COVID-19: health disparities and vulnerable populations

[0:00:00]

RICK WEISS: Thank you, Josh. And welcome, everybody, to this SciLine media briefing. A quick one-minute introduction to SciLine for those of you who may not be familiar with us—we are a philanthropically supported, editorially independent, free service for reporters of all types—science reporters, general assignment reporters, local reporters. Our goal for all of you is to help you get more research-based scientific evidence into your stories. We know that it’s harder and harder sometimes to get ahold of scientists, especially in these days with so much demand on this beat, and we know that deadlines are coming faster and faster. So our efforts through media briefings like this one and the other services that we provide are all geared towards getting you in touch with scientists or in touch with validated and credible scientific information to help you get those facts into your stories. Today, we have a great briefing for you with four experts. We often have three; this time it’s four. And we’re going to go an hour and 15 minutes.

I just want to give you very quick, one-sentence introductions to each of them, and we’ll get started. Their full bios are on the SciLine website at sciline.org. We will hear first from Dr. Margot Kushel, professor of medicine at Zuckerberg San Francisco General Hospital and Trauma Center and director of the UCSF Center for Vulnerable Populations. She’s going to talk about what the research says about the impacts of COVID-19 on homeless populations.

Second, we will hear from Dr. Brie Williams, professor of medicine at UCSF as well and director of the Criminal Justice & Health Program there, as well as director of Amend, a program aimed at changing correctional culture from a public health perspective. She will talk about COVID-19’s particular impacts on incarcerated people, a largely invisible but very large group of chronically underserved individuals.

Dr. Carrie Henning-Smith will speak third. She’s an assistant professor at the University of Minnesota School of Public Health and deputy director of the University of Minnesota’s Rural Health Research Center—to talk about another important but often overlooked, underserved community: rural populations.

And fourth, we will hear from Dr. Sharrelle Barber, assistant research professor in the Department of Epidemiology and Biostatistics at Drexel University Dornsife School of Public Health, who will tell us what we’re learning from the research about how COVID-19 is disproportionately affecting racial and ethnic minorities. So we’ll start with Dr. Margot Kushel. Margot, it’s all yours.

[0:02:52]

MARGOT KUSHEL: Thank you so much. Let me just share my screen here. There it is. Thank you for having me today. As I said, I’m going to speak about homelessness and COVID. People experiencing homelessness face significant threats from the novel coronavirus. First of the reasons is due to their living conditions. Whether they be in emergency shelters or unsheltered settings, these create a tinderbox for the spread of disease. There is no way to shelter in place when you don’t have housing. People who live in shelters, as you can see in this picture, often live in alarmingly crowded conditions in which they sleep close together, share bathrooms, eat together in the less—in a…

RICK WEISS: Margot, you may not be in the right mode for us to see that.

MARGOT KUSHEL: To see the slide? OK. Sorry about that.

RICK WEISS: We’re seeing your cover slide.

MARGOT KUSHEL: You’re seeing my cover slide. I’m not sure. I’m seeing…

RICK WEISS: There we go.

[0:03:56]

MARGOT KUSHEL: There you go. Is it—you seeing it now? OK, very good. Thank you. In unsheltered settings—let’s see if you can see this—people may sleep in groups or alone but come together frequently, for instance, to find food where they may gather in large groups and be exposed to one another and attend to other basic needs. We have seen major outbreaks of COVID in homeless populations. Particularly, they’ve been described in shelters. There have been major shelter outbreaks thus far in Seattle, Boston, San Francisco, New York City, Dallas, Philadelphia, Baltimore, Toronto, Bangor, Maine, and other places. These outbreaks have shared several key characteristics: a very high infection rate—as an example, in San Francisco, after one or two people were symptomatic, an entire shelter was tested, and 66% of residents were found to be infected—as well as a high rate of infection among staff, who are often low-income workers themselves. The testing, importantly, happened—when people were discovered to be infected, most were asymptomatic when they tested positive. Many, but not all, developed symptoms afterwards. But this highlights the role of asymptomatic spread and the reasons why testing people only when they’re symptomatic will fail as a strategy.

There’s much less known about outbreaks in unsheltered population in large part because we’ve done very little testing there. Second point I want to make is that people experiencing homelessness who contract COVID are at high risk for poor outcomes of their disease due to underlying health conditions, older age and poor access to health care. We know that older age is a significant risk factor for poor outcomes among people with COVID, and approximately half of single adults who are homeless are 50 and older. Our research has shown that people who are 50 and older who are homeless have health conditions that make them much more similar to people in their 70s and 80s in the general population. In addition to this, homeless individuals have a very high prevalence of the very same comorbid conditions that create increased risk for poor outcomes, so even if they’re younger, they’re more at risk. These include things like chronic lung disease and heart disease, diabetes, hypertension, HIV and the like. They are much less likely to have a regular primary health care provider. Thus, despite their high risk, it makes them much less likely to access testing or present for care early in the course of their disease. Just to show you this risk, in New York City, which has obviously been hit hard by COVID, there have been over 60 deaths reported thus far amongst homeless people who are COVID. This is thought to be an underestimate.

But just for example, they report typically 300 to 400 deaths in an average year for people who experience homelessness. Third, people who are homeless and have COVID face a higher risk of hospitalization, both because they’re more likely to have severe disease, as I just mentioned, but also importantly because they’re more likely to require hospitalization for less severe disease. If someone had a mild case of COVID and lived in an apartment, we would tell them to go home, stay away from other family members. We might check in with them daily. We might ask them to call us if they got worse. But for a homeless person with COVID, there’s such a high risk of spreading the disease and a very low ability to self-care in their—in the shelter or outdoor population. Thus, hospitals are much more likely to admit people with COVID even if they don’t meet the disease criteria for admission. Once they’re admitted, they have to stay longer because we can’t discharge them to a place where they might spread the disease. It’s always important noting the incredibly high overrepresentation of racial minorities amongst the homeless population—black Americans are overrepresented by a factor of three or four, Indigenous or Native Americans by a factor of eight—and also the role of housing overcrowding, which is on the spectrum of homelessness. In Latinx households, they are much less likely to be identified as homeless but much more likely to live in very crowded conditions, which have shown to be associated with high risk of disease.

So what is to be done? The most effective measures have been to move people from shelters and encampments into single settings, such as hotel rooms, which are now empty because of the crisis, or dorms with private bathrooms. Connecticut has accomplished this on a large scale. California has a statewide program called Project Roomkey, which has two goals: to move people who are homeless, at highest risk of poor outcomes, older age or comorbid conditions into hotels, and to provide hotel rooms for people who are infected or need to quarantine because of a close exposure. Except in Connecticut, this has not met the scale of need. San Francisco has done better than the rest of California, but we only have about 800 homeless people in shelter, compared to a population of 10,000. And conservatively, 3,000 or 3,500 meet the criteria. Doing this has required some creative thinking because people are not just moving into hotels, but they really can’t leave because we’re trying to keep them isolated from one another. And it’s presented an opportunity to try new things around how to manage people with alcohol use disorder, opioid use disorder, smoking, etc., in these conditions. Other things that have been done are providing places for people who have COVID and don’t require hospitalization to be together and receive basic medical care to decrease pressure on hospitalizations and allow health care providers to keep an eye.

