This Podcast Will Kill You - COVID-19 Chapter 16: Disparities, Take 2

Episode Date: April 13, 2021

The COVID-19 pandemic has disproportionately impacted racial and ethnic minorities, especially here in the United States. Higher infection, hospitalization, and death rates due to COVID-19 have been observed for historically marginalized groups, and the harmful effects stem beyond those relating to health, with higher unemployment and food and housing insecurity also reported. Yet these disparities did not emerge anew from this current pandemic; rather, this pandemic has served to amplify existing structural inequalities in the healthcare, educational, legal, and housing systems, among others. In this episode of our Anatomy of a Pandemic series, we explore the deeply entrenched roots of racial disparities in the US, how our narrow focus on outcomes often fails to capture the complex causes of inequalities, and ways in which we can begin to work towards health equity in this country. We are so thrilled to be joined by Harriet Washington (@haw95) (interview recorded March 10, 2021), writer and medical ethicist, whose groundbreaking work on this subject through books such as Medical Apartheid, A Terrible Thing to Waste, Carte Blanche, and others has led to much-deserved critical acclaim.As always, we wrap up the episode by discussing the top five things we learned from our expert. To help you get a better idea of the topics covered in this episode, we’ve listed the questions below: Can you tell us a bit about your new book, Carte Blanche: The Erosion of Medical Consent, and what inspired you to write it? Although health disparities have been around forever, it was only within the last few decades that the term itself was coined, and it’s often only vaguely defined. Would you mind describing what we mean when we talk about health disparities? Can you talk a bit about how it’s not just being able to go to a doctor or afford a doctor, but how things like access to education, chronic stress, and environmental justice interact with and compound each other when it comes to health disparities? What are some of the different ways that we measure health disparities?  Can you talk about why it is important to understand the context of these disparate outcomes?  Can you talk about the disproportionate impact that COVID-19 has had on communities that were already facing significant barriers to healthcare? How has the narrative of ‘race-based medicine’ shown up in discussions of the disproportionate impact of COVID-19 on certain groups of people? How can we increase health equity in this country? What can we do at an individual level to help, and what are some policies at the state or national level that could help narrow this gap? How can the medical establishment work to earn back the trust of these communities that we have historically disenfranchised (and in many ways continue to disenfranchise) when it comes to health? See omnystudio.com/listener for privacy information.

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A one-night stand would end in a courtroom. The media is here. this case has gone viral. The dating contract. Agree to date me, but I'm also suing you. This is unlike anything I've ever seen before. I'm Stephanie Young. Listen to Love Trapped on the IHeart Radio app, Apple Podcasts, or wherever you get your podcasts.

I'm Amanda Knox, and in the new podcast, Doubt, the case of Lucy Letby, we unpack the story of an unimaginable tragedy that gripped the UK in 2023. But what if we didn't get the whole story? been made to fit. The moment you look at the whole picture, the case collapsed. What if the truth was disguised by a story we chose to believe? Oh my God, I think she might be innocent. Listen to doubt the case of Lucy Lettby on the IHeartRadio app, Apple Podcasts, or wherever you get your podcasts. Hi, my name is Corey O'Hara and I'm country director for IDE Nepal. We're an international nonprofit that creates livelihoods for the rural poor. Currently, Nepal is looking pretty good on the COVID-19 front. People don't mind wearing masks here and the climate's mild so people can socialize outside.

Tests are only showing a few hundred new cases per day now. That's down from about 5,000 a few months ago, and for comparison, the country has a population the size of California. And officially fewer than 2,000 deaths have been linked to COVID here. But unofficially, everyone knows our numbers are artificially low. We're pretty sure that due to social stigma, deaths in rural villages are being reported as heart attacks or something else, and testing rates are very low now as well, so it's also unclear what the current spread of the disease is nationally. We know that we're better off than most of the world as far as disease spread goes, though, which is lucky. The bigger problem here has been with our food supply. Most people in Nepal are subsistence farmers with very little land

who grow most of the calories they eat. About two-thirds of the national population depends on this kind of small-scale agriculture. And the national lockdowns we've faced, even more than the disease have had a devastating impact on these rural communities. Our first case here was in January, a student who returned from Wuhan, and after that we were all on high alert with restrictions on travel from China, then Europe, and on border crossings from India. Then when we saw our second case in March, the entire country locked down. This was a severe restriction on all movement nationally.

Police in many areas took their jobs very seriously. Here in the city, I saw people being beaten with canes and arrested for going to the market being outside at the wrong time. All transportation in the country was stopped except with a medical permit. In some areas, police beat farmers for working in their own fields. And that kind of severe response was eventually rained in, but it was well covered in local press, and many farmers around the country were understandably terrified because of it. Meanwhile, supply chains totally broke down. In the first three months of lockdown, we saw produce rotting in some parts of the country where buyers were unable to come pick it up and farmers were unable to deliver it to markets.

Many farm supply shops were forced to close or were unable to restock their shelves, so farmers didn't have access to the seeds and basic supplies they needed for the spring planting season. A lot of the corn or maize that went into the ground this spring was low-quality seed left over on farms from a previous season rather than more trustworthy high-yield varieties that farmers typically purchased to plant. For some crops that wouldn't matter, much, but not corn. So we saw yields drop dramatically in those fields. Poor families depend on that crop for the summer months all the way until October's rice harvest, and then the rice harvest should carry them through to the following spring. Instead, we saw terrible hunger problems spreading

across the country over a period of several months. Just to compound these food supply problems, this year we were invaded by the fall army worm, a corn pest from the Americas that caused extensive damage at exactly the point when farmers weren't able to buy supplies to manage it. At IDE, we've been working with government and donors to coordinate the national response to the pest through integrated pest management approaches, which means low toxicity tools like pheromone traps and organic pesticides. Our surveys during the lockdown showed that our messages were getting out there about how to treat the pest appropriately, but because suppliers weren't open, farmers couldn't get the tools they needed to respond. Then in June, we saw another insect

plague, the desert locust which came to Nepal for the first time since 1960. It's been a tough year for Nepal's farmers. Our summer rice harvest was good, though, but we're still seeing the after-effects of that first strict lockdown. Prices for all foods here rose by about 25% during those months, and they still haven't stabilized. We're all paying a lot more for food these days, and in rural communities, that means people have less to eat, and what they're eating is lower quality in cheap cereal grains. Meanwhile, households that depend on remittances from family members working abroad lost their main source of income. And the ones hardest hit are landless renters and farm laborers who don't have land of their own. Nepal's situation isn't really that unusual globally.

