How structural racism is magnifying the public health crisis

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• Hari Sreenivasan:

  As protests for Black Lives Matter continue across the country, many state and local leaders have declared racism a public health crisis. This comes as coronavirus cases are disproportionately impacting communities of color.

  One of the many institutions facing a reckoning of sorts is the healthcare system itself.

  I spoke recently with Dr. Rhea Boyd, a California-based pediatrician and public health advocate who says structural racism in the healthcare system is only compounding the public health crisis.

• Hari Sreenivasan:

  This pandemic and also our reckoning with race has brought a couple of different big ideas together, which is that there are unequal health outcomes for Americans based on the color of their skin. How does the health care system play into these inequities?

• Dr. Rhea Boyd:

  You know, that's a really critical question, and it's not one that we often ask, but our health care system and how it distributes resources to populations based on their racial and ethnic identities absolutely shapes the racial health inequities we see emerging generally, and right now in the pandemic, one example of that is the insurance marketplace. Our health care system offers you health care based on your insurance access. But we know that that access tiers the quality of care that patients receive. And there's been data to suggest that it racially segregates the care that patients receive. Those are examples of how business models and health care drive broader inequities. And there are reasons why we need universal health care in the United States.

• Hari Sreenivasan:

  You know, we have heard about, for example, maternal mortality statistics for black women and how they're worse. I mean, what are the systemic failures that get black women to a position where that outcome, well, I guess really isn't paid attention to enough. But when you think about it throughout the lifecycle of a person of color in America, what are those gaps that we take for granted?

• Dr. Rhea Boyd:

  So racial health inequities like the maternal mortality gap, like the infant mortality gap. They reveal legacies and current practices of racial exclusion and discrimination in our country. They reflect who has access to safe environments, clean water, fresh air and who doesn't. Who has access to health care? Like we've already mentioned, who has access to employment and industries that might offer certain protections that during this pandemic might keep people more safe. Things like paid sick leave or parental leave or even just access to PPE. All of those critical supports are racially distributed in our society. And there are reasons why we see broad inequities generally and specific inequities during the pandemic.

• Hari Sreenivasan:

  During the pandemic, what we've also seen is a disproportionate amount of impact on health care workers of color. What can we do to try to restructure a workforce that, well, kind of relies on the labor of all Americans? But it seems that some of the tasks that are at higher risk, we're putting these people at higher risk are falling disproportionately on people of color.

• Dr. Rhea Boyd:

  This is one of the devastating things about how racism works in society, even being a member of a protected workforce like health care during a pandemic still isn't enough to keep black folks, Filipino workers, like you mentioned, like the next folks an indigenous population safe because when they leave their jobs, they still go back to structurally unequal living conditions. And that's it really puts people at risk.

• Hari Sreenivasan:

  How do you incentivize equitable outcomes? I mean, as you mentioned, there are pretty powerful forces. How do you make sure that there are these outcomes in the long run that people can get together around?

• Dr. Rhea Boyd:

  In health care, one way to do that is with government regulation. I think government regulation is one of the hallmarks of anti-discrimination advances throughout society, that you need the government to say that certain things are allowed and certain things aren't allowed, that certain things are rights and other things are privileges. And I think in this country, we need to say really firmly and we need our government to say it for all of us, that health care is a right, that everyone should have access to it, and that our government will invest in ensuring that that's a possibility. That then would create incentives, financial and moral, within health care to ensure that everybody has access to that right.

• Hari Sreenivasan:

  If we wanted to reach that perfect world where the incentives were aligned with kind of our moral instincts, that people should have equitable outcomes in health care, they should have equal access to health care. How do we get from where we are today and the system that exists now to that one?

• Dr. Rhea Boyd:

  So there's a couple of examples we could choose. One is Medicaid expansion, expanding Medicaid increases access to basic health services, which could increase access to COVID testing, to treatment and just basic primary care. The other one that we absolutely need to be doing is desegregating our health care workforce. So we talked about how our workforce, particularly during a pandemic, has been prioritized for certain critical protections like access to PPE. But that means that other workforces and other essential laborers, including people and vital supply chains like meatpacking plants, for example, haven't had that same access to PPE. How we get there from here is to think about how we redistribute PPE by industry to ensure that there aren't racial and ethnic gaps and who has it. Because we know in healthcare our industry is predominately white at every level, from student to CEO. And we know that essential laborers outside the health care workforce tend to be predominately folks of color and particularly women of color. And so we need to redistribute the PPE and share it from our health care workforce to other industries to ensure that everybody who goes to work labor safely.

• Hari Sreenivasan:

  As workplaces go through their own reckonings on race, what should the health care industry, which are doctors and hospitals, know and study about racism before they practice their craft?

• Dr. Rhea Boyd:

  So racism hurts people and we know it contributes to premature mortality for all racial and ethnic groups in this country. And that means doctors need to better understand the mechanisms by which racism harms health. In medicine, we need to make understanding the impacts of racism on health professional competency. Every clinician should know it.

• Hari Sreenivasan:

  Finally, I want to ask, are you concerned about the vaccines that may arise for COVID-19 and how that plays out? I mean, whether there's equal access to the vaccine, whether there is equal adoption, depending on where you live and the color of your skin.

• Dr. Rhea Boyd:

  Absolutely. Health care services aren't distributed equitably in our society, and racial and ethnic minority groups tend to be excluded. And so I do have concerns that if a vaccine is created and it isn't made freely available to everyone, that costs will be a huge barrier to folks getting it.

• Hari Sreenivasan:

  Heading into this fall, we know that influenza comes back and we know that not everybody gets a flu vaccine when they have a chance to. If people choose not to take the influenza vaccine, choose not to take the COVID-19 vaccine. What kinds of situations are we setting ourselves up for?

• Dr. Rhea Boyd:

  I think we have to prepare for a reality where at least half of adults may not get the COVID vaccine similar to the same half of adults who don't get the influenza vaccine. We need to prepare for it. And what I mean by that is we need to institute universal protections for everybody. The government has to enable all Americans to wear a mask. It has to make testing available to all Americans routinely, not just once, routinely. So that as folks exposures change, they also can change how they move throughout the world so that they don't risk infecting others. We also have to provide income supports. We need another federal relief package so that folks can safely stay home from work if they're sick. And so that folks can still pay their rent and stay in separate living facilities so that they don't again, expose others potentially.

• Hari Sreenivasan:

  All right. Dr. Rhea Boyd, pediatrician and public health advocate. Thanks so much for joining us.

• Dr. Rhea Boyd:

  Thank you so much for having me.

  BROADCAST VERSION

• Hari Sreenivasan:

  This pandemic and also our reckoning with race has brought a couple of different big ideas together, which is that there are unequal health outcomes for Americans based on the color of their skin. How does the health care system play in to these inequities?

• Dr. Rhea Boyd:

  You know, that's a really critical question, and it's not one that we often ask. But our health care system and how it distributes resources to populations based on their racial and ethnic identities absolutely shapes the racial health inequities we see emerging generally, and right now in the pandemic. One example of that is the insurance marketplace. Our health care system offers you health care based on your insurance access. But we know that that access tiers the quality of care that patients receiv, and there's been data to suggest that it racially segregates the care that patients receive. Those are examples of how business models and health care drive broader inequities. And there are reasons why we need universal health care in the United States.

• Hari Sreenivasan:

  We have heard about, for example, maternal mortality statistics for black women and how they're worse. What are the systemic failures that get black women to a position where that outcome. well, I guess really isn't paid attention to enough. But when you think about it throughout the lifecycle of a person of color in America, what are those gaps that we take for granted?

