Good morning everyone
and welcome to our UC San Diego Health
COVID Grand Rounds.
Today is the last in a really exciting
series of special grand rounds that we
started back in july. We've been focusing
them on
very timely topics related to the SARS
COVID-2 pandemic
this morning we'd love it if you join
our discussion and submit any questions
that you have through it for us through
menti meter
go to www.menti.com and the code is
going to be listed on youtube
we live stream these symposiums on the
UC San Diego Health youtube channel and we post them
after all summer they've been hosted by
our Dr Chris Longhurst who is the
associate chief medical officer
and a clinical professor of medicine and
biomedical informatics
and pediatrics here atUC San Diego
Health. Dr Robert Schooley is a professor of
medicine and infectious diseases atUC San Diego Health
he is in another commitment this
morning and so I am filling in
for him. I'm Cheryl Anderson, a professor
and dean
of the Herbert Wertheim School of Public
Health and Human Longevity Science.
Thank you very much Dr Anderson, today
we're super excited to have
two guest speakers from two
distinguished universities here with us
today remotely
first we've got Dr Carlos del Rio. He's
the executive associate dean
and professor at Emory and Grady Health
System and Dr del rio is a native of
Mexico
and specializes his research in 
AIDS HIV, hiv h1n1
and has been part of the task force at
the CDC
for the h1n1 influenza pandemic in
2009. Secondly we also have Dr
Julius Wilder. Julius is from Duke
Clinical Research
Institute. He's a practicing
gastroenterologist, he's been at Duke
since 2000, did his residency
and fellowship in gastroenterology there
as well as a fellowship at the
Duke Clinical Research Institute and
he focuses on identifying creating
solutions
for why poor people people of color and
non-native English speakers are at a
disadvantage
around liver transplantation and so
today we're really pleased to have
these two guest speakers. I think Dr del
Rio's going to set the stage and then
hand it off to Dr Wilder.
So thank you again for joining us today
and we look forward to the conversation.
Well thank you Chris and and thank you
also to Chip for the invitation it's
really a pleasure to be with
with friends at UCSD doing grand rounds
this morning. I hope you can see my slides right now
and if you can't just let me know
but what we're going to talk about today
we're going to talk about
COVID-19 and health care disparities and
i'm going to present some data and then
Julius will present
some go deep into why do we see
healthcare disparities and then we're
going to have a conversation
around this topic so
if you haven't read it i think this new
york times article
on health care disparities in cobit is
probably one of the best ones to look at
and there are two graphs here that I
want you to pay
a close attention to. Number one is that
the coronavirus cases per ten thousand
population have been very different
in whites versus black and brown
people
but also if you look at the the impact
by age groups you can see that among
white people the great majority of cases
were in people over the age of 80
well among black and latinos it's really
starting
within the age of 30 20 to 30 that you
start seeing an increase in cases
and you really see not this very you
know elderly distribution that we see in
white people.
Furthermore when you look at the race
ethnicity at the
at the highest coronavirus rates what
you see is that
in most counties what you see is
it's a proportioners of of black people
and latino people that are being
impacted by the epidemic and you can
almost go up and down
the east coast and see the same thing.
You know you could see red, really red and yellow
highlighted in most places
and when you look for green which is
white you can see that while this has
been an impact it hasn't been as severe
as what we're seeing right now
and in fact if you put that into where
we are today in the states
what you see is that the epidemic
primarily is impacting the southern states and and and the
west such as California
and what you're in Nevada and what
you're seeing is this is this our state
where there's
a disproportionate number of the
population is African-American and hispanic.
So when you look at the national trends
what you see is obviously
you know deaths are starting to come
down, hospitalizations are starting to
come down,
you know daily death case counts are
starting to come down
but when from the peak of the summer but
when you divide that by region you see a
very different picture and here you can
see
cases by region and you see the
northeast where the cases have really
plummeted
versus in the south we saw this huge
increase and now starting to come down
and the same thing happens with deaths. Thus in the northeast have really
plummeted
well in the south we really have not
seen that significant decrease
so in fact again look at where the
epidemic is
and see what the disproportionate impact
of the disease has been and continues to
be
in people of color.
From data from the Kaiser Family
Foundation we can see that from march
to the end to the sort of middle of july
the the age-adjusted hospitalization
rates
were significantly higher in fact you
know for whites it was 53 per hundred
thousand
well for blacks and hispanics as well as
African-American
and native Americans was over 200
cases per 100 000 population
so this is four times greater risk of
being hospitalized
if you're black, hispanic or native
American compared to being white.
And this actually is basically no
different if you look at medicare
beneficiaries again looking at people
over the age of 65
you see a very similar trend in which
basically you know
blacks and hispanics and
African-Americans, indians are
disproportionately impacted by this
pandemic
so what do we see what have we seen here
locally and this comes from an mmwr
study we did very early on here in
Georgia
in the month of march and we saw a
couple of things number one
is that when we looked at hospitals in
Georgia
while the median age of people
hospitalized was 60.
In fact almost 30 percent of the cases
were under the age of 50.
Furthermore when you looked at who was
being hospitalized around those 300
people that were hospitalized in the
month of march with COVID-19
you saw that 83 percent of those
hospitalized here in Georgia were
African-Americans
compared to 47 of the non-COVID
admissions so we see a you know
a very striking difference in the
hospitalizations. So there was not really a major
difference in gender, 51
of the cases were female there was an
increase in the number of people that
live in institutional settings
but it was really that disproportionate
impact in African-Americans and in
younger population that we were
concerned about
and when you look at the underlying
conditions,
what you found is that one in four
patients admitted did not have any
underlying condition
and the prevalence of comorbidities did
not defer by race. So it's not just oh we have greater
comorbidities in African-Americans that
is driving
a higher risk of hospitalization or
disease,
we did see that the median hospital stay
was no different and we also saw that of
course if you were in the ICU you were
hospitalized for a longer period of time
so what did we what did we see is as
far as
care well the care was no
different, black patients were not more
likely to receive mechanical ventilation
or die during hospitalization.