There are half a billion small farmers around the world who have all been facing these same kinds of issues in the past year. They typically feed or support about half the world's population. So this isn't a small problem. These kinds of small family farmers can sometimes be unusually resilient in a crisis because they've always had to depend on different coping strategies. But in an extended crisis like this, and in some areas like Nepal, a crisis after crisis after crisis, we've seen that supply chain breakdowns in the agriculture sector mean disruptions to the food supply months down the line.

We've already seen what happens in the U.S. when there are interruptions in the toilet paper supply. Now just imagine what that situation is like for small farmers globally who have to be. haven't been able to harvest enough food to feed their families or to bring to market due both to COVID-19 and to the world's response to it. I am a hospital social worker in Oregon, which has been relatively less hard hit than other areas of the country and world. It's still been an incredibly difficult and confusing year, even more so for our hardworking bedside staff like the nurses, respiratory therapists, CNAs.

As a social worker, I can see every aspect of my patient's lives. has been changed by the pandemic. Most commonly, people feel alone, disconnected, and unstable. Any pre-existing problems like depression, housing instability, domestic violence, addiction. COVID makes these problems devastating and sometimes deadly. The hardest situations for me to watch involve family, maybe because I haven't been able to see my family and friends for so long. One of my patients in the ICU and his wife, who were 40-something, able-bodied working professionals and their child all had COVID.

While dad was in the ICU, mom died of respiratory failure at home in front of her kid, who then had to spend two lonely weeks quarantining at a family member's house without seeing anyone. Another older gentleman was admitted with COVID only a day or two after two of his adult children had died of COVID. He spoke only a Mayan dialect which we did not have access to in our language bank. His family said goodbye over a video call. These stories, sadly, are common. COVID has disrupted our grieving process in horrifying ways. People die alone with strangers in full protective gear who don't speak their language. We are isolated, unable to hold each other or gather together.

It's been a really hard year. and in some ways a lost year. I am so angry and sad about how our country has handled COVID. I have moments of hope like when I got my vaccine doses, but I also fear things are going to get a lot worse before they get better. Hi, Aaron and Aaron. My name is Amanda, and I'm a microbiologist with a passion for epidemiology and infectious disease. My sister Megan and I wanted to reach out and tell our dad's story because we feel it's a COVID story that needs to be told. Our father had immigrated from Mexico when he was a little boy and had made his life in the U.S.

As he got older, he was spending more and more of his time traveling back to Mexico. On many occasions, he would fly back to the U.S. when he was unwell from not taking care of himself or treating his various ailments or illnesses, and my family would work diligently to get him healthy again, only to see him fly back to Mexico. Most recently, he had left an assisted care facility a few months into the pandemic to fly back to Mexico to be with his girlfriend. in spite of being asked not to because of the pandemic, because it was dangerous for somebody his age with his illnesses to be traveling. We not heard from him for many months, and then the day after Thanksgiving, things changed. His girlfriend had reached out to us to see if we'd heard from him.

She said that he was trying to make his way to the airport when he had gotten confused and started driving in circles. He was pulled over by the police and escorted back to the hotel after explaining to the officers he didn't feel well and couldn't breathe. The police dropped him off and said that they would call an ambulance. He had called his girlfriend and said he was confused, couldn't breathe, and felt like he was drowning. That was the last time anyone had spoken to him. The hotel staff found him deceased in his bed the next day. While the outcome may have been the same, we're disappointed that the police didn't do more to get our dad help. Instead of driving him back to the hotel, why didn't they drive him to a hospital to make sure that he was treated for whatever illness he was experiencing?

We can't help but wonder if the police would have. have done more if he wasn't an older Hispanic man in the southwest United States. Thank you for taking the time to hear our story. We hope that it shed some light on the discrimination that people of color experience daily, both as part of this pandemic and the health care system in general. Thank you. And remember to wash your hands and wear you masks, you filthy animals. Thank you so much for sharing your stories with us to all of our first-hand account providers. And thank you also to everyone who has written in to share your story with us. We really appreciate it and we are very grateful that you're willing to share your

stories with us. Yeah, we really are. Hi, I'm Aaron Welsh. And I'm Aaron Allman Updank. And this is, this podcast will kill you. Welcome to the 16th installment. 16th episodes in our anatomy of a pandemic series covering COVID-19. That's a lot of episodes. We say this every episode. We do. Well, we are very excited for this particular episode because we get to revisit a topic that we covered earlier in the pandemic, but from a very different perspective. Yeah. So this week we are talking about disparities and what kind of disparities that we are seeing in COVID-19, particularly in the U.S., and we are.

super excited, but before we get ahead of ourselves, let's start with a quarantini. We should start with a quarantini. This week we're drinking quarantini 16, 16, entire quarantinis. That's a lot of quarantinis. It is. It's a lot of recipes. It really is. Aaron, you're a boss for coming up with them all. So what is in the quarantine 16? The quarantini 16 is, well, it's rye whiskey, orange juice, lemon juice, and a bit of grenadine. Yum. And we will post the full recipe for this Quarantini 16, as well as our non-alcoholic placebo-rita.

On our website, this podcast will kill you.com, as well as on all of our social media channels. Yes. Other business items really quick, Erin? The usual stuff. If you head to our website, you will find a link to our bookshop.org affiliate account. You will find a link to our Goodreads list. you will find a link to merch, to transcripts, to alcohol-free episodes, and a link where you can submit your first-hand account for COVID-19 for this anatomy of a pandemic series.

