April 30, 2020 Vol. 5: COVID Has Made Invisible Inequities Visible

San Francisco, CA.  The pandemic has had a crushing effect on all of us and, like many of you, has caused me to take stock of my life and reflect deeply. Every day as I review medical reports, scientific data, studies and the real-world ramifications associated with COVID-19, I find myself asking: Can we ameliorate the many structural inequalities in our country that shouldn’t be ignored any longer while improving local and national health outcomes? How can we sharply reduce the likelihood of the next pandemic? And, do we as citizens have the political and cultural will to do something big with what seems like a once-in-a-century opportunity? My cautious answer to these questions is: with courage, we can!

I’m reminded of the quote by Barack Obama’s former Chief of Staff, Rahm Emanuel, who said “Never allow a good crisis go to waste. It’s an opportunity to do the things you once thought were impossible.” We’ve made immediate changes to our way of life that many before COVID said were impossible, and these likely have had meaningful impacts not only on our health relative to COVID but also overall. In California and across the entire planet, we are breathing air that is cleaner than it has been in decades due to the massive and sudden worldwide decline of carbon emissions. One source of air pollution, of course, is commuter traffic. Before this crisis, fewer than 10% of employees in the United States regularly worked from home. As of April 2020, Brookings estimates that half of employed adults are currently working from home.

To be fair, those who can telecommute tend to be higher income workers and this group is also less likely to be among more than 26.5 million Americans who have become unemployed in the last six weeks as a result of this crisis. Our interdependence has never been starker; our lives as we’ve known them hinge on warehouse workers, grocery clerks, garbage collectors, delivery and postal workers, as well as restaurant and hospitality industry employees, none of whom can telecommute. And what about our school teachers and the low wage caregivers who look after not only our children but also our elderly and disabled loved-ones? Let’s not forget the vital farm workers who supply our food. The pandemic has disproportionately harmed lower income workers and their families, and it highlights some of the massive structural inequalities and inefficiencies locally and nationally.

Lower wage earners tend to be immigrants and people of color. It’s time to truly reckon with the reality that economic stratification and centuries of structural and de facto racism in the United States continue to adversely impact people who are African American, Latino, Indigenous, or impoverished, all of whom generally experience worse medical outcomes than their white or other more affluent peers. 

I am struck daily by the massive and disproportionate number of deaths among people of color and those living in densely populated urban areas. For example, in Chicago, African Americans are 30% of the population but accounted for about 69% of COVID-19 related deaths. Some of the sickest patients do not speak English. Moreover, the lack of adequate beds and facilities in some urban areas are resulting in unnecessary death. This map of confirmed infections in San Francisco based on zip code shows how these same disparities are playing out in our own city, with Latino residents representing 15% of our population but well over 25% of deaths. It’s important to recognize that this isn’t just a problem ‘somewhere else in America—like in the rust belt or southern states—it’s a problem on the West Coast, too. 

As Dr. Wilfredo Matias, MD, a physician at Brigham and Women’s hospital in Boston has written, “Members of our marginalized communities are either dying from [COVID-19] at staggeringly disproportionate rates, being asked to undertake risky work at staggeringly disproportionate rates, or losing their economic livelihoods at staggeringly disproportionate rates.” 

 COVID-19's Devastating Impact on African Americans

These harsh and dire local, regional, and national outcomes including death, grief, anxiety, unfathomable medical debt, and soul-crushing sadness are hitting African-American, Latino, Indigenous, and impoverished communities the hardest—by a lot. For me, there is no question that life after COVID must be dramatically different from life before COVID. 

Obviously, our lives at the end of April 2020 already look different on the surface. For example, masks or face coverings are now mandatory in San Francisco. We also need to continue to maintain physical distance from one another. Early social distancing helped us in the Bay Area to slow the spread of the virus, especially when compared with New York City and other areas that were slower to implement similar policies. And while it’s very clear that the way forward is “Test, Trace, Isolate,” this regimen is new and it is going to require a huge undertaking on the part of public health departments to carry out. Under this process, for every person who tests positive for COVID-19, public health workers will trace all of their contacts over a period of time and then isolate all of those individuals (for up to 14 days) so they do not infect anyone else. This is something that has never been done before in the United States.

