Structural racism and health in Black communities

[0:00:00:]

RICK WEISS: Hi, everybody, and welcome to this media briefing brought to you by SciLine. Just as a quick reminder, for those of you who are not familiar with us, we are a philanthropically funded, editorially independent free service for reporters. We provide a variety of services to help get more research-based scientific information into the news. Among those services are these media briefings, which provide you the opportunity to hear briefly from, typically, three experts on an area that’s of scientific relevance in the news and a chance to ask questions and get answers at the end of the briefing.

Today’s topic is not new by any means, but one that has become newly visible, for sure, with the arrival of COVID-19, and that is the impact of racism on health outcomes in this country. And in this briefing, at least, we’re talking about not the interpersonal, day-to-day manifestations of racism through the experience of racial slurs or, you know, individual insults, but we’re talking about elements of structural or systemic racism that are effectively built into society and that take a chronic toll on affected populations.

And to get into this with us, we have three experts with fantastic backgrounds, research backgrounds in this area. And I will just briefly tell you who they are because their full bios are on the website. We’ll hear first from Dr. Margaret Hicken, who is the research associate professor at the Institute for Social Research at the University of Michigan. She’s an interdisciplinary demographer and epidemiologist, and she will start us off with an overview of structural racism in the context of health. And she’s going to offer a particular focus on racial residential segregation as one aspect of U.S. structural racism and a contributor to health inequalities.

And I am getting some background noise here, so I’m going to ask our speakers to mute until their time comes up, actually. Thank you.

We’ll hear next from Dr. Chandra Ford, who is a professor of community health sciences and founding director of the Center for the Study of Racism, Social Justice and Health at UCLA’s Fielding School of Public Health. She’ll focus on the implications of structural racism embedded in the health care system, including implications for access to that care and race-based differences in the experience of receiving health care with some interesting, I think, historical perspective by looking back at earlier days of the HIV/AIDS epidemic.

And, finally, we’ll hear from Dr. Hedwig, or Hedy, Lee, who is a professor of sociology at Washington University’s new Center on the Study of Race, Ethnicity and Equity. She’ll talk about the constant systemic stressors faced by individuals, families and communities of color and the health costs associated with having to maintain a constant state of vigilance in light of these race-related stressors.

So with that, let’s just start right off. And I’d like to introduce Dr. Maggie Hicken.

[0:03:18:]

MARGARET HICKEN: Thank you so much, and thank you for this opportunity to share my work. And I’d like to also thank the panelists. I’m very excited for this discussion. So to begin, I’d first like to say what I mean by racism. Rick already did a really great job, but I’d like to be even more specific. So I borrow from philosopher Charles Mills when I say that racism is a political system. It’s a particular power structure of formal and informal rule, socioeconomic privilege and the norms for the differential distribution of material wealth and opportunities, burdens and benefits, and rights and duties.

So here we are talking about structural racism, the interconnected institutions that comprise the structure of American society. So—but one thing is that structural racism is simply the actualization of cultural racism, which encompasses the socially accepted ideologies, values and behavioral norms of what it means to be American. These were historically set by white men and are currently maintained by all of us as an American society. So these norms, values and ideologies are often invisible to many of us because they are givens, and they are our assumptions and our default way of looking at things.

However, our value system here gives rise to the institutions that we support and how these institutions operate. Ultimately, cultural racism shapes the answer to the question, who deserves to live a long and healthy life? For example, given the robust evidence on the importance of education in the lives of children and their future, if we as a society valued the social, economic and life chances of children, we might invest more heavily in our educational system, as other societies do. Or perhaps, more specifically, given the evidence on the persistent racial inequities in education, if we valued the lives of Black children as much as we value the lives of other children, we might invest more in high-quality public education for all children equally, no matter their race.

So one note, as Rick had said earlier, is that because cultural and structural racism are woven into the very fabric of American society, they do not require personal dislike of any particular racial group, of any particular person. They don’t even require any explicit action on the part of us—on any part of us. It continues to operate without explicit intention of doing harm or of any personal dislike.

So the structure of our society is composed of these interconnected institutions: our educational, criminal justice, our economic systems, our media, and our families, et cetera. So these institutions also don’t operate independently but work together to maintain white privilege that is ultimately set by the cultural racism, by who we value and what we value. Importantly, then, as one institution appears to move toward equity, other institutions will move in to maintain that overall equilibrium of white privilege and control of Black Americans set up by cultural racism.

And so I’m going to use some examples of the institutions that direct the development of our neighborhoods as an example. So neighborhoods are not naturally occurring. They are created through the policies and practices, investments and disinvestments, by both the state and commercial interests.

So residential segregation, where families of different racial groups on average live in different neighborhoods, I would argue, is a major tool by which we seal in racial health inequities. By separating families of different racial groups from each other, the state and private entities can then target their social, educational, economic, environmental, and political investments to certain neighborhoods and away from other neighborhoods. So at first, residential segregation was heavily mandated, heavily promoted by the state. But now it is self-sustaining with support from several institutions, from private businesses, from local homeowners’ associations and practices.

And there’s some examples that I want to give of how institutions that guide neighborhood development work together to control Black Americans and families and maintain white privilege. So first, we have collusion, you know? Based at the most fundamental level, we have collusion between local governments and commercial interests to direct public and private resources away from Black neighborhoods, toward white neighborhoods, especially toward white, affluent neighborhoods. But even when civic resources are not available or when they’re scarce, white, affluent neighborhoods have shown that residents will band together to provide their own high-quality resources, even basic sanitation, that is not available for residents of other neighborhoods.

Then, through the criminal justice system, the educational system, the Environmental Protection Agency, the state, then, hyper-polices, disinvests in education in and then directs polluters toward Black neighborhoods. And what results, then, is this pipeline from Black—particularly poor Black neighborhoods—to the criminal justice system through this over-policing, oversurveillance and devaluation of the property there. So mass imprisonment has been shown to destabilize communities, as, I think, Hedy may talk about, resulting in poor health even for those residents who are not directly related to those who are imprisoned.

And I can definitely take questions on the evidence on over-polluting neighborhoods and things like that and what came first, whether the people or the people or the polluters came first.

So residential segregation has important implications for racial health inequalities. For example, cities with high levels of segregation, where Black and white families live separate, in separate areas of the city, show very large Black-white inequalities in numerous chronic conditions ranging from cardiovascular disease to hypertension, diabetes, obesity. Residents of neighborhoods with higher segregated clustering of Black residents experience a greater risk of developing these diseases, as well, compared to residents of other cities. And recent evidence also suggests that moving to neighborhoods with lower levels of racial segregation, lower levels of clustering of Black residents, is associated with, then, a decreased risk of developing hypertension for Black residents.

And so it’s not simply that Black but not white families live in poor areas of the city, because even when we look at non-poor areas, there is still substantial health inequalities, with roughly 25% of white adults but 55% of Black adults experiencing hypertension even after accounting for many health behaviors and health care characteristics and things like that. So indeed, upwardly mobile Black—upwardly mobile and middle-class Black families are not able to translate their social class into more affluent neighborhoods to the extent that white middle-class families are. And they’re generally exposed to the same neighborhoods experienced by poor, Black families, which has definite implications for health.

So one of the things that I have been studying now—and that the science is moving forward—is how does this happen? And I know that Chandra and Hedy are also going to talk about this. But one of the ways that I’m studying how this will happen is through changes in—molecular changes in our body and how our genes are regulated. So I’m studying the role of segregation and epigenomics, which is a field of study that examines the chemical components of our body that attach to or shift parts of our DNA. So it’s not part of our genetic makeup, per se. But it helps direct the genes that are turned on and off. And these epigenomic parts of ourselves can be in—parts of our cells are actually influenced by our environment. And social epigenomics is actually a new field of study supported by the National Institutes of Health by where we examine the ways in which the social environment can affect these genome—these epigenomic pieces. And so I look forward, then, to taking questions. This is still a very new field of study. But the the theoretical development is, actually, very promising. So thank you very much.

[0:11:49:]

RICK WEISS: Thank you, Maggie. It’s so interesting, you know? Molecular biologists have been talking for some time now that it’s not just that DNA controls our life and our environment, but the environment can affect our DNA. But the idea that societal influences can actually have a molecular impact and have that translated into health is, I think, a really interesting frontier to follow. Up next, we will hear from Chandra.

[0:12:18:]

CHANDRA FORD: Thank you. I was asked to address racism and health care and implications for the COVID-19 pandemic. The evidence on COVID-19 is still emerging, so I’ll highlight lessons learned from the HIV epidemic in particular, which parallels the COVID-19 pandemic in ways that are highly relevant. I’ll start with situating health care within a public health framework, illustrate just two of the many ways racism operates in health care, and I’ll conclude by citing two recent studies and three resources that I think offer solutions.

The COVID-19 pandemic is a public health crisis, so this schematic situates the health care system within a public health framework. The entire schematic constitutes a public health response. The latter portions, shown here in the orange and red chevrons, are the health care system. It is the portion of the public health response that focuses on detecting infections and primarily treating persons with the disease. Much of the focus to date has been on improving access to care, specifically access to COVID testing, but lessons learned from the evidence on maternal mortality, as well as the HIV epidemic, include that having access to health care, though critical, does not eliminate disparities, in part because inequities also occur within the health care system.

Racism occurs at each stage of the health care continuum—and that is the continuum you see here—which represents different points of entry into the health care system. The nature of the racism exposure at each point of entry, the implications for inequities and the types of interventions that are likely to be effective depend in part on the stage of the care continuum at which the racism exposure occurs.

For example, the HIV care continuum includes diagnosis of an HIV infection, getting linked then to specialized HIV care, retained in care at the recommended number, frequency and types of visits and then being retained—excuse me—adhering to the prescribed treatment or medication regimens. With HIV, one thing that we have found is that African Americans have concerns about racism that affect how well they are retained in care, so later in the continuum. But those same concerns do not appear to be a barrier to African Americans getting tested for HIV infection.

Two readily identifiable ways that racism operates in the health care system, though not the structural mechanisms directly but influenced by it, include implicit racism or implicit bias, which we often hear of widely, as well as racism-based mistrust and conspiracy beliefs. Implicit racism encompasses both the perceptions that providers hold of patients, perceptions that differ systematically based on patient race, together with the actions providers unknowingly take based on those perceptions. It operates beneath their level of consciousness and without their express intent. Examples include not taking Black patients’ concerns seriously and assuming that Black patients will not adhere to prescribed treatment regimens. Researchers have shown that white providers, for instance, prescribe medications at lower doses and later in the course of disease for Black versus white patients. The implicit bias literature has shown that these patterns are attributable in part to implicit bias.

Racism-based mistrust of the public health and health care sectors is longstanding and well-documented among African Americans, and it stems from legitimate concerns due to historical and ongoing experiences with racism in these sectors. It indirectly affects health care outcomes by influencing African Americans’ willingness to accept prevention messages and engage with the health care system. Racism-based conspiracy beliefs grow out of this mistrust, and they are completely unrelated to, for instance, the science denialism that we see with climate denialism. Racialized conspiracies—racialized conspiracy beliefs are condition-specific and population-specific.