Yeah. Basically, we're just saying you should check out our website. There's a lot of stuff there. A lot of stuff there. Yeah. All right. So, this episode, like Erin said, we're very excited to be revisiting disparities. In our earlier episode on disparities, we had a very episode on disparities, we had a very episode.

a really amazing conversation with Dr. Jonathan Wittall from Doctors Without Borders about how vulnerable populations are disproportionately impacted by public health crises. And we discussed how these issues play out on a much more global scale. But in this episode, we're zooming in a bit to talk about racial disparities in health care in the U.S. and in particular, how the COVID-19 pandemic has profoundly amplified these disparities. Where did these disparities come from? What do they look like, especially in the context of COVID-19. How do we measure them? And importantly, what are we doing to reduce or eliminate these disparities to achieve actual health equity in this country? Yeah, that's a big one. To help us answer these questions and so many more, we are thrilled,

like, so fan girl excited. Oh my gosh, yeah. Yeah. We got to chat with Harriet Washington, amazing writer, medical ethicist, whose books medical apartheid, deadly monopolies, infectious madness, a terrible thing to waste, and most recently, Cart Blanche, the erosion of medical consent, have received wide critical acclaim. We recorded this interview on March 10th, and we were recording this on March 25th, so just keep that in mind when we discuss any numbers and stuff like that. But you know what, let's just get to the interview. So we will let Harriet introduce herself right after this break.

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Lucy Letby has been found guilty. But what if we didn't get the whole story? The moment you look at the whole picture, the case collapses. I'm Amanda Knox, and in the new podcast, doubt the case of Lucy Lettby, we follow the evidence and hear from the people that lived it, to ask what really happened when the world decided who Lucy Lettby was. No voicing of any skepticism or doubt. It'll cause so much harm at it.

Every single level of the British establishment of this is wrong. Listen to Doubt, the case of Lucy Letby, on the IHeartRadio app, Apple Podcasts, or wherever you get your podcasts. My name is Harriet Washington. I'm a writer, and I focus on medical ethics, research ethics, typically. I've been doing a lot of work lately around informed consent and some of the hidden problems with it, such as it disappearing from the landscape without anyone really realizing it. But I also work on other things. I'm very concerned about conspiracy theories. And I've been to several international conferences presenting on some aspects of conspiracy theories that kind of elude us. We talk about them in order to dismiss people's fears, but sometimes these are real conspiracies, not just conspiracy theories. And sometimes the fears are actually, you know, rational. So that makes a situation harder, but we need to confront that. And those are some things I'm working on. I'm also interested in the use of art in medicine to promulgate political stances and frankly perpetuate lies.

So that's a fascinating topic. I keep busy. Well, thank you so much for joining us. We are so excited to chat with you today. So can you just start us off by telling us a bit about your new book that just came out and what inspired you to write it? Well, it's hard to think it was. inspiration is the right term, but the erosion, the book is entitled Cart Blanche,

and it focuses on how the erosion of informed consent. Informed consent is that very detailed and very informative mode of transmitting information to people who are thinking about engaging in metal research. Before you engage in the research, you ought to know what the risks are. You ought to know what the potential benefits might be. You ought to know the lifestyle effects. You know, will you be able to, unable to drive? will you be very tired?

You also need to know what your options are. Are there other medications that are not experimental but are tested, tried and true that you might prefer to take? Are there non-medical things that you could do for your condition? Or do you have the option of not taking any treatment at all? All these things have to be spelled out to you in great detail, according to American law. And that's largely because of abuses that we vowed would never happen again. Things like the Holocaust, where people were murdered in the name of medicine. and pretending and do research.

The Nazi doctors actually focused on Jews, polls, other people, but mostly Jews. And, you know, they incurred harm, forced them into research, sometimes killed them outright as part of studies. And then in this country, we had prison research, the long history of abusing African Americans in research arena that culminated in people's horror over Tuskegee. All these things made Americans and American doctors swear that they would never, um, have this done in medicine again. And it's worth noting it was American doctors and lawyers who went to Nuremberg, Germany, to confront the Nazi architects of the Holocaust. So all these things culminated in what we hear every day, one way or another, that in this country, no one can be forced into medical research without their consent, but it's actually wrong, as I detail in the book. Many people have been

it's escalating. We're talking about tens of thousands of people forcing to medical research without their permission. Yeah. This kind of issue of eroding consent that you touch on in the book and how it disproportionately affects people of color, it's really just one dimension of health disparities, both here in the U.S. and abroad. And we know that although health disparities have been around forever, it's only within the last few decades that that term itself was actually coined. And it's often only vaguely defined. Would you mind describing for us kind of what we mean when we talk about health disparities? Well, if you ask 10 people, you get 10 different definitions. But I think the simplest and most useful definition is simply treating any group of people and mass differently than you treat other people. So if, for example, there are studies then showing that consistently and routinely,

African Americans are less likely to have their complaints of pain acknowledge and treated, then that's a very important health disparity. In fact, in 2016, University of Virginia study showed that half of all medical students surveyed thought that African Americans didn't feel pain the way whites did. And a good number of practicing doctors think that too. That's a very clear example of a health disparity that has wide-ranging effects. Instead of having their pain addressed with appropriate medication or other treatment, African-Americans are often dismissed as drug-seeking.

and sent away without any medication and stigmatizing notes in their medical charts. So that's a very dramatic example. But frankly, you'd be hard-pressed to find any area of American medicine where you're not going to find disparities in the way that black and white people are treated. And that emanates from the 19th century, where you had this wave of very prominent doctors and scientists telling the country and telling the world who African-Americans were. And one of the things they said about African Americans were that African Americans had very different bodies from white people. They suffered very different diseases.