Governor Gavin Newsom has outlined six factors to be satisfied before the current stay at home order is phased out: (1) The ability to monitor and protect our communities through testing, contact tracing, isolating and supporting those who are positive or exposed; (2) the ability to prevent infection in people who are at risk for more severe COVID-19; (3) the ability of the hospital and health systems to handle surges; (4) the ability to develop therapeutics to meet the demand; (5) the ability for businesses, schools and child care facilities to support physical distancing; and (6) the ability to determine when to reinstitute certain measures, such as stay-at-home orders, if necessary. But even within those parameters, there’s still uncertainty. We’re learning more about this infectious disease every day, and we’ll need to continue to adjust our outlook and activities in big and small ways in the coming weeks and months. It could take up to two years to get back to a life that doesn’t require physical distancing.

As we begin moving to “Test, Trace, Isolate,” this may be the single best period ever to contemplate macro level improvements that may have seemed impossible only a few months ago. Public policy changes to address income and health care inequality in the United States will likely be debated in Congress and the States. Other experts will answer questions such as when we can safely return to commercial air travel or enjoy dinner in a packed restaurant. Still others will (hopefully) address the dangers that huge industrialized factory farms (e.g. for beef, pork and chicken) pose to line workers, food and environmental quality, animal safety, food supply chains, and the growing risk of future pandemics due to animal diseases jumping to humans (like the 2009 H1N1 swine flu and COVID-19). As a primary care and functional medicine physician in a major urban area, I believe it is my duty to raise questions in order to illuminate changes that would help address such structural inequities and risks to public health. 

We Need a National Healthcare System that Serves Everybody

It’s clear that our current convoluted system isn’t taking care of people in the United States the way we need it to. I believe that, like other wealthy industrialized countries around the globe, including Canada, Australia, France, Germany and others, we must create a medical system to which all people in this country have affordable access. The crisis created by COVID-19 has made even more obvious what we have long known to be true: Minority groups and the impoverished among us are suffering and dying at disproportionate rates mainly because of a lack of accessible and consistently good medical care and, for some of our neighbors who are not citizens, fear of detention/deportation by federal immigration authorities (even during this pandemic). In addition, because access to group medical insurance in the United States is still largely tied to employment and employers, millions of Americans lost their jobs and insurance when the pandemic hit, just when they needed health insurance the most. The pandemic has laid bare this critical flaw in our system.

The impact of this pandemic on marginalized communities is not limited to COVID-19 itself, either. The disease has exacerbated problems including a lack of access to good information, food, and resources to help kids learn at home while schools are closed. As these basic needs continue to be overlooked, undercut and ignored, the stress on families and communities will grow, adding to the risks of developing future health problems. It is also a tragedy of epic proportion that our nation’s elderly are being wiped out in underregulated nursing and long-term care facilities throughout the country. Rachel Maddow of MSNBC has provided critical reporting on this topic. I am appalled that many of these older individuals died alone, without their families and loved ones nearby.

This current health crisis is showing us that we need to value all individuals and populations equally, recognize and rectify systemic injustices and provide resources according to need. In my view, it is a moral outrage for corporate chieftains and some politicians to value profits over life (and the thousands of people who will die when some states open too soon). More than one anti-science elected official has suggested in recent weeks that grandparents should be sacrificed to save the economy! 