San Francisco, in addition to keeping people in hotels, is planning to open a COVID-positive shelter. Boston Health Care for the Homeless has a large facility with 500—capacity for 500 at the convention center. Other places—Seattle, New Haven—have similar programs. The CDC has recommended from early in the pandemic against sweeps, meaning not to move people who are in encampments to other places, but many continue to do that, and some, in fact, are moving people from outdoor spaces into shelters where, ironically, they may be at higher risk of disease. There was an outbreak in Philadelphia that was attributed to this. The CDC has also recommended thinning shelters with fewer people in them, more cleaning, bringing food in. It’s unclear if this is going to be sufficient to make a big difference. There is a dire need that is thus far unmet for increased routine testing in homeless shelters and encampments. Because of the evidence that COVID can be spread by asymptomatic or presymptomatic individuals, using symptom screening is inadequate. The high rates of transmission, as well as the high risk for poor consequence, highlight the need for increased testing.

Ultimately, the solution to the crisis of homelessness and COVID is and has always been housing. Not only does COVID present a serious threat to the health and safety of people who are homeless, but the presence of homelessness and COVID presents a threat to health care systems’ ability to care for all. In this, each and every person’s health is intertwined. To stop the spread of the virus, we can’t afford to leave anyone out of our containment measures. We must make sure that all can stay home when they have to. I often say, and I will repeat today, that there is no medicine as powerful as housing. This is even more true today than it is always. I’ll be happy to take questions later. Thank you. Oh, and I provide some resources, which will be provided on homelessness and COVID.

[0:11:09]

RICK WEISS: Thank you so much, Margot. And I do want to remind reporters that all the slides you’ll see today will be posted on the SciLine website, so you’ll be able to study those more carefully and go to the links provided at the end of some of them for resources. And we will move here to Brie Williams.

[0:11:42]

BRIE WILLIAMS: OK, thanks. Thanks so much, Margot. I always like hearing from you. I’m Brie Williams from Amend at UCSF. So there are 2.2 million Americans incarcerated in the U.S., and 11 million cycle through jails each year. An alarming 1 in 3 black men and 1 in 6 Latino men experience a lifetime risk of incarceration. Incarcerated people are also generally in very poor health. There are about 170,000 who are 55 or older. As you can see from these photos, which are from the Prison Law Office from a recent lawsuit in California, many of the U.S.’s more than 5,000 facilities are profoundly overcrowded. Social distancing in these facilities is often virtually impossible. In the setting of COVID-19, this is particularly important because our health is interconnected. People who live in prison, people who work in prison, people in the community—we are all interconnected. So, for example, hundreds of thousands of staff enter and exit prisons and jails every day, coming back into the community or back from the community into our prisons and jails, bringing with them whatever illnesses they have caught.

Present health care systems also are only developed to provide chronic care, not hospital-level care. So what that means is that when patients become very sick with COVID-19, they have to transfer to community-based hospitals. And many of these community-based hospitals are in rural communities. Most of our prisons—over 5,000 prisons and jails are in rural communities. So you can imagine a prison of 3,000 people in a small California—or Northern California town, for example. If they were to have an outbreak of COVID-19 in this community where the community hospital has only four or eight ICU beds for the entire prison population—for the entire population of the community, that would be really quite a stress on the community health care system. And many people who are incarcerated are very concerned. Some things that we’ve heard: I don’t have a mask. There’s only one phone for 10 people. That’s not very sanitary. We can only call our attorney and not our families. I already feel so alone; I don’t want to tell anyone I’m sick because I don’t want to be sent to isolation. Officers are also very concerned. For example, one said: I’m my mother’s durable power of attorney and my father’s ride for appointments and shopping. I have little kids. I need to be healthy for them, and working in this environment is not healthy. Yeah, I know I signed up for the job, but none of us saw this coming.

It’s scary as hell. Too many people are not taking this seriously. And there’s good reason to be fearful. In March, we had very few cases documented in prisons and jails across the U.S., probably due to very poor testing. Now, even with poor testing, we’re seeing that eight of the 10 largest U.S. outbreaks are in prisons and jails. It’s about 16,300 residents and over 5,000 staff are affected. And, again, this is in very poor testing. So over 4,000 of these cases are from just two Ohio prisons alone that did mass testing. This accounts for at least 218 resident deaths. And although some states are flattening the curve, cases in some of those very same states’ prisons are on the rise. So, for example, these are graphs from California, and then the California Department of Corrections and Rehabilitation. And this is really virtually identical to many of the prisons that have COVID-19 cases around the nation. I have to point out that the y-axis, the vertical axis, are very different numbers. But just to give a sense of the shape of the curve, in California, we’re seeing what we call this flattening or decreasing of the curve where new cases are starting to decrease each day. And this is over March to early May. Well, in the Department of Corrections, we’re seeing a steady and consistent rise.

We’re really at the beginning of finding these infections in our jails and prisons. We’re also seeing serious concerns that are arising about ethical medical care for seriously ill patients. So, for example, and these are sort of conglomerate quotes, but a community hospital physician who says things like, I asked for the number of my patient’s next of kin to ask what his wishes would be if he could not communicate with me. I was told I was not allowed to call them. The prison medical director would decide for him. Or an attorney—her father was moved from the prison to a community hospital. She was told his organs are failing and she needs to sign a do not resuscitate order. She wanted to speak to his hospital doctor to make an informed decision. She was told she was not allowed. She asked whether someone could put a phone near her dad so she could say goodbye. She was told that that, too, could not be done. So what can we do? Well, the first, most important thing is we need to release substantial numbers of people from facilities operating near, at or above bed capacity.

This is a public health incarceration strategy. It’s really not a political strategy. This is really public health, where emergency task forces need to be developed in every prison in every state and every jail to evaluate and release—create release plans for housing and medical care, first for focusing on older and chronically ill people so that they can go to places that enable them to follow social distancing guidelines, most preferably would be a home of a family or friend, and then, really, everybody else. Even the younger and healthy people need to be depopulated from prisons and jails so that we can allow more social distancing among those who remain. And that’s the second point is cohorting, which is really creating small, mini communities of as few people as possible in the prisons—usually less than 10. And these communities would have to maintain absolute social distance between themselves and have—be assigned different staff members. And then, finally, just like Margot said in our homeless shelters, we need to rapidly scale up testing, including of all asymptomatic staff and residents.

And then, finally, we need to clarify that there are some minimum ethical care guidelines for prisoners—really, all people—at the end of life. First, self-determination—that we have the ability to choose what medical interventions we do or do not want at the end of life. Second, we all have a right to name a proxy, a family member or friend, who can make decisions for us if we cannot. And third, we really all have to have the right to say goodbye to loved ones, whether that’s in video conferencing or by phone calls not in person. So I’ll just leave you with this one thought, which is that correctional health is public health. The health of absolutely all of us is interconnected, especially during a pandemic. None of us is going to be safe until all of us are safe. And I welcome you to learn more about the work that we’re doing at https://amend.us/covid/. Thanks so much.

[0:18:12]

RICK WEISS: Thank you very much, Dr. Williams. We will move to our third speaker now, Dr. Carrie Henning-Smith.

[0:18:21]

CARRIE HENNING-SMITH: Thank you. I’m going to share my screen here. OK. Can you see that OK?

RICK WEISS: Looks good.

CARRIE HENNING-SMITH: OK. I’m just really glad to be able to be on this panel today, but especially to be able to present and show all of the ways that these different vulnerable populations are interconnected. I’m sure that that point will come across really clearly. But I appreciate going right after Dr. Williams, who pointed out that prisons and jails are disproportionately located in rural areas. It’s a rural issue. I’m speaking today about the impact of COVID-19 in rural America. Rural areas make up the vast majority of landmass in the United States and 15% to 20% of the population, depending on how we define it. And rural areas differ from urban areas in really important ways that matter for how COVID-19 is playing out today. First, demographically, rural areas are older on average. They have lower median income, lower educational attainment, higher poverty rates, higher rates of uninsurance and higher rates of unemployment compared with urban areas. Rural residents also have lower life expectancy, higher rates of disability and higher rates of underlying health conditions compared with urban residents.

