to farmworkers. So what they basically do is go to work and hope and pray that they come home another day not sick.

One challenge, at least for my patients in New York, is the whole public charge rule. So you have a lot of people who, you know, maybe they're undocumented or they may not even be undocumented, but they're just worried about tapping into public programs because they're afraid of how that might impact their status in the United States. Is that at all even on their radar?

Of course. Yeah. You know, not everybody has papers. And so that automatically eliminates you from the vast majority of public support. And then as you said, for immigration purposes, immigration process has been getting so harsh of late that people who need some of the forms of support that people who are poor in this country are to receive, are loath to receive them because they're afraid that that will actually prejudice them in their immigration process moving forward. You know, there's a lot of H-2 workers, for example, and more and more these days because of how harsh immigration has become. And H-2 workers don't have health insurance. You know, when you get sick as an H-2 worker and you can't work, most of the times you get sent right back home. And so they won't even admit to being sick until it's too late. And when workers can't afford to be sick and miss work, but they also can't really afford to go to work because if they do, they're going to get sick, that's the rock and a hard place that farmworkers are facing right now.

Let's say one of these farmworkers or an entire farm of workers gets sick with coronavirus, what specifically does that mean for our food supply, especially if we consider that these are, quote unquote, essential workers?

There's two parts to the equation of trying to keep people from really getting knocked down by the virus. One is prevention, and the other is providing adequate health care when they are sick. So on the prevention side, the Coalition of Immokalee Workers, the group I work with, has been working 24/7 to do everything possible to enhance protective measures for the community. And the growers who are part of the Fair Food Program have been doing the same thing. One grower just donated 7 handwashing stations and the fire chief is going to refill them every night and the farm and the public health officials will make sure they have soap and towels. So education and resources are being distributed as much as possible. But there's no way that you can keep the virus out of a place like Immokalee. As far as anybody knows, there hasn't been a positive case in Immokalee yet. But once the virus gets established in Immokalee, it will spread like wildfire. For us, that brings in that second half of the equation. What do you do when an entire town has contracted the virus. So what we are looking to do, we were asking everybody we can possibly ask, you know, from the governor on down here in Florida, is for a field hospital to be set up in Immokalee and in other farmworker towns in Florida before everybody gets sick, before it's too late. It is the most urgent call that we are putting out to the world today in Immokalee and in farmworker communities really from Florida to California. Is to provide rudimentary health resources to these communities because they are essential workers and they're required to go to work for us. They are first responders in the food industry for us so we can continue to eat while we hole up inside our homes until the all-clear has sounded. But we have to treat them better than simply hope they don't die, which is really what the plan is at this point. There's no other plan in place.

And I think this has been a big problem with this entire pandemic is that until it affects someone personally, they don't really pay attention. They don't, they don't take it seriously. How might this affect the food supply in a way that the average American might become more conscious of what's happening?

Right. We are quite possibly 2 weeks away, maybe 3 weeks away from having 50% of the farm labor force in this country unable to work, which means there will be food shortages in terms of, in particular, fruits and vegetables in this country if we don't protect the workers who pick those fruits and vegetables and get them on our tables every day. That to me is, you know, if someone needs to see this through their own eyes as opposed to concerned about the people who do the work, that's the concern they should have. You know how you go to the store and there's no toilet paper? That could be the case for produce.

Well, I really hope it doesn't come to that. I really hope that some of these measures, including the field hospital, are instituted sooner than later.

In times of crisis, you learn things about yourself, you learn things about the people around you that don't come out when everything is comfortable. And one of the things that we all have learned is who's really essential in our lives to helping make our country function. And everybody kind of knew the police, the healthcare people, they do incredible work and everybody kind of knew that. I think what we're seeing today is just how brave they all are and how much they deserve our support. But what people didn't really think about, because this country has been so comfortable for so long, is how important food is. If you don't have food workers, you won't have food. It's that simple. There aren't machines that pick our fruits and vegetables. It's human beings.