So it was greater impact but not
disparities in outcomes.
Now again I remind you where the hot
spots of the disease are right now in
the
in the us and it's
primarily in the south
but i want to pay attention to this.
This is from a recent study of
seroprelands in New York
and you can see again that if you look
at where has the disease been
you look primarily at poverty areas you
look at The Bronx you look at Queens
you don't see a lot of prevalence in the
upper east side you don't see a lot of
prevalence in the financial district. So is it race or is it poverty that is
driving the epidemic
and in fact it looks like a lot of it
could be related to poverty,
and this is something that we will come
back to and i think Dr
Wilder will talk more about is how
poverty is really when we look at race
it really is not biology but it's more
socioeconomic status.
Now mortality definitely seems to be
higher also
among African-Americans nationwide
and in fact when you look at the ratio
of coronavirus deaths that have occurred
in black people
it really is significant that in many
states this has been a significant
proportion of the deaths.
And in fact when you look at the color
of coronavirus
you know one in 1,125 blacks have died
from COVID-19
versus almost 1 in 1 in 2,500 white
people,
so almost double in the in the percent
for 100, half the number per hundred
thousand population that have died
and if you look at this graph again you
see that
increased excess mortality in blacks has
continued over time.
And in fact if if blacks had died at the
same rate as
whites.
Almost 20,000 blacks almost
10,000 latinos
and almost 1,000 indigenous
populations woul still be alive today.
So CDC recently published this
infographic. I'm not going to go into
detail but just
again summarizes all this data and says
what the disproportionate impact in
cases and hospitalizations
and deaths have occurred among
African-American and latino populations
now if you go to the community and you
ask well you know almost one in five
blacks I have known somebody has died of
of COVID-19 today i mean this is just
astonishing when you think about it and
it really impacts
and tells you about the population
impact of this pandemic
so what do we need to do and what
happens from a state, well i'm looking at
data here from California and you look
at California
where 39 percent of the population is hispanic
but 60 percent of the cases are among hispanics
and you look at
African-Americans four percent of the
population, six percent of the population is
African-American,
eight percent of the deaths are
African-American and if you look at
Georgia for example in comparison
you see a similar difference in which
you see a higher percentage of the cases
among hispanics
but a higher percentage of the deaths
among African-Americans so how do we
deal,
how do we dig deeper into this and i
think one thing they need we need to
consider
is social determinants of health and
it's the fact that as Mary Bassett puts
it,
you know it is really about home, about
where you work, about living in crowded
apartments, about
transportation, about crowded workplaces,
about the inability to isolate
that makes you know populations sprout
and black populations at a higher risk
of this infection. So is it a disproportionate burden of
comorbidities? I'm not sure that's the
case and at least our data here does not
seem to reflect that
but clearly poor people in urban
settings live in more crowded conditions
are more likely to be employed in
public-facing occupations that
will prevent you from physical
distancing and that in fact
may be what's going on. So is it living,
is it biology, this is something we can
discuss further.
So in summary people of color are
experiencing a disproportionate burden
of COVID-19 cases and deaths. People of color are experiencing
significant higher rates of infection
and deaths compared to white people.
The disparities in black and hispanic
people are widespread across the country
and cases and deaths are concentrated in
areas with high shares of black and
hispanic residents. And the disparities in COVID-19 deaths
for people of color persist across
age groups and people of color are
experiencing more deaths among younger
people
compared to white individuals. Now racial
inequalities in the u.s healthcare
have been intensified with the pandemic
but are not new.
We know they exist in other diseases and
that's something we can talk about.
So we have an opportunity as I wrote in
this recent
article in Contagion Live, we have an
opportunity and as this
this editorial in JAMA stated I think a
silver
lining of COVID could be that this is an
opportunity to develop strategies that
would begin to finally eliminate
inequalities in healthcare in the United
States as this editorial by Williams and
Cooper state,
this is an opportunity to develop a new
kind of herd immunity.
If we do better at a population, we take
care of people better we give them
better access to
care, better access to housing, to
employment, we may in fact
have the kind of herd immunity that will
prevent us from having another pandemic
and with that I'll end then i'll pass it
over to Dr Wilder.
Great, thank you Carlos for that
wonderful
sort of overview and summary of what
we're seeing right now
in terms of you know what we
understand to be driving
these outcomes. You know as we
think
about what it mean,s can you guys see my
screen okay?
Yeah you can see it okay? We got it. Good, 
great
you know what i'm going to talk about
is there's social determinants.
I think that Carlos appropriately
speaks to the idea that
there may be this question about
biology but we'll get into that but
but the title of this
I think speaks to the real issue.
There's a jazz group from Baltimore
that I used to love
and they had a song about what what
about the leaves on trees or broken
branches and what they're really talking
about is this idea
that it gets down to the root, what are
the root causes of these issues
and and these root causes go beyond just
the biological explanations for what
we're doing
and the relevant financial relationships.
but what i'd like focus in the coming half with you is to first
of why this available important um and
and and why we need to talk more about
this and have
including some uncomfortable
conversations about this um has come up
a number of times
then we'll kind of delve into what
social determinants are, the ones that we
think that are driving
COVID-19 outcomes and and Ill focus
on a few mechanisms there and really what i want to do in that
discussion is to begin to provide you
with some insight
around theory  and and sort of
mechanisms because in the setting of
doing so we can then begin to have
 conversations that allow us to create
sustainable and successful solutions
to address these disparities that we're
seeing
and then I'll briefly touch on some next
steps and i think a lot of that
conversation
will begin here but then we can continue
that as we move forward into the second
piece
of our talk you know many of you may
have seen this before it's a very
common sort of cartoon
I like to bring it up because I think
it's important we're on the same page
about what we
what we need to do you know we talk
about equality often and that's what
this first box is showing and in that
image
we can see that everyone's being treated
equally and a lot of folks will pat themselves in the back for for
treating people equal. The problem with that is that if you
treat people equal but folks aren't
starting in the same place
then all you're really doing is
perpetuating inequality,
and so just treating people equal is not
going to really speak to the fundamental
issues of driving
health disparities. Now in the second box
you know we talk about this idea of
providing support right
 you know trying to be equitable and
that is important
and certainly a valid thing to
pursue,
but if you would just sort of play along
with me in terms of the analogy you can
imagine that
if we're providing support here in the
in the case of boxes
you know how much those boxes cost, how
many of those boxes do we have,
what happens when you fall off that box,
how long is that box going to be there?