All of that put together means that rural residents are at higher risk from COVID-19 and severe effects of it compared with urban residents. The slide that I’m showing you here shows rural-urban differences in death rates from the five leading causes of death from 1999 through 2014. Those five causes are heart disease, cancer, unintentional injury, respiratory disease and stroke. For every one of these five conditions, the rate is consistently higher in rural counties. If we were to look at just about any other chronic condition, any other health condition, you would see a similar pattern and higher rates in rural areas. Particularly relevant for addressing the COVID-19 pandemic, rural areas have more limited access to health care. Since 2010, 128 rural hospitals have closed. Eight rural hospitals have closed in 2020 alone, and at least three of those have closed since the pandemic began with COVID-19 as one of the causes of their closure. Approximately half of all rural hospitals operate in the red on an annual basis, even before COVID-19. Now they’re not able to do routine and elective visits and procedures, and that’s further straining their finances. Rural areas also face persistent health care workforce shortages at every level. Nearly 80% of rural areas are designated as medically underserved. Rural residents live farther, on average, from emergency rooms. And rural counties are also less likely to have ICU beds or ventilators available. When they do have them, they might just have one or two instead of enough to serve the population. Rural areas are also less likely to have access to reliable broadband Internet and cellular connectivity. That’s really relevant in this current context. It makes it difficult to access health care and other services remotely.

We’re hearing a lot about telemedicine. It doesn’t work if you can’t connect remotely. It also makes it really hard for people to remain socially connected and to have the opportunity to work remotely if that were to be available to them. So COVID-19 took longer to hit rural areas. When we first heard about COVID-19 in the U.S., we were hearing about it in Seattle and New York and New Orleans. That’s no longer true. As of last week, 85% of rural counties had at least one case. More than 30% of rural counties had at least one COVID-19 death. An analysis from the Kaiser Family Foundation that came out last week showed that the rates of increase in both COVID cases and COVID deaths over the past two weeks were higher in rural counties. And as we’re talking about rural areas, it’s really important to acknowledge that rural places and rural people are not monolithic. Approximately one in five rural residents is a person of color or an Indigenous person. Those folks face higher risk from COVID-19 for all of the reasons that we’ve already discussed. They’re more likely to work in low-wage jobs, including many essential services, less likely to have reliable access to health care, and they’re more likely to have underlying health conditions.

As of April 27, the county with the highest COVID-19 death rate in the entire country was Randolph County, Ga. This is a rural county in southwest Georgia with a population just under 8,000 people. It’s also a county where the majority of the population is black. Research we did at the University of Minnesota Rural Health Research Center at the end of last year showed that rural counties with a majority of black residents—those are those counties that are showing up red on your screen on this slide here—have among the highest mortality rates in the country even before COVID-19 hit. Similarly, we’re hearing a lot about the Navajo Nation, which is largely in rural Arizona. It’s been disproportionately impacted. As of April 24, it had the third highest COVID-19 rate in the country, right behind New York and New Jersey.

Testing, contact tracing and treating COVID-19 are especially challenging there. Residents of Navajo Nation are less likely to have phones, running water, electricity and access to health care. Similarly, we’re hearing a lot about rural meatpacking sites and communities that house those. Those are places with high percentages of Latino and immigrant employees, typically low access to health care and health insurance, and people living and working in close quarters. I do want to say, as we’re talking about within rural diversity, there are also a number of bright spots within rural areas—incredible resourcefulness. And rural areas are smaller, and sometimes that can be an advantage. It can allow them to be more nimble, more innovative, but only with sufficient resources to do so. Like the other presenters, I’m leaving you with some resources today, some places where I go to find information on COVID-19 in rural areas and some research that underlies what I talked about today. I thank you for your time, and I look forward to the questions.

[0:25:43]

RICK WEISS: Fantastic. Thank you, Dr. Henning-Smith. And we will move, fourth and last, to Dr. Sharrelle Barber.

[0:25:59]

SHARRELLE BARBER: Hi, everyone. It has definitely been an honor to be on this call with so many distinguished academics talking about the disproportionate impact COVID-19 is having on marginalized groups. Today, I want to talk briefly about structural racism and racial inequities in the COVID-19 pandemic. So I actually want to begin this conversation with the data as of April 30 from the 38 states and Washington, D.C., that are actually releasing data by race. This slide shows the rate of COVID-19 deaths reported by race. And as you can see, there are significant racial inequalities in COVID-19 deaths in the United States, with blacks experiencing the most striking inequalities. Black mortality rate is 2.6 times that of whites. And in some states, these gaps are even wider. Here are a few notable ones.

In Kansas and Wisconsin, black residents are seven times more likely to die than white residents. In Washington, D.C., blacks are six times more likely to die than white residents. In Michigan and Missouri, blacks are five times more likely to die. And in Arkansas, Illinois, Louisiana, New York state, Oregon and South Carolina, blacks are three to four times more likely to die of COVID-19 than whites. Here’s some additional data. This slide shows the percent of COVID-19 deaths compared to the proportion of black population in each state. So we know that in the United States, blacks make up 13% of the population but have suffered 27% of the COVID-19 deaths. And, for example, in Washington, D.C., blacks make up 44% of the population, yet 79% of confirmed deaths. And in Michigan, they make up 14% of the total population, yet 44% of the confirmed deaths. These racial inequalities are very striking and—very striking. So it’s important that these racial inequalities are placed in proper context.

So in the early weeks of the pandemic, as data on racial inequalities began to emerge, my colleagues and I wrote a piece for the Interdisciplinary Association for Population Health Sciences entitled “Racism In The Time Of COVID-19,” outlining with extreme clarity the ways in which structural racism would be operating during this pandemic. We knew that blacks die at higher rates for just about every leading cause of death in this country and that the COVID-19 pandemic would be no different. We also knew that while COVID-19 is indiscriminate in its transmission, its propagation within a society steeped in structural racism would lead to disproportionate impacts among marginalized racial groups in this country. And here are a few of our key points.

One, we noted that access to testing would be limited among black communities. Research has shown that blacks and other marginalized racial groups are more likely to be uninsured and less likely to have access to health care in their local communities. In Philadelphia, early data showed that black neighborhoods had less testing than white neighborhoods, despite being more likely to test positive for COVID-19. I also know from two reports from federally qualified health centers, one in a black community in St. Louis and one in the Mississippi Delta, that at the onset of the pandemic, each of these federally qualified health centers only received a total of five tests while mostly white suburban and white neighborhoods around them received many more. In addition to access to testing, we also know that when blacks navigate the health care system, they are much more likely to experience bias and discrimination.

This is well documented with a seminal report, “Unequal Treatment,” being released by the Institute of Medicine in 2003. But even more recently than that, research examining the extreme inequities in maternal mortality among blacks where black women are three to four times more likely to die, many—much research has cited not being heard or not being listened to when presenting with symptoms and other forms of bias and discrimination that lead to their higher mortality rates. There have, in this pandemic, been anecdotal reports of blacks being turned away from testing and treatment even when presenting with symptoms such as shortness of breath and fever. I’ve heard several of these stories where folks have gone into emergency rooms and presented two, three, four and five times and being turned away from testing.

The next point I’d like to make is that of focusing on our low-income essential workers. So research from the Brookings Institute reports that blacks and Latinos are disproportionately represented among low-wage essential workers. And during this pandemic, they have been the least protected but the most exposed, lacking the personal protective equipment and income protection, such as paid sick leave and hazard pay, to ensure their safety during this pandemic. And the reason I think that essential workers are particularly important to note in this—in terms of racism and COVID-19 is because these workers and the exposure of these workers does not only impact the workers themselves, but this also has implications for their families and communities, which leads me to my final point, and that is the role of racial residential segregation. Urban areas across the United States are racially and economically segregated, a byproduct of racist policies that date back to the 1930s. This leaves the structural factors within communities that make exposure, transmission and death more likely. Crowded homes, lack of access to clean water, exposure to environmental toxins are putting blacks at risk during this pandemic.

And these are just a few. There are some more. But I just want to note that these interlocking systems of racism reinforce one another and create a deadly cycle of exposure, transmission and subsequent death among blacks and other marginalized racial groups during this pandemic. During my final slide, I want to point out a few solutions and really want to think about the ones—solutions that need to be put in place during the pandemic but also beyond this moment. And so everyone on this call has said that we have to expand access to free testing and treatment, particularly in communities of color, where we know testing has not been adequate. And we are probably massively undercounting cases within these communities. And because of these structural issues, that is actually amplifying the pandemic in those communities. In addition, we need to be taking care of our workers and providing them with living wages, adequate protections and guarantee workers’ rights during this time. These workers are literally the lifeblood of our economy right now.

But again, as I said before, they are the least protected—the least protected and most exposed, and we need to protect them. This has implications for them—the workers themselves, their families and their communities. We also need to be providing adequate economic relief because, again, blacks are disproportionately poor in this country, and relief in this moment needs to ensure that they have everything that they need in order to survive this pandemic. And then, finally, I just want to note, as we are beginning to see states across the country reopen, we need to make sure that those strategies center racial and economic equity and justice. We cannot afford to reopen economies without making sure that the most marginalized racial groups among us have all that they need during this pandemic. And then, finally, I’d like to just highlight a few solutions beyond the pandemic—free health—universal health care for all, providing living wages, equitable investment in communities of color and dismantling systems and structures of racism and economic exploitation that have plagued this country for many, many decades.

And so I’ll just close with this. I’d like to just say that as a social epidemiologist, part of my job description is to count deaths. It has been painful to witness the disproportionate deaths among blacks and other marginalized racial groups that are the direct result of structural racism, economic exploitation and the reckless and uncoordinated federal response. As others have noted, this nation and those in power are far too comfortable with the deaths of some groups. And we in the scientific community have an obligation to speak truth to power in the midst of this pandemic. Thank you for your time. More than happy to take questions, and also have some resources for you all as you continue your reporting on this issue. Thank you.

[0:35:24]

RICK WEISS: Thank you, Dr. Barber. And thank you for that very strong and personal conclusion. There’s a lot of talk about how we’re all in this together, and we are as a nation. But, clearly, some Americans are in it in very different ways than others. And I really appreciate the beginning of this conversation and a chance to help journalists tell the story of those different realities, many of which have not really been adequately told yet.

So let’s start with the Q&A. Just as a reminder to reporters here, if you would like to direct a question to our panelists, please click on the Q&A box and submit that. Let us know if there’s anyone in particular you’re directing it to, although any or all are, of course, welcome to chime in as well.

RICK WEISS: And we will start here with a question from Helene Epstein. She’s a freelancer based in New York. She asks, is underdiagnosis or lack of access to care, whether that lack of access is perceived or real, a contributing factor in COVID-19 deaths for patients of color? Is underdiagnosis or lack of access to care a contributing factor in COVID-19 deaths?

[0:36:36]

SHARRELLE BARBER: I would say absolutely. We are severely, as most folks on this call have said, undercounting, just from a general public health standpoint, right? And so we are primarily, at this point, doing diagnostic testing within the context of health care systems. And we know that COVID-19—folks can have the virus and be asymptomatic for weeks, right? And so the fact that we’re not doing widespread surveillance, first, is a public health issue for all of us. But for those who are most vulnerable to this disease—communities of color, our homeless folks, folks in prisons—the fact that we’re not doing the kind of widespread surveillance to know where the disease exists is really contributing to the disproportionate transmission—exposure, transmission and death among communities of color. And so I know, for example, in Philadelphia, there was a group of black doctors who have worked to massively increase, or to the extent that they can, increase testing over the last couple of weeks. And they’re finding rates of COVID-19 that are being missed by our current practices, right?

So we know, again, that this is happening. There’s data early on that I mentioned earlier that showed this, that there’s more—there’s less testing in black communities and poor communities despite having higher numbers of cases. And we know it’s, again, it’s a structural problem. These communities didn’t get access to testing. Federally qualified health centers were not given those things. And we know that those centers are the centers that, you know, serve poor and minority communities. So, again, testing is absolutely one of the—one critical point that is making the pandemic worsen in communities of color.

RICK WEISS: Thank you.

[0:38:23]

BRIE WILLIAMS: I’d like to agree. Just to add to what you’re saying, in prisons and jails, you know, if we don’t test for it, we don’t know it’s there. And if we don’t know it’s there, we can’t make sure that people maintain their health. And so we know that especially for older adults and people with serious chronic medical conditions, the decline in respiratory function can be quite precipitous. And people can do—be doing pretty well, just with a little bit of a cough. Then suddenly, really, their health absolutely declines very, very quickly. And so if we don’t know that people have asymptomatic or presymptomatic disease, then we don’t know to be checking on them. And, you know, if a nurse or a health care professional is not going around in prisons and jails or in homeless encampments and checking on the people who we know have this, then they can decline—their health can decline very, very quickly and we miss incredibly important moments to get them the respiratory care that they need.

[0:39:23]

MARGOT KUSHEL: And I also think Dr. Barber’s point was really well taken in terms of I would take the counts of deaths attributable to COVID with a little bit of a grain of salt at this point because what we really need to look at are excess deaths compared to what we would otherwise expect, because people who are dying at home, you know, without testing, those deaths are not being counted amongst the COVID deaths, but almost certainly they are. I also think it’s worth saying that overwhelmed health care systems—I’ve been really struck by the different percentage of deaths from health care systems that are not overwhelmed compared to their being overwhelmed.

And while we don’t have great treatments—hardly any treatments, we really have supportive care for this disease. If you’re an overwhelmed health care system and if people are unaware that they’re infected, have poor access or are turned away, they are more likely to present in extremis, like, present when they’re already really sick, and the system is more likely to be overwhelmed that, you know, that care for predominately minority populations, and, thus, they might wind up having poor outcomes, you know, for an additional slate of reasons.

[0:40:31]

RICK WEISS: So a related question, and maybe Dr. Henning-Smith could add to this one. It is from Brian Grimmett from the Kansas News Service. The vast majority of new cases of COVID-19 in Kansas are coming from meatpacking plants and prisons. That’s connected to increased and focused testing at those sites. They’re finding that most of the positives are asymptomatic. What, if anything, can we learn from that? What does that say about our knowledge of the disease in most other places with limited testing?

[0:41:03]

CARRIE HENNING-SMITH: What, like I think we’ve already said, it suggests that in places where we are doing a lot of testing and we’re seeing a lot of positive cases, it’s probably a very good sign that we have a lot of undiagnosed cases elsewhere. I also think the places, like in Kansas, where we’re seeing high rates detected in meatpacking plants and prisons in rural communities highlight a couple of things. One, I don’t think these are the places that are typically portrayed or thought about when we think about rural America. And yet, this is very much rural America. And I hope that we will continue to shine a light on different places and different people within rural areas, especially those people who are marginalized or not given a living wage, not given adequate housing, not given an adequate and safe place to live. And I think that’s—it’s happening in real time. And as all the other presenters alluded to, as I said, as we keep hearing, everything about COVID-19 is exposing the worst of us, what’s already existed. None of these are new phenomena. They’re just exposing all of the structural flaws and inequities that we already had baked into the system.

[0:42:23]

RICK WEISS: Yeah. Very interesting.

[0:42:23]

BRIE WILLIAMS: I also want to just reiterate a point that Dr. Barber and Dr. Kushel both made, which is that I think it’s important to say it explicitly. We use the term asymptomatic, and we actually don’t really know the degree of asymptomatic, or is this presymptomatic disease? So I think it’s really important before we jump to conclusions about there being enormous amount of asymptomatic disease in these highly overcrowded facilities and meatpacking industry places that we need to circle back in a week and two weeks and three weeks, as Dr. Barber said, and really find out how much of this was actually asymptomatic or how much of this was actually, in retrospect, just presymptomatic. Thanks.

[0:43:09]

MARGOT KUSHEL: Absolutely.

[0:43:11]
RICK WEISS: Question here from Rodrigo Perez Ortega, reporter at Science magazine. Do you know of any research on migrant populations in detention or waiting on the U.S.-Mexico border and COVID-19? If not, what’s your take on it? And how are migrant communities being hit by the pandemic?

[0:43:32]
SHARRELLE BARBER: I think that’s actually a really, really important point. And I didn’t get to get to this in the talk that I gave. But a couple of things on the migrant populations. One, just like other marginalized racial groups, there’s probably severe undercounting. But migrant populations, both documented and undocumented, also have this history of surveillance in their communities that make them distrust even the health care system. So they may not even—may not be accessing health care systems, et cetera. So I think that’s really important to note that, you know, we’re seeing these rates among blacks, but, you know, we might be really missing. And migrant communities, undocumented communities and the like might be severely undercounted and be rendered invisible during this epidemic.

In detention centers specifically, I don’t think they’re releasing data. A team of us were trying to look for data specifically on detention centers. I have a colleague at the University of Miami who’s been looking into this because of her work in incarceration. And there’s a—the data is not being released on COVID-19 within these populations. And, again, I think this is really rendering this population invisible. But, again, just like prisons—and I think Dr. Brie Williams can speak to this—they have overcrowded conditions, unsanitary conditions that would make the pandemic, you know, really wreak havoc in these settings. So, again, I think we’re really just, you know, among all of these groups, severely undercounting, really don’t know the extent to which this pandemic is playing out there. And this is—it’s really tragic that this is happening.

[0:45:09]

BRIE WILLIAMS: I don’t have a lot to add, just to say I absolutely agree with Dr. Barber. You know, the No. 1 public health response to COVID-19 for institutional settings is to depopulate as much as possible and to find more appropriate places where people can house and practice the community standard of social distancing and sheltering in place. An immigrant detention facility is no different, unfortunately, than prisons and jails. It’s unconscionable that we have people who are, really, incarcerated in these facilities that are overcrowded, that are under-resourced, where people have, oftentimes, limited access to health care on a good day. But during this COVID-19 crisis, it’s really—it’s unimaginable that we’re doing this. There’s not really much else to add.

[0:46:03]

RICK WEISS: Or even limited access to water, as one of you mentioned earlier. It’s amazing to think how much we’re told to keep washing our hands, and it seems so simple.

[0:46:10]

SHARRELLE BARBER: Yeah.

[0:46:10]

RICK WEISS: But it’s not so for many people. A question here from Pauline Arrillaga from Cronkite News in Arizona. Can some of the panelists talk about whether implicit bias may play a role in these COVID-related disparities? And if so, in what ways? How might that larger issue of implicit bias be remedied in medicine more generally?

[0:46:35]

SHARRELLE BARBER: Yeah. I guess I’ll take—I’ll start with that. I mean, absolutely, I think this is playing out. Anecdotally, we’re hearing stories of people being turned away two, three, four times, presenting in hospitals, presenting in emergency rooms, literally being nearly out of breath but not being admitted. And, I mean, it’s just—again, this is why these deaths are just so devastating and so tragic. But I think there’s also some very explicit bias happening. So, for example, when we look at protocol for rationing of care, many of the algorithms that are used to ration care utilize preexisting comorbidities as a part of the algorithm to say who gets lifesaving equipment such as ventilators, right? We know that blacks, Latinos, poor folks are disproportionate among those who have comorbidities.

So programmed into the algorithm that says who lives and who dies or who gets lifesaving equipment is, like, race—you know, racism because those comorbidities are caused by, again, these structural factors that have existed in our country for decades and decades and decades, right? And so there are so many—and that’s why we have to see this as a very vicious system of structural racism that’s operating, because it’s not just one thing. It’s not two, you know? It’s all of these things together that are really, again, creating this system of increased exposure, increased transmission and increased death, particularly among the most marginalized populations in this country. And so, I mean, there are so many things and so many ways that this is just showing up during this pandemic. And, as Dr. Carrie said, you know, this is just really exposing what already existed before this crisis.

[0:48:22]

RICK WEISS: Anyone else want to address that? OK. Question here for Dr. Henning-Smith—this is from Vincent Gabrielle, reporter at the Knoxville News Sentinel. I’m based in Tennessee where 20 counties lack a hospital or ER and 30-plus counties don’t have anything hooked up to the Syndromic Surveillance Network. Tennessee began reopening in May, and I worry that this was pushed before we even understood the prevalence in rural areas. Can Dr. Henning-Smith comment on this?

[0:48:57]

CARRIE HENNING-SMITH: Yeah. I worry about that, too. And it’s, again, not a coincidence that we’re seeing a lot of cases pop up, a lot of the highest prevalence in rural counties happening in those same states where we have deeply inadequate and inequitable access to health care. Many of these states are states that haven’t expanded Medicaid, that make it prohibitively difficult for many people, particularly people of color in rural areas, to access care. It’s worth noting that Tennessee is one of those states that’s lost a hospital—a rural hospital—this year. Things are not getting better there, at least not in the short term.

I think it’s also worth noting that many of those same states were making—state-level decisions are really important here, and many of those states that made decisions not to expand Medicaid, not to make it easier for people to access health care instead have made it more difficult. Many of those states are the same states that are loosening restrictions on social distancing. Again, it’s not a coincidence that I pointed out a county in rural Georgia. Many of the rural hot spots that we’re seeing and the highest death rates are among counties in rural Georgia, where we’re seeing a lot of loosening of social distancing guidelines. And I worry a lot about what that means for rural residents in those states generally, but particularly for rural residents with all of the other disproportionally disadvantaged identities that we’ve talked about here today.

[0:50:38]

RICK WEISS: Here’s a question that actually is a composite question. We got similar questions from a few reporters for any of you to address. Basically, it asks, what are some reliable sources of data that journalists should be tracking to keep on these health disparities—to keep up—sorry—on these health disparities related to COVID? What about broader datasets that accurately describe homeless populations across different parts of the United States? Dr. Kushel, do you want to start with anything that you might be aware of that might address the homeless distribution? And then others might want to chime in with similar advice for data journalists.

[0:51:20]

MARGOT KUSHEL: So, first of all, for a general point, one of the things that has really hampered our efforts in homelessness is the incredibly poor quality of the data. We really have very little idea. And just so you know that hospitals have been very unreliable reporters of homelessness, which also worries me because it means that hospitals are sending people back out, likely not even recognizing that people are homeless. There—you know, the data on homelessness—I would sort of push areas to try to report out information on homelessness and COVID. So far, I’m not aware of anyone who’s doing that systematically. New York City Department of Health—New York City has slightly better data because 95% of their homeless population is sheltered, meaning they know who they are, whereas on the West Coast, where two-thirds of the homeless population is unsheltered, they have no idea who’s homeless or who’s not homeless.

So New York City is pushing out, slowly, some data. We’re trying to gather some data in San Francisco and push it out as soon as we get it. But I would say that data sources are poor. The National Low Income Housing Coalition, the National Alliance to End Homelessness and the National Health Care for the Homeless Council are all trying to put together these data sources. The CDC does now have a working group on homelessness. They have put out a few MMWR reports. And they’re working to get better data. So those are all reasonable sources, but the data is going to be poor, unfortunately.

[0:52:48]

RICK WEISS: Others?

[0:52:50]

BRIE WILLIAMS: For prisons and jails, there’s a couple websites that are trying to really track the instance of infection in these facilities, as well as mortality and morbidity among both officers and residents. Those are—one new one, which is @dataprison on Twitter for the prison data project. There’s a prison data project through the UCLA Law School. I don’t have that Twitter account right here, but I will look for it. And Marshall report—or the Marshall Project is doing a very good job reporting a lot of these data, as well.

[0:53:30]

SHARRELLE BARBER: So…

[0:53:30]

CARRIE HENNING-SMITH: For rural populations—oh, sorry.

[0:53:32]

SHARRELLE BARBER: No, go ahead.

[0:53:33]

CARRIE HENNING-SMITH: Rural populations and COVID-19, there are a couple of places that I would point people. One is to my colleagues at the University of Iowa RUPRI Center for Rural Health Policy Analysis. And they are releasing near daily reports that update the case numbers and the death rates in rural counties compared with urban counties. And then if reporters don’t already know about the University of North Carolina Sheps Center for Health Policy Research (ph), it’s worth noting that they do a really nice tracking of rural hospital closures. It’s the first source that I turn to for closures there. But it’s also worth reiterating the point that data are sometimes hard to come by. And we’re all talking about vulnerable populations—marginalized groups where data are not always released. Dr. Barber mentioned that not all states are releasing data on race and ethnicity—same is true by geography. I think we are all hungry for better data, and yet we have some sources that we go to for good data.

[0:54:34]

SHARRELLE BARBER: No, and I’d like to actually come back—also add to that point is that, again—and this has been said—you can’t address what you can’t see. So data isn’t just about—in this point, it’s not just about research. It’s literally about being able to save lives and to know where the disease is, etc. So I’ll just say that again to reiterate—we cannot address, you know, and we cannot tackle, what we can’t see. The rate and the data that I’ve been turning to, particularly looking at racial inequalities, is—the APM Research Lab has done a really good job. The data figures that I showed at the beginning, they update pretty regularly, also have noted which states are reporting data and releasing data by race. Again, I will note that the data on race—there is a substantial amount of missing data in all of these datasets, again, because of the way we’re not—we have not systematized data collection in—you know, across the board. So there are caveats to the data. But, again, this is a good source.

Again, the COVID-19—the COVID Tracking Project is also a good resource, as well as—I just came across another one that is actually looking at various dimensions of equity. And I actually want to make this point that, you know, racial data is good, but, you know, there are intersecting processes happening from multiple, you know, dimensions of marginalization. So, you know, things like poverty intersect with race, intersect with where people live. So, you know, again, we’re needing data on race, but we also need data on, for example, at the ZIP code level, so we can see which communities are being most impacted by this. And so the states’ reporting of COVID-19 health equity data—there’s a website—again, I cannot share this, but they are doing a good job of saying which states have data on different dimensions of equity that we need to be tracking during this pandemic because there’s—again, these things are interlocking. They reinforce one another. And it’s important to understand the complexity of the pandemic so that we can, again, come up with the proper solutions to mitigate transmission and to mitigate death.

[0:56:39]

RICK WEISS: Great resources. Thank you very much. A question here from Anna Nogrotsky (ph), reporter based in Massachusetts for Dr. Henning-Smith—the media has become increasingly concentrated in urban areas in the past decades. Urban reporters can’t travel to rural areas for on-the-ground reporting right now. What would you like to see us do as reporters to adequately cover what’s happening with COVID in rural areas? What news coverage would you like to see more of?

[0:57:09]

CARRIE HENNING-SMITH: That’s a great question. What I would like to see more of is media coverage that talks about the diversity within rural areas. I sometimes say that I think we’ve seen an increase in reporting on rural places and rural people, particularly since the 2016 election. And some of that reporting has been very good, but I think very—too much of it centers on older, white, male farmers who certainly live in rural areas, and I care about them very much, but they are a tiny, tiny percentage of the people who live in rural areas. So I’d like to see more coverage that talks about the wide diversity—economically, racially, ethnically, gender, age and every other variable that you can look at diversity on. And then I think the point about not being able to travel to rural areas is well taken and really important. And I would urge that any good reporting would include the voices of people who are living in rural areas. So you can take my perspective, but please, also talk with people who are living and working in rural areas across the country to get a feel for the diversity within rural places.

[0:58:24]

RICK WEISS: Right. Dr. Kushel, can you talk more about hotels taking homeless populations? Are they openly willing to do so?

[0:58:34]

MARGOT KUSHEL: I think it’s been a slow process. I think, you know, as I said, Connecticut—small state, very badly hit by COVID—really mobilized quickly and was able to make it happen. California, it’s been more of a struggle. The governor initially set a goal of 51,000 hotel rooms, dropped it to 15,000 hotel rooms, and they’re nowhere near that. The problems have been sort of multifactorial. On one hand, a lot of the hotels have been unwilling to participate, I think, because of stigma about this population. Other concerns that they’ve had—that it’s been hard to get them online. It’s also been a remarkably difficult to get staffing in place. These have been very complicated negotiations. And I think there is a difference—you know, the hotels for people who are infected, a lot of hotels have been—and staff have been understandably concerned about their—you know, their risk, particularly the staff who need PPE, and we’ve had such a hard time getting it, our personal protective equipment. But a lot of other places have had difficulty of staffing up.

So there have been places where they’ve been able to bring the hotels online but haven’t been able to get adequate staff in place. The whole process has moved really, painfully, painfully slowly, and I think it’s a combination of both stigma, hotels being reluctant to open to this population. It’s been much easier to convince hotels to take health care workers, for instance, than it has to convince them to take people experiencing homelessness. So I think it’s an ongoing issue.

[1:00:09]

RICK WEISS: Now, I’m curious, just while we’re on it, whether that is one of the options for prisoners who are released. Are we assuming prisoners are being released to families, or are they going to hotels? Is there a program to get prisoners who don’t have some place to go if they’re going to be released? Where do they go?

[1:00:28]

BRIE WILLIAMS: Well, there’s five—over 5,000 prisons and jails, and so you have over 5,000 solutions or lack of solutions. You know, there are a number of people who are incarcerated who have family or friends who are willing to have them come back home, and those people are saying that they are not being tapped, that they are not being asked, that they have a place and they are not getting the opportunity to house their loved one. Then there are people who do not have a place to go. And for those people, we have to—you know, you have to—you do have to work with the local community’s homelessness plan. Those same people, many of them will come out. So 95% of prison and jail inmates eventually leave and return to our communities. So they will leave. They will come back. They will be our neighbors.

And so the question is, you know—I am hopeful that COVID-19 will not last for years and years. I am doubtful, but I am hopeful. People are going to be released. They cannot be kept post—past their parole date simply because, you know, COVID-19 exists. And so some of the questions—we’re going to have to develop systems in place and plans to incorporate people who are returning to our communities into our homelessness planning programs. And every state and every county and every local jurisdiction is having a different response to that.

[1:02:00]

MARGOT KUSHEL: I think this is a place where the structural inequities are so clear. You know, white people are so much more likely to be homeowners because of practices, redlining, you know, all of the other practices that have basically left black Americans out of homeownership. And what we found in homelessness research is that, you know, there’s this myth that people are homeless because they’re disconnected from their families or friends and that is certainly not true and really not true in the black community.

But black households face enormous barriers to taking in their loved ones because they themselves are more likely to be renters and face, basically, the threat that if they bring in someone who’s not on the lease—forget about whether that person has a felony record, which adds this whole other, you know, threat—but face this threat of them being evicted if they take someone who’s not on their lease or if they’re living in housing that’s federally subsidized, they face additional barriers. And then there’s this whole other layer of barriers for people who have a criminal record, which we know is—has much more to do with your race than your behavior, right? There’s such—just incredible structural discrimination in our criminal justice system. So these issues are all completely overlapping.

[1:03:12]

SHARRELLE BARBER: And I’d like to just add one more thing. I know we’ve been talking about these kind of vulnerable populations almost—and, you know, these populations over here. But we’re in a pandemic. So the extent to which we don’t control this in the—among these populations, we don’t control it at all. And so I think that’s what we need to also just be just impressing upon folks is that it’s not just those folks over there are going to experience it worse; we’re all—the whole country is going to be experiencing this because of these overlap—their systems, their structures. And we’re dealing with a pandemic that we really don’t know a lot about. And so, again, you know, again, I loved Dr. Williams’ quote—none of us is safe until all of us are safe in this pandemic. And we have to get it under control here, or we don’t get it under control at all.

[1:04:06]

RICK WEISS: We have a few minutes left here. And I want to take a question here from Kerry Fehr at—sorry—Kerry Fehr-Snyder, who’s the managing editor at KJZZ station in Arizona. Arizona Gov. Doug Ducey has been reluctant to release inmates with lethal health conditions. We have previously reported that the parole board is being ignored despite its recommendation to release inmates, so they can die at home. What else should journalists be covering on this issue? Big question.

[1:04:38]

BRIE WILLIAMS: Thank you for your question. This is an incredible frustration, really, throughout the states. This is not just a problem in Arizona. A lot of the focus of early release has been in jails and has been for people, you know, awaiting trial or held for minor charges. And it really has done very little to kind of harness medical expertise around who is at most risk of seriously becoming much more ill than they already are from COVID-19, as well as the reality of who is a danger in society. I mean, the fact is the vast majority of people in prisons have very good records while incarcerated. But people who are older and with complex, chronic medical illness and serious illness, recidivism rates are vanishingly small. And so these are the populations where we should be absolutely focusing first and foremost on whether or not they have families and communities and homes to go to.

For people who are in our prison’s hospices, for people who are already applying for compassionate release and awaiting a decision about it to apply for compassionate or early medical release in the U.S. you have to already have a plan around discharge planning in place. And so for these people, their paperwork is done. This investigation about their home situation is complete. And so it makes very little to no sense to me that this has not been the absolute first focus of attention. I can’t really answer you why this is not happening across the states beyond politics, but I would say that this is a time when politics needs to be set aside. Where—as my co-panelists have said—this is a pandemic. This is not business as usual. We need to roll up our sleeves. We need to talk about our differences later, but right now we have to control the pandemic.

And so to any degree necessary that you can perhaps report on the number of correctional health care staff and correctional custody staff that are interacting with patients with serious illness on a very, very frequent basis—these are people who require a lot more care and custody because they are so ill, because they are physically and mentally or functionally impaired. They come into contact with more people. And more contact in an overcrowded facility equals more potential to spread disease. And so these are—perhaps you can talk from a public health angle about the absolute public health rationale for releasing people to a home where they can shelter in place and comply with local social-distancing requirements. Happy to talk to you offline, as well.

[1:07:36]

RICK WEISS: I think we’ll have just one last question here. And this is a follow-up from Julian Epstein in New York. This is a little bit more of a medical question, but see if someone wants to address it. Given the comorbidities and preexisting conditions for patients of color and given the lack of effective treatments, would timely and accurate diagnosis—I take it she means diagnosis of COVID—improve death rates? Or would it just have little impact? In other words, can early intervention actually help today in these populations? Or do the existing health inequities present too high a barrier?

[1:08:13]

SHARRELLE BARBER: I would say that’s why it’s important to know, really understand where the disease is spreading, so it won’t spread further in these communities, right? Because, again, we know that they are disproportionately represented among those who have comorbidities. That it would, you know, decrease the death rate I’m not—I don’t—I wouldn’t—I’m not sure. I don’t want to speak to that. But I do know that, again, the testing, kind of access to treatment, all those things combined can I think, you know, mitigate some of what we’re saying. We want to eliminate all of it, but it won’t eliminate it—you know, none of this is going to be eliminated. What we’re trying to do is mitigate, right? And so, you know, again, there’s so many different things that are happening, underlying chronic conditions being one reason that the racial minorities are at disproportionate rates of dying. But there’s so many others that we can control and that we need to address in the midst of the pandemic.

[1:09:11]

MARGOT KUSHEL: And I would add, you know, yes, we don’t have a cure. You know, the medicines have been sort of disappointing, but we do have supportive treatment. So in addition to absolutely what Dr. Barber said about reducing the risk of spread, allowing—giving people the opportunity to isolate from their family or friends. You know, so much of this spread seems to be presymptomatic. And I think Dr. Williams’ point is really important. Asymptomatic doesn’t mean never get symptoms. It’s that people are asymptomatic when they’re tested, and then they develop it. So one is you give people the opportunity to present—to prevent spread to their loved ones or make their loved ones aware.

But also I have no question that supportive treatment, what we’re using, you know, is helping people stay alive. And we’re going to get better at this. We’re going to get better over time. And so sort of just throwing our hands up and say, if you have COVID, it’s a death sentence, I don’t think is accurate or fair. And in that reason—you know, for that reason, if it were your loved one, my loved one, we’d want them to know so they could have careful monitoring so they could get anticipatory guidance. Bree probably as well has seen we’re doing a lot of care for people who have COVID, a lot of telehealth or where—you know, chatting with them every day and trying to give them guidance of when they actually need to present to the hospital and when they don’t. I have no doubt that we can improve people’s survival if we get to them sooner. Just because we don’t have been medicine doesn’t mean we don’t have supportive treatments.

[1:10:38]

BRIE WILLIAMS: And I would add in here that for many people who are—previously may have chronic health conditions but have never thought about what they would want in the event that they become seriously ill and also face the end of life. Having knowledge about a serious life—potentially life-limiting illness gives people the opportunity to have conversations with their family and friends to talk about what they would want, to talk about what’s important to them, to talk about what their goals of care would be. And we really—when people don’t have information, then they are not able to get the take of conversations and knowledge and communication about their wishes to their health care staff or to their families and loved ones that they should. So I think it another reason it’s really important to have these diagnoses because people get sick really, really quickly.

[1:11:32]

RICK WEISS: Well, on that note, I want to start to wrap up today’s briefing. I do want to give each of our speakers just a final half a minute each to offer the reporters on the line a final take-home point or a story suggestion, something they would like to make sure that you all leave this briefing thinking about. And I will start from the top with Dr. Margot Kushel.

[1:11:53]

MARGOT KUSHEL: Great. Thank you. I think that we can’t report enough on the interaction between housing and COVID on a spectrum from housing crowding—which is different than density. Density is the number of people on a block, that seems to be less the problem than housing crowding, the number of people in a household—all the way to homelessness. And to say that in some ways this—homelessness has always been a crisis for people’s health. We are now spending a lot of money and a lot of time and a lot of public health effort trying to mitigate a crisis that is entirely of our own making. Homelessness is entirely a sort of made crisis because of, you know, disruptions in federal funding and federal support for it. And now everyone’s scrambling from behind. So I guess I would say focus on the needs of people who are experiencing homelessness. Recognize that many of them are in the workforce and many of them are front-line workers who are then, you know, going from homeless shelters or encampments to be fast-food workers, you know, back to those encampments.

We’re going to see a lot of suffering, a lot of death, and it’s going to be very hard to control this pandemic, as I think Dr. Barber said, if we don’t address it in all populations. So I would focus on the intersection between all of the things we’ve been talking about, recognize that they’re just part of our community. These people are part of their communities, and they’re just extraordinarily high risk. I feel like we’re spending a lot of time sort of focusing on people in parks, you know, sort of out sunbathing and not spending a lot of time focusing on people living in homeless shelters and encampments and correctional systems and, you know—and others where they’re at incredibly high risk. That’s where the risk is. That’s where the suffering and death is. And, frankly, that’s what’s going to keep us from reopening, which is all of our goal (ph).

[1:13:40]

RICK WEISS: Sounds like that’s where the journalism should be. Dr. Brie Williams.

[1:13:46]

BRIE WILLIAMS: Yeah. I think this has been an incredible panel. So, first, I just want to say thank you so much. It’s such a pleasure to be on the panel with the other three panelists. I’d say, you know, a lot of the conversation has been on decarceration release already. That has to continue to be the push. The reason for that is to cohort people to allow people who are left inside to be able to be socially distant and to spread the limited resource of prison health care out throughout the population in a more efficient and effective manner. And we have to ramp up testing of all asymptomatic staff and residents. I think secondarily we need to begin turning our attention to these horrific stories that are beginning to emerge around the nation of people with serious illness who are dying or about to die of COVID-19 in our community hospitals and how incredibly difficult it is to get them ethically appropriate palliative care, meaning the appropriate care of people at the end of life, at the time that they need it where they need it and when they need it. I would also say that I would love to see some reporting that focuses on correctional officers and correctional health care workers who, again, are very much putting their lives on the line.

Many times, these are jobs that are—there are no other job opportunities in the rural communities or the underserved communities where people live. These are very complex, difficult positions. There’s a lot of fear. And there is, you know, focusing I think—I can’t remember if it was a Dr. Henning-Smith who talked about the need for hazard pay and other types of worker rights or if that was Dr. Barber—but really focusing on what is the experience of being on the front lines in this pandemic when people know very little where you are working in a place where it is almost impossible to socially distance and how absolutely terrifying that can be and really focusing on occupational safety and what this means moving forward. So I guess, overall, I’d say, please don’t forget about the population of people who are incarcerated in our nation’s prisons. This is—nobody was sentenced to a life sentence of COVID-19 and death by COVID-19. And this is a really—it’s a devastating window into how racist and terrifying our criminal justice system is for the many people who live and work in them. Thanks so much.

[1:16:06]

RICK WEISS: Dr. Carrie Henning-Smith.

[1:16:08]

CARRIE HENNING-SMITH: I want to echo my thanks for being on this panel and to my co-panelists, who are incredible. And I also wanted to echo the point that this is a pandemic that impacts all of us. We can’t other any community here without getting hurt. And we particularly can’t other rural people and rural places. We’re seeing, in really visceral ways, the ways that we’re connected now, with disruptions to our food supply chain, what’s happening in meatpacking plants, dairy production. I think we’re seeing the way it’s showing up on our grocery store shelves. I’m hoping that we’re realizing the ways that we are actually already interconnected and have been forever. In the very immediate short-term, we need to focus on stabilizing health care, health care access in rural communities so we don’t see any more hospital closures, so that we can support the small group and the very brave group of health care providers who live and work in rural communities, who are on the front lines of treating this.

And then in the long-term, we need to think about some of the structural inequities in economics, in access to job opportunities, access to health care and health insurance, access to broadband internet and infrastructure in rural communities. And above all, we need to focus on the ways that rural areas are not monolithic. The risk is not equally distributed within rural communities for COVID-19 or for any other health outcome.

[1:17:40]

RICK WEISS: Thank you. And finally, Dr. Sharrelle Barber.

[1:17:43]

SHARRELLE BARBER: Yes. Thank you so much. Again, it’s been a complete honor to be on this panel with so many amazing scholars. Again, I would just stress a couple of things. One is just data, data, data. We cannot address what we cannot see. We have to use data to make the [invisible visible]. And that means collecting data on race. But it also means collecting data on other sociodemographic characteristics such as poverty, such as where people live and gender, et cetera, so we can see the ways these inequities are intersecting to magnify and to, really, amplify COVID-19 in certain populations. I actually—and actually, as we are in the midst of many of our states relaxing social distancing orders and seeking to reopen, I would just say, we are not ready. And we’re especially not ready for the communities that we have talked about today. We don’t have enough testing. We don’t have enough contact tracing. We don’t have enough places to isolate people so that they can safely recover. And this impact is going to be disproportionately felt among marginalized racial groups, among poor rural folks, among prisoners and among the homeless population. So you know, our itching to reopen is really not driven—is really driven by greed. And we’re not taking the lives of those that are most vulnerable into consideration.

And then finally, something I learned from my research in Brazil—(non-English language spoken)—”I am because we are.” We’ve said that all on this call today. And this public health crisis that we’re in is just amplifying that even the more. The extent to which we don’t deal with this pandemic among all of these populations means we don’t deal with the pandemic, which is why myself and scholars from UCLA and Harvard have decided to join with the Poor People’s Campaign, which is a large movement of grassroots folks from across the country. Because what we require in this moment is not just the kind of immediate actions necessary to curb the pandemic, but to really rid ourselves of the structures that have created this crisis, the structures that have created what we’re seeing in terms of the disproportionate impact on certain communities. And so I would cover the stories of not only what the—kind of the disproportionate impact is, but the communities who are rising to—raising their voices, who are saying, we’re not going to take this sitting down. We need to be amplifying those voices because they are the ones on the ground directly impacted but continuing to advocate and really mobilize to put—to hold local, state and federal officials accountable. Those stories also need to be told if we’re going to move the needle during this pandemic. So thank you.

[1:20:28]

RICK WEISS: I want to thank all four of you for spectacular presentations and discussion today. It’s so important. I’m really glad we got to cover this aspect of what’s going on in the country today. Thank you all. Reporters who are on, I would ask you all to—as you leave this briefing, you will get a prompt to do a very quick three-question survey. It takes less than a minute to do. It really helps us to keep high quality briefings coming your way, so please do us a favor and do that. Take that one minute as you log off to answer that survey. And finally, just, again, thanks to our panelists, a fantastic discussion today. All these materials will be up on our website within the next 24 to 48 hours. Follow us on Twitter @RealSciLine. And thank you. We’ll see you at the next SciLine media briefing. So long.