With respect to HIV and family planning, for instance, evidence has repeatedly shown that between 20% and 25% of African Americans believe that the disproportionate burden of HIV that affects the African American community reflects either a conspiracy of intent or a conspiracy of neglect, such that, for instance, quote, “AIDS is a form of genocide against African Americans,” unquote. On top of this, an additional 25% percent of African Americans believe that the HIV-AIDS epidemic might be a conspiracy to commit genocide against African Americans.

Much of the focus with COVID-19 has been developing a vaccine—so getting tested and getting a vaccine. However, the development of effective treatment does not necessarily eliminate disparities. This chart shows the proportion of all AIDS diagnoses. And at the time, we thought of AIDS as an end-stage condition of HIV disease. The proportion is on the Y axis by race and ethnicity from 1985 to 2009.

And there’s a lot we could discuss here. I just want to draw your attention to one point, and that is that although African Americans accounted for a disproportionate share of all infections since the beginning of the epidemic, it’s really—in 1984, with the introduction of the lifesaving antiretroviral therapies and their widespread availability by 1996, that the disparities are exacerbated, and that is that African Americans actually surpassed whites in terms of representing a greater share of all of these end-stage diagnoses than whites, and that that pattern was exacerbated, importantly exacerbated, by the availability of antiretroviral therapies. This graph merely shows that that trend has continued through 2018 and that African Americans not only began accounting for a greater proportion of all AIDS diagnoses—so proportion in the prior slide—but also for a greater number, absolute number, of diagnoses than whites, which is remarkable given Blacks represent only about 13% of the U.S. population.

Recent evidence and resources offer guidance for developing solutions. The evidence suggests interventions that address specific ways racism operates in health care can be effective, whether the interventions are themselves explicit about racism or not. One example of a possible solution comes from a recent study by my late colleague Billy Cunningham. Previously, researchers had established that among Black and white patients, all under the supervision of white HIV care doctors, Black patients were prescribed HIV medications later in the course of disease. The purpose of this most recent study was to see if, by providing an information system that improved the quality of the data in all patients’ medical records, they might somehow circumvent individual providers biases. And the results of the study showed just that, both that they were able to eliminate—reduce substantially health disparities and, importantly, to contribute to improvements for all patients.

A very different intervention model was implemented by the ACCURE Project, Accountability for Cancer Care Through Undoing Racism and Equity in North Carolina, using a community-engaged participatory partnership involving two cancer centers, community members, patients as well as others affected by cancer and academic partners. Kristin Black and her collaborators drew on anti-racism principles from the undoing racism program to, quote, “interrupt the pathways by which structural racism impacts,” unquote, disease progression among patients with breast cancer and lung cancer. And it was really phenomenal to hear about this work when I had a chance to visit with this team in North Carolina. What they found was that through this process of community—full communitywide engagement to understand and address structural racism, the health—the cancer centers were actually able to reduce disparities both in breast cancer and in lung cancer. And this effort is described in much greater detail in the first of these resources provided here—”Racism: Science and Tools for the Public Health Professional.” In addition to that book, “Unequal Treatment,” the second book here, and “Communities in Action: Pathways to Health Equity,” both products from the National Academies, are resources I would highly recommend for those interested in trying to understand solutions to these racism-based health care problems. Thank you.

[0:22:53:]

RICK WEISS: Thank you, Chandra. It’s so important for reporters covering COVID-19 now, where so much of the talk is still about racial differences perhaps being biological or, at best, being about access to see that there is this whole stratum of differences that matter underneath that and great to see that, actually, social science research is starting to find solutions to it. It’s a whole area, I think, of journalism that is still undercovered. So wonderful to see that. I will turn here to Hedy.

[0:23:25:]

HEDWIG LEE: Hi. I’m here to share with you information regarding unique, structurally rooted chronic stressors faced by African Americans. But before I do that, I want to define stress so that we’re all on the same page. So stress is a negative emotional state occurring in response to events that are perceived as either, one, taxing or, two, exceeding a person’s resources or ability to cope. There are two kinds of stress—acute stress and chronic stress. And chronic stress, as I will explain, is bad for your health. But, first, let’s talk about acute stress. The body is superbly adapted to dealing with short-term stressors, and it needs to be. When we’re in a stressful situation, like handling our car when it’s hydroplaning or running to not be late to an important meeting, our bodies’ energy stores and other hormones increase to help us run and maintain focus. You recover quickly, and you go on about your day. But chronic stress, on the other hand, is something that wears you down over time, day by day, and overtakes you, like this image that I’m showing here. Constantly experiencing discrimination or harassment at work is a good example. The body is pathogenic to this kind of prolonged psychosocial stress. There is no recovery. The hormones and chemicals released constantly to deal with chronic stress can harm the body over time. And chronic stress is a powerful predictor of mental and physical health through the direct biological pathways I just described but also through health behaviors used to cope with chronic stress, like overeating and drinking. And this is the kind of stress I want to talk to you about today.

I’m going to focus on two of these, but I’m happy to talk more about other stressors, and I’m sure the other speakers would, too. And the two I’m going to focus on our racism-related vigilance and criminal justice contact. If there’s time, I want to talk about how reparative actions, like the removal of Confederate monuments, might be salubrious for the health of populations. So hopefully I can end on an optimistic note.