You know there are all these different
things to think about
when we're trying to use resources to
provide support
as opposed to this third box which
speaks to addressing the fundamental
systemic barrier that's driving the
disparities that we're seeing>
If you can do and achieve the third box
then it doesn't matter what the pandemic
is, it doesn't matter
when the next pandemic occurs, you won't
see the kind of disproportionate burden
on people of color and poor people that
we're seeing right now with respect to
COVID-19 and we need to have this
conversation right now, I think that
there's been a lot of social unrest in
this country as you think about George
Floyd and Ronald Taylor
and it's great that we're having that
conversation
and important that we have that
conversation but as far as medicine is
concerned even outside of that
you know as we think about the
nation that we're going to be serving as
physicians and we think about the
diversity
of the communities
we're going to be treating and serving
it's important that we're prepared
because this country is becoming more
and more brown
and we have to think about what that
means in terms of
the issues and health issues that
population will have a lot to be
thoughtful
about what it means in terms of how we
can best serve that more diverse
community.
And so you know my PhD is actually
medical sociology and so I got to put my
medical sociologist hat on
which is always fun for me to do, I don't
get to do it often but
you know what I would propose is that as
we think about COVID-19 it is a perfect
example of a fundamental cause of
disease and what I mean by that
and this is a
a theory that was first proposed by
Link and Phelan back
in the 1990s, they're also medical
sociologists and they talk about these
fundamental factors
that have an impact in terms of your
resources
and in the setting of having an
impact on the resources
they impact your ability to avoid
adverse health outcomes
or to sort of mitigate the impact of
experiencing a negative health outcome
and not only is that they affect
your resources but they act on multiple
diseases
and they act on these diseases through
multiple mechanisms.
And so you sort of think in sort of a
sort of decision here in the picture you
can see
that here this idea is that you know
what you have
is that you know race I report here
as it comes to COVID-19
acts as a fundamental cause of disease,
that it is
acting on adverse health outcomes
through multiple replaceable mechanisms,
some of which that
Carlos spoke to earlier and
then in the setting up so it's resulting
in the differential health outcome that
we're seeing right now.
And you know something that that
Carl's a little too and we can talk
about more
is that there's the impact that race has
with
sociologic status as an intervening
mechanism that's very real,
it occurs and it's something that we
need to think about but
I would actually argue that and
Carlos alluded to this that race
can also act independently of social
economic status
and in the setting of doing so result
in adverse health outcomes and in this
case is doing so in the setting of
COVID-19 to help us understand the
dispersion burden
and the more average outcome among
people of color.
So knowing that it can impact multiple
diseases and knowing that it can
do so through multiple intervening
mechanisms then as we think about race
and ethnicity
if we want to address this issue it's
important that we delve deep into all
the different intervening mechanisms
right, because knowing that it's multiple
mechanisms involved addressing one
mechanism
will not you know adequately address the
fundamental driver
race that's contributing to differential
health outcomes as it comes to COVID-19.
And so what I'd like to do is to spend a
little bit of time now and
talk about what some of those
fundamental causes of disease
well really talk about race as a
fundamental cause of disease
and some of the intervening mechanisms
through which it acts to contribute
to advertise outcomes in Copenhagen
and what you're seeing here is a
depiction
of that a sort of conceptual model
where race
acts as a fundamental cause of
disease through its impact on
socioeconomic resources
social resources healthcare resources
you know and then
specifically around the idea of
increased risk of exposure
directly in terms of racism and in
terms of increased risk of complications
and how that is contributing to what
we're seeing right now
in communities of color with respect
to the burden of COVID-19
and that having been said race can
act directly
in some respects on it  we're trying
to understand more but  think Carlos is
right, you know this
emphasis on biology I think is not
right. 
First of all we don't really know
what the biology means to be quite
frank
and oftentimes that comes from an
idea
that race is always often considered a
co-variant
when trying to understand you know
the health disparities.
But what we're learning more as we
begin to study things like structural
racism
we begin to study health behavior
models race really should be treated
as a fundamental predictor
that other innovative mechanisms are
involved in terms of it reaching the
outcome.
And so and the reason that's
important is because biology is not
always just
biology, you know we know you know the
adverse outcomes of COVID-19 as it relates
to diabetes,
hypertension, obesity and CAD
and certainly we know that there are a
number of factors that contribute to the
burden of those diseases
in people of color but the fact matter
is that an important
cause of the burden of those
comorbidities in people of color
is social determinants and so what we
have is a vicious cycle
where we're blaming comorbidities you
know as the leading etiology and cause
of the disproportionate burden of COVID-19
outcomes but quite frankly the reason why those are
disproportionate in people of color is
because of social determinants in the
first place.
So you can't really separate the two
from each other and so I would agree
with Carlos that
the emphasis on sort of biology as an
explanation
for why we see this disproportionate
burden of COVID-19 is incorrect.
We can talk some more about that in
our discussion,
there are some factors as we think
about the the conceptual model i showed
before that i think are important
and that Carlos highlighted and
i'd like to delve a little bit deeper
and to speak to those things now. I
actually grew up in Maryland. I'm in North Carolina now but I grew
up in Maryland just north of DC in
Germantown
which is right there sort of north of
DC, kind of near Bethesda
and what you're seeing here is a
picture from the Washington Post about
residential segregation. You know the
civil rights act of 1864 part of what it
was supposed to do was to help
address issues around segregation but
if you look at
measures of residential segregation
right now
the one the measure that uses something
called the genie coefficient, residential
segregation
in the United States today is worse in
some parts of the country than it was
in the 1960s and that's sort of
what you're seeing here you're kind of
seeing
you know Maryland, Montgomery County, a
very fluent county,
Arlington, Northern Virginia or Nova
as referred to in that area, again
affluent areas
predominantly white areas and then you
see on the right side here the very
segregated area we see
blacks, now that's Prince George's
County
and interestingly enough you know the
first thing that comes to mind is the
idea that that class
explains it but not fully because
actually some of the most
affluent neighborhoods that you're
seeing in this picture right now are
actually found in the blue.
