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Outsized Impact of COVID19 on Minority Communities: Podcast with Monica Peek and Alicia Fernandez



This was a remarkable podcast during this moment in which our country is hurting in so many ways.  

Today's topic is the impact of COVID19 on minority communities, but we start with a check in about George Floyd's murder and subsequent protests across the country.  Our guest Monica Peek, Associate Professor of Medicine and Director of Research at the MacLean Center of Clinical Medical Ethics at the University of Chicago, notes right off the bat: COVID19 and the reaction to Floyd are related.  The covid epidemic has created an economic crisis, a heightened level of worry, and a disproportionate number of deaths among the African American community.  When we add COVID on top of the long history of police brutality that has been heightened over the last several years that has been ignored by the federal government - in that context, it's not surprising that we're seeing protesters put their lives on the line to stand up for what they believe in.  These protesters are putting their lives on the line due to the twin risks of reprisals from police or national guard, as well as the risk of acquiring COVID during a protest.

As we turn later to the topic of COVID19 and impact on minority communities, Alicia Fernandez, Professor of Medicine at UCSF and Director of the UCSF Latinx Center of Excellence, notes that so many people reach for a biologic rationale for the excess exposure and mortality among minority communities - it's a genetic factor, it's racial/ethnic differences in ACE receptors, or it's the higher rates of diabetes and kidney disease among minority communities. How is it then that Latinos, and immigrants in particular, who tend to be younger and healthier, have higher mortality rates? What COVID19 is exposing are the underlying disparities in social determinants of health.  For example, Africans Americans and Latinos represent a disproportionate share of essential workers, are more likely to live together in multigenerational households, and may reside in areas with less access to testing and high quality hospital care.  

We turn finally, to what we can do.  As Monica says, "This is the fight of our lives.  And this may be our last fight."  Alicia notes that we need better reporting about detailed race, ethnicity, and language of people impacted by COVID for public health reasons.  We talk about the need for professional interpreters for all goals of care conversations with patients (and Yael Shenker and Alicia's must read article for all clinicians on this topic).  And we return to Doug White's framework that persons who reside in areas with a high Area of Deprivation Index score get a boost in their chances of obtaining scarce treatments for COVID.

Finally, I encourage you all to watch this YouTube video of the song Seriously (song choice for the Podcast), sung by Leslie Odom Junior (Aaron Burr in the original Hamilton), about how Barack Obama might have reacted aloud to the 2016 election.  It's speaks to this moment as well.

-@AlexSmithMD




  


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TRANSCRIPT

Eric: Welcome to the GeriPal podcast, this is Eric Widera.

Alex: This is Alex Smith.

Eric: And Alex, who do we have on the podcast with us today?

Alex: We are honored to be joined by Monica Peek, who is Associate Professor of Medicine and Director of Research at the MacLean Center for Clinical Medical Ethics at The University of Chicago. Welcome to the GeriPal podcast Monica.

Monica: Thank you so much for having me. I'm excited to be here.

Alex: And we are also honored to have Alicia Fernandez who is Professor of Medicine at UCSF and Director of the UCSF Latinx Center of Excellence. Welcome to the GeriPal podcