Roundtable: What Health and Policy Experts Saw as COVID Exposed Structural Racism

Racial, economic disparities are driving calls for health care to be made more equitable

NJ Spotlight and NJTV News hosted a virtual roundtable last week focused on the impact of structural racism under COVID-19 and strategies to improve equity as New Jersey responds to the pandemic. Speakers discussed racial disparities exposed by the outbreak, ongoing efforts to reduce gaps in health-care access and outcomes, and what else is needed to create a more equitable — and healthy — society.

The following are edited excerpts from the July 29 discussion:

Dr. Shereef Elnahal, president and CEO of University Hospital, in Newark, and former state health commissioner, on what he saw during the pandemic’s peak in mid-April. At that point University was treating some 300 COVID-19 patients daily and struggling to stay ahead of “unprecedented” shortages of frontline staff and protective gear:  

One thing that I noticed, of course, when I was walking around the wards is that almost every patient … was a person of color. And that isn’t too different from the … normal state (given) who our hospital serves in the city of Newark, being a majority minority community. But it was literally almost every single person, in proportions that outweighed what we normally see.

We saw a fourfold increase (in) the number of dead-on-arrival patients when our ambulances (were dispatched) to different residences across the city. And unfortunately, when we ran the racial and ethnic statistics against those numbers, even though, again, Black and Hispanic residents in Newark make up essentially a majority of residents here, they were overrepresented in the number of folks who were dead on arrival.

Dr. David Ansell, senior vice president for community health equity, Rush University Medical Center, Chicago, associate provost for community affairs at Rush University, and the author of several best-selling books on the history of racial inequity:

One needs only to go back 125 years to W.E.B. DuBois, who wrote a sentinel study of the “Negroes” in Philadelphia, which pointed out the very problems of these life-expectancy and illness gaps that we see today. In fact, if you add over the last hundred years the excess black deaths in the United States simply because Black people have not had the same health experiences — and due to living conditions (and) other sorts of situations — (you get) 7.2 million excess black deaths. So COVID just pulled the curtain back on facts that thoughtful, observant, knowledgeable people had been speaking for years.

Dr. Denise Rodgers, vice chancellor for inter-professional programs at Rutgers University Biomedical and Health Sciences, chair in inter-professional education at Rutgers Robert Wood Johnson Medical School, on poverty and other social determinants of health:

We are facing a global pandemic that has upended the lives of nearly everyone on this planet and, as such, is a disaster of such a scale that it should allow us to take a step back and think about what do we really prioritize as human beings on this earth. And so when we begin to have a conversation about social determinants of health, let us invigorate those conversations now with clear acknowledgement of the need to end poverty in this country and ultimately, of course, to end poverty throughout the world.

Let us have bold ideas that are required in facing certainly the medical consequences of COVID. Think about how rapidly we are developing vaccines and technologies and learning about treatments for COVID. Let us put that same level of energy into curing many of the social ills that have beleaguered this country for so long. And let’s start with poverty. Let’s really begin an earnest conversation about eliminating poverty.

Dr. Ansell, on the economics of health care: The other piece to this is we have decided in this country for many years that our economic system is going to drive our health care system. So the prices, not only the scarcity of mask, ventilators, staff, you name it, but actually the price competition around it have put many, many hospitals and health systems  — including wealthy ones like (Rush) — in deep financial trouble and at risk for not being able to take care of these communities.

We have a lot of disentangling to do, and now is a moment in time. And you think about the trifecta of this moment: On the one hand, COVID with once again its disproportionality; two, is a Black Lives Matter (movement and…) witnessing again of murder of Black people by police, as this sort of a narrated lynching that we all had to watch; and third, the huge economic dislocation that’s occurring in our midst right now nationally. We’ve just got to reframe this problem, particularly as it comes to who has access to health care, how is health care financed, how the supply chain works, because really we are in some ways the worst, certainly the worst developed country, in the world in terms of COVID response.

Assemblyman Herb Conaway (D-Burlington), MD, Assembly Health Committee chairman, director of the Burlington County Health Department, on New Jersey’s recent uptick in COVID-19 transmission and the public’s role in staying safe:

 We still need to caution people. People are having big parties; they shouldn’t be having those … (and) they are not being careful to wear masks. Now masks have been used since the Dark Ages to protect from contagion, and that we’re having any question … from the highest levels of our government about the importance of wearing masks is confounding. And it’s obviously very troubling. But people need to stay home, and if that’s done … we might get lucky and avoid a second peak coming this fall as people are predicting.

Dr. Elnahal, on patient outcomes at University Hospital early on, and the importance of connecting people with quality care: We did see near equivalent (clinical) outcomes in most areas for (racially diverse) patients with coronavirus, which is unusual because … Black and Hispanic and other minority groups have much higher incidence of chronic disease and baseline issues. But that gives me hope, because if we can get folks into care, especially with this pandemic … then we have the potential of achieving equitable outcomes. But the problem is the upstream social determinants that made people more vulnerable (and) potentially less trusting of health care institutions to make them not even want to seek care whether it was for COVID or not.

The way that you protect people from falsehoods and misinformation with health care and public health is to get them connected to care, because if they trust their provider, whoever it may be — maybe it’s a nurse practitioner, maybe it’s a physician — then they build that trusting relationship. They’re going to follow that guidance. They’re not going to be looking to Twitter. They’re not going to be looking to CNN. They’re not going to be looking to some of these outlets where these falsehoods are given audiences.

Dr. Rodgers on the need for science-based guidance and effective leadership: All of this is also confounded by, in my opinion, quite frankly, the mixed messages that we are getting as a country around COVID, and what’s important to do. I want to … reiterate the mind-boggling world that we’re living in, where there’s controversy about whether or not to wear a mask. And this plays out in Newark and other places as well, where some people say this isn’t important. There are conspiracy theories that abound about COVID. And we’re we just haven’t been nearly as effective as we need to be in educating the public about COVID, what it is [and] what people can do to prevent themselves from getting this disease and, as importantly, from spreading it to others. So, we saw a very, very rough patch in the spring in Newark. We are better now, but I have great concern about what may come in the fall and winter if we see a confluence, particularly of COVID and influenza.

Assemblyman Conaway, on vaccines and the danger of a potential backlash: I spend a lot of time working on vaccine policy and smoking policy. And one of the things that, again, leadership counts. We still have a problem with menthol in cigarettes, principally because of economic considerations that ignore the racial impact of menthol and its use in cigarettes on the African American community, (opposition) often led by African American leadership. We’re going to see the same thing, I predict, unfortunately, in this COVID situation where we see people pushed out front, talking down vaccines and so people (are) actively lying … about the vaccine program and the success, scaring people away from using these vaccines.

And as this COVID vaccine is developed, mark me, there will be Black leadership out there speaking against this vaccine, which will do what? Which will lead to another epidemic of coronavirus that might be prevented by a vaccine, and all the economic dislocation that occurs from that. And if we don’t get some of the social and racial equity (issues) right, we’ll have a disproportionate impact on the African American community. So leadership counts with all these things.

Dr. Elnahal, on equitable allocation of vaccines and other resources: We’re going to be and we already are in an environment of scarcity for so many critical things, whether it’s medication that we use to sedate people in our intensive care unit while they’re on ventilators, to Remdesivir and other therapeutics, to a vaccine. Whatever vaccine or a set of vaccines work, there needs to be a fair allocation system that ensures that communities of color and vulnerable communities are not left out or disadvantaged by whatever formula or scheme is put in place to make those decisions. And the only way to do that is to have those communities at the table when those things are being formulated. And I’ll tell you, the state of New Jersey has already started doing that. The Commissioner of Health (Judy Persichilli) has a committee focused on equity and there are already conversations we’re engaging in as a hospital, a hospital that serves primarily a community of color that make me encouraged. But as you know, these issues of supply chain and … more generally stockpiles also hit federal government policy and decision making. And we have to ensure that our voices are heard at every level of government.