So first, I want to talk about racism-related vigilance or constantly having to think about, anticipate and prepare for discrimination. It is an important form of stress for Black Americans that is a consequence of racism. Black Americans have developed adaptive strategies to negotiate everyday social spaces such as the workplace, stores, parks and other public spaces to deal with racism. And vigilance can manifest in many forms, including adapting presentation of self, including your style of dress and the way you speak, avoiding situations where the likelihood of discrimination may be higher and preparing daily for the possibility of experiencing discrimination. So Rick talked about discrimination, but we’re here talking about how communities have to prepare for these experiences every single day.

So there’s a diverse literature providing evidence of these behaviors. So for example, African American male college students making sure to always have their backpack and ID so as not to be misidentified as an interloper when they’re walking on their own school grounds, or Black women avoiding shopping in certain stores because they don’t want to be followed or assumed to be thieves. And preparation for vigilance was eloquently discussed by Melody Cooper, the sister of Chris Cooper, the Black birder in New York City who had been mistreated by a white female parkgoer, when she wrote an op-ed about the situation. I think this is a really good example of what we mean by vigilance. So she wrote, because even though he walked away and even though I’m relieved, there has still been a toll. We felt it before the incident with Amy Cooper. Every time we walk out of our door, we have cause to worry. My brother worries when he sneaks through the trees to catch a glimpse of a beautiful warbler. I worry when I check late into an Airbnb and every time my son gets in the car. Others wonder if a trip to the corner store or gas station might result in a phone call that will end their lives. So many of us wonder if we’ll be put at risk by our mere existence. And this is the form of chronic stress that takes a toll on the body and have been linked to things like hypertension, sleep difficulty, mental health and obesity.

The series of pictures tweeted by artist Moise Morancy that I show here allude to the limits of these vigilant behaviors. So vigilance is a rational response to living in a racist society. But it is not only taxing on your health, it may not matter to protect you from discrimination or harassment, which is what he’s trying to evoke in this image.

The second chronic stressor I want to talk to you about is racial disparities in criminal justice contact. One in every 15 Black men are currently incarcerated. One in two Black women have at least one family member that’s currently incarcerated. And more recent estimates suggest that even highly educated Black Americans also are impacted, with 1 in 2 black adults with a college degree or more having a family member—having had a family member in jail or prison. There’s been a lot of recent research on racial disparities and police contact as well. For example, we know 1 in 1,000 Black men and boys will die at the hands of police. Contacts with the criminal justice system have health implications. So, for example, police killings are a leading cause of death for young Black men.

But health consequences extend beyond those in direct contact with the system to families and communities connected to these individuals. So families deal with the consequences of incarcerated family members financially, emotionally and physically, and there’s a wealth of research linking those experiences to health I could talk about in the Q&A. Overpoliced communities face stressors related to being under constant surveillance, as Maggie alluded to earlier. And some new evidence suggests African Americans can even experience stress due to witnessing racial police violence on social media.

Here, I focused on African American communities and only two forms of chronic stress, but there are many others to discuss also impacting Native American and Latinx populations that I’m sure we’re all happy to talk about as well.

So finally, on a more optimistic note, recent reckonings with histories of racial violence through actions like the removal of Confederate monuments and other symbols of oppression may have a salubrious impact on the mental and physical health of communities, particularly communities of color. And to my knowledge, this has not been tested. But there was just a great AP article using the term rapid reckoning. There have been 38 removals of monuments since the death of George Floyd, for example. So while we’re in a moment where racial disparities across multiple domains are being laid bare, we are also in a moment where there are movements for change—lots of recent examples in the news that we can talk about. As scientists, understanding the impacts these movements will have for health and well-being is an important next step. So thanks for listening. And I’m excited to take questions.

[0:30:00:]

RICK WEISS: Thank you, Hedy. That was so clear—really appreciate that presentation. So for the reporters on the line now, as a reminder, you can hover over the Q&A button at the bottom of your screen and offer your questions up. You can point that question to a particular speaker or leave it generally available for any to answer. And I’m going to start right off here with a question from Kate Gavagan from sciinthetri.org in North Carolina for Dr. Hicken. You mentioned DNA methylation. The question is, is this epigenetics? And can you explain the relationship there between the epigenetics that you referred to and DNA methylation?

[0:31:21:]

MARGARET HICKEN: So that’s a really great question. Actually, DNA methylation is a form of epigenetics—epigenomics. So there are different kinds of epigenomics, and DNA methylation is one of them. So that is when certain molecules are attached to the DNA to guide gene function, so whether genes are turned on or off. And epigenomics guides a lot of our makeup of why we have certain hormones produced at certain times of life, why we develop as children.

But the field of social epigenomics is about how things in the social environment can actually affect the DNA methylation, the attachment and detachment of these molecular pieces. So we are still really early in this field of social epigenomics and DNA methylation have a social environment then affects methylation.

So there has been one study that I know of on neighborhoods from a few years ago from the University of Michigan that suggests that living in socially disadvantaged neighborhoods, so neighborhoods with high levels of poverty and also that are more segregated—higher levels of black residents—is related to—the residents that live in more socially disadvantaged neighborhoods actually show a methylation pattern, a DNA methylation pattern and epigenomic pattern related—consistent with inflammation, turning on genes that are related to inflammation, which is then related to cardiovascular disease, diabetes, hypertension, et cetera. And so, right now, what we’re doing is trying to push that forward to see if segregation, then, specifically is related to other parts of the epigenome.

[0:33:29:]

RICK WEISS: It’s so interesting. And I’ll just mention on the side I know there’s still early days research in epigenetics. Some of these changes are actually heritable. And it would be very interesting to learn in the long run whether some of these socially induced impacts on DNA might not only be causing issues now but for people’s children as well. I have a question here from Lesley McClurg at KQED in California. Beyond maternal health, what field in medicine do you think is most impacted by racism in health care? I suspect a few of you might have something to say about that. Anyone want to address a particular health problem?

