0:07      Kay Summers: From the School of International Service at American University in Washington, this is Big World, where we talk about something in the world that really matters. Viruses are supposed to be the ultimate equal opportunity offenders. They're just looking for a host, and they aren't supposed to discriminate. Why then do data indicate that the novel coronavirus is killing Black and Latino people in New York at twice the rate of white people. Why have Black people accounted for 72 percent of coronavirus fatalities in Chicago, though they comprise less than a third of the total population there. Today, we're talking about how inequities become magnified in a pandemic. I'm Kay Summers, and I'm joined by Nina Yamanis. Nina is a professor here in the School of International Service. Her research focuses on improving the health of underserved populations. Her current projects focus on adolescent girl's health in Sub-Saharan Africa and the influence of community action on Latino immigrants' health in the Washington, DC, area. She also conducted field research on the Ebola outbreak in Sierra Leone. Nina, thanks for joining Big World.

1:14      Nina Yamanis: Thank you, Kay, for having me.

1:16      KS: Also thank you for joining us remotely since we're still not able to be together in the studio. I appreciate it.

1:21      NY: Oh, no problem.

1:23      KS: Nina. I'm going to go out on a limb and guess that you are one of the people who wasn't surprised by many aspects of what we've all been experiencing as a result of the novel coronavirus. As a public health scholar, how foreseeable was a pandemic like this, at least in the abstract?

1:42      NY: Well, for many years we've seen epidemics that have crossed national boundaries, and even Anthony Fauci, who's now in the news all the time, about two years ago, warned that we needed to be prepared for a pandemic. I served during the Ebola time and then before that there was the SARS epidemic. So many public health scholars, global health scholars had been warning about a pandemic. Given that globalization has increased the speed at which viruses can travel around the world, it's completely foreseeable that that something like this would happen.

2:22      KS: Right. One thing that's been readily apparent is that even though everyone says a virus doesn't recognize national boundaries or race or wealth, where and how you live has a massive influence on how well you live during a pandemic and how likely your recovery is if you get sick, and this isn't just anecdote. Nina, tell us what are the social determinants of health, and how do they normally impact people's health care experiences on a regular basis when we're not in a pandemic?

2:54      NY: Yeah. So social determinants are things that are outside of individuals. So they are the political, social, and economic forces that shape our health, and they can reflect relations between people but also the systems that we interact with—be it the justice system, the education system, the economic system, and so on. So I think there are two ways in which they really influence our health. They influence how people have access to basic resources, and those resources include knowledge, money, power, prestige, social connectedness, but also things like health access and health insurance. And that access can be influenced by things like whether or not we trust medical providers or whether or not health care providers discriminate against us, or whether there are policies in place that prevent us from accessing healthcare, like the fact that undocumented immigrants don't have access to health insurance in this country.

3:54      NY: The other is about exposure to risk and protective factors that influence our health. So things like stress and unhealthy food products and so on. So people who live, for example, in food deserts don't have access to healthy food and so they're more exposed to risk factors that might cause diabetes. And these social determinants can affect people systematically based on how the population treats people of different races, religions, socioeconomic status, gender, age, and so on.

4:26      KS: Well, one thing that comes to mind for me is I know that I have read that, even when you control for income, that African American women suffer much worse outcomes in pregnancy in the US. Which would seem to have less to do with money and more to do with race. So is that kind of what we're talking about as well?

4:48      NY: Yeah, I think, we really can't explain that disparity between black and white women in terms of pregnancy outcomes and infant mortality by anything biological. There's no individual reason why a black woman should either die during pregnancy or have a higher risk of infant mortality. There is no biological reason so it must be something in the social environment that's causing those disparities. And so things like access to health care, how far you live from a health care provider, whether you trust that health care provider, what your local hospital is like, what kind of resources you have, what kind of social support you have, whether you need to work throughout your pregnancy, multiple jobs. But it's also about mental health and chronic stress due to racism and systematic discrimination that could potentially affect those unequal outcomes.

