Bloomberg Distinguished Professor, Johns Hopkins University
Visiting Professor, Milken Institute School of Public Health
Senior Fellow for Global Health, Economics, and Development, Council on Foreign Relations
Drs. Lisa Cooper and Leana Wen discuss the racial inequities that exist in the health care field today and how that impacts the course of the COVID-19 pandemic.
BOLLYKY: Great. Good morning. It’s my pleasure to welcome you to this roundtable at the Council on Foreign Relations on Racial Inequities and COVID-19. My name is Tom Bollyky and I’m the director of the Global Health Program. We’ve actually had to expand the size limits or participation limits on this roundtable twice to accommodate the level of interest. And I’m not surprised by that, but I am pleased to see the level of interest in this topic.
To paraphrase and to borrow a phrase from Dostoyevsky’s famous quote about prisons, you can tell a lot about societies by the way they respond to epidemics of infectious disease. Plagues put a mirror to the societies they afflict. Pandemics expose the failures of governments to invest adequately in the health care of their constituents and the collective risks that arise from the failure to extend social protections to vulnerable groups.
So what has the coronavirus pandemic revealed about the state of race and healthcare equity in America? That’s the topic of today’s discussion. We will also be forward looking in this conversation, as well as taking stock of what has happened so far in this pandemic. If we’re going to—if the United States must bear the terrible costs of this pandemic, we might as well learn and profit from the experience. And we’re going to be looking at what lessons can be learned about addressing healthcare inequities and racial inequities as part of pandemic preparedness and response in the future
We are very lucky to have two wonderful speakers to guide us through these topics and questions. You have their impressive bios before you, so I will just grossly truncate them and focus on their current titles and what they do now. Dr. Lisa Cooper is a James Fries professor of medicine and a Bloomberg distinguished professor at Johns Hopkins Schools of Medicine, Nursing and Public Health. She directs the Urban Health Institute and the Center of Health Equity at Johns Hopkins and has long been a leading expert on health inequities in the United States. Dr. Leana Wen is an emergency physician and a public health professor at George Washington University. She is also a contributing columnist for the Washington Post and previously served as Baltimore’s health commissioner.
We’re going to start with ten minutes of opening remarks from each of our speakers, first Lisa and then Leana, after which I will ask them a couple of questions to get us started and then turn it over to this this great group we have assembled for this roundtable today. As a reminder, this meeting is for attribution. So anything you say here can, will be, and may be used against you. So be aware of that. And with that, I will turn it over to Dr. Cooper to start us off.
COOPER: So good morning, everyone. And it’s a pleasure to be with you today. And as Tom mentioned to you, you know, we’re in the midst of this pandemic. And as of today over eight and a half million people have been infected worldwide. In the United States alone over two million people. And we’ve had close to 120,000 deaths to date—about 117,000. And what we’re learning is that is that is about the number of deaths that have occurred in Western Europe in a contiguous area of countries with similar population to our country. So at the rate we’re going, we’re going to outpace Europe and in terms of the number of deaths that we have in our country.
Particularly disturbing data show that in our country COVID-19 is not impacting everyone similarly. We have African Americans who are disproportionately impacted with their death rate of approximately two and a half times that of whites. We also have Latino populations that are dying at higher rates—getting infected at higher rates, in particular. This is very dramatic across many, many states. And the highest sort of disparities we see are among African Americans in the District of Columbia, right, where many of us are located, where it’s about six times as high as it is for whites, and across several states, including Wisconsin, Michigan, Missouri, New York, and South Carolina. We also have American Indian and Native American populations that are dying above their population share, particularly dramatically in New Mexico.
And for Hispanic populations this is mostly occurring—the disparities that we’re seeing in death rates are mainly in New York, and also in Illinois, and in Tennessee, and Wisconsin. So one of those statistics that we’ve heard recently that came from the American Public Media Lab is that if they had died of COVID-19 at the same rate as white Americans, that at least 14,400 black Americans, 1,200 Latino Americans, and two hundred Native Americans or American Indians would still be alive. So this is really devastating news. And it sort of exposes the inequities in health and in society—in our society, across our society, by race and socioeconomic status.
So a lot of people have been asking me, I know, as I go around and talk about this: To what extent is this due to—is this all due to sort of poverty and socioeconomic status? And we know that that is a large contributor. We know that because of sort of centuries of systemic inequalities in investment in neighborhoods where African Americans and Hispanics have, you know, been made to live as well, as well as American Indians, that those groups have a less impact to things that would help them stay healthy, such as safe housing, clean a water, environment safe from crime, access to healthy food, you know, all these things that we think about, up to education and employment opportunities. So, you know, I think that those of us who work in this area were not surprised at all by the disparities that occurred once COVID-19 came to the United States. But I think for many people who don’t do the work in this area, often they were sort of surprised by all of this.