They had immunities of certain diseases. They didn't feel pain the way whites did. These beliefs are not lodged in the past. These beliefs have surfaced today in these studies that consistently show that we don't create African American pain. But I worry about the things that we're not studying or not following. What other beliefs from the 19th century are still held by doctors, but we don't interrogate. them. I see quite a few. Yeah, absolutely. So in these discussions of health disparities, sometimes the conversation focuses solely on barriers to quality health care in the U.S. But in reality, those inequalities

are only one part of the story. So can you talk a bit about how it's not just being able to go to a doctor or afford a doctor, but how things like access to education, chronic stress, and environmental racism interact with and compound each other when it comes to these health disparities? I frankly don't see any difference between environmental exposure and the more traditional barriers you mentioned. It's simply another barrier. The fact is that we know the African Americans, Native Americans, Hispanic Americans are much more likely to be forced to live in areas that abut, toxic spewing industrial parks, bus depots. old housing that is rife with interior lead paint. These exposures are strictly racial. In fact,

they had been characterized for a very long time as socioeconomic, and people often spoke about vulnerable people being low-income people. And although poverty is a risk factor, it's a risk factor that is dwarfed by racism. Studies have shown consistently that your race is what dictates whether you're exposed to environmental toxins or not. In fact, one study showed that African Americans with an average income of like $60,000 a year are more exposed to environmental toxicity than very poor whites who only have an income of, say, $10,000 a year, very poor. So it's not poverty, it's race. And these barriers are of many varieties, but they're racial barriers, and that's what's really important to me. They can be categorized in many ways.

But if you're focusing on the victims and focusing on improving their health, then the most important character, to reason to me is how prevalent they are and what effect they have on people's health. Environmental racism has an extremely profound effect on people's health, and yet it's not often enough included in initiatives to resolve health issues and address health disparities. I wrote an article for Nature last year showing that environmental racism is a key indicator of stability to coronavirus 19. In fact, the risk factors caused by environmental racism, are the same risk factors that make one susceptible to coronavirus 19. So these are all, all barriers to better health for people of color.

But of course, we have to realize that we will indict some of the barriers as if they arose of their own. These barriers arose for a reason. And that means that in some sense, these barriers were all created by people. It's racist policies that sometimes date from the 1950s and 60s that did. how African-Americans are trapped in areas where there's a lot of environmental toxicity. So we have to remember that these are human decisions, human actions, and existing policies and laws that need to be changed. It's not just a matter of, this seems to be standing between

African-American and good health. We have to take a more holistic view. Absolutely. What are some of the ways that we actually kind of measure these health disparities? They're measured in so many ways. Sometimes people look at the years of life loss, the years of health loss. And depending on what question you're trying to answer, there are variety of ways you can do it. And some measurements are better for certain estimations. But what's really important is the fact that no matter what measure you use, if it is an accurate measure, you're going to find a dramatic difference in the health status of people of color.

otherwise comparable white people. And that's because of our health care system. We have a health care system that is rife with policies and behaviors that may not be encoded in policy, but certainly exist. These behaviors are part of the health care system. So one thing that frustrates me is how frequently, when we look at health care disparities and we see a very pronounced health care disparity, the initial response is to look at African American behavior. How can we change it? How can we educate African Americans? How can we get them to come to the doctor more often. How can we remove this fear of medical research? That's the wrong focus. In fact, to focus on African Americans is to imply that there's something pathological about

African American behavior. When it's not African American behavior, it's the untrustworthiness of the U.S. health care system. If you don't look at both things, not only are you not going to be successful in changing it, you are unfairly stigmatizing people of color. Some of these measures are not very good measures. I mean, one of the things that is illogical is how often people will invoke education. They'll say, well, well-educated people seem to have better health according to this measure. And better education will improve African American health status. Better education is always a good thing for a variety of reasons. But this is an error. You have to understand that for African-Americans, race actually countermands many of the advantages of education.

For example, African-American men who are college graduates earn less money on average than white high school graduates. Dr. David Williams at the Harvard School of Public Health, a brilliant public health scientist, was relating to me how when he went to the reunion of his class at Yale, most of the African-American men in the class had already died. The fact is having a Yale degree did not save them. from the effects of health care disparities.

So education is not a good measure, and we have to stop using measures that have not been proven because too often, in my view, they are direct mythologies. That's a mythology. It also has a subtle form of blaming the victim. You know, if you had done better in school, if you were a smarter and more diligent student, then you wouldn't be suffering so. That's not true, and that's not fair. Right, yeah.

So these health disparities are also often measured as outcomes, like the differences in mortality rate or years of life lost, incidents of particular diseases. But these outcomes represent the end result of a lifetime or multiple generations' worth of inequalities. And the narrative too rarely focuses on addressing the root causes of these inequalities. So can you talk about why it's important to understand the context of these disparate outcomes? That is such a brilliant question. Because if you think about it, frankly, what good is it to examine this at the end of life? What we'd like to do is intervene so that that lifespan can

look more like the normal American lifespan. And intervening is something that we have been slow to do, quite frankly. One of the ways in which I think my vision has been informed, by the research I did, looking at the history of medicine, is that I have a different idea of why we have some of these disparate treatment that leads to early death and greater disability. People use a term bias. I'm not saying that's not accurate. It's often appropriate. But what I see is not so much bias as mythology. The 19th century scientists that I mentioned earlier on, they had this belief of, this nucleus of beliefs about African Americans, and they basically veiled their beliefs, you know, their mythology about who blacks were. They veiled it thinly in scientific data to make it look scientific.

Science was beginning to trump other ways of knowledge in the 19th century, and that made it more palatable. It made it more impressive. Didn't make it scientific, though. So these beliefs about who African Americans are, why they die and why they survive are largely mythological. you know, sort of perpetuated from the 19th century without enough scrutiny. We need to, in this era of evidence-based medicine, we need to go back to the drawing board and start applying scientific analysis to some of our beliefs and policies. We have policies that, for example, assume the education is going to elevate health status and life expectancy. Maybe, I don't think so. We need to look at this. We need to have research.