Fortunately and thankfully, we have other intelligent and thoughtful leaders throughout the nation including Governor Newsom who are basing their decisions on science, data and experts. These political leaders and others to be elected in November will help determine if we institute Medicare for All, Medicare for All Who Choose It, or some other universal healthcare system similar to Canada Health or the NHS in the United Kingdom. It is time for political, religious, business and social leaders (as well as voters) to come together to build a consensus for a universal healthcare system for everyone. It seems to me, as an informed citizen who rejects our broken system, we should all actively seek out and support political leaders at the local, state, and federal levels who are not only forward thinking but also free of conflicts of interest due to links and interests in the for-profit pharmaceutical and insurance industries, for-profit hospital systems, and other similar organizations.

We Need A Robust National Medical and Research System

In addition to my frustration around the disparities and unfairness within the healthcare system and lack of universal health insurance, I am appalled at the lack of a coordinated federal pandemic response, including the CDC’s failure to quickly roll out the millions of COVID-19 tests we have so desperately needed. The lack of funding and ability to rapidly introduce nationwide testing is simply unacceptable. The truth is that the COVID-19 official death toll in the United States of over 60,000 (at the end of April) is due principally to the United States’ botched testing, inept containment efforts and the refusal of Mr. Trump to implement a comprehensive federal plan. Moreover, it is quite likely that this 60K figure at the end of April massively understates the actual number of deaths and it could be months or years before we have an accurate count. But the problem is even larger than bungled testing and incompetence. The federal response to COVID was also weak and ineffective because the current president had already gutted our national pandemic and strategic preparedness.

By comparison, New Zealand (whose population is about 4.9 million, or one-fifth the size of the New York metro area), enforced a four-week lockdown early and had more recoveries than cases, with only 12 fatalities due to the disease. South Korea and Taiwan are other examples of countries that have successfully orchestrated coherent national policies to contain COVID-19 and test, trace and treat their people.  It is a national disgrace and travesty that updated projections, as of April 27, indicate the United States is on track to have 74,000 unnecessary COVID deaths by August 2020 (with a high estimate of 130,600). By comparison, the American death toll for the entire Vietnam war was 58,220.

Furthermore, we should never again find ourselves in a situation where we are even considering having to triage ventilators or ration personal protective equipment and it is unacceptable that we have put our healthcare workers at such unnecessary risk. The death toll due to ineptitude including systemic failures, lack of coordination, and the federal government’s blocking states from receiving basic, necessary equipment will be studied and debated for years to come and will potentially include criminal prosecutions. As we address the obvious shortcomings exhibited at the federal level and in some states like Georgia, Iowa and Florida, we must recognize and meet the need for counties and states to be able to rapidly expand their ICUs and other facilities for severely ill patients in the face of future pandemic challenges

We Need a Strong and Localized Food System that Prioritizes Health

Health isn’t just the absence of illness or disease, but it is a state of vitality and balance. It involves integration of body, mind, emotions, and soul, where we can adapt to life’s stressors and grow fitter, stronger, smarter, wiser and more connected with every experience. Our health is intimately connected with our environment, and one of the ways we look after our health every day is through the food we eat. Food is medicine

We know that vegetables and fruits are more nourishing for our bodies than, for example, processed sugary snacks. But to me, whether a food is “good” depends on a variety of factors. For example, strawberry season is here, and maybe you have a pint of them in your refrigerator. Were they grown with pesticides? Conventional strawberries top the list for the number of pesticide residues they contain and therefore they’ve contributed to damaging the ecosystem, put farm workers at risk via their contact with these harmful chemicals, and will expose you to those same toxins. Good food respects the earth and its inhabitants, and we cannot afford to be ignorant (or act as if we are ignorant) of this profound interconnectedness.

The reality of this interconnectedness is even more striking when you consider the impact of huge, industrialized factory farms. Worldwide meat consumption is rapidly increasing, and the vast majority of the world’s meat comes from factory farms that often sacrifice worker and animal health in pursuit of profits. In these giant industrialized facilities that supply about 99% of America’s meat, animals are tightly packed together and live under harsh and unsanitary conditions. 