Prince George's County has one of the
highest concentrations of high
affluent African-Americans in the country
and so what you
it's not just a matter of class what
we're talking about even segregation
among individuals based on race and high
scs, you see it playing out here in
Maryland and Virginia but you all see it
playing out actually within
the city of DC and so as we begin to
look at the county and even the
more sort of city level outcomes and
neighborhood outcomes like Warlos was
speaking to earlier
you know what does it mean, well you know
when you think about segregation
and in a pandemic where you live and
work for that matter is extremely
important
in terms of understanding your risk of
exposure to any disease and certainly an
infectious disease for that matter. We think about black and latinx
populations, groups that again have been
disproportionately affected by COVID-19,
they tend to live in more segregated and
poor neighborhoods
and there are reasons for that. This isn't a selection thing but when
we look at
policies right because I talked about
you know first if we're talking about
intervening mechanisms and how
multiple mechanisms come into play for
understanding social terms of health
I mentioned the civil rights act of 1964
and its role around issues
in things like residential segregation but
other policies have been implemented
that have perpetuated
racial segregation such as under lending,
redlining
and blockbusting and so we address one
piece but other factors or policy
have erupted to drive the segregation
that we see. And so because
of this residential segregation what
does that mean? Well it means that you
know these populations are living in
higher density areas which of course
makes
social justice things more difficult. Obviously you want to be key when you
think about a pandemic
um and then if you actually look at the
resources in those neighborhoods
uh they tend to have you know fewer
chemical technological resources
less specialists or certified
physicians and
it's often associated with
higher rates of negligence, adverse
events and mortality
and so where you live can directly
impact your risk of being exposed, can
impact your ability to seek appropriate
care
and therefore certainly can explain what
we're seeing
where black and latinx populations
are
having to engage and deal with more of
COVID-19. Now I would also sort of submit that 
there are two other issues that we need
there are two other issues to think about
that have come up that have been
highlighted within this pandemic, one of
them I have here, another one I'll just
mention
so imprisonment is another important
thing
to consider when trying to understand
the national burden
of COVID-19 we know that people of color
are disproportionately represented
in prisons. Educational
attainment is an
important predictor of being placed in
prison but regardless of educational
level we still see significant
racial inequalities with respect to
being imprisoned
and so when we think about policies and
ways to address adverse health outcomes
and health disparities particularly in setting up COVID-19
and trying to understand some of the
data in terms of you know in terms
of nationally
among people of color you know the
concentration of COVID-19 within
prisons
is something we need to think about and the reason why it comes to mind
for me as I have
because I actually hepatology as well,
is because of hepatitis c
where a lot of the burden of hepatitis c
that we're seeing right now people of
color can be linked
to people who have been imprisoned. 
Similarly another sort of
piece of residence another sort of
aspect of residential segregation
in people of color is nursing homes. We've seen the burden of COVID-19
in nursing homes throughout our country
but if you actually look at
nursing home you know the 
nursing home population,
you will see that once again there is a
disparity and a segregation that exists
in terms of nursing homes where you have
more affluent gated communities
predominantly being individuals who
are white whereas nursing homes
with less resources,
nursing homes where you've seen these
high concentrations of COVID-19
predominantly being nursing homes where
there are people of color living there
and so this idea of residential
segregation is important.
I think it is a main driver in
terms of a social determinant of what we're
seeing in terms of COVID-19
and can be seen in terms of
neighborhood. I think imprisonment is
an
important thing for us to keep in mind
and think about as well as in terms of
what we're seeing in terms of nursing
homes
and in North Carolina, you know when
we look at our state
you know we can see that you know
about eight counties within North Carolina actually
would sort of hold half of the
population
of black folks that are in North
Carolina all right but if you look at
COVID-19 cases by county in North
Carolina you will see that those same
eight counties
are also where you're seeing higher
rates
of COVID-19 and so this idea of
where you are
and what it means to be who you are,
where you are and and how that
drives COVID-19 is an important
thing for us to consider
so you know there is the virus
but then there is the quarantine and
so
one of the sort of most scary pieces to
this
is that you know as Carlos alluded to
the burden in terms of morbidity and
mortality immediately
from this virus is scary but when we
reflect on what the quarantine
from this virus and the economic hit
means to our country as a whole
 in its impact long term
it's something that we're gonna really
need to consider and think about and be
very creative in terms of trying to
address
Black medium household income is three
fifths out of whites,
wealth is less than one sixth out of
whites and we look at the older
population specifically, a group that
we know that has
is particularly vulnerable to COVID-19.
There are tremendous differences in
terms of household
on average net worth and
interestingly enough we were just
talking about
residential segregation. Part of that issue
around
wealth is why you see
multi-generational households more often
among people of color
so when we think about the sort of idea
of the pandemic there's a pandemic
versus the quarantine
in the immediate impact of that
pathogen but also the long-term economic
impact
of what it means to be in the quarantine
and how it's hurt our economy and how
those individuals
who are disproportionately represented
in terms of people of color at the
poverty level
um are going to be long-term, both
short-term and long-term quite frankly
are going to be more impacted by this
and so as we think about solutions
around this
pandemic and what it means and how it's
impacting communities of color
you know understanding the economic
impact and this disproportionate impact
on communities of color will be
important
when trying to think about solutions
moving forward particularly as we
prepare for
what's going to happen to us here in the
winter and as you prepare for for
future pandemics. Along those same
lines though
occupational segregation is something
that we need to think about you know
we often don't really consider this I
think it's really only become something
to the forefront
in medicine because of what we've seen
happen with COVID-19
but you know black and latinx
populations represent you know
25 percent of service industry workers 60 percent of people
 in production and transportation
and in other words they are
disproportionately represented
in terms of occupations that are going
to put them at increased exposure
to COVID-19 and at the same time are
over-represented in low-wage jobs like
health benefits and so
they're less likely to have health
insurance and access to health to high
quality care
um they're more likely to be essential
workers um they have increased exposure
because of this work
um they don't have paid sick leave which
is a problem for a number of reasons
right because they may be sick and less
likely to take sick leave
which increases spread of virus but if
they do take that sick leave potentially
can get sicker because of their inability
to get the resources that they need for
healthcare resources.
