The Surgeon General: COVID-19 comments

We are in the midst of a global pandemic, and our lives have been reduced to uncertainty. We have been thrown into a war with a mysterious and lethal virus that has no antidote, vaccine, or recommended treatment plan. What a time to be alive.

As I type this on April 24, 2020, there have been 895,766 total COVID-19 cases reported in the US and 50,439 deaths. And while the coronavirus has swept across the entirety of the United States, it is no secret that communities of color have been hit the hardest. A recent CDC report found that COVID-19 was found in 45% of people who were white, compared to 55% of white individuals in the surrounding community. However, 33% of hospitalized patients were black compared to 18% of blacks in the surrounding community. This data gives an insight into the gross overrepresentation of black people among hospitalized patients. Data has been released detailing COVID-19 deaths in New York City further highlighting the disparities with Black/African American persons (92.3 deaths per 100,000 population) and Hispanic/Latino persons (74.2) being substantially higher than that of white (45.2) or Asian (34.5) persons. Reports from Chicago show that black people account for more than 70% of all COVID-19-related deaths and more than 50% of total cases in the city while making up only 32% of the population. Louisiana reports a similar figure, while only 32% of the state’s residents are black. In Milwaukee, where blacks comprise only 26% of residents, the numbers also mirror Chicago’s data. Perhaps the most evident display of this overrepresentation is seen in Richmond, Virginia where 92% of COVID-19 related deaths have been suffered by black patients. Richmond has had 312 COVID-19 cases and 58.3% of these have been black patients, with white patients accounting for just 22.1% of cases. I think you get the point; black and brown people are bearing the brunt of severe COVID-19 cases. My goal here is not to beat you over the head with redundant stats.

On April 10, 2020 United States Surgeon General Jerome Adams made some controversial remarks during a White House coronavirus press conference, during which he discussed how communities of color can fight the spread of COVID-19. At the time of the presser, Dr. Adams urged communities of color to: “Avoid alcohol, tobacco, and drugs. And call your friends and family. Check in on your mother; she wants to hear from you right now. And speaking of mothers, we need you to do this, if not for yourself, then for your abuela. Do it for your granddaddy. Do it for your Big Mama. Do it for your Pop-Pop. We need you to understand — especially in communities of color, we need you to step up and help stop the spread so that we can protect those who are most vulnerable.”

A statement such as this misses the mark on many levels. Let’s begin by addressing the notion that a higher proportion of minority communities use alcohol than Non-Hispanic white Americans. According to the U.S Department of Health and Human Services survey, 56.7 percent of White Americans described themselves as “current drinkers,” compared to 42.8 percent of African Americans and 41.7 percent of Hispanics.

Next, let us debunk the notion that minority communities use tobacco at higher rates than Non-Hispanic white Americans. According to American Lung Association survey, in 2015 the proportion of Black Americans who smoked cigarettes (the primary way of consuming tobacco in America) at pretty much the same rate as Non-Hispanic white Americans, while Latino Americans actually smoke less than Non-Hispanic whites across both genders.

The Health Impact Pyramid depicts the potential impact of different types of public health interventions. There are five layers with the first being Counseling & Education (eating healthy & physical education classes), second Clinical Interventions (diabetes medications), third Long-lasting Protective Interventions (smoking cessation treatments), fourth Changing the Context (Health Laws), and fifth Socioeconomic Factors (poverty and education). The idea is that the lower down you go on the pyramid the more impact that those interventions can potentially have on public health. Remember this, I will be referencing this pyramid throughout the remainder of this reading. Dr. Adams’ suggestions of trying to “avoid tobacco, drugs, and alcohol” to mitigate the health disparities in minority communities fall under the Counseling & Education tier, which means it is predicted to have the smallest impact on public health. So apart from the remarks not being backed by empirical evidence (and perpetuating implicit bias), they are also predicted to not be very effective in accomplishing much at all.

So, Dr. Adams’ statement begs the question: does “we need you to step up” mean that the reason black and brown people are dying from COVID-19 at a higher rate is due to irresponsible personal behavior and not because of systemic inequalities? No, it doesn’t. The reasons why communities of color are experiencing worse outcomes with COVID-19 are multifactorial. Minority communities have been placed at risk for contracting coronavirus and suffering from COVID-19 due to carrying a high chronic disease burden, being more likely to be exposed as essential workers, being more likely to live in crowded housing, having less access to testing, lower rates of health insurance, provider bias, and being more likely to live in areas with minority-serving hospitals, which deliver lower-quality care. None of which more responsible behavioral choices on behalf of the individual can fix.

