Noble Maseru, PhD, Professor of Public Health Practice at the University of Pittsburgh and Adam Milam, MD, PhD, MHS, Anesthesiologist at Cedars-Sinai Medical Center, talk about the COVID-19 health discrepancies in under-resourced communities.
Noble Maseru, PhD.
You served as Health Commissioner in Cincinnati and Detroit. Can you tell me a little bit about that?
Noble Maseru: I served three years as the Health Officer and Health Director for the city of Detroit. I’m a native Detroiter. I’d been away for some years and came back in 2003 to help the city out. In 2006, I relocated to Cincinnati and as good fortune had it, I was offered and accepted the appointment as Health Commissioner for the city of Cincinnati. I served there for 10 years and retired in 2016.
There are several factors that are leading to health discrepancies during COVID-19. I think one is the comorbidities that exist. Can you speak to that?
Noble Maseru: Everybody, all communities have comorbidities. When we’re talking about morbidity, that’s an illness or a sickness. For example, asthma, hypertension, diabetes, obesity being a morbidity and a comorbidity, meaning, that an individual has at least two of those maladies. The African American community and other communities of color have been exposed to what we call underlying conditions. What are the drivers that are responsible for the diabetes, hypertension or asthma? One is not necessarily born with that morbidity. A person who lives in a community that has been subjected to particular social conditions would give rise to greater vulnerability. As a result of housing segregation, the African American community has been forced to live in housing situations that have greater exposure to unsafe sheltering, specifically lead exposure. We know what that does in terms of behavioral issues. In terms of asthma, the housing environment has greater exposure to particles in the air and we know that low-income communities are subjected to environmental toxic exposure. That exposure to the toxins, air pollutants and contaminants give rise to a greater likelihood of people contracting respiratory diseases like asthma. A trigger for asthma is not solely that atmosphere but there’s also exposure to contaminants like vermin, insects or roaches. Also, psychosocial stressors can also trigger situations for persons with asthma. If you’re living in a community where the social environment has a propensity for issues like gun violence, how does one rest and not be subjected to the stress, bullying and things of that nature? So, in terms of a comorbidity those are the kinds of things that we’re talking about when we say that an African American, persons of color or those living in low-income communities are in an environment that’s unsafe. We don’t want to say comorbidity or the medical aspect of the comorbidity but what drives the social conditions that bring about those morbidities. So that’s what we’re talking about when we say pre-existing social conditions. We need to address those pre-existing conditions. Folks automatically think about comorbidities, heart disease, diabetes. They think about that from a medical intervention and not necessarily the social conditions. In 1900, life expectancy in America was 47. One hundred years later at the turn of the century life expectancy was 77. So that 30-year extension was attributed to addressing social conditions about housing, living wage and environment. 25 of those 30 years of extending one’s life expectancy was on social conditions. Going back to what we should be doing in terms of the pandemic and equity, the response should be to do a social intervention and not a medical intervention because the medical intervention is the Center for Disease Control and Prevention. The other five years was attributed to medical intervention and hospital. But the health care industry gross domestic product is $3.2 trillion, only 3% of it goes to public health and prevention. The other 97% is going to medical, so if 83% of improvement is attributed to social peace then we should be thinking about a living wage, safe housing and safe streets.
Of the social determinants of health was the notion of underemployment. How does that relate to COVID-19?
Noble Maseru: When we think about underemployment, we’re looking at an hourly wage of less than $15. So, in the federal governments eye, their living wage is called the minimum wage, which is $7.25. The essential workers like law enforcement, health care workers, sanitation and those workers who are integral to keeping our economy functioning. There’s a significant proportion of persons who are essential workers who are earning less than that $15. For example, for those employed in nursing homes the average wage is around $13 an hour. Other individuals who are essential workers are grocery store cashiers. Those individuals are making roughly $8 to $9 per hour. Of course, it varies by geography. If one lives in San Francisco, that $15 should be lifted to maybe $20. But in terms of COVID-19 the essential workers that are under a living wage are already exposed to a situation of economic insecurity because they’re living from paycheck to paycheck. By the way, we have more than 40 million people that are unemployed now. In March, there was roughly 11 fatalities due to COVID-19. Fast forward to June and it’s roughly 110,000. Similarly, in terms of unemployment, individuals who work at the supermarket are part of the essential workforce and they’re exposing themselves. They’re already vulnerable because they’re living in the communities where life expectancy and other areas of exposures are greater. And just we did an analysis computation in Pittsburgh and Allegheny County. For 63 of the selected neighborhoods life expectancy ranged from 62 to 84. So, that’s a 22-year differential. If I’m living in Larimer, I’m an essential worker. I’m already exposed because of the comorbidities and the social conditions. Now I’m additionally exposing myself because I’m taking public transportation. I’m also being exposed by working in an environment that is not necessarily safe because it was only a month or three weeks ago that employers were providing cashiers with personal protective equipment. So that’s why we have this situation where nursing homes in Hazelwood ballooned in terms of deaths and infection whereas nursing homes in Shadyside had zero.