Another important piece is this idea of
working remotely
they work in industries and occupations
where they're less
likely to take advantage of work
remotely or from home
and so your occupation 
particularly in the center of a pandemic
and i think 
occupational segregation right now is an
important social driver
of what we're seeing right now with
respect to the typical impact
of COVID-19 and I do want to talk about
structural racism.
I think that it is time for us in
medicine
to have a frank conversation about it,
you know in my experience I think a lot of
times we hide behind bias
to avoid this issue of structural
racism
but until we really engage in this
you know you know face to face and have
some conversations we will not
be able to address what we're seeing
right now in terms of the
disproportionate impact of COVID-19.
Structural racism and this is sort
of based off Feagin's sort of
description
you know involves is a fundamental cause
um and
influences a number of aspects you
know of of our culture
and is interwoven within all of our
culture and all of our institutions
and so you know the structural
factors around government and
educational institutions
it impacts our individual resources
in terms of knowledge
and power, money, and certainly
there is
more literature and better
understanding now about what it means in
terms of the psychological advantages in
terms of social networks and
in the belief superiority and
segregation as we alluded to earlier.
All these factors come into play
that are a result of the historical
legacy of
of slavery and then you know
decades and decades of Jim Crow and
segregation and how they
impeded upward and social economic
mobility for people
of color and then structural racism to
maintain
a certain level of privilege for white
folks continues to drive
unequal access and ultimately result
in these fundamental causes
and official determinants driving these
adverse health outcomes. If we're going to
address disparities in this country
regardless of what's
talking about but certainly something
like COVID-19 we need to begin to
think about how we can begin
to address structural racism in our
within healthcare
and so we've been talking about race but
I think that
the conversation that we need to have is
systemic racism. 
There's been a lot of conversations
in papers written about race
and so forth but I think the
conversation needs to change. I think we
need to have a more difficult
conversation
and talk about systemic racism because
again that acts through all the
mechanisms that we've been talking about.
The residential segregation, the issues
around systemic status,
the issues around occupational
segregation, all of these things are
being driven
um as a result of systemic racism. It
can act in terms of scs
as you can see in the red box here but
the broader blue circle again
recognizing that
systemic racism can act independent of
scs through multiple mechanisms
driving adverse outcomes when it
comes
to COVID-19 and so our ability to
address this pandemic quite frankly any
future pandemics
is going to be dependent on our ability
to address similar terms of health
and specifically speak  to this idea of
systemic racism, what it means
in medicine and to our patients.
I'll quickly go through a couple of next
steps here I think that
you know that literature around 
COVID-19 disparities needs to talk
about some of the racism and understand
these these sort of
social determinants and how they act
directly and indirectly on outcomes and
other populations. 
We need to get better data on
other minority populations. We
have began to pluck pretty good data on
on our black and latinx populations but
we need to delve deeper in some of our
other populations particularly our
Native American population which
I think if we do so we'll see likely
even
more concerning um outcomes with respect
to morbidity and mortality
and we need to standardize protocol for
testing and treatment in these
communities,
 knowing they're most vulnerable and
knowing that it's a pandemic and so you
can't hide every gated community,
it will come to you. It's important
that we identify those people
who are at greater risk of having it
and at greater risk of having negative
outcomes
and we think about how best to test them.
And along with that testing is the next
point which is
vaccination you know right now we're
struggling to
get minority participation in clinical
trials understandably because the
legacy of what it's meant to be in
clinical trials for people of color
but if we are going to truly begin to
address this pandemic
and and long term get us through
this we're gonna need to be very
creative
and think about how we can engage
communities of color to ensure
appropriate representation in
clinical trials so that we can
then provide vaccinations for the group
at greatest risk of the disease and the
group that apparently is having worse
outcomes
from the disease. I will stop
there and I think we'll move on at this
point to
the question and answer period. 
Terrific well thank you very much both
of you for the the enlightening
overviews.
I want to welcome our health system
CEO Patty Maysent
who's joined us as well and we've got a
couple questions coming in on the menti.
I will remind everybody the menti
code if you're watching live is in the
youtube description and so with that
I will take a privilege to ask that
the first question that came in. Dr Wilder, Dr del Rio as black and
brown people move up the socioeconomic
ladder
do comorbidities drop correspondingly?
That's a great question, you know not
necessarily
if you know one of the. the link
between socioeconomic status
and race and and disparities is
amazing you can see it at the lowest
rungs
of scs but you can still see racial
and ethnic disparities
 at even the highest rungs in terms
of
adverse outcomes as well as overall
mortality.
But there is  there is some data from
for example the military
and other places where when,
that when the ground is equal when you
have given people equal access to
care, equal access to to employment, I
mean when you look at the military you
know it doesn't matter if
you're a colonel, you're an
officer, regardless of
color you have the same access to the same
housing etc., there's some nice studies in
breast cancer and other diseases showing
similar outcomes
when you have similar opportunities so I
do think that
improving the conditions and sort
of leveling the playing field
is a critical component in achieving. The
problem is even when the playing
field is level,
it's really not level and I think that's
part of what you see
is that as people move up the
socioeconomic ladder there still is
you know a hierarchy. A hierarchy there
still is differential pay that we see
there still is
differential in where you can live and
what employment can you access and what
schools can your kids get into et cetera
et cetera
so you know it really is addressing
those other
components of structural racism
that I think well it's not just the
socioeconomic status it's really the
whole issue
of addressing structural racism. Yeah
Carlos you're absolutely correct you know  the
transplantation,
you know when you look at this
sort of the MELD score
was created to address disparities in
individuals
receiving a liver transplant and by
using that calculation
in many ways we address a lot of the
racial ethnic disparity
around receiving liver transplantation
but disparity still exists overall in
terms of access to those important
organs because of that pipeline where
we're losing people.