• Dr. Rhea Boyd:

  So racial health inequities like the maternal mortality gap, like the infant mortality gap. They reveal legacies and current practices of racial exclusion and discrimination in our country. They reflect who has access to safe environments, clean water, fresh air and who doesn't. Who has access to health care. Like we've already mentioned, who has access to employment in industries that might offer certain protections that during this pandemic might keep people more safe. Things like paid sick leave or parental leave or even just access to PPE. All of those critical supports are racially distributed in our society. And there are reasons why we see broad inequities generally and specific inequities right now during the pandemic.

• Hari Sreenivasan:

  During the pandemic, we've also seen is a disproportionate amount of impact on health care workers of color. What can we do to try to restructure a workforce that, well, kind of relies on the labor of all Americans. But it seems that some of the tasks that are at higher risk, we're putting these people at higher risk are falling disproportionately on people of color.

• Dr. Rhea Boyd:

  This is one of the devastating things about how racism works in society, even being a member of a protected workforce like health care during a pandemic, still isn't enough to keep black folks, Filipino workers, like you mentioned, like the next folks an indigenous population safe because when they leave their jobs, they still go back to structurally unequal living conditions. And that's it really puts people at risk.

• Hari Sreenivasan:

  How do you incentivize equitable outcomes? I mean, as you mentioned, there are pretty powerful forces. How do you make sure that there are these outcomes in the long run that people can get together around?

• Dr. Rhea Boyd:

  In health care, one way to do that is with government regulation. I think government regulation is one of the hallmarks of anti-discrimination advances throughout society, that you need the government to say that certain things are allowed and certain things aren't allowed, that certain things are rights and other things are privileges. And I think in this country, we need to say really firmly and we need our government to say it for all of us, that health care is a right, that everyone should have access to it, and that our government will invest in ensuring that that's a possibility. That then would create incentives, financial and moral, within health care to ensure that everybody has access to that right.

• Hari Sreenivasan:

  As workplaces go through their own reckonings on race, what should the health care industry, which are doctors and hospitals, know and study about racism before they practice their craft?

• Dr. Rhea Boyd:

  So racism hurts people. And we know it contributes to premature mortality for all racial and ethnic groups in this country. And that means doctors need to better understand the mechanisms by which racism harms health and medicine. We need to make understanding the impacts of racism on health professional competency. Every clinician should know it.

• Hari Sreenivasan:

  Finally, I want to ask, are you concerned about the vaccines that may arise for Covid 19 and how that plays out? I mean, whether there's equal access to the vaccine, whether there is equal adoption, depending on where you live and the color of your skin.

• Dr. Rhea Boyd:

  Absolutely. Healthcare services aren't distributed equitably in our society, and racial and ethnic minority groups tend to be excluded. And so I do have concerns that if a vaccine is created and it isn't made freely available to everyone, that costs will be a huge barrier to folks getting it.

• Hari Sreenivasan:

  Heading into this fall, we know that influenza comes back and we know that not everybody gets a flu vaccine when they have a chance to. If people choose not to take the influenza vaccine, choose not to take the Covid 19 vaccine. What kinds of situations are we setting ourself up for?

• Dr. Rhea Boyd:

  I think we have to prepare for a reality where at least half of adults may not get the Covid vaccine similar to the same half of adults who don't get the influenza vaccine. We need to prepare for it. And what I mean by that is we need to institute universal protections for everybody. The government has to enable all Americans to wear masks. It has to make testing available to all Americans routinely, not just once, routinely. So that as folks exposures change, they also can change how they move throughout the world so that they don't risk infecting others. We also have to provide income supports. We need another federal relief package so that folks can safely stay home from work if they're sick. And so that folks can still pay their rent and stay in separate living facilities so that they don't again, expose others potentially.

• Hari Sreenivasan:

  All right. Dr. Rhea Boyd, pediatrician and public health advocate. Thanks so much for joining us.

• Dr. Rhea Boyd:

  Thank you so much for having me.