The other thing we know is that African Americans in particular, but also Latino Americans, are overrepresented among frontline and essential workers. And you’ve probably heard a lot of talk about the fact that, you know, these are folks that are cleaning our facilities, that are driving our public transportation, that are selling food to us in our stores, working in our meatpacking plants, and in our other food production plants. And so they’ve had to work outside of their homes during this time and have had to use public transportation often because of not having financial resources to drive their own cars. And so that contributes in large part to the disparities that we’ve seen. And we know that a lot of these populations, because of their social inequities, also are at higher risk for many of the chronic conditions such as diabetes, heart disease, hypertension, obesity, that that predispose them to have a more severe outcome once infected with COVID-19.
So now, you know, I know we’re going to be talking much later in the conversation about what some potential strategies are in the short term to address these issues, as well as what we might do to better prepare ourselves when this happens again—because it’s pretty clear that this is likely to happen again. So I don’t know how long I’ve gone at this point, but I think I can stop there or I can continue with more sort of opening comments if you would like.
BOLLYKY: Sure. Those are terrific remarks, Lisa. Thank you for that.
Why don’t we turn to Leana to give her a chance to make some opening remarks, and then I’ll ask some questions that hopefully can draw out what we can do in the short and long term. But why don’t we start with having Leana go next?
WEN: Thank you very much, Tom. And I’m glad to be joining all of you. Thanks to CFR for hosting. And I’m thrilled also to be joining my colleague, Dr. Lisa Cooper, whom I’ve known from my time at Baltimore. And we’ve actually been on a number of panels together before in the past. And so I think Dr. Cooper laid out this very well about why it is that we’re seeing these intersecting crises, that we’re seeing how COVID-19 has unmasked to these underlying disparities—chronic medical conditions, as well as the conditions in which people live—in which African American and minority communities live, that that unfortunately has really made the disproportionate burden of COVID-19 fall on these already vulnerable communities.
So I want to talk about solutions because I think so often we hear about these problems of systemic racism and disparities and we think, well, what can we do? There is so much to unpack. And we’re talking about many decades of problems that have gotten us to where we are, with these intersecting crises. And so where do we begin? Well, I want to give eight ideas for concrete steps that can be taken now, understanding that these are small steps. That some people are going to say, well, they’re nibbling around the edges. But I’m an emergency physician by training. I believe in acting now and not letting perfect be the enemy of the good. So they are eight things.
One, target testing—specifically, targeting testing to African American, Hispanic, minority communities that are hit the hardest. We have to decrease all the barriers to testing that there are. For example, obviously, making it free, but also making it accessible—not requiring a prescription from a physician. Testing should be going to where people are. Drive-in sites are not appropriate if people don’t have cars. We also need to have testing be available in churches and public housing, wherever it is that people are.
Second, track the demographic information, not only as has been required now for infections, hospitalizations, and deaths, but also demographic information of testing. So let’s say that in a community we find out that the positive rate for COVID-19 is 5 percent. That sounds great, because as well below the 10 percent threshold that that indicates that you’re doing enough testing. But if you find out that African Americans are testing positive a 20 percent, that doesn’t just illustrate that African Americans have a higher rate of infection. It illustrates that we are not testing enough African Americans. And so having demographic information for testing also allows us to target resources and ensures a level of transparency and accountability too.
Third, when we hire contact tracers we need to hire contact traces from the communities that they serve. Not only is that important for cultural competence and language competence, it also serves as an employment opportunity because it also is minority communities that have been hit the hardest from the economic fallout of COVID-19 as well. And of course, hiring these contact tracers from the communities that they serve, they also are the most credible messengers too.
Fourth, we need to have free facilities for isolation and quarantine that are readily available. You know, we know that it’s best practice to tell someone to isolate for fourteen days if they get COVID-19. But what happens if that person lives in crowded multigenerational housing where they can’t social distance, and where they stand to lose their wages if they if they do so, if they forego work? I mean, we need to have—there are actually several proposals. I joined with Scott Gottlieb, Mark McClellan, and a number of bipartisan leaders to call for converting unused dormitories and unused hotel rooms into these free quarantine facilities, and also to be providing a living wage for those individuals who have to go through quarantine too.
Fifth health insurance coverage. This should be obvious, but just to say it again: You know, if you were uninsured prior to the pandemic or if you became uninsured as a result of losing your job and your job is linked to insurance, then not only does it make COVID-19 harder to treat but your underlying medical conditions could be exacerbated as a result. And that could, in turn make, COVID-19—make you more susceptible to COVID-19. So increasing Medicaid, opening state exchanges, really expanding health insurance coverage, critical during this time.
Sixth, tagging on to what Dr. Cooper had said about meatpacking plants and other facilities, we need to have strong workplace protections. You know, I’m used to seeing from the CDC very clear, direct guidelines about what is necessary to combat infections. And I wish that they had used less, for lack of better words, less waffling language, this time. There’s language and their guidelines about how people should be wearing masks, if feasible. How social distancing should be encouraged. Well, I want to see from the CDC something like: Unless these fifteen guidelines cannot be met, then reopening a particular workplace is not safe.
If we had very clear, specific, direct guidance from the CDC, that also further empowers OSHA and local and state officials to, who are regulatory authorities, to be able to enforce these regulations. And strong workplace protections protect the individual. They also protect the public. And we know, again, that because minorities are—tend to be essential workers who will suffer if these workplace protections are not in place, that’s another reason for having these strong workplace protections that improve health for everyone, but also help to reduce disparities.
Number seven, we need to prepare for the next surge. It was a national shame that we ran out of PPE the first time around, when we didn’t have enough masks and gowns for our frontline healthcare workers. Well, that could happen again unless we are prepared for the surge that could come in the fall with a double whammy of flu season combined with COVID-19. And, by the way, we also should not just have PPE for doctors and nurses. Why not also have them available for everyone working in a nursing home? Or what about all the grocery store cashiers and bus drivers, who also tend to be people of color? If we are not prepared, then everyone suffers. But again, the disproportionate burden is going to fall upon those who are African American and in other minority communities as well.
And then eighth and finally, we need to have much more support for local public health, which has already faced many cuts over the last decades. We know that the local public health workforce has declined by something like 20 percent in the last decade or so. And that’s led, even before COVID, to health departments that are often the safety net for the community making really difficult tradeoffs between what diseases they should be treating. And I think we can all agree that treating COVID-19 at this time should not come at the expense of preventing overdose deaths, or treating cardiovascular disease which, again, also then make treating COVID-19 much harder.
So I know that overall, there needs to be much longer attention to issues like social determinants of health. We need to also very urgently address racism as a public health crisis and public health emergency in and of itself. But I also believe we cannot let perfect be the enemy of the good, and that they are at least eight concrete steps that we can be taking now in order to reduce the impact of racial disparities and racism on the COVID-19 crisis that we’re facing.
BOLLYKY: Great. As someone in think tank I particularly I have an affinity for policy-driven lists. So thank you for that. I thought that was really excellent.
Dr. Cooper, I wanted to give you a chance. You had also had prescriptions of what we might do in the short or long term. So if you have additional ones, or you’d like to respond to the ones that Leana has put forward, that would be great. If you could also weave in your remarks—and, after Lisa goes, Leana might want to do this too—who’s doing this right on a state or community level? Where should we look to for hope? But why don’t we start with letting you put forward any modifications or additions you wanted to add to that that very good list to get started.
COOPER: Sure. First of all, Leana, that was an amazing list. And—making sure I’m unmuted myself, right? Good. That I actually have a similar list, which is a five point list. (Laughs.) Which includes many of the same factors that that Leana mentioned. So, I mean, they do include things like making sure that we are collecting and tracking data on not only deaths, but also illnesses and testing, right? Percent of positive testing and who’s being tested. I also think it’s important to—on the lines—along the lines of what she mentioned related to using members of communities to be involved in these efforts around a contact tracing and identification of cases. I think part of what public health and other leaders need to do is really focus on communicating very clearly with the public, as Leana mentioned, but also engaging with trusted members of the impacted communities.
I think what’s oftentimes lacking is that we have people who don’t have any connection to those communities coming in and trying to deliver messages, and as we know there’s a longstanding history—a legacy of mistrust of health professionals as well as researchers in African American and other minority communities. You know, well justified due to, you know, past egregious acts, actually, that that took place where those populations were harmed. So I think it’s really important for us to work with trusted members of those communities.
And that might include church leaders. It might include leaders of community-based organizations that provide services to those communities. It just might involve people who don’t necessarily have a title, but that we have come to know as people that members of communities trust. So I think that that’s an important message I wanted to make sure we added, to work in partnership with those leaders and those organizations that are that have been in those communities for a long time, whether it be businesses. It could be barbershops and beauty salons. It could be churches. It could be, like I said, service organizations.
You know, I also agree with the testing and the access to health care. I think that that’s—one of the things we’re really concerned about at this time, is that not only are our vulnerable communities being hit harder by COVID-19, but because of the lower levels of access to care that they already are experiencing that at this point in time they’re not even getting treated for the other conditions they have. So, you know, I have patients—I see patients in East Baltimore. I’m a general internist. And I can tell you, a lot of my patients have diabetes. They have high blood pressure. And we can’t see them right now. And they don’t have access to the lot of the tools they need.
So I think a lot of focus on enhancing digital access for these communities is going to be very important, because not only will it impact their access to care during this time, but it’s also going to impact educational access for many young adults and children as well. So I think that that’s an area where local and national leaders can really focus a lot of their attention.
I think that we’ve talked about the other things, about trying to make sure that people have access to the basic needs they have for housing and food security right now. I think working closely to expand SNAP benefits, for example, and as Leana mentioned making sure that people have opportunities to sign up for health care exchanges and expanding Medicaid access, I think all of those things are also going to be critical, as well as the protection of frontline workers. So my plan is a five-point plan, but it’s got all the same components. We just kind of—I’m more of maybe a lumper than a splitter. (Laughs.) So that’s what I would say. And I couldn’t agree more about the fact that a lot of these conditions we see are the result of structural racism and I think people in minority communities have actually been sort of frustrated by the fact that we won’t name it. And so now it’s time to really, like, name it.
It’s not because, as many people think, well, you know, people from minority communities just aren’t making good decisions and that’s why they have poor health, you know. But people’s decisions are shaped by the opportunities they have. The opportunities that we have provided to these communities has been horrible, honestly, for over a century or more now, due to the policies we’ve had, whether they’ve been intended or unintended. They have been structural inequities and, you know, we say we need to name it so that we can actually address it head on, instead of trying to come up with other ways of talking about it or dealing with it that don’t actually get to the root causes.
BOLLYKY: Terrific. That’s wonderful. And I’m glad there are so much agreement between the two of you on proposals, whether they’re lumped or otherwise.
Do either of you want to offer other examples? I mean, the country is having a moment where I think there’s a greater appreciation of the role that race plays in the inequities in American society. There is, of course, also a greater appreciation of the threat of pandemics and epidemic threats in general. Where are you seeing those realizations feeding off one another in a positive way? Who’s doing this right? Maybe we’ll start with Leana, if you have ideas, since Dr. Cooper just went.
WEN: You know, back in 2015 after the death of Freddie Gray while in police custody here in Baltimore, I and my health department—I was the health commissioner the time—we started talking about racism as a public health issue. And I will tell you that we got a lot of raised eyebrows, and then we had to back into it to meet people where they were and convince them, right? Just saying racism is a public health issue, people didn’t quite know what that meant , and what we were getting at. And so we began talking about racial disparities. I mean, you can’t argue with the fact that there are disparities in health outcomes looking at our city, where you have neighborhoods just a few miles apart where a child born can expect to live sixty-five years versus eighty-five years depending on where they happen to be born in the color of their skin. I mean, that is true.
And to a point that Lisa made, when you—when people start saying, well, you know, it’s because of “lifestyle choices,” quote/unquote, that people are making that lead to higher cardiovascular disease, well, how about the fact that one in three African Americans in our city and live in a food desert compared to one in twelve whites? And so when I see a patient coming into the ER and I say to this patient: You need to eat healthier. And they tell me, actually, I need a board two buses and then walk ten blocks to get to a Whole Foods. And by the way, that Whole Foods is way too expensive for me. The closest thing that comes to a vegetable or fruit in my local corner store is a banana, but that banana has been there two weeks and it’s brown and shriveled. I mean, you know, when I hear that it’s—that’s not about the choices that people are making. That’s about the systems that we have in place and our historical legacies of things like redlining, and not having transportation that lead there.
And so in any case, it took some time to kind of back into talking about racism as a public health issue. And I actually think it’s—I think it’s remarkable how much the tide has turned. And we are now finally addressing these issues and, as Dr. Cooper said, calling it out, naming it is important. I think we now need to pivot to the next step, which is what do we do about it? And to your question, Tom. I’m not sure I’m a lot of people have been doing the work yet. And I think part of it is the lack of tracking. We’re seeing a lot of issues around data with COVID-19. I mean, they’re just is inconsistent data. The data are not reported the same way across different states. The CDC even has been lumping in different tests inappropriately. I mean, it’s not consistent.
I think we need to have data for, again, the demographics of infections, hospitalizations, and deaths to even begin to know what we’re dealing with. Because right now for—until pretty recently there were only four states that were reporting any racial demographic data at all. And still the data are not reported in a way that can help us. For example, some states will say, we’ll lump together Asian American and Pacific Islanders. Others have them separate. I mean, how do you disaggregate that? So I think, you know, my ideal is for us to have a real-time dashboard that the federal government compiles, but that states and locales input their data. And those data should include not only the infections, hospitalizations, and deaths, but also testing, contact tracing, the resources that are directed to various communities so that, again, we can have a real-time accounting of what’s happening, and we can do real time targeting.
We could say, oh, look, it’s obvious that we’re not targeting this community sufficiently. We need to marshal our resources to get to have the need to go to where it is that people have—or, have the resources go to where it is that people need the most. And I think it’s that type of specific targeting that’s not happening now, because we are the data aren’t clear. And I’m not sure if there is an example across the country where something like that is done, where we’re not only taking into account health outcomes but we’re also specifically having a disparities metric too.
BOLLYKY: Great. Thank you. Lisa, are you seeing any positive early examples, even with the data limitations you want to point to? After I let Dr. Cooper answer this, I’m going to start turning it over to the audience. So feel free to raise your hands now and think of your questions, but I’ll give her a chance to answer my question first, and then turn it over to all of you.
COOPER: Sure. You know, I would really like to raise up the state of New York and New York City as an example, an exemplar. That was a very, very hardest hit city and state—the hardest hit in our country. And I know that they were unprepared, and the initial response was, you know, fragmented. But I do think that New York really did step up to the plate in a major way. And, as a result of that, has shown flattening of the curve there, and things have improved dramatically there, whereas in other areas of the country where the messages from leaders have been not as clear and where decisions have not been informed by true public health and science evidence, that—you know, that we’re seeing infection rates going up now.
And really, we’re going to probably see a whole new wave of infections coming up very soon. And we’ve got certain states, North and South Carolina, for example, Texas, and Florida, where the infection rates are going up. Like, there were over 2,000—over 2,500 per day in the last week. Whereas, we’ve seen the infection rates going down in New York, as well as in the state of Maryland. Maryland, our own home state, has actually dealt with the situation relatively well. We do have some major hotspot areas in Prince George’s County, as well as in Baltimore City that we are still dealing with, and Montgomery County.
But I think where we’ve seen the best responses have been where the communication with the public has been done primarily by public health professionals and not by politicians, or in coordination with one another, where the messaging has been clear, where the focus has been placed on the most hard-hit groups, and where there’s been a much more sort of focus and strengthening of resources allocated to the public health sector and to addressing their social determinants, including, you know, what—we call them social determinants, but as we know they’re the legacy of structural racism.
So I—and I think people who have spoken out about that and been clear about their commitment to addressing those issues have seen a lot of response—positive response from their communities, with people being willing to do the hard job of, you know, obeying these laws—or, not—they’re not really laws—but these recommendations that are really within—not only in their own best interest, but in the interest of everyone. You know, to a mask, to engage in social distancing, to practice all of the same on hygiene practices. So I think that there are glimmers of hope, but we still have a long way to go.
BOLLYKY: Great. That’s terrific. Thank you both.
Let me turn it over now to the great audience we have assembled.
(Gives queuing instructions.)
Let’s start with Kumanan.
Q: Hello. I’m Kumanan Rasanathan, and I’m a member of Health Systems Global. Thank you so much for the presentations. Dr. Cooper and Dr. Wen.
Rudolph Virchow said, you know, in the middle of the 19th century that the history of epidemics is the history of disturbances in human culture. And you focused on these very pragmatic solutions, on measurement, of what can be done now, and community mobilization. But, as you said, Dr. Cooper, I mean, when we found out about COVID I think none of us, unfortunately, were surprised at the sort of racial disparities that we might see. And I wonder that beyond the pragmatic solutions there is really, as Tom said, a moment to—it is a grand political project to really address social determinants, or think about disparities in health care. Do you see, with this catastrophe that’s happened and this focus on racism that we’re seeing, do you think in the U.S. there is this appetite, perhaps, for that grander political project that might really shift these underlying drivers of these—of this racial injustice and health inequities?
COOPER: So I see that there is an incredible appetite among the public. I think this is really kind of like a grassroots movement that we’re seeing. We’ve had a commitment to these issues by certain political leaders, but not by all of our political leaders. And I think what we’re seeing is that this is coming from the society at large. It’s coming from a lot of younger people, frankly, who I think are fed up with what they’ve seen happening in our country over the past five years or so. You know, even decades of lack of investment in the things that are important to their future. You know, education, healthcare, opportunities for employment. And now they’re starting to see, which I think a lot of people have not seen for a long time, the connections between our social and environmental conditions and health.
I think a lot of times—for a long time, many people sort of kept those things in different worlds. And because of this pandemic I think—and the interconnections we’ve seen amongst ourselves—we’ve seen how equally vulnerable we can be to health threat and how interconnected we are. Like, for example, if we don’t take care of our frontline workers, then what happens to the rest of society? So, you know, not only does the does an illness spread, but our entire economy gets shut down as a result of that. And it impacts everyone. So I think people are beginning to see those connections a lot more.
And I actually think this movement is coming from people, and it’s a grassroots movement. And if our political leaders are smart enough to listen and act, then we have a moment that we can actually seize upon here. I think the example of the—(phone rings)—I’m sorry about the telephone—about the police brutality that we’ve seen, it is such a remarkable example of racism. You know, it can’t be ignored. It’s not something that may be as hidden as something out like not enough opportunities to have healthy food, for example.
So I think when you see that someone is actually not even allowed to breathe, and they—you know, that they actually are dying literally on camera, it’s actually a metaphor for what’s been going on for years in our—in those communities. You know, this is just a physical manifestation of all of the inequities that have been going on in different institutions. And the political—the police, and the law enforcement system, and public security is just one manifestation of that. And it’s a very dramatic representation, but I think people really—that really hit a lot of people emotionally. And it is making them see a lot of connections that they didn’t see before.
WEN: Yeah. And if I can add to that, I mean, I certainly agree that this is a moment that, you know, frankly, we haven’t seen before. But also, I don’t know that I could have imagined that this might have happened. And I do agree on—really, with everything that that that Dr. Cooper said, the fact that this is youth led, the fact that there is momentum for systemic change. I think it’s great. I am at heart, though, a practical incrementalist. And one thing that I do worry about is that we let perfect be the enemy of the good. What I don’t want to see happen coming out of this is for people to say: Let’s just throw out the baby with the bathwater. Let’s overturn everything. And then I don’t know where we’d go, you know?
I mean—you know, I’m all for dismantling systems if these are—if we have something to replace it. But I really worry about us saying: Well, let’s wait until all these things are done, because the incremental reforms that we’re making now are just not enough. Well, there are people who are suffering right now and I want to help those people right now. And so while I certainly agree, and I know this is not what Dr. Cooper is saying, but I think some of sometimes when I hear the activists speak they want everything. Well, I want everything too. But while we get to everything are there certain things that we can do right now?
And that’s my—that’s always been my focus. I think as an ER doc, right, I want to treat the patient in front of me who’s dying right now. Yes, I would love to have us solve the problems of income inequality and racial disparities and get, you know, health insurance for all. I mean I want all these things too. But in the meantime, what is it that we can do? And I hope that we can do the both, and—solve the acute issues as we focus on these chronic underlined problems too.
BOLLYKY: Great. Thank you for that.
Q: Henry Greenberg.
There is an institutional public health, the American Association of Public Health, the Association of Schools of Public Health, that seem incredibly quiet. And I was struck by this in Dr. Wen’s point seven, that CDC comes out with a bunch of waffling recommendations and there’s no organizational in public health pushback. Is it possible that these organizations can be resurrected from their quietude and play a role? I mean, how does public health engage this if it’s institutional leadership seems to be sound asleep?
BOLLYKY: Right. Who wants to start with can the CDC be saved?
Q: Or can public health be saved.
COOPER: Well, I don’t really—I beg to differ. I don’t actually think that public health leadership has been silent. I think they have been speaking. Maybe it’s—maybe the media isn’t capturing their statements as much as they’re focused on some of the other messages that are not as sound or as clear. But I think the public health associations have been very vocal and verbal, and I think we are—I mean, we’re out there like twenty-four/seven right now making the case and engaging with policymakers everywhere, as well as with the media. So I don’t think we’ve been quiet.
I think that what is happening now is that we’re seeing. Our society actually developing the kinds of attitudes and responses that we actually need to change political will. I think part of the problem with us not being able to make more progress is because, honestly, we did not have political will. And one of the things that changes political will is public sentiment and public action. And so we were trying to—what we are trying to do as public health professionals—and I’ll let Leana also chime in with her perspective—is to engage with our public and make sure that they see the value of what we’re doing, and they see the connections between these issues. And that by shaping their attitudes and responses and their sort of commitment to civic engagement, that that will bring about the change that we’re looking for. So, you know, I don’t know what we can do to be more visible, but I know that I don’t think we’re being silent on this—on any of these issues.
WEN: Yeah, I would agree with that. You know, actually, I think that public health has been out there much more than we’ve ever had. I mean, there’s a saying that public health saved your life today, you just don’t know it, because there is no face of public health, right? We are successful when we are invisible. Well, I actually think that COVID has changed that dynamic. And every time I turn on the TV to any cable news, I see yet one more of my public health colleagues who’s on was on the news and trying to educate. In part, we are doing this because the public health leaders in the federal government have been silenced, right? I mean, there’s no other way to say this. That the CDC at this point should be holding daily briefings.
We’re in the middle of a pandemic. We need to be hearing from our public health leaders every day. Imagine if there were a briefing, led by the CDC, where they talked about the state of the outbreak, they synthesize the new research coming out, they talked about the guidelines of what people should be doing, and they talked about the trouble spots and what they are concerned about. I mean, that’s what we should be hearing from the CDC every single day. In the absence of that, I think public health individuals who were in—who are experts in academia, or experts who were for previous health officials, I think have been stepping up and trying to do the education that I know our federal public health leaders can’t.
I think to the—Henry, to your point about why aren’t we—why maybe we are not seeing more criticism? I think one of the issues is we know that the CDC and other public health leaders in the federal government are trying their best. It’s not their fault. And I think it is a fine line to be walking. One of the most concerning, I think, trends that we’re seeing in recent days is the targeting of local and state public health officials, that a number of them have had death threats that are levied at them simply because they’re giving public health guidance. People have had to resign or resigned because of—you know, of feeling unsafe for their families, that they’re personally being targeted.
And I really worry about this particular trend. And I think it’s not just public health that needs to speak up. I think that the American people also, and influential leaders like all of you, have to help us and say: Everyone suffers when science is muzzled. Everyone suffers when public health isn’t leading a public health response. And at the end of the day, what’s going to get us through this crisis is—public health is not the enemy of the economy, as sometimes it’s painted, but having a robust public health response is the roadmap to getting our country back on track.
BOLLYKY: Great. Great answers, both of you. I completely agree. I’ve been working in global health for the better part of twenty-five years. And I don’t think I’ve ever seen more my colleagues in the media, and speaking, and writing then I’ve had through this process. I do think there is an interesting dynamic going on with CDC. That’s worth its own roundtable. And I agree with Leana that I worry about public health officials, as the case for re-imposing nonpharmaceutical interventions with rising cases coming into play. I think we’re already starting to see that, and it may get worse. So great comments.
We have two people in the queue. I’m going to start with Patricia Rosenfield and then go after that to Tom Novotny. If the remainder of you would like to ask a question please raise your hands to do so. And again, I will call on people in the order in which I see you.
Q: Yes, thank you very much for this fundamentally vital conversation. Whoops. Thank you very much for this vital conversation. I really appreciate what Dr. Wen, Dr. Cooper, and you, Tom, have been saying in tackling the systemic issues that we’re confronting today. But I wanted to really ask both our speakers to look forward now because I’m worried about the sort of Andy Warhol fifteen minutes of fame phenomenon, that we are—we see—and I do appreciate the importance of acting now, not letting the perfect stand in the way of what we can do now.
But I want to look at—I’d like to hear more from you about the preventive strategy, how we learn from other countries as well as the communities such as in New York that are doing the right thing, but how we sustain the attention to this. Let’s say once a vaccine is available, if that should happen, and the problem is reduced, and the energies are not coalesced, we don’t build the coalitions that are going to sustain the energies that are out there for this interdisciplinary intersectoral push to end not only systemic racism, but systemic inequalities across many communities in this country. So how do we move forward? What do we need to do to build the coalitions to keep—so this isn’t an Occupy Wall Street moment, an Arab Spring moment, that this is sustained?
COOPER: Right. No easy questions today, I see. (Laughter.) No, I mean, I think this is a real concern that everyone has is that, you know, we’ll soon forget everything and go back to business as usual. And, you know, of course, there are many of us who do this every day. So, this is this is never far away from the top of our minds. And, you know, I think we were going to just have to continue to put in front of people, to hold up to them to remember this moment, and to remember how everything came to a screeching halt because of health, and because we didn’t—we hadn’t invested and focused on our public health, and how we hadn’t valued that.
And how fundamental health is as a human right, so that it’s, like, it’s—it allows us to do pretty much every single thing we do. And if we don’t provide that to our citizens, that basically we’re preventing people from living, from having the kind of quality of life that they—that we say that we offer. We say that that’s what our country is about. And so I think really reminding people about what our core values are what we say they are, and are we actually, like, investing in the things that we say are important to us?
And I think you’re right, what you mentioned about looking at other countries. We—right now we have a national leader who, you know, sort of pokes fun at other countries or criticizes other countries that actually are doing a much better job of all of this than we are. So I think we really have to hold up the successes of those societies, and those countries, and have other—have people in our country realize, you know what, we have a lot of rich resources in this country. But look at—look at what other people did with so much less than what we did.
And actually, maybe we do humble ourselves. We do need to learn from some of those other examples and try something different, because we’re not—right now we’re not being who say we are. And I think a lot of Americans really feel strongly about certain values, the values of opportunity, that are provided. That they—you know, there’s this belief that it’s—this is the land of opportunity. Well, we’re not being—this is not the land of opportunity for everyone. And as a result of that, what has happened to our country? It’s impacted everyone. And sure, those of us who maybe have—can afford more and have more resources haven’t been hit as hard, but the reality is that everyone has been hit by this.
And so I don’t have a, you know, perfect answer to any of this. But I think that what we’re going to have to do. But I think it’s going to need all of us. I think it’s going to be our faith leaders. It’s going to have to be our other civic leaders. It’s going to have to be our young people, as well as our health and public health leaders. So—and, you know, people like you, who are engaged and concerned who are participating today.
WEN: Can I—if I can add onto this too? And I’m going to sound like a pessimistic in this, I really don’t mean to be, but I’m I am really worried. I’m worried about two things. And, Patricia to your very good question, I worry about two things that are getting in our way—that are going to get in our way as we move through this crisis. One is about complacency. We are already seeing complacency, right? We haven’t even gotten anywhere close to beyond the first wave of this epidemic. We’re still seeing rising number of cases in many parts of our country, but we’re already seen a complacency about what’s happening. Somehow we have accepted 600 to 1,000 deaths a day as our new normal. And that obviously really worries me.
But I worry about the attention going into the future about all these systemic issues that we’re raising and also, as you said, about prevention. We know that we got into the state of where we are because we didn’t have the public health infrastructure, the way that other countries had. If we had testing, contact tracing, isolation setup in the very beginning, we had a chance to contain this disease and not get to the point where we have more people dying per day in the U.S. than other countries have had die during the entire pandemic. So I worry about that. Are we going to really think about prevention once this is over, when we’re not even thinking about it while we’re in the middle of the pandemic now?
The second issue, and this might be kind of throwing a—whatever the term is, throwing a flame or something out there, but I just wanted to raise this issue—I worry that we can’t get a coalition together because there is such a gap sometimes between the progressive left and the practical—the practical moderates. And I say this because I’ve been thinking a lot in recent days about the defunding the police movement that when you talk to people about this I think there are a number of people who understand the movement to be about reinvesting in the public safety in a different way, and reinvesting in social services, and divesting from the police, per se.
And of course, reforming the police department, but divesting from the police into other—into other places. Then there are some people understand defunding the police to be abolishing the police and anything short of abolishing the police is inadequate. And I worry about something like that happening around healthcare too there’s the Medicare for All or nothing crowd, and then they are the others squad, the incremental let’s improve on what we have with the CA crowd. And I worry that we cannot get these two groups together enough to come up with tangible solutions. And I think we could also get in our own way when coming—when it comes time to the next step of where do we go from here?
BOLLYKY: Great. There’s a really rich conversation to be had in terms of strategy, whether we adopt more aspirational set of asks to move us forward, and then realizing we’ll get less, or that we need to focus on more moderate proposals and make incremental progress. I think it’s a fascinating discussion that really covers a whole range of issues in our country right now.
That said, we have two questions. So we’re going to have to try to get those first, and then we’ll see if we can make time for more of that. We have Tom Novotny and then we have Dan Crippen. Tom.
Q: Hi. Thanks, Tom. Tom Novotny from San Diego State University. Great discussion from Drs. Wen and Cooper.
And my question’s a little bit further down into the weeds on public health, and that has to do with tobacco use. And what I wanted to just sort of emphasize, you mentioned lifestyle choices is one thing that’s oftentimes used as a blame the victim, actually, but it’s far more insidious than that in the case of tobacco where there’s targeting—targeting minority communities, and everything from the FDA’s exemption on menthol flavorings as something that actually affects minorities, or African Americans in particular, in terms of their use of tobacco. But what we’ve now seen with COVID is an increased risk for progression to ventilator and severe outcomes for those who are diagnosed and in the hospital attributable to smoking. That is the relative risk over meta-analyses is probably close to two, double that is, the risk for that sort of progression. And it seems as though there’s no clear statements from the surgeon general, from the CDC, from the NIH about the need to say, everybody, quit smoking, one way or another, and to implement some policies in the face of this pandemic that actually might even help assist with that, whether it’s providing more assistance in terms of cessation, but also even such things as restricting sales, perhaps. Communities can have the right to do this under the FDA legislation.
I just wonder, you know, from the minority community, from the minority side, why we haven’t seen that message come through? Certainly it hasn’t come through in a more general way, but in particular because of the high association of the co-morbidities, et cetera, and the adverse outcomes that are now experienced by the minority community, that this isn’t at least one message that needs to come through?
BOLLYKY: Great. Before I have our speakers answer, we have four more minutes. So I’m going to take the other question—Dan as well. And then we can have the speakers answer both questions in their final remarks.
Q: Thank you both for taking your time. But a great discussion.
But both Drs. Cooper and Wen mentioned disparities and outcomes are significantly caused by disparities in health, the existence or pre-existence of chronic disease, multiple chronic diseases contributes to the deaths of COVID. Both of you also mentioned healthy foods are important in in all of this too. Diabetes, obviously, hypertension have been contributing to deaths, particularly in minority populations. Food deserts, as Dr. Wen mentioned, have seemed to be shrinking, still exist. But what can we do to improve nutrition in minority populations specifically?
BOLLYKY: Great. Does one of you want to take the tobacco question, the other the nutrition? I leave it to you to decide which goes with which, but we’ll have three minutes left to cover both areas.
COOPER: What would you like, Leana? I mean, I do more work in the food environment than I do with smoking, but I think some of the policies—I mean, some of the principles actually apply in both scenarios. I mean, I think first of all we do have a lot of evidence about, you know, things that do work to improve the food environment. And I think we need to work more to get those programs implemented. I think some of the things that we can do actually would be related to providing economic incentives.
You know, giving people food, food allowances, so that they can actually spend their money and actually giving them some education and coaching around how to shop for healthy food or with the food vouchers, you know, some combination of sort of financial as well as educational and motivational strategies. So, you know, we’ve seen programs like that be highly effective on small levels, but then they haven’t been, like, disseminated at a larger level. So I think that there’s a lot that could be done in that realm.
And I think relying on federal policies to determine everything is not necessarily the answer. I think when you have an awareness or know that there’s data to inform a specific policy it’s really sort of the prerogative of—and the sort of the imperative—of people who know that information to engage with the local policymakers around that, making sure they’re aware of that information and that they can actually use whatever tools they have at their—in their toolbox to make changes. And I think—you know, I think the issue around smoking is something that probably some people just are not aware of.
And everybody so sort of caught up in the bigger picture, and so many of the other issues that nobody has focused on that particular piece. And if people know that there’s a particular thing that they can address, like that, I think particularly decision makers, like public health officials, like policymakers, would, like, jump onto the opportunity to do that. So I think if anything, I would just say my message would be—is not to wait on federal policies to change, to work to bring those about. But actually, that I think local leaders have a lot more influence than we realize. And that’s really who we should be working with.
BOLLYKY: Great. Leana, last minute.
WEN: Sure. I would just add that, there is—there a robust conversations happening about this idea of individual responsibility versus collective responsibility. I actually cannot really imagine a lot of jurisdictions tolerating something like a smoking ban right now. I think that we could, though, do a lot better job of education, of education on here are the things that you can do to improve your own health, and by keeping yourself healthy—including stopping smoking and eating better foods when possible—that that’ll also help to improve your health overall, but also protect you from COVID.
And so I think there might be a slight tweaking and that messaging. When we look at countries like South Africa that did for some time banned the sale of alcohol and cigarettes during COVID, I’m not sure that they saw, you know, the results that they might have anticipated coming out of that. And I think, you know, we just—it’s at this point when, yes, we’re all in this together, but we have to be thinking a lot more about what are the policies that we can set that will empower rather than further, I think, limit and anger individuals during this period.
Thank you, for both of you participating in this meeting today, and the thoughtful, and insightful, and often provocative remarks. So I’m grateful for that. I hope the rest of you will join me and expressing thanks for that, whether that involves mining applause or just taking home the messages we’ve heard today, and incorporating them into the work that you’re doing on public health, or global health, or in your other fields.
Thank you so much for joining us. (Applauds.)
WEN: Thank you.