5:39      KS: So we know that even on a good day, even on a "normal day" in this country, the social determinants of health play a role in the real outcomes for real people. So in a time like this, how do the social determinants of health play a role in the spread and the impact of the novel coronavirus?

5:59      NY: So we've seen that people who live in the most impoverished, crowded, and racially and economically disadvantaged counties across the US are experiencing higher rates of COVID-19 infection. First of all, they're likely to get the virus more, and we've seen that in multiple studies, including the one that you mentioned in Chicago, but also a recent paper by Nancy Krieger, a social epidemiologist at Harvard also showed that those people who lived in the most impoverished, crowded, and racially and economically polarized counties were having higher rates of COVID-19 infection and death. So we can see the disparity in the death rates themselves and the infection rates themselves. But we can also see the disparity in the extent to which people can prevent themselves from getting COVID-19. So those who live in worse economic conditions, who live in more crowded conditions, or who have to go to work because they're essential workers are less able to protect either themselves or their families from COVID-19.

7:05      KS: Right. I know we've all been seeing the coverage and kind of confronting for the first time what essential means in our society and the idea that it would be sort of unthinkable that we wouldn't have access to grocery stores and we wouldn't have access to kind of whatever food we want to eat whenever we want it, but then the question becomes who has to be there? Seeing everybody who's coming in to buy staff, not knowing if someone's infected, putting their health and their—possibly their life—at risk has really brought a lot of these income inequality issues to the forefront I think for a lot of people who never considered it before, maybe.

7:49      NY: Yeah. I think someone from Chicago, I think, put it really well, which is that in this time of crisis we are all depending on people who have suffered systematically from health disparities to step up and help the rest of us stay safe. How do we reconcile that? The fact that people who are essential workers already have higher rates of health problems and are suffering economically and so on. And yet we're all relying on them for our own families to stay safe. So what can we do as a society to really help them stay safe is the question. And that, I think, gets into how we have historically dealt with populations that are vulnerable in our country and social determinants and how we're going to go forward dealing with it.

8:35      NY: So the fact that people can't be protected at poultry plants from each other, I mean that's a major problem not only for them but also for us because we're relying on them to deliver poultry to our homes at this time when we can't go out or people at grocery stores and how they're having to show up day in and day out and that we need them to be there. How are we protecting them? Giving them face shields or allowing them to take paid sick leave. Like these are all things that they need in order to stay healthy and we need them to stay healthy.

9:06      KS: Nina, we talked a little bit specifically about how some cities have seen different outcomes, New York and Chicago specifically. In the US more broadly, have the effects of COVID-19 been experienced differently by different populations and if so, how?

9:22      NY: Yes. Well, as you mentioned, Blacks have been dying at a higher rate than whites, and unfortunately we don't have great data across the US on this. Many states have not reported race as a factor in terms of how many people are getting tested and how many people are dying. So we're relying on some specific states and counties that have reported this information. But the more we can see it reported, the more we can investigate it. There's been a call by several public health experts to collect data on race and age and geographic location. But if you take the case of Chicago, where we see that Black Chicagoans are dying at a rate nearly six times greater than white Chicagoans. While we also see that some of the hardest hit communities in Chicago are the South and West sides, and those communities have struggled historically with unemployment and health care access. Residents there have higher rates of diabetes, heart disease, lung disease, and high blood pressure.

10:24      NY: And those chronic conditions make the coronavirus even more deadly. So you can imagine these communities, when the coronavirus enters, are already entering a place where the virus might have a higher likelihood of resulting in death. Black communities have been especially hit hard, but also Latino communities. We know that in terms of undocumented Latinos, they were left out of the stimulus plan from the government. Many of them, we have about seven million undocumented in this country who lack access to health insurance. They lack access to employment benefits or paid sick leave. So at a time when they may be sick, they can't take time off work because they have to pay their rent and feed their families because they have no other source of money for feeding their families and paying their rents.