[0:34:26:]

CHANDRA FORD: I would say that I would not privilege maternal health as unique—as impacted more. The issue is not really one of quantity but rather how racism affects different people in different ways. And so with respect to, for instance, maternal mortality, one of the reasons I would caution against focusing on maternal mortality is that mortality is a very particular outcome that’s easy to recognize, but there are other—especially, it looks like it’s right—that we can see it and it almost seems immediate, perhaps. But there are many other outcomes along the entire life course and many other ways in which racism affects both the individuals and communities and populations, families. And so, really, the question, even within the context of health care, is about the many different ways in which it has impacts both in terms of attitudes, behaviors, et cetera but also directly on the body.

[0:35:47:]

HEDWIG LEE: Yeah. I would just add that we use measures of mortality because they’re easier to get access to. We just have lots of limited health information, so there is also a need to be collecting more data, especially when we’re thinking about collecting information for a racial, ethnic or minority population. So the bulk of our research is around those topics more because of data availability and less because other measures of health are not sensitive to chronic stress and racism.

[0:36:18:]

CHANDRA FORD: That’s a great point, Heddy. And just to echo something there, I would also add that whereas we actually have seen this with the COVID-19 pandemic. And whereas we do get some data on, for instance, testing, where there’s a big black box, in many respects, is, what happens once people get into the health care system? Are there strategies put in place to monitor inequities or even to track them? That, I think, is an area that requires really a lot more data.

[0:36:54:]

RICK WEISS: Thank you. A question here from Cara Anthony, a correspondent at Kaiser Health News based in St. Louis. I’m wondering if someone can point me toward research that addresses why Black men and women are often misdiagnosed with cancer, Alzheimer’s and other conditions; separately, also curious about studies that address why doctors overmedicate Black patients. Sounded like we heard earlier that in some cases they may be undermedicated, but it would be great to address that issue. Hedy, do you want to start on that?

[0:37:27:]

HEDWIG LEE: Sure, I mean, yeah, and I’ll probably pass it on to Chandra and Maggie because I think Chandra put up a really great book that’s an older book now, but the Institute of Medicine “Unequal Treatment” highlights a lot of the work that talks about sort of doctor bias in terms of diagnoses and a lot of studies, experimental studies, other kinds of surveys, that show this systematic bias. There are many other people that we could talk about. One person that just comes to mind is a gynecologic oncologist named Kemi Doll at the University of Washington, who’s doing a lot of work on underdiagnosis of endometrial cancer among African American women, which is a highly—it’s easy to actually treat, but Black women are underdiagnosed and dying more quickly. Gwen Ifill is one example of a person who died of endometrial cancer. She’s doing a lot of work there, so I would, you know, also check out her work, and I’m going to let the others chime in here.

[0:38:24:]

RICK WEISS: Maggie, did you want to add to that?

[0:38:26:]

MARGARET HICKEN: Yeah, thank you. So I think that also a part of it—I can speak to certain things about cardiovascular disease and about kidney disease. Those are the two—I study chronic disease like that. So a lot of times what we use is we have algorithms that help physicians determine how to make diagnosis, what medications to prescribe. And the thing is that these algorithms that we use or the way that we define disease is actually historically racial biased. We just still continue—medicine still continues to use these equations that just somehow account for race in some, you know, in some mysterious way.

And so there have been—Dorothy Roberts has been talking a lot about these algorithms and how they actually kind of reify this biological difference between the races that just has really not been shown. The other thing is that I draw from Melissa Harris-Perry, who wrote a book several years ago called “Sister Citizen.” And while she talks about Black women in particular, it is about this—I think more broadly there is evidence to suggest, and Chandra had also touched on this, that the physician, they see what they want to see. And so when a patient comes in with certain conditions, you know, we—physicians—they attach certain stereotypes that are endemic to American culture about different racial groups. And so they may take in certain information and not take in other information. So I think it’s a combination of a history and this—what we consider science and the use of these algorithms in diagnosis. But also, there is some implicit bias, as Chandra had talked about, and I can definitely pass it on to her.

[0:40:17:]

CHANDRA FORD: The only thing I would add is that the literature on implicit bias, as well as on other forms of contemporary racism—so a lot of the ways in which people have thought about racism are tied to the ways in which racism operated in the mid-20th century. But as we think about the ways it operates in the post-civil rights era, it’s in more sophisticated, more nuanced ways. And the specific outcome, or—excuse me—condition or population and context really matters in determining whether people are likely to be over or underdiagnosed, in addition to the general stereotyping that we see in the society. The public health and medical sectors are not, and they never have been, accepted. You know, they’ve always reflected the same kinds of racial stereotyping and racialized dynamics that the broader society contains.

[0:41:24:]

RICK WEISS: Thank you. A question here from Bonnie Juettner, a freelance reporter based in Milwaukee. I’ve noticed that in Milwaukee, volunteer groups that offer services in our local jails and prisons can no longer visit because of COVID-19. Do you know if there are public policy concerns about the sudden drop in services to people who are incarcerated? Also, with regard to incarcerated populations, is there research on how it affects the human body when people are denied access to fresh air and nature? At the Milwaukee Security Detention Facility, inmates are not given any outside time and don’t have access to windows. Hedy?

[0:42:01:]

HEDWIG LEE: Yeah. I think that’s a really great question. It’s multifaceted. And I’ll say a couple of things because I could take the whole time responding to this. First is the conditions of confinement in prisons have been a problem pre-COVID. People who have been doing research in these areas, like me and others, have already been ringing alarm bells around the fact that population groups in prison are not getting the services that they need, whether those are health or other kinds of requirements to live a healthy life, like access to healthy foods, proper ventilation, proper materials to be able to sanitize correctly. And you’ve probably seen news reports about this. So I think many people who’ve been studying this were just sort of holding their breath when the COVID pandemic hit.

There are, I think, pockets of individuals talking about this across states, a lot of advocacy groups that are trying to collect better information. And to be sure, the services that were coming into prisons are important and crucial, especially given the lack of services writ large in most prisons and jails in terms of being able to accommodate things that the actual prison or jail can service.

I myself work through the prison education program at Washington University. And, of course, because of regulations, people can’t come in. So I think this is an important issue that needs more attention that’s being talked about. And there are definitely funders across different states, et cetera, that are trying to work with researchers and advocacy groups to sort of help with that.

And also, to mention, as it relates to my presentation, is that a lot of the consequences of these experiences also impact the health of family members and communities that individuals in jails and prison are connected to. They’re the ones paying the commissary and already have—strapped for cash are then having to send that money to family members. They’re the ones worrying and having to call and use time to figure out what’s going on. And when—and in some states, there have been early release of individuals. But because there has already been infection, that means individuals are returning to communities that may not also have the capacity to deal with being able to, for example, properly quarantine. So it’s a multifaceted issue. It’s not just a criminal justice policy issue. It extends to so many dimensions of our sector. And so I think that’s a really great question. I don’t know if I answered it. But those are just some of the things that popped in my head.

[0:44:30:]

RICK WEISS: Great information there. Thank you. Question from Jackie Fortier at KPCC Southern California radio. Health officials say they’re talking to, quote, “key opinion leaders” in Black communities to encourage people to get COVID tested in L.A. This seems like a very old school approach with the increase in secularism, et cetera. I’d love to hear the panelists’ thoughts on building trust within health care with young, Black Americans. Dr. Ford?

[0:45:02:]

CHANDRA FORD: There wasn’t a specific question in terms of response. But what I will say is that when I have tried to share some of my work around conspiracy beliefs, HIV conspiracy beliefs in particular, it’s interesting to me that the first response I often get in academic audiences is this desire for me to use the findings from my research as the basis for returning to the communities and pummeling into their minds that they simply need to accept the recommendations of the public health and medical sectors. Instead, actually, I don’t think that’s the responsible approach. I think the responsible approach is to see those concerns as reflecting some, you know, overt or underlying issues that need to be addressed, and to really focus on addressing those underlying concerns with a realization that, in doing so, then we’ll actually be able to have a substantive impact.

One of the reasons I do have some concerns about efforts that simply ignore the mistrust and conspiracy beliefs that the African American community may express is that health educators work to get folks to be able to make wise decisions given the information they have. And at some point, we have to recognize that people do have their own well-being, you know, at heart, that they are trying to make the best decisions that they can with the information they have. And so the question is not whether or not we can get them to stop trusting their own sources of information, their own self, just to accept what we tell them to do. I think it’s important for us to provide information and resources in a way that allows them to make decisions that align with our best recommendations because they reflect our on better behavior as a field.

[0:47:14:]

RICK WEISS: Thank you. A question here for any of the speakers from Alice Callahan. She’s a health reporter based in Oregon. Are you concerned that if and when we have a safe and effective vaccine for COVID-19 it will be less accessible or less likely to be utilized by African Americans or other racial groups who have been disproportionately affected by the pandemic? If so—do you have any thoughts on solutions for this disparity? I have a feeling there are thoughts on this. Hedy, do you want to go first?

[0:47:50:]

HEDWIG LEE: Yeah. I mean, I think—and I’m going to—I feel like—I’m surprised Maggie didn’t jump on this. I’m going to let her go after me. You know, I think for almost all of our research, one of the things that is sort of a punchline for people who do work in this area is that even if we were to equalize health care access, we’re still going to see disparities. And we can talk more about what that means.

But I think access to a vaccine, of course, is key. But we also have to be addressing other conditions that impact the health and well-being of individuals and put them at risk for COVID-19 infection in the first place—people over-represented in essential jobs, racial residential segregation, housing quality, et cetera. They’re all intermixed. And so thinking of just about the vaccine in a very narrow way is going to be problematic because you’re still going to see disparities.

And I also think it’s going to be important to frame this—when we do talk about the COVID vaccine, as Chandra alluded to, I think there needs to be real discussions around access because I think, oftentimes, the narrative in the media can turn to individual behaviors and perceptions when we’re really not thinking through access issues. Clearly, access issues are impacting communities now—access to PPE in, for example, reservations, et cetera. These are true—these are crucial issues now, even before we’ve gotten to the immunization. So I think we can use what’s happening now to help us to kind of foresee what could happen in the future and, hopefully, intervene so those things aren’t happening. But, again, I want to talk about the vaccine, but we need to be thinking more systematically, systemwide, or we’re going to end up in similar situations where, again, we’re going to see disparities. But I’ll let the others chime in.

[0:49:26:]

MARGARET HICKEN: So I think that Hedy gave a really great response to this and that essentially we can’t look just to the vaccine because we’re—but that this is how institutions operate together and how we need that—we can’t just look to one institution or to one solution to actually resolve health inequalities because we’re dealing with COVID right now, but it’s because there was all these inequities in COVID testing, but also diagnosis and then mortality, are because we have already laid the groundwork of vulnerability that Hedy talked about. And so by only addressing the vaccine and not addressing all of the institutions that have created this vulnerability, we’re dealing with COVID now, and we may then try to equalize access to this vaccine without addressing anything else. There will then—we will not be prepared for the next time something like this happens, and there will be a next time. There was always a next time that highlights how we have set up the structure of our society so unequally that it leaves Black families completely vulnerable at the expense—you know, at the—and without other families experiencing that same risk, on average.

[0:50:47:]

RICK WEISS: We have two similar questions here. I’m going to read them both to you because they get at a similar thing, and it’s a great opportunity for our speakers. One is from Jaclyn Cosgrove at the L.A. Times—what’s one story you have really been wanting to read in the news about structural racism and health in Black communities that you haven’t seen written yet? And similarly, from Anna Boiko at KUOW in Seattle—what kind of stories would you like to turn on the radio and hear about—health inequalities, inequities in Black communities? So an opportunity for you folks to talk about what you’re not hearing in the news.

[0:51:27:]

CHANDRA FORD: I think two points for me—one would be the resilience that African American and other communities on the margins of society have historically and have always drawn on and fostered as a way to find creative strategies and survive difficult moments. So that’s one. The other is—I’m very curious to see the process happening on the research end. So while we are largely focused on the problem out there in society and communities, how are the resources being allocated in terms of solutions? And can we turn the gaze toward the public health and research and medical enterprises to see how well they are addressing the inequities that are, I think, part and parcel to the problem?

[0:52:34:]

RICK WEISS: Anyone else have a dream story you’d like to see in the news?

[0:52:37:]

MARGARET HICKEN: Yeah. If I could wish for something, I would really love it to hear more—to have journalists really kind of dig in because they’re so wonderful about being able to really get at the root of these issues—is to bring out this idea of cultural and structural racism. You don’t have to call it that, but this idea of that—we have decided as a society who matters and who doesn’t matter, and we base all our institutions on this, and we operate our institutions the way—in that way, and that if you actually, then, question the way that institutions operate—like, why do we have to do it in this way? Because it’s always been done that way or whatever answer. But in actuality, you can trace it back to who we have decided is valuable. And so I would love to be able to see because then we can uncover the intentionality and that this is not a mistake. This is not an accident. This is not something that is only happening now with COVID or with cardiovascular disease or with anything, that this was set up quite intentionally over time.

[0:53:49:]

HEDWIG LEE: And I’ll just add—I think it maps onto what Maggie says. I think this is also a moment, a cultural moment, where there’s been a lot of reckonings. I mentioned that in the last part of my presentation—reckonings with our histories of racial violence and, really, trying to move to not only address them but to dismantle those both systematically—so thinking about systems, like police funding, for example—but also visually, in terms of the removal of monuments and other kinds of oppressive signage across universities and schools and even—I mean, even roads. I mean, there’s a controversy here in the St. Louis area because there is a road called Old Slave Road, and there’s been so much work to try to remove it. And now we’re in a moment where that’s actually going to hopefully happen.

And so the question is—I think it would be really interesting to start unpacking, what are the outcomes of these? I think it’s not just a social issue; it could potentially be a health issue. There is some work suggesting that oppressive symbols are bad for health. So I would love to see people sort of digging into that, especially at this rapid moment of removal of these symbols of oppression. I think that’s sort of an interesting and exciting thing to think about it. And it’s somewhat relates to kind of what Maggie’s talking about, to really dig into our history.

[0:55:09:]

CHANDRA FORD: If I could just add one more that is much of—with everything that is going on in our country right now and actually globally that involves a lot of overt racism, there’s been limited attention to the more subtle ways in which liberal and aversive forms of racism operate. And I think that’s very concerning because it suggests that, you know, in a short spell or sometime after we get through this major crisis that these forms of racism that have not been addressed are going to—the consequences of those will become apparent. So I would love to see more attention to both reframing articles so that they do not simply point at, you know, the stereotypical, quote, unquote, “racists” but also that they draw out some of the ways in which racism operates in more progressive or liberal contexts.

[0:56:06:]

HEDWIG LEE: Sorry. Just because I just wanted to add—because that relates to some of the work on vigilance that Maggie and I do together. I think it’s really important. And actually, that’s probably one of the reasons why infant mortality is talked about a lot is it—because it really highlights this. You can see that infant mortality rates for college-educated Black women are similar to those for white women with a high school degree. And I think it harkens to these other invisible stressors that we’re not always seeing but that definitely have—take a toll on the body, and even for high status people of color, African Americans, et cetera.

And so I think it’s important because it’s also a stressor, too, that we don’t often think about but does matter for outcomes. I think Melody Cooper did a good job describing what is it like to feel like that every single day, to every single day have to worry about your son whenever he leaves, to every single day have to worry about, you know, how you’re dressed and where you go and expect that you might experience discrimination or somebody saying—you know, or somebody mis-identifying you, you know, getting confused. I mean, this has happened to me, people confusing me with the other person of color in my department. You know, that takes a toll on the body, and we should be talking about that, too.

[0:57:19:]

RICK WEISS: And I’m going to say to the reporters on the line here that we have so many good questions. I want to get to a few more, so our participants have agreed to go an extra 10 minutes here. So we’re going to just get a few more questions into this briefing. And I’m going to start here with Danie Alexander’s question, who’s a producer at KCUR Public Radio in Kansas City. Are people of color proportionally represented as subjects in medical research? And can that skew results if not when it comes to certain developing treatments for medical conditions?

[0:57:58:]

CHANDRA FORD: I would say the short answer is yes. And at the same time, there must be a caution against ratifying the notion that there are inherent biological differences between groups.