The essential workers can’t afford to stay at home. They must go and do their jobs and that puts them at higher risk.
Noble Maseru: One of the expressions that I hear some folks say is, they’re essential workers but are their lives essential. That’s another area in terms of disposability – that some workers and communities are expendable. We’re talking about the determinants of health but what are the decision determinants? If I’m a planner and I have communities where the differential is 20, 10 years of life expectancy, I’m going to be thinking about what the reasons are for that. So, as a decision maker why wouldn’t I address the conditions for social improvement. Why wouldn’t I shift resources when I know we can improve life expectancy and the well-being of the community. That’s why I go back to the appellation of some of our communities of white brothers and sisters who are subjected to similar social conditions. Why wouldn’t I provide interventions in those communities where we know we’ve been successful? In terms of COVID-19, we know there’s a disproportionate impact on persons of color and neighborhoods that are under-resourced. So, we should be thinking about a health equity response to that. We should be looking at having greater testing in nursing homes or in certain communities. But when we look at the actual numbers, we see that there’s under testing that mirrors low life expectancy in neighborhoods and communities.
You’re saying there’s under testing in some of these communities?
Noble Maseru: We’ve already done the numbers and there’s a huge differential just in under testing. What we don’t know is what’s the mortality pattern. Why is it that we don’t have data on the death rate of the communities that are tested? That’s a decision that someone is making to not release that information.
Can you touch on the difficulty of contact tracing in some of these communities?
Noble Maseru: We should keep in mind, where does contact tracing come into the equation in preventing and stopping the spread of COVID-19? Because our objective is to stop the spread of the disease on the medical, intervention and public health side as well as a vaccine. We don’t have a vaccine, so that means we know the transmission is in human contact. We must figure out ways to stop the transmission of the disease. So, we’re sheltering in place, self-quarantining, washing our hands, wearing masks and social distancing. In certain prisons inmates are making PPEs, but they don’t have access to them. So now we have a situation where certain populations are expendable. But in terms of contact tracing, we want to identify individuals who have the disease with tests. We also know that people are asymptomatic, so you want to identify. That means we need to be thinking about it in terms of what would be the greatest exposure or situations of greatest risk. Once you identify a person that tests positive, the next thing you want to do is tell them we want you to self-quarantine for 14 days or two weeks. Its problematic for people who are economically challenged in terms of density and living in multigenerational houses where they may all be living in one, two or three rooms. We know what that means in terms of transmission. So, we’re saying Mr. Jones, who did you have contact with? Well, I’m an Uber driver and I can give you a list of the folks today that were in my car. So, in our health department we have our communicable disease investigators take that list and we track those individuals that he had contact with. So, we’re advocating. We’ve had community folks go knock on doors and follow up with individuals that were not contacted on the phone. We utilize our police officers in the community. They go out and knock on doors to establish a relationship, which is what you want to have – neighborhood policing, people who are familiar with what’s taking place. So, you want to identify and you’re going to isolate, and then you’re going to do the contact tracing.
What would you say to people as they go to the polls and they think about these health disparities and issues?
Noble Maseru: I believe there’s solutions. There are varying degrees of expectations where we could have an impact. We can have an immediate impact by doing what we call fair and equitable COVID-19 testing in these under-resourced neighborhoods and communities. That’s not a long-term fix. We should be thinking about these questions in terms of bias, intentional and unintentional in those kinds of things. When we have a situation where we have a police officer who extinguishes somebody life and we know there’s a culture in tension, that can be an immediate fix. So, there’s racism that we need to deal with. But we know that nutrition, poverty and the things that cause those conditions can be addressed. So, everybody must vote. But we want to ensure that there is a social justice lens to what we do. We have metrics that can determine and measure a community in terms of housing and the education system, so we know if it’s under-resourced. So, we can make a short-term fix and know where the uneven development and under-resourced communities are. We have a responsibility to vote people in office who are accountable to what is occurring based on the knowledge and the science we have. But we also want to know why we have persons who are not providing an equitable response to what’s taking place in our communities. So, it’s not about waiting every two or four years. We should hold persons accountable when we see what’s taking place.