You know all up to the point that they
actually get listed for transplantation
and so
you know I think what Carl's talking
about is sort of what we were
highlighting earlier is that there are
multiple mechanisms that play
such that even if you can get you know
good money or a good job there are other
factors that are going to drive
you know these differential health
outcomes and access to the resources that
are important for
for staying healthy.
Thank you both so much for doing the
ground rounds for us
I'm just thrilled that you're here and
helping us think through these issues.
I have to admit that listening to the
stats is a relatively disheartening
and here we are over 200 days into
trying to manage this pandemic here
at UC San Diego Health.
Do you have any guidance for us either
of you for,
you know we're kind of in the in the old
analogy of flying the plane and building it
at the same time.
Do you know where you would focus your
energies if you were in our seats
relative to trying to address
disparities as we continue to manage the
pandemic?
Things that we've looked at you know
we've tried to expand our testing
to areas where we can reach
black and brown healthcare workers
specifically
trying to think about the social
barriers for testing
and what it means to be quarantined and
isolated and all of those kinds of
issues. Do you have any
thoughts about if you were sitting in
our seats where you would focus your
energy?
You know I would start by saying that I
think about it you know I come
and I'm sorry Chip is not here because I
come to this from my
HIV world and my HIV hat
and I think what we learn in HIV is the
importance of community, right
and the importance of of trust and the
importance of involving of the community
in order to really do this and the
challenge that I have and for example
I see with the COVID vaccine is you know
these are communities we pay no
attention to and all of a sudden we're
going to go out there and say oh we need
to test you we need to vaccinate you
and you know for example I can think in
Southern California and certainly here
in Georgia but i bet you it's born in
Southern California
latino communities you know people who
are you know undocumented immigrants are
going to say wait a second I don't want
that because I could be deported I could
be
you know identified so
community trust I think it's a critical
component and I think
you know when communities that we that
we can work with and we have trust
I think the outcomes tend to be
different so clearly this is an
opportunity for health care systems
to truly work with community and to not
just go
and do testing now and we won't pay
attention to you later but really how do
we build
the community. You know links that
actually
are the foundation of trust not just for this
pandemic but also for the future.
The second thing i can think about is
 also you know you and you said it
Patty, is focusing on your employees and
looking at you know who are your most
disproportionate employees, where do they
live,
 what a community, what
anxieties do they have what's happening
in their communities
and what can the healthcare system do to
work with
with your most vulnerable. And you know
unfortunately
what I see in in many places including
my place and I'm not sure in yours but
for example you see 
we have outsourced the food
people and the cleaning
 facilities and other people so
they're no longer our employees
yet they're still part of our
environment so how can we work with them
to ensure that they have equal access to
the kinds of things
that our other employees have just
because they have the privilege to work
with and
be our employees but we're all working
in the same facility, we're all sharing
the same environment.
So having those kinds of town hall
discussions
and really having that opening into
saying hey how can we work with you that
you know you may be as a dexa employee
or an employee of other corporation but
you're in fact
part of UCSD you're in fact part of our
environment how can
what's what's the issuance in your
community that we as a health care
system
can help facilitate. I think those are
things that will go a long way
in improving the outcomes that we see in
this pandemic.
Yeah I would echo what Carlos
says and I think that
 as an institution you know trying to
leverage the people that you have that
do good qualitative work
and who have a sort of a knowledge of community-based
participatory research
is gonna be key in engaging the
community so that you can really
understand
what are the root causes um that are
driving
access to these resources< You know
there's this literature on vaccine
hesitancy
and i think that
conversation is to happen right now.
I think testing, testing's important we
need to continue to do testing that's
going to be important for our ability to
understand
you know how this is behaving and
also be key I think
for that next step which is going to be
targeting how we approach vaccination
within these communities.
I think that these communities should
be priorities when it comes to
vaccination
 but i think for our our ability to
get these communities to be willing
to take the vaccine it's gonna,
we have to start right now
in terms of engaging them, engaging
influencers within those communities
who are the individuals that have
the trust of that community. How can we
partner with those influencers
to increase the likelihood of
individuals of color within those
communities,
you know having this vaccination. My
barber is like he's like I'm not gonna
get that vaccination you know because
they're gonna put a chip in there
and they're gonna they're gonna know
where I'm at and what I'm doing all the
time and I'm like what are you talking about?
But these are the fears that people
people have and Carlos alluded to
this whole idea around sort of 
contact tracing around the issue of
testing I think that's gonna be something
to think about being more creative about
as well
in terms of how we do that and trying
to think about ways we can do it so the
people again are not concerned
about privacy in some of our
unique immigration
you know population be concerned
about things around deportation and that
kind of stuff. And so
you know we need to be really thoughtful
and I think and I think particularly the
vaccination piece and that conversation
needs to happen right now
so that when we do have that vaccination
that we have at least a plan in place
to begin to get it out in those
populations and that works.
That's great great guidance from both of
you thank you so much. Luckily we have
our
our partner in in our public health,
Dr Anderson to help us with some of
those issues. Yeah we're looking forward
to it I think
you are nailing some of the key
issues. In fact we had a question come in
that you both just answered around
you know after thinking about all of
your presented information what are some
of the biggest
impediments when you're trying to care
for communities of color
so thank you for raising those issues
around trust
and partnership and thinking about you
know do people have access to our
hospital system.
do they have insurance. understanding
among medical professionals. and I want
to jump
off on this part of that person's
question around lack of understanding
around medical professionals.
You both sort of hit on it in your
presentation
that we have you know
hundreds of thousands of papers about race
and where we are right now is we're
seeing that
systemic racism and structural racism
the need to get
a higher level of understanding and
discussion.