The combination of unsanitary, incredibly overcrowded conditions, growing resistance to antibiotics that are needed to keep animals alive in such terrible conditions, lack of genetic diversity, and global trade means serious diseases (including viruses) can easily rip through entire animal populations. And sometimes, these diseases are able to infect humans, creating a pandemic. While factory farming didn’t cause COVID-19, factory farming could easily be the literal breeding ground for the next viral or bacterial pandemic. As Michael Greger, the author of Bird Flu: A Virus of Our Own Hatching, has said, “If you actually want to create global pandemics, then build factory farms.” 

Given how poorly the animals are treated, it should come as no surprise that factory farms are also known for treating their workers extremely poorly, exposing them to hazardous working conditions, and counting on the workers’ reluctance to complain

It’s beyond irresponsible to continue or expand factory farming, a system that we know causes disease, pollutes our air and water, makes tools like antibiotics ineffective for fighting disease, and abuses the animals and people who work there. 

We should make factory farms a thing of the past by phasing them out in favor of local and regional ranches, farms, agricultural production and processing plants. This will safeguard our food system and our own health, improve food quality, cut down on carbon emissions and allow us to take better care of the planet and each other. In January 2020, U.S. Senator Cory Booker introduced federal legislation that would crack down on monopolistic practices, place a moratorium on large factory farms, and create a level playing field for family farmers and ranchers. This would be a first big step in the right direction to phase out the largest factory farms by 2040.

Ironically, when Tyson Foods was forced to close a pork processing plant in Iowa last week because so many workers contracted COVID-19, closure highlighted another flaw with massive factory farms—that our food (and medical) supply chains are fragile and in grave danger of breaking. In response, the Trump administration ordered the largest meat and poultry processors to reopen without any attention to protecting their already sick and endangered workers.  

What was invisible is now visible—we cannot continue to rely on a handful of massive industrialized meat plants for significant portions of our food supply when the health of line workers is willingly sacrificed and animals continue to be abused. There is much to learn and know in connection with food safety and factory farming. Prompted in part by the birth of his own child, bestselling author, Jonathan Safran Foer, wrote a gripping memoir and investigative report titled Eating Animals in 2009, which is still a compelling, informative and timely critique of the factory farming industry.

We Can Make Sweeping Improvements When We Pull Together

The last two months have proven that when we act together to protect ourselves and our neighbors and communities, we can have an enormous, unprecedented impact locally and around the world. Is this one important silver lining of this pandemic? I believe it is. And, yes, we will have severe short-term economic disruptions. But after COVID, we can usher in a better country and a better world. If anyone doubts that massive positive change is possible, look at the enormous improvements in air quality across the globe highlighting nature’s powerful regenerative potential. Just glance at these “before and after” images of the smog in downtown Los Angeles which are astonishing.

If through our collective behavior we can so dramatically impact global air quality in less than seven weeks, we have at least as much power to ameliorate other flawed and toxic systems in our country. We could eliminate structural economic disparities, improve workers’ rights, institute national health insurance, strengthen food supply chains, support animal rights, fund medical research and preparedness, and protect our environment. 

Now is the time to demand that our political and thought leaders and policy makers attack and correct the structural inequities and injustices that have become so much more visible during this crisis. We need new leaders and leadership at the federal level (and in some states too) to augment the incisive leadership we have witnessed and benefited from in the last two months at the state and local levels in California, New York, New Jersey, Michigan, Illinois, Ohio, Washington and other states. Thoughts and prayers are not enough. Please, let’s not waste this crisis!

Julia Getzelman, MD was educated at Stanford University and Yale University Medical School. She is the founder and CEO of GetzWell Personalized Pediatrics, which is a direct primary care medical practice in San Francisco, serving infants, children and teens as well as providing functional medicine and nutrition consultation and using genetic polymorphisms as a foundation for treating a variety of chronic health problems in children and adults including ADHD, anxiety, behavior issues, GI complaints and autoimmunity. 

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