that looks more objectively about certain measures. If African Americans are dying early, very often the focus is on biological dimorphism, differences, or purported differences between black and white bodies. You'll see a lot of intense and expensive research going on and find what looked to me as rather modest differences, if their differences are all. Very modest differences. A lot of investment is made in finding them and the argument that because there seems to be preponderance of some kind of subtle genetic difference, all this effort and resources poured into that. But sometimes there are screamingly important differences that are not being investigated for like environmental exposure. If we spent the same amount of money on finding ways of separating people of color from a constant environmental assault, I think that would be money better spent. So we need to do the research to find out what's going on. One of the things that I found really frustrating and almost comical if it weren't so sad is the focus on the Tuskegee experiment as a rationale for the

supposed reluctance of African Americans to join clinical trials for COVID vaccine and now to accept the vaccine. You know, I get so frustrated when I hear this because having studied this history in great depth and understanding that the history of medicine has elided the experience of African Americans, I realize that researchers invoke Tuskegee because that's all they know. They don't know about the history. They don't know about the many, extensive, rich, and frankly and flagrantly, the violations have taken place that African Americans know about. It happened to their family. It might have happened to them. And so they will invoke Tuskegee, but where's the research to show it? I've looked at it. The research is very poor. It begins with the

assumption that Tuskegee is at fault, which is not the way science operates. They should be asking open-ended questions. That's research that needs to be done. In fact, it has been done. Thomas Levice at Johns Hopkins did a series of studies and found that it's not Tuskegee. In fact, he found in one of his studies that people who had never heard of Tuskegee or African Americans who had never heard of that study were more fearful of medical research than people who had. So despite all the evidence, you know, we are still clinging to this mythology that black people are afraid of Tuskegee and therefore they're not interacting with the healthcare system appropriately, which is not true. First of all, they are interacting appropriately. And second of all, if they were not, you could not blame Tuskegee for it. But again, like this is like some very stubborn ignorance that needs to be resolved. And public health science should be focused on resolving it. So, of course, these health disparities have existed long before the COVID-19 pandemic. But in this last year, I think they've really become both magnified and deepened in many ways.

So can you talk a bit about the disproportionate impact that COVID-19 has had on communities that were already facing significant barriers to health care? Well, it's devastating. We already know that life expectancy has fallen. the volume of deaths alone is completely devastating. And it's not novel. You know, this is not unique at all. Think of what happened with HIV. Early on in the 80s and 90s,

we didn't really know what we were dealing with in the 80s. One thing that emerged very quickly was that it was infecting and killing many more African-Americans than whites. This hepatitis C, 20% higher rate in African-Americans and whites. This is not at all a novel event. It's quite something we frankly should have expected. Infectious disease simply reflects what's already transpiring, the vulnerabilities that already exist due to things like environmental racism,

due to things like disparate access to health care and poorer treatment when you finally do access health care. All these things, you know, are vulnerabilities that are magnified whenever you have a health crisis. An infectious disease is like the perfect agent to magnify these things, and it's happened repeatedly. And frankly, coronavirus 19, I would love it if it were the last wave of emerging infectious disease that we faced, but that's very unlikely. Look what we've gone through just in the past decade or so, you know, HIV, hepatitis C, Zika, Chagas disease. A lot of these have not been well recognized in the media because they're affecting enclaves of people of color. Toxoplasmosis, you know, these diseases are coming in waves and they're coming regularly.

We're going to be dealing with others after coronavirus 19. So I think it's time to act on what we already know that when you have people who are already marginalized and separated from health care access and treated poorly by the health care system once they interact with that, of course these people are going to become victims of the infectious disease. And yet, where's all the scrutiny? A lot of the scrutiny? The scrutiny is on African-American behavior. Oh, what are they doing? Are they failing to practice social distancing? Even the Surgeon General, remember in April last year? Surgeon General got on TV. He did deliver a good message for the most part, but then he began talking about avoiding drug use and alcohol use,

as if these were special concerns for African-Americans. And he's African-American, and he's a surgeon general. He certainly knew or should have known the African Americans and Hispanic Americans were less likely to be able to practice social distancing as he urged them to do. It's time to take our heads out of the sand and apply what we already know about the vulnerability of populations who are treated badly by the health care system to these infectious diseases, including, but not limited to coronavirus 19. Yeah, this mythology. This mythology. that there is a biologic basis for health disparities, this narrative has shown up repeatedly throughout discussions of COVID-19. Can you talk a little bit more about that and how, what are

some of the examples that you have seen in which this like race-based medicine has shown up during this like specific COVID-19 pandemic? Oh, there's so many. The focus on social distancing. Okay, so that's behavioral, but also plays on an old trophy that African Americans cannot be trusted to act in their own best interests medically. They're unable to comprehend the right way to behave. So people began talking about where people choose to live, which is completely absurd. No one chooses to live in a walk-up tenement in New York City, you know, where you are. crowded around people where you can not social distance, where you are forced to share elevators with people, and you're almost certainly to be exposed in this very dense environment to someone who's

infected. But then there are other things as well. In France, there was a study, I forget exactly what data came out, but I found it staggering. There was a study coming out of France basically saying one of the reasons why we're seeing high rates in black people in the U.S. and in the U.K. And we can expect to see it in France is that black people react differently to infection. Black people are systematically more susceptible to infection. I'm reading the study and I'm thinking, I'm not epidemiologist, but this is just not making any sense. They didn't talk about any particular infectious agent. They wrote infection very broadly.

So I'll just say I had my strong doubts. And yet the paper was published. I didn't see any retractions. I didn't see criticism of it. It's something that was simply accepted. The belief in bodily differences, of course, often evolves around genetics. And so I've also read about very small genetic differences purportedly found between African-American and white.

And the thing is that it's a bit meaningless. If there was indeed some genetic difference, how do you know it's a difference in African-Americans? A lot of the research that uses racial labels never defines how they came by that racial label. I'm constantly amused to see research in which African Americans and Hispanic Americans and whites are compared and contrasted without ever defining the terms. Because Hispanic Americans can be people of any race. So some of the Hispanics they were referring to are undoubtedly people who identify as white or as black or as both Hispanic and black. And so it really makes no sense. I think that a lot of the data is not only less than rigorous, that even if there is a small

difference, you know, there's no proof that that difference actually has a significant effect on coronavirus infection or effects. Race simply maps very poorly on genetics. And yet people are clinging to the straw in order to support their belief in biological dimorphism. Meanwhile, again, things that we know. know are impacting one's risk of developing and sickening and dying from coronavirus go unaddressed. Not only environmental exposure, although that's very important, but also things like your access