If I—

if we have one thing happen after we get to the other side of this nightmare, it would be that people recognize the importance of the people who put food on our tables and treat people who pick our fruits and vegetables with some respect.

Well, Greg, thank you so much for calling our attention to this issue and for helping us recognize that there are other essential workers who are not always top of mind the way we think about healthcare workers and police officers and firefighters, that farmworkers are really essential workers too.

Well, thank you, Salim, for the incredible work you're doing. So thank you very much.

Every week we answer a couple of listener questions. Our first question is from Rebecca Yelson.

Hi, this is Rebecca from Albany, Oregon. I have a 4 and 7-year-old in preschool and elementary school. Recently, our schools closed proactively on March 11th, and this occurred because there was a cluster found at a veterans home about 20 minutes from here.

So I am curious how effective school closures are in preventing the spread of COVID-19, and our school district is currently set to reopen on April 28th.

I'm curious if you think this is likely to happen and if closing until April 28th is a long enough period to prevent the continued spread of COVID-19. Thank you.

So Rebecca, we're still learning a lot about this coronavirus, and one of the big questions has been to what degree do children contribute to community transmission of the virus? And it does seem like they do probably play a role, as they do in the case of influenza. Many children seem to have very minimal symptoms or no symptoms at all, but may well be spreading the virus to their parents and grandparents. So you mentioned that your school district is set to reopen April 28th. I think given the social distancing guidelines that are in place right now and some of the projections for how the pandemic is likely to evolve, I think it's highly unlikely that the schools in your area will be reopening that soon. So Rebecca, while I can't be sure one way or the other whether the schools in your district will reopen after April 28th, I think it would be wise to assume that they may not and for your family to plan accordingly.

You know, one more thing to think about here is that if you look at other epidemics around the world, when schools are closed but then the children are still running around, going to playgrounds, socializing, the virus spreads outside the school through kids. It's the combination of the fact that students aren't socializing at school and they also aren't supposed to be socializing at home. And I think when you put that together, this is a very important tool in the effort to slow the spread of coronavirus. And our next question comes from Emily Shaw, who works in recreation therapy at a mental health hospital.

Hi, my name is Emily. My question has to do with the efficacy of the homemade masks that I see people making. And the reason I'm asking is at this particular hospital and probably several others as well, we come into contact with our patients every day and we're unable to really follow the rules of social distancing when it comes to work because everybody's on the same hallway, the patients are in the day room together, at dinner together, et cetera. So we're not being given personal protective equipment each day. To protect the workers nor the patients unless they are exhibiting symptoms like coughing or sneezing. So is it worth it to have a homemade mask because it's impossible to find a medical mask to protect ourselves during our shifts, or is it pretty much just not doing any good at all? Thanks. So Emily, you're, you're quite right. You are working in an institution where there may be a higher risk of spread of infectious diseases. I do think what is working for you is that these are not patients that are hospitalized for COVID-19. So in a sense, your risk is higher than what it might be in the general community, but it's not quite the same as being in a hospital. And so what I would advise is Basically what the CDC may be providing guidance on before too long is taking measures to prevent spread from yourself to the patients you're working with. And so that would include wearing a bandana or a scarf or a homemade mask when you're at work. And again, that's not so that you're protecting yourself per se, but it's really so that you're protecting the patients that you're working with day to day.

Emily's question reminds us that we have so many other people in the healthcare system who we don't think of as part of this kind of frontline force, but are definitely taking risks to serve other people. And so as we go to protect, obviously first and foremost, the people in the ICUs and providing the direct care, but also people like Emily who are providing vital services to people who may well have COVID at this critical time. To send us your question, record an audio file on your phone with your question and then 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 intern is Sonia Baradwa. Our music is by the Blue Dot sessions. 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. 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. Also check out our sister podcast, American Diagnosis. You can find it wherever you listen to podcasts or at americandiagnosis.fm. 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.