Is there anything else that you want people to understand in relation to COVID-19?
Noble Maseru: In relation to COVID-19, let’s demand that our health systems and plans work collaboratively and bring in qualified health centers and let’s hope those qualified health centers are involved in terms of testing and those type of things. It’s important to think about health care dominance. Let’s make sure that our response to the pandemic is social condition and determinants intervention dominant. Let’s have a cooperative collaboration with federally qualified health centers so we can have a preventive community-oriented approach to what’s taking place.
Adam Milam, MD, PhD, MHS, Anesthesiologist at Cedars-Sinai Medical Center.
Talk about minority health disparities. How big of a difference in both cases and in mortality have you seen?
Dr. Milam: We don’t have numbers for every state and city but the early numbers from Chicago where African Americans were representing about 40 percent of the cases and about 14 percent of the population. That disparity was also seen in Detroit and Baltimore. The disparity wasn’t as large in Los Angeles, but the disparities still existed. So African Americans and Hispanics were overrepresented in the cases and mortality from COVID-19 compared to their representation in the community or city.
Do you see it across the board from those in their 20s through seniors? Or is it primarily older people of color?
Dr. Milam: The problem is we don’t have good data for all the numbers. Most states are only releasing data stratified by race and ethnicity. So, it’s not broken down within ethnicity and race by age. Until we have data on that we’re unable to answer that question.
What’s causing it?
Dr. Milam: There’s a lot of factors. The thing that was originally described to explain the disparity was the higher rate of comorbidities in the African American community. African Americans have a higher prevalence of diabetes, high blood pressure, chronic kidney disease. All of those are risk factors for COVID-19 and for progressing to severe lung injury and death. We know that African Americans have higher rates of those diseases for a lot of different reasons. We talk about social disparities, social determinants of health, housing, access to adequate health care and physicians, healthy food availability, all those factors are related to those diseases that I mentioned. Then think about things like housing and the ability to social distance. You may have multigenerational housing and it’s difficult or almost impossible to socially distance in a house like that. African Americans are more likely to be in urban areas where there’s a higher population density. All those factors are related to the severity of COVID-19.
Some of the minority population might be in houses that lend themselves to breathing problems. Mice and rodents can cause an allergic reaction and I know having healthy lungs is important to fighting COVID-19 off.
Dr. Milam: Having healthy lungs is helpful in preventing the severity of COVID-19, so pre-existing conditions like asthma and then having pollen, dust and smog in like Los Angeles could also contribute to a worsening of your lungs and COVID-19 symptoms.
You mentioned some of the social determinants. How about the economy, jobs and essential workers?
Dr. Milam: If you must travel to work on a bus and use the Metro system your exposure is increased. If you don’t have the ability to work from home, that’s also a risk factor. We know that African Americans and Hispanics are more likely to not have a car and use public transportation. They are also in positions where you can’t work from home. So those are both risk factors in increasing your exposure to the SARS-CoV-2 virus.
Is there anything in the short term that can be done?
Dr. Milam: These are pre-existing things that we’ve known about for decades. In 2003 the Institute of Medicine put out a guide where they described some of the social determinants of health and every year, we talk about ways to try to prevent or mitigate some of these social determinants. It was in healthy people 2010 put out by the CDC, also healthy people in 2020. We haven’t tackled the core issues which are built in racism and implicit bias lead to a lot of these health disparities and health inequities. We really haven’t tackled them. Big things like education, adequate access to quality health care, those issues just haven’t been tackled. We’ve been putting band aids on a lot of these issues but not addressing the core issues.
In your work at the hospital have you seen any COVID patients?
Dr. Milam: I’m in the Department of Anesthesiology. Anesthesiologist go around and help protect the airway for patients. When this pandemic started our department was responsible for what we call intubated or putting a breathing tube in for patients and getting them on a ventilator. We’ve been working closely with COVID patients and we still work with patients who are positive for COVID in the operating room. So, a lot of exposure. Luckily at our hospital we had a lot of personal protective equipment, but a few health care workers have fallen ill. On a day to day basis we’re working with COVID patients.
Is there anything you want people to know about the disparities?
Dr. Milam: The disparities already existed and COVID has just really amplified it. Now it’s all over the national media and in the national spotlight. I think now is the opportunity to address some of these issues that have been lingering for three to four decades. It’s well-established in medical and public health literature. Policymakers know about this disparity. I even worked on a report back in Baltimore where I’m from and they found a 20-year gap in life expectancy for communities five miles apart within the same city. These disparities aren’t new issues because of COVID-19.
Interview conducted by Ivanhoe Broadcast News.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
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