to a doctor. More African Americans don't than whites lack a primary care physician. Without a primary care physician, you not only have greatly reduced immediate access to necessary health information, you have no advocate within the health care system. And if you're African-American, you need an advocate because when you get to the health care system, you're likely to be treated differently. You know, your symptoms are likely to be dismissed. Your pain is dismissed. You're sent home very often without appropriate treatment or any treatment. And then when you sick and worsen and die and go to the hospital, if you're fortunate enough to have access to the hospital, then you're not going to get the same type of treatment as whites. So all these things we know exist and we should be

focused on quantifying and eliminating these things. Instead, we're hunting for some mythical genetic difference that is going to explain to us why people of color are more vulnerable when frankly, we already know why they're more vulnerable and it has nothing to do with genes. Absolutely. I feel like that sums it up. So how can we actually work to increase health equity in this country? What are some things that we could do at an individual level to help? And what are in your mind some policies at the state or national level that could help narrow this gap? How much time do you have? I do have some ideas. In the context of coronavirus, discussions about policy are focused on basically, I call it the get rich quick syndrome. They're focused on things that can be affected very quickly

in hopes that you'll have a rapid change. That's highly unlikely. And even if we're going to work, I'm not sure that's the direction we'd want to go. Remember, I said that, and I'm sure you are very well aware, this will not be our last emerging infectious disease. There's going to be another one. Every time we have a new health challenge,

we will have to go back to the drawing board and undertake the really quick policies, the things that, you know, are aiming at changing people's behavior very quickly, are likely to be temporary as well. I think it makes more sense for us to face the facts and look at long-term changes that will yield long-term solutions. And that means something more intense, something a little bit more comprehensive, that's going to take longer time. So if we do that, if we look for meaningful, persistent changes,

we have to look at where the problems are. First of all, we've done a lot of studies showing that they exist, but fewer studies looking at why they exist and how to address them. For example, lots of studies on pain. We know African-American pain is treated very badly. It's not acknowledged. It's not treated appropriately. people are stigmatized as drug-seeking when they're in pain. We know this. So we need to focus now on how to fix it. What's causing this? And, you know, frankly, sometimes it's good to know what causes a problem. But sometimes I think it's wasted time and effort that we really can't afford rather than worry about what exactly is causing the problem. Because that can be grounds for a lot of them, let's just say, unhelpful nasal gazing. People,

talk about implicit bias in part because it's more comfortable than talking about explicit bias. What's important is that there is bias and it needs to be ended. So we often talk about education and training, but look at pain. I'm not sure education and training is the root. I'm sure it's not enough because if you look at pain, the studies showing that half of medical students, a good proportion of practicing doctors think African Americans don't feel pain. and treat them accordingly. So we've established that. If you talk about education and training, where are you going to do it?

How are you going to direct it? You don't find this information in textbooks. That's not why medical students think this. They think that because this is what they're learning on the clinical floors. They begin on the clinical floors in the latter part of their education, and they see consistently African-American people who are complaining of pain being turned away as drug-seeking. that's a tacit part of their training. They internalize that, they replicated, and then they will teach that to their own students

and residents. So we need to break that cycle. Instead of education and training, I think we need to treat this like we treat other behavioral problems. It's really a quality of services problem. A medical student would not be allowed to graduate without acquiring certain knowledge and certain skills. A resident would not be allowed to finish his residency if he weren't able to

to do certain things required of it. These students and these practicing doctors should not be allowed to advance in their profession until they've demonstrated that they are treating all patients equally. And we need to devise structures for assessing that. The way we assess whether they can run a central line or do any other tasks required for their profession, we need to assess that.

Not on paper and pencil tests, medical students are all smart enough to know to give the right answer. It doesn't mean they're doing the right thing. But we need to build that into medical education and make behaving appropriately prerequisite for graduating, for advancing in your field, for getting a promotion, for becoming chief resident. It's time to monitor the behavior of not only the individuals, but also the systems, hospitals that have been, should be checked, overseen, their data should be scrutinized, and hospitals that show a record of not treating. a group of patients appropriately, African-Americans or anyone else, should be made to undergo penalties. You know, we shy away from penalties for health care providers because we have such respect for them. They have such high social status. But I think we need to use these rewards and penalties.

Meaningful penalties that will not only encourage compliance, but also send them message to health care providers that this is important. It's an important hallmark of, you know, of your ability to practice medicine well. So I think we need a change of perspective here. I also think we need to have laws that change. The policies and laws reinforce health care disparities. One of them in the research arena is a structure of IRBs. IRBs by law only have to have one person who is unrelated to the institution on the IRB board. So what can that person do? You're sitting there and you're facing what? five, 10, 15 scientists, all of whom want to do a particular study. You are the appointed layperson and you're not comfortable with it.

But what kind of effect can you have? First of all, you know, you're intimidated. These are scientists. You don't speak their jargon. You can't understand everything that they're saying. And they certainly don't have any incentive to listen to you. You have to be there. You're allowed to speak.

But what influence do you have? If you have no influence, you can't. And so I wrote in Medical Apartheid that was back in 2007 that IRB should be constituted of half laypersons and half scientists. And that way the lay persons on the IRB could have a real voice and some real leverage. If the people from whom you're going to draw the subject pool, here's about the study you want to conduct. And they have questions or concerns.

This is a way to make their concerns addressed in a, meaningful way. And then I heard from peers who said to me, that's not going to work because late people can't understand the scientific, you know, nuances and procedures and they're not going to know what's going on. I said, but scientists can explain it to them. Otherwise, how can the scientists explain it to the subjects they enrolled in the study as they're required to do by law? Scientists are very good explaining on even complicated scientific issues. It takes some time, you can't do it off the top of your head very often, but I know I've read a lot of studies. I've talked to a lot of researchers and I know how good they are at doing this. So it's something

it needs to be done. We need to involve lay people in numbers that will make their participation meaningful. This will also, I think, lower resistance in the larger community. When they know that people like them are involved in advising the studies, I think they'll have greater confidence. It's not something that's just being, you know, enforced on them from above, so to speak. So I think those are really important policy changes. I have others as well in that. One of my big recommendations is to get rid of health care lobbyists. Lobbyists have no place in health care.