So my question for you is you know as we
think about raising the next generation
of public health
professionals and medical professionals
how do we
really try to in our educational
programs as well as in
our clinical actions get at this idea
of systemic racism
and ensure that you know when people see
a race variable
they can make the connection back to the
social determinants of health
and the systemic and structural
practices and policies
that are impacting the outcomes that we
see?
Yeah that's a really important question
and I think a question that more
academic medical centers and
medical schools and
other health institutions are beginning
to to grapple with.
And honestly as I reflect on my
experiences
in my training we have always
treated this issue of health disparities
as a separate thing
or this issue of bias or racism
as a separate thing and I think an
important piece
to us being able to first of all train
providers who are able to provide
high quality care to a
increasingly diverse population is to
really integrate at every level
of our training this idea that these
issues
are real and that they have a
negative impact,
not in a separate class but as a part of
the entire curriculum that we do in
terms of the training that we provide
our medical students and our
residents and our fellows.
And I think that this is an important
moment
for medical schools and health and
health centers to think about how they
can integrate this type of training
into everything that they do not only
for the trainees and medical students
but also for providers
and how to be creative again in
ways that you that you do that.
But I think that's an important piece
it has to not just be a separate thing
but this issue of understanding
structural racism,
understanding these terms of health
needs to be something that's interwoven
into the very fabric
of what it means to learn medicine and
practice it and until we do that
you know we're still going to have
issues in terms of people being able to
engage these issues
and properly study them because i think
a lot of the research that's been done
has not been able to create
significant and sustainable changes
around these health outcomes
because of our inability to teach people
the concepts,
the right way on the front end so that
they can do the research in the correct
way to
advance us forward. Yeah i know I totally agree
with Julius. I think, Cheryl, the other
things I think about is is who are we
recruiting, who are the students that
we're bringing in,
are we ensuring that they come from
different not only ethnic and racial but
socioeconomic backgrounds?
What kind of faculty do we have,
how can we how can we force our
faculty, our students, our residents
I say to become you know to to get
uncomfortable? Because I think in order
to address racism you really need to get
uncomfortable
it is an uncomfortable topic and if we
don't
teach people how to get uncomfortable
we're not going to be able to solve it
because you know again it's not just a
matter of being trained on racism you
really need to become an anti-racist.
What are you going to do to really fight
racism?
And then finally i think we need to you
know from a public health standpoint I
really think we need to stop publishing
papers that talk about the problem
and we need to start thinking about the
solutions. We really need desperately
need
you know health systems and schools and
academic institutions
to actually implement interventions that
matter
and i think whether it's in
our country or globally.
I mean i get tired of seeing you know
people in global health describing 20
times the same problem over and over and
not doing anything and doing this
mild this interventions that really
don't impact
the broader impact. So how do we teach
our students that health
is not just working with the health
department as well as really working
with the schools? It's really working
with the food pantries, really working
with
you know the transportation system. We
really teach our public health students
that health
has more to do with where you live and
what you eat and where you work than
actually what your genes are. You
know it's this whole concept that
it is not your zip code but you know
it's not your genetic code but your zip
code that determines the kind of
diseases you're going to get
and how do we teach our students to
again
to work in the community? And maybe
genetics is more sexy but the other
things are more impactful.
And to Carlos' point iId say that
includes how we fund research.
Right, you know there is a strong
emphasis on the basic science and the
genetics and those are important things
but as a country if we really want to
address you know
disparities and systemic racism we need
to fund the research
that will help us again clarify and
contextualize the intervening mechanisms
and then create the interventions that
Carlos is talking about that we need to
start studying.
That is an important piece and
that is how NIH becomes anti-racist.
As medical institutions we become
anti-racist by ensuring this training
and we become anti-racist by putting our
providers
and trainees in the community to engage
the community not just when people are
in the ED and sick
but as a part of what it means to work
in this health system we need to be engaged
in the community in other ways,
doing community service that also would
help the community trust
and the wellness people to engage health
systems back in and so yeah
i think all those factors or issues are
going to be important as we think
about
how we can better serve communities of
color and get around this issue of
racism.
And I'm an eternal optimist. I do think that this
as that editorial in JAMA says I do
think this is a silver lining in this
pandemic,
that we may this pandemic may actually
jolt us enough
to actually do some of the things that
need to be done. Because you know I mean
outcomes and race and ethnic
disparities and disease outcomes have
existed for years you know I mean
I remember one time in my office I have
a map of
HIV in the United States and somebody
came in and said
why do you have a map of diabetes in the
United States?
Because you could superimpose them right?
Same thing yeah
yeah same thing with hepatitis c you
know if it's I mean it's
and again this is like so this is I mean
to your point Carlos this is why we know
it's a fundamental cause of disease.
Multiple diseases through multiple
disease mechanisms and so we have to
address those fundamental issues like
structural racism if we're really going to fix it.
So Julius that's a great segue because
we've talked a lot about what we can do
as individuals,
as health systems and as communities
but I'd like to to hear a little bit of
your ideas of what we can do federally
so imagine if you will the uh the
elections blown up
and in November, Julius and Carlos
you're both elected president and vice
president.
So what are you doing...Carlos is presidenet, I'm vice president...
so what do you do in your first year
to address
anti-racism at the federal level
through
policies and funding mechanisms. Yeah
wow there's a million different ways I
can answer that question and I'm not
sure how much time we have for this
for this talk here but you know it's
my answer might surprise you. But the
first thing i would do
is to change education in this country.