11:16      NY: And I've heard just anecdotally here and in the local DC area, we have Latinx communities who are significantly impacted by the virus in places where everyone is sick, yet they're struggling to meet their daily needs. And they also may experience medical mistrust because the Trump administration has targeted immigrants and instituted the public charge rule, which means that any access of public services will be counted against them in immigration proceedings. So you have many undocumented immigrants and other underdocumented immigrants who now fear accessing health care. Although they have feared it before, so it's not anything super new, this has made it worse.

12:07      KS: Nina Yamanis, it's time to take five. And this is when you get to wave a wand and remake the world as you'd like it to be by singlehandedly instituting five policies or practices that would change the world for the better. So what five policies would you institute to improve health equity in the US?

12:27      NY: First of all, I'd like to see access to equitable health care, including mental health care. And this means health insurance, good health systems, quality health systems. So if everyone could have access to the same health insurance and good quality health systems, I think that would be amazing. The second thing I think is related to social determinants, which is equal, fair, and desegregated housing. So we know that so much of where we work and live is related to how we experience health. If people are able to live in environments where they can access good food, where they can go on walks, where they can be outside without fear of violence, it would go a long way towards improving health.

13:12      NY: The third thing is to legalize immigration. We have 11 million undocumented immigrants in this country. They do essential work in our country like work in agriculture, provide childcare for our children, and their health, as we've seen in the COVID-19 pandemic, is related to the health of all of us. The next one is to reduce income inequality, which I think could be done in a number of ways. Some of the efforts towards increasing minimum wage. Income inequality is so related to health, and we have a long way to go in this country to achieving better income equality. And then the last one is to redress historical injustices that have propagated institutional and interpersonal racism. We see so many different ways in which our institutions have propagated racism—our criminal justice system, our education system, our economic system. We need to redress those inequalities and the historical roots of them by doing reparations, better and more equal policies for pay and for education. I would like to see us lifting up those that we have historically repressed.

14:26      KS: Thank you. Nina, we've talked a lot about the novel coronavirus. I'm curious, as we talk about social determinants of health and outcomes, if other pandemics or epidemics have followed this pattern. We're thinking about SARS or H1N1 or even HIV AIDS. How have these trends of access and care followed or not followed the pattern with other pandemics?

15:03      NY: Well, I think I'll speak about the pandemics I'm most familiar with because SARS was pretty unique, it only spread to a few countries. But Ebola I think is—we really saw disparities in terms of country-level disparities, that the three countries that were the hardest hit during Ebola were some of the poorest countries in the world. For example, Sierra Leone, where I was, had the highest infant and child mortality rate in the world and so these were really weak health systems in terms of their ability to take care of normal everyday health outcomes. And so when Ebola hit, it really exposed that weakness and meant that it lasted a much longer time than in a place that had a better health system to contain it. For example, Nigeria was able to really sniff out Ebola quickly and they also had a public health workforce that was trained in vaccinating for polio. Sierra Leone didn't have any of that, they had really no public health workforce to go and do all the contact tracing necessary.

16:11      NY: And then people were living in such poor conditions that they couldn't keep away from each other. So I saw people who were quarantined who were 15 people to a 10-foot or maybe 25-foot area. And with HIV, we also see that HIV affects those who are most vulnerable in society. So in the US it affects gay and transgender—people who identify as gay and transgender. It affects Blacks and Latinos more than it affects whites. So we know, for example, that Blacks are much more likely to die of HIV than whites. And that's in the order of seven to nine times more likely to die than whites.

16:54      NY: And we've recently seen an uptick in HIV new cases among Latino men who have sex with men. And that's when HIV cases have been, new cases have been decreasing among different age groups. We see an increase among Latinos. In Tanzania, where I work, and generally in Sab-Saharan Africa, young girls are two to three times more likely to be infected with HIV than boys and young men. And it's no coincidence that women are oppressed globally but especially also in Africa, Sab-Saharan Africa, and they're vulnerable to gender power differentials in that context and that makes them vulnerable to HIV.