Essentially what's happening, as I understand it, we're electing lawmakers to enact our will. And instead, the lawmakers are essentially receiving money via lobbyists to enact the will of corporations that might be very different from what we have in mind. In fact, frankly, I think they often are. The corporations are focused on the bottom line, not on improved health care as their number one policy. So those are two big changes. We need to revoke, I think, the laws around that encourage patenting by corporations of universities. The law was passed in, the laws are passed 1980, and the shorthand is a Bay Dole Act and there were other lesser laws. But this is what actually changed American medical research and changed the agenda setting from the institution. It was a

public health-centered institution to corporations who, again, are centered on the bottom line. These corporations are why their focus on maximizing profits is almost, not completely, but almost total. And that's why we have 20 drugs for erectile dysfunction and only one new drug for malaria in the last couple decades. So I could go on, but those are my basics. Yeah. So we have one final question for you. So you just went through many different things that we can do to kind of help to increase health equity in this country at a, you know, hospital level, at a national level and so on. But in general, how can the medical establishment work to earn the trust of these communities that we have historically disenfranchised? And in many ways, as we've talked about during this interview,

continue to disenfranchise when it comes to health. The U.S. healthcare system is untrustworthy. If it wants to gain the trust of people, it must become trustworthy. And I know it's technological, but it's also reflecting the fact that this will not be a fast solution. It's been four centuries of abuse in the health care arena. So it's unrealistic to expect to fix the problem in a few months or even in a year. But the health care system has things that needs to do desperately. One of them is to become more inclusive. And I mean racially inclusive, but I mean more than that.

I mean, right now, we have a health care system in which there is a interaction between patients and their physicians and perhaps a patient advocate. But the health care system has got to give more points of entry for lay persons into the system. There are already some unused avenues for monitoring and oversight within the health care system. We need to start using them. For example, in research, there are provisions built into the law for government oversight of medical research. Provisions are very important because you have IRBs that are supposed to conform to laws. And I don't know how many, but I'm sure many of them do.

But many of them do not. Many of them have permitted too much research that is clearly in violation of laws and of ethical strictures. But the oversight is not well funded. There's no money for the oversight. It's there in the law, but it's not happening. So that means that, you know, the research generated by an institution is as good as its IRB. You have a conscientious, meticulous, patient-centered IRB. You have good research.

You have another type of IRB or IRB that is reliant on fast-track approval, essentially rubber stamping research, and that's exactly what you're going to get. That's why we need the federal over-examping research. oversight that's already in the law, it needs to be funded and put into operation. We also have provisions in the law to remedy some of the problems caused by the jealous corporate protection of patents. They're protecting their patents above all else. And they often will produce medications that cost a better part of a million dollars a year so that people can't afford it. There's a provision for this in the law that allows the government to step

them, take the patent from that company, give it to a company that commits to producing a drug at an affordable price, pay off the first company, something for the use of the patent, and that way the first company gets some money, not the million dollars a year they were looking for, of course, but people who need the medication will get the medication. That's a great solution. Well, it's not a great solution, but considering the system, which I think is not a bad system, that is a solution, but our government refuses to undertake it. They won't use it to give our people affordable drugs. They used to allow direct TV, but they don't use it to allow us to have good drugs.

So, you know, we have to look at things that are already in the law that could afford us some relief and could afford African Americans and other people easier, affordable access into the health care system that we're just not using. We're ignoring that. I don't know why we're ignoring it, but I will say, It's yet another reason why we need to get lobbyists out of health care. I'm not saying the lobbyists have anything to do with this, but I am saying that it certainly benefits lobbyists if we don't exploit these laws.

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In 2023, a story gripped the UK, evoking horror and disbelief. The nurse who should have been in charge of caring for tiny babies is now the most prolific child killer in modern British history. Everyone thought they knew how it ended. A verdict? A villain. A nurse named Lucy Leppie. Lucy Letby has been found guilty. But what if we didn't get the whole story?

The moment you look at the whole picture, the case collapses. I'm Amanda Knox. And in the new podcast, Doubt, the case of Lucy Letby, we follow the evidence and hear from the people that lived in. To ask what really happened when the world decided who Lucy Lettby was. No voicing of any skepticism or doubt. It'll cause so much harm at every single level of the British establishment of this is wrong. Listen to Doubt, the case of Lucy Letby on the Iheart Radio app,

Apple Podcasts, or wherever you get your podcasts. I'm Clayton Eckerd, and in 2022, I was the lead of ABC's The Bachelor. Unfortunately, it didn't go according to plan. He became the first Bachelor to ever have his final Rose rejected. The internet turned on him. If I could press a button and rewind it all I would. But what happened to Clayton after the show made even bigger headlines. It began as a one-night stand and ended in a courtroom, with Clayton at the center of a very

strange paternity scandal. The media is here. This case has gone viral. The dating contract. Agree to date me, but I'm also suing you. Please search for it. This is unlike anything I've ever seen before. I'm Stephanie Young. This is Love Trapped. This season, an epic battle of he said she said, and the search for accountability in a sea of lies. Listen to Love Trapped on the Iheart radio app, Apple Podcasts, or wherever you get your podcasts. Thank you so, so much, Harriet. It was such a joy to chat with you. It was unbelievable. What a great conversation. Oh my gosh. Yeah, we covered so much information. Yeah, we really did. So, as peruge, shall we go over some five learning points? Let us do that. All right. Number one, the many barriers to health care that exist were put into place by people.