One of the biggest tricks people have
played on on this country is this idea
that
these the idea of what it means like
racism and and understanding our history
you know if people really understood
what happened in this country, hundreds
of years of slavery right and then
reconstruction and reconstruction there
was actually brief benefit in terms of
voting rights act,
black folks in the south being elected
to congress but then whites in the south
recognizing this
and creating laws to again impede their
upper mobility like in terms of you know
Jim Crow
in terms of grandfather clause they
couldn't vote right and what that
meant from generation to generation to
generation and how that has created what
we see
right now in terms of opportunities with
respect to socioeconomic
status and also with respect to how i
mean
knowing that history um and how unique
that history is particularly in the
United States where you have a
large population that still exists in a
country where they were actually
slaves and we're only what the civil
rights act was 64 and voting rights act
was 65.
so i think the first thing i would do
Chris I can talk, my mom's a history
teacher as you can tell,
I would begin with education
and so that people really
understood
what it means to be a person of color
and have the context
because I think what happens a lot of
times is that people begin to blame the
victim
that a very individualistic approach to
the world
can lead to you wanting to blame the
victim for what we're seeing in terms of
health outcomes but if you don't
understand
the fundamental history of what it
means to be a person of color in this
country
of what immigrant populations are
experiencing and what their history of
how they got here
and how that impacted their resources
and access to resources, impediments to
their ability to be
operatively mobile that history I think is
important. So the first thing I would do
would speak to that issue that issue
of history and education so people
understand that there's a whole list
other things i'll let Carlos go now that
I've talked for a while but would
history be the first thing I think I
would
look at trying to address yeah i think i
think
you know there's so many things that
need to be done but addressing
addressing for example
you know the the epidemic of
incarceration that we have in this
country that disproportionately impacts
black men
I mean I think that's a critical
component
in trying to give opportunities to
people and trying to change
what's happening right i think that
you know educational opportunities I
think that really emphasizing the
importance of
 access to to to
education and to to quality education
and you see when you when you said
Julius about reforming an educational
system you know we live in a country
where
education is controlled at the district
level which is funded by where you live
and if you are segregated in your
housing
then you're automatically segregating
your schools
So yeah we've created a system of of
inequalities to begin with because the
school my kids can go to is very
different than the schools that
you know the woman
that is in cleaning my office can send
her kids to
and that puts us in a different starting
point and therefore
by the time our kids get to be 20
they're in a very different place so
so how can you how can you address some
of those issues that really
put people at disadvantage from the day
they're conceived?
I think is one of the things that we
really need to think about because it's
not just 
about creating opportunities, it's
really about decreasing the enormous
barriers that people have
to take advantage of those opportunities
absolutely.
Julius your analogy of equality
equity and removing those barriers I
think is really helpful in this
case in terms of how to think. I think we
have a time for one last question. Cheryl or Patty?
Yeah and I just want to let you know
that we're getting tons of thank yous in
the chats
and the requests to have you come back
to talk with our faculty, our trainees
and our research teams
hopefully in person. Hopefully in person
that's right.
Yeah who wouldn't go to San Diego right?
So just you know one last question.
Julius, you talked about how important it
is to get on the issue of vaccine
hesitancy.
Right now we at some point have to think
about herd immunity in this country
if we're ever going to you know get
beyond
the public health orders that shelter us
in place right now.
Someone asks have you found significant
rates of vaccine hesitancy prevalent in
African and Asian countries and how do
those differences
compare with fears that we see here in
about vaccines in North America?
That's a great question you know I'm
actually not familiar
with the measure of vaccine hesitancy in
other countries.
We do have data that speaks to it and
like in terms when it comes to like the
flu vaccine,
that gives us a little bit of insight
in terms of knowing that oftentimes poor
people and particularly communities of
color
are less likely to engage like the flu
vaccine
any 40 number of reasons and
that
and using that we're beginning to
think about how that can help us
understand you know the issues that
we'll run into when it comes to
hopefully that COVID-19 vaccination
that'll be coming out sometime soon.
But you know I'm not familiar with
vaccine hesitancy.
In other countries per se I know
that when we think about
treatments for diseases in low and
middle-income countries for instance
you know oftentimes
if we have that treatment available and
we can get the resources there folks
will take those treatments
but you know in terms of vaccine
hesitancy i have to look and see if that
has been studied in an in-depth way
in Africa and in Asian countries
but i think you know along that same
line we do need to think about how
this vaccine when it is made is going to
be distributed not only to poor people
in the united states
but also how we can globally ensure that
it gets the low middle up and countries
again because we're talking about a
pandemic
and so herd immunity is not just you
know Durham, North Carolina or the
triangle or North Carolina or the
southeast United States but
you know we really need to make sure
that we're making this thing available
and understand how it's going to work.
You know more globally so I will just
end by saying that the National  Academy
of Sciences has actually put at the
request of
HHS a committee that is looking at this
sort of equitable distribution of
vaccines not only locally but globally.
Bill Feige who is I adore and
and Helene Gayle are co-chairing that
committee and i think this week or next
week it's actually open
the committee is open for public
comment
and I would strongly encourage people to
look at that
you know at that National Academy of
Sciences Committee
and engage in the conversation with them
because it's an
outstanding committee. I think they're
going to put together a really good
report
and some of the issues that you're
talking about are precisely going to be
there.
So i think the the one thing I would say
is engage
engage with those places, engage with the
National Academy of Sciences, engage with
the different decision makers
because that's how we're going to change
things like equitable distribution,
equitable access to things like the
vaccine. I also want to say that I want
to distinguish
vaccine hesitancy which to me is it
speaks more
of the anti-vaxxer sort of the you know
white privilege you know
of Orange County population to
what we see in communities of of color
and disenfranchised communities around
this vaccine which is more
you know concerns about abuse concerns
about Tuskegee
and those are two very different things.
Totally different mechanisms you're
absolutely correct.
You need to be addressed in a different
way, we should not lumping them together
because there really are very different
things.
Well I want to thank you both Dr del Rio and
Dr Wilder for a really enlightening
conversation and as a pediatrician I
like ending with vaccines.
On behalf of UC San Diego Health
Sciences I appreciate all the time that
you spent this morning and preparing for
our
community audience. I want to say thank
you for joining this series
and for our UC San Diego audience. I want
to remind you that our regular 
department of medicine grand rounds
starts and and resumes again next
week and on September 9th
Dr Davey Smith will be giving a
COVID-19
pandemic lecture. So thank you again 
for joining our summer series.
Thank you to our guests and have a
great Wednesday. Thank you Dr Wilder.
Yeah thank you thanks for having me.
Take care.
 