Dr. Adams’ call for underserved populations to practice personal accountability is consistent with previous messaging towards racial/ethnic health inequities in the past. This was the same method that was used by the “Just Say No” advertising campaign that was prevalent during the 1980s and 1990s during the height of the crack epidemic and the beginning of the war on drugs, whose effects are still prevalent in black communities to this day. The “Just Say No” campaign was given legs by the educational program Drug Abuse Resistance Education (DARE). Which by the way, to no surprise, was not very effective in accomplishing its mission of preventing drug usage. In fact, two studies suggest that enrollees in DARE like programs were actually more likely to use alcohol and cigarettes. The “Rap-it-up” initiative was an attempt to finger-wag minority communities into practicing safe sex, a defective effort to mitigate health disparities in HIV transmission. The campaign did not address the socioeconomic issues that are well documented to be directly and indirectly linked to the increased risk for HIV infection in African Americans. Lower socioeconomic status leads to worse outcomes on the HIV continuum of care, including lower rates of linkage to care and viral suppression. I say all of this to ask, what do “Just Say No”, “Rap-it-up”, and Dr. Adams’ comments all have in common? They are all first-tier Counseling and Education interventions on the Health Impact pyramid. In other words, they will likely have minimal impact, if any at all.

This is all said without the intention to discredit Counseling and Education intervention. Health education when combined with other intervention efforts is significant, but we simply cannot stop there and call it a job well done. Also, our Counseling and Education efforts must be based on empirical evidence, and not implicit bias. We must address the other four tiers on the Health Impact triangle if we are truly aiming for a more equitable future.

Too often when we look at health disparities we think that we are seeing race, when we are really seeing the effects of systemic racism that has manifested as adverse health outcomes. Blaming individuals for these negative outcomes is shortsighted and misses the mark. It is equivalent to blaming residents of Flint for having lead poisoning rather than focusing on the broken system, and fixing the water system.

We must focus less on individual-level behavior, and more on the larger structural issues at hand. We can shift our focus to implementing more robust coronavirus testing initiatives in minority neighborhoods. We can provide financial support to small Black and Latin-owned businesses to help them weather the inevitable fiscal storm that lies ahead. We can mandate that landlords and mortgage lenders provide a reprieve for monthly housing payments. The possibilities are endless. One of the very few upsides to a catastrophic event such as a pandemic is that it presents a fertile ground of opportunity for innovation and change for a better world. It is well documented that interventions that address the conditions in the places that people live, learn, and work have the greatest potential impact on public health. If we are as serious as we say we are about mitigating the health disparities in this country that COVID-19 has only managed to further highlight, then we should probably start there.

References:

1.  Age-Adjusted rates of lab-confirmed COVID-19. NYC Health, www1.nyc.gov/assets/doh/downloads/pdf/imm/covid-19-deaths-race-ethnicity-04 162020-1.pdf. 2.

2. Borr, Tamara Gilkes. “How the War on Drugs Kept Black Men Out of College.” The Atlantic, Atlantic Media Company, 17 May 2019, www.theatlantic.com/education/archive/2019/05/war-drugs-made-it-harder-black- men-attend-college/588724/.

3. Center for Behavioral Health Statistics. 2018 National Survey on Drug Use and Health: Methodological Summary and Definitions, www.samhsa.gov/data/sites/default/files/cbhsq-reports/NSDUHMethodsSummDe fs2018/NSDUHMethodsSummDefs2018.htm.

4. Centers for Disease Control and Prevention. National Center for Health Statistics. National Health Interview Survey, 2015. Analysis performed by the American Lung Association Epidemiology and Statistics Unit using SPSS software.

5. Heavey, Susan. “How the Flint Water Crisis Has Further Exposed Health Disparities.” Association of Health Care Journalists, 25 Jan. 2016, healthjournalism.org/blog/2016/01/how-the-flint-water-crisis-has-further-exposed -health-disparities/)

6. “Hospitalization Rates and Characteristics of Patients Hospitalized with Laboratory-Confirmed Coronavirus Disease 2019 – COVID-NET, 14 States, March 1–30, 2020.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 16 Apr. 2020, www.cdc.gov/mmwr/volumes/69/wr/mm6915e3.htm?s_cid=mm6915e3_w.

7. McLaughlin, Kelly. “All but One Coronavirus Death in Virginia’s Capital Have Been Black Americans. The County’s Health Director Isn’t Surprised.” Business Insider, Business Insider, 29 Apr. 2020, www.businessinsider.com/covid-19-richmond-virginia-majority-of-victims-black- americans-2020-4

8. National Survey on Drug Use and Health (2018) Volume 1, Summary of National Findings. Prepared by the U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Office of Applied Studies

9. Ramos, Elliott, and Zamudio. “In Chicago, 70% of COVID-19 Deaths Are Black.” WBEZ Chicago, WBEZ Chicago, 24 Apr. 2020, www.wbez.org/stories/in-chicago-70-of-covid-19-deaths-are-black/dd3f295f-445 e-4e38-b37f-a1503782b507. 10. Scott O. Lilienfeld and Hal Arkowitz, Why “Just Say No” Doesn’t Work, Scientific American (January 1, 2014).

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