Environmental racism is one example where explicitly racist policies like redlining, segregation policies, the Indian Removal Act, and so many more created inequalities in environmental conditions between Black, Native American, Hispanic or Latino, and other minorities and white people deliberately. And these policies haven't disappeared. They exist today in the Dakota Access Pipeline, in the Flint Water Crisis, and they persist in unequal access to clean water, fresh food, clear air, safe housing, and many other things that a lot of people take for granted. These barriers, created and enforced by racist laws and policies, especially within health care and behaviors not encoded in policies, these have a direct impact on

the health of people today. Despite these systemic inequalities and barriers, much of the focus of health disparities, especially racial disparities, focuses on individual human behavior, essentially blaming the victims of health disparities for their conditions. Yeah. Number two, racial disparities in health are generally reported as outcomes, disproportionate death rates or infection rates, disease prevalence, shorter life expectancies. These disparities don't magically appear in a vacuum. They are the result of a lifetime or generations' worth of unequal access to health care, of racist medical or environmental policies, of excess stress. And of course, it's important that we measure these outcomes and that we're having

these discussions, but it does us no good if we don't also address the root causes of these disparities and how they interact and compound each other to lead to such stark differences. So step one is finding out, okay, what are these disparities? But step two, which really should be taken alongside step one, is how do we increase health equity by addressing the roots of these disparities? These are not something that we can fix by making one simple change. We need to put some of our resources to understanding what it is about the health care system, the legal system, the educational system, housing policies, our entire society in general that perpetuates these outcomes that we can measure. Racial disparities are often multigenerational and are always multifaceted, and making any

improvements requires us to take a step back to see the bigger picture and put policies in place that address the roots of these inequalities rather than at the branches. Number three, speaking of root causes, a lot of attention. in medical research has been paid to trying to prove biological differences between races, leading to race-based medicine. However, these supposed biological differences are rooted in pure racist mythology, perpetuated in the 19th century when self-styled scientists, thinly veiled their racist views in scientific language. Despite the fact that in the decade since, there have been ample studies illustrating that these biological differences in race,

truly our mythology and have no basis in fact, these racist notions permeate the way medicine is taught and practiced today. Many physicians make decisions based on this mythology, the myth of differences in pain tolerance, lung capacity, predisposition to certain diseases, and there is a tremendous amount of research conducted to find a biological basis for racial disparities in health outcomes. Instead, we need to use those resources to go back to the drawing board and actually apply evidence-based medicine to addressing health disparities, rather than relying on this mythology created and perpetuated by eugenicists and racists. We have to shift the focus from these supposed biological differences, which truly do not exist, and instead focus on the things that are

actually different due to systemic racism, like access to health care, like environmental conditions, like access to education, clean food, water. I mean, the list goes on and on. Yeah, it really does. Number four, while the disparities that we are seeing with COVID are not unique, and infectious diseases often reflect the vulnerabilities that exist in societies, the disparities that we are seeing today due to COVID are bleak. In the U.S., studies throughout this pandemic have consistently found that black people are at least twice as likely, and some studies have found up to six to eight times as likely to test positive for COVID than white people. They are hospitalized at least three times greater rates and account for significantly higher proportions of deaths due

to COVID. And the same is true for other minority groups. Native Americans are almost four times as likely to be hospitalized due to COVID. Hispanic or Latino people, three times as likely. And the thing is, these are national estimates that I'm citing from the CDC. Some individual studies in various states have found much higher disparities among racial and ethnic groups. And the thing is, it hasn't been limited to COVID disease, hospitalization, or death. Job loss. have also been higher among black and Hispanic Latino people. COVID has caused increases in food insecurity, housing instability, access to other medical care, including routine vaccinations for kids.

And we have done a terrible job in ensuring equitable access to vaccinations so far, and not just in the U.S. According to one study in England, elderly black people were half as likely to be vaccinated compared to white people for COVID-19. And in the U.S., a patchwork of vaccine distribution has led to severe inequities by race and ethnicity that vary state by state, but overall the stats are pretty grim. Some reports and news outlets seem to tie this inequity all back to vaccine hesitancy. But that's really its own form of victim blaming, and it's not the root cause of the disparities that we're seeing. Yeah.

So number five, how do we fix it? It is not going to be easy and it's not going to be quick. It has been four centuries of abuses and health care in this country, so we can't expect to fix the problem overnight and we can't expect that education itself is going to fix the problem. We have to apply meaningful changes in the way clinical medicine is taught and practice. individuals and institutions need to be held accountable for disparities that persist, and the health care system has to do the work to become more inclusive. This might mean having more points of entry into the medical system.

It might mean more monitoring and oversight with actual repercussions for noncompliance, and it might mean changes to laws such that there is an incentive to prioritize actual human health and well-being instead of corporate interests. It's going to be a long road, that's for sure. Oh, yeah, absolutely. If you'd like to look in more detail and know exactly where we got some of the data in this episode from, we have links to all of our sources on our website, this podcast will kill you.com. Most of the stats came directly from the CDC's website, as well as a couple of peer-reviewed journal articles that we found. Again, thank you so much, Harriet, for taking the time to chat with us. I feel like this was a very informative episode.

Absolutely, definitely. And I think a really important one as well. Mm-hmm. Yeah. And thanks again also to everyone who provided a first-hand account. We really appreciate it. Yeah, thank you. Thank you to Bloodmobile for providing the music for this episode and all of our episodes. And thank you to the exactly right network of whom we are a very proud member. And thank you to you listeners for listening through this episode. We hope that you learned something. Yeah. And enjoyed it. Well, until next time, wash your hands.

You filthy animals. I'm Clayton Eckerd. In 2022, I was the lead of ABC's The Bachelor. But here's the thing. Bachelor fans hated him. If I could press a button and rewind it all I would. That's when his life took a disturbing turn. A one-night stand would end in a courtroom. The media is here. This case has gone viral. The dating contract.

Agree to date me. but I'm also suing you. This is unlike anything I've ever seen before. I'm Stephanie Young. Listen to Love Trapped on the Iheart Radio app, Apple Podcasts, or wherever you get your podcasts. I'm Amanda Knox, and in the new podcast, doubt the case of Lucy Letby,

we unpack the story of an unimaginable tragedy that gripped the UK in 2023. But what if we didn't get the whole story? Evidence has been made to fit. The moment you look at the whole picture, the case collapsed. What if the truth was, disguised by a story we chose to believe.

Oh my God, I think she might be innocent. Listen to doubt the case of Lucy Letby on the IHeartRadio app, Apple Podcasts, or wherever you get your podcasts. This is Special Agent Regal, Special Agent Bradley Hall. In 2018, the FBI took down a ring of spies working for China's Ministry of State Security, one of the most mysterious intelligence agencies in the world. The Sixth Bureau podcast is a story of the inner workings of the MSS. and how one man's ambition and mistakes opened its fault of secrets. Listen to the Sixth Bureau on the IHeartRadio app, Apple Podcasts, or wherever you get your podcasts.