17:38      KS: Nina, Michigan's governor, Gretchen Whitmer said, "This virus is holding up a mirror to our society and reminding us of deep inequities in our country." And again, I don't believe that any of this has been a surprise to public health experts like yourself, but I'm wondering what would it look like, in terms of public health policy, if the US Government truly tried to address disparities and health care access. What kind of policies could they or would they put in place that might actually get at the roots of some of these problems?

18:16      NY: Well, I think first health care access for everyone, right, and health insurance for everyone. This is something that has been targeted by the Trump administration. They have—and some states have refused to expand Medicare, Medicaid in their states, and the extent to which the Affordable Care Act has been under attack just shows that this has been really difficult. But I think if we were able to achieve health care for all, that would be one important first step in getting people access to the health that they need. And it's not just about access, it's about equity, right, and the kinds of healthcare that you have access to. So there's a huge literature on health care quality and the difference between access and quality. So you might have access to a rural hospital in your area, but you might not have access to the best cancer treatments, if you live in that area or you might still have access to a hospital, but you might live in a food desert.

19:20      NY: So this brings us back to the social determinants of health, that it's not just about having health care access, it's about the places where we live and work and how they impact our ability to take care of our health and access the kind of care that we need. So when we think about health care, we also have to think about things like equity and education, equity and employment, equity and access to food and water. Even some cities in this country, they don't have good access to water, and we're asking people to wash their hands.

19:52      KS: Nina, I'm curious if you have any thoughts about this on the provider side, because we've talked about how some of this institutionalized racism, it comes into play when the provider is making the decisions about whether or not to listen to a patient or to believe them or to kind of take the extra five minutes to really understand what's happening, and there's a lot of unconscious as well as conscious bias that plays into that. So how, from an overarching policy standpoint or educational standpoint, do you get at that piece with the health care providers themselves?

20:32      NY: Well, I think implicit bias training within medical schools and training on the social determinants of health, that can be really important and one great first step. And providers often know these things up close, right? They might see patients who are struggling, or let's say they have a patient who's diabetic, and that patient is not doing well or not able to maintain their insulin or living in a food desert or something like that, not able to access food. The provider sees that up close and personal and knows that patient keeps coming back and not getting better. I think what I'd like for providers to do is to see how the broader context influences their patient outcomes. It's not just about those patients not listening; it's about what's happening at home. What kinds of challenges are being faced both socially and economically, and how does that impact people's ability to care for themselves?

21:30      NY: But I also think we're talking about many years of historical and systematic oppression, and it's led to medical mistrust on the part of populations of color. You have very much still present in the minds of Black Americans are the Tuskegee Syphilis Study that led to deaths among Black men who were not treated for Syphilis purposefully by the researchers. And for Latino immigrants, you have very much in their minds the idea that they could be deported, and just the systematic racism that exists in this country against Latinos or people being asked to speak English when they go to the doctor or being asked for a social security number or being asked to pay for a COVID-19 test, which has been reported in some outlets. So these kinds of every day microaggressions contribute to a sense of mistrust and fear on the part of populations of color in this country to access health care. We have to address underlying racism and institutional racism and interpersonal racism in order to enhance trust and improve health for populations of color in the US.

22:42      KS: Nina Yamanis, thank you for joining Big World and helping us understand how your wallet and your race help determine how good your health care is. It's been really informative to speak with you.

22:53      NY: Thank you.

22:54      KS: Big World is a production of the School of International Service at American university. Our podcast is available on our website, on iTunes, Spotify, and wherever else you listen to podcasts. If you leave us a good rating or review, it'll be as great as that movie you've been wanting to see popping up on Netflix. Our theme music is "It Was Just Cold," by Andrew Codeman. Until next time.