[0:58:17:]

RICK WEISS: Interesting contrast there. OK. I am just getting one here. Can you speak in more detail—this is Lesley McClurg at KQED in California—can you speak to the unique fears that people of color may have for the COVID vaccine? Is there a particular issue of trust here?

[0:58:47:]

CHANDRA FORD: I guess I can start. The first thing I would offer is a qualification that there is limited empirical research on this yet—so far. But I can say that anecdotally based on what my team and I are working on in California that we’re hearing from people, community members who go to get testing who want to follow all the recommendations and are being hampered or impeded by health professionals in doing that, being turned away, for instance, without getting a test. Questions that have been raised that I’ve seen in my own research with respect to HIV have to do with, if—do we always get the same quality of product in our community, or do they give us basically the leftovers? Would we be getting the same vaccine, or, you know, would we be first in line for the vaccine and—because, you know, they need to experiment with it? So again, it speaks really to the issue of trust.

[0:59:51:]

RICK WEISS: Any others on that? Then I will jump to a question here from Jaclyn Cosgrove at the L.A. Times. Do you have some examples of communities actively addressing structural racism and health in Black communities in thoughtful, meaningful ways? So much of journalism focuses on the problem, and we often forget to report out solutions.

[1:00:21:]

MARGARET HICKEN: So I can speak a little bit about structural racism with regard to the environment and environmental pollution. There has been within communities movements, you know, activism and movements to remove polluters. So there’s one—there are actually several, but I can think of one. So I was in North Carolina getting my master’s degree at this time that this was all happening years ago, so hog farms in North Carolina, these factory farms that produce a lot, a lot, a lot of waste. And animal waste is not treated the way human waste is when it’s put into the environment and it’s used as fertilizer. And what they do is they have these large lagoons and they spray it into the air and—among the surrounding Black communities. So hog farms are more likely to be placed—these lagoons are more likely to be placed around Black communities in North Carolina.

And so community activists worked with—and the North Carolina Environmental Justice Coalition worked with people at the University of North Carolina, epidemiologists there, to develop evidence—they worked—so it was a community activist organization, the people in the neighborhoods and epidemiologists at the University of North Carolina working together to produce the evidence to go to Raleigh, to go to and show that actually that this hog waste was—that the state was permitting these industrial polluters, these hog farms, to be close to neighborhoods closer to Black families than other families and that it was actually reaching the Black families and was being ingested and inhaled, resulting in rashes and chronic respiratory problems. So and that—there have been certain successes and—but there’s still definitely battles with regard to—it’s a long haul in North Carolina with the hog farms. But that’s one example.

There are some other examples with regard to water potability in Latinx communities in California. But there have been. But it’s always—what I know of—it is that it is not communities actually working with EPA or with the state. And there’s actually a great book that just came out about the problems within the EPA. And they’re not actually advancing environmental justice causes that they are—have been mandated to promote. But it’s communities working either with universities or just on their own to make change. But there are stories, definitely.

[1:03:21:]

CHANDRA FORD: I also would add that two of the books that I showed in the—at the end of my slides have case studies of exactly that—what communities have been doing to achieve equity or to improve their well-being. So check those out, too.

[1:03:42:]

RICK WEISS: Great. Thanks. At this point, I do want to just do once around and give each of our speakers an opportunity to wrap up with a final take-home point or something that they really want to make sure that all of the reporters on the line walk away with from today’s presentations. So I will start with you, Hedy Lee.

[1:04:04:]

HEDWIG LEE: I think that there are still many communities and issues that are invisible, and I just want us to continue to work for—just unpacking and making things that are invisible visible. The questions were so great. I saw one about the U.S. territories and U.S. Virgin Islands. I think it’s true we don’t think about these communities. They’re also U.S. citizens. They are also facing a health crisis, environmental crises, etc. So I just encourage you to continue to think about invisibility and understand the ways in which, when we make communities invisible, we might be negatively impacting them, and when we make problems visible, we can better understand some of the health issues that they face.

[1:04:42:]

RICK WEISS: Thanks. Chandra Ford.

[1:04:46:]

CHANDRA FORD: I would say that racism is a public health issue and that it’s not just about how we feel or a social—you know, something bad in society, but it’s something that we need to treat as a—the same way we would treat any other risk factor or risk condition. And I would also add that there is reason to be optimistic about being able to actually do something about it. So that would be my piece.

[1:05:18:]

RICK WEISS: Great. We don’t need to invent a brand-new vaccine for this. That is good news. And, finally, Maggie Hicken.

[1:05:30:]

MARGARET HICKEN: So I’d like to say that cultural racism, which is this idea that who—of whose life counts, determines how our institutions operate and which institutions get funding, et cetera, et cetera. And then residential segregation is this tool that state and private entities use to direct resources by these institutions into certain neighborhoods and away from others. And segregation is consistently linked to racial inequalities in health and may even operate at the molecular level.

[1:06:00:]

RICK WEISS: Fantastic. I want to thank all three of you for really strong presentations and Q&A, helping reporters hold others’ feet to the fire on this really important public health, social issue. I want to remind reporters on the line that you can follow us on Twitter at @realsciline. I want to ask all of the reporters on the line to please take a half-minute as you log off to answer three quick questions on the survey to let us know how we’re doing and what we can do better on these briefings and, last, to remind everyone that the video and the transcript from this briefing will be available on the SciLine website—sciline.org—in the next couple of days or so. So we encourage you to refer back to that and share it with others—a lot of really important content here, a lot of great story ideas. Thank you all very much for attending. And we’ll see you at the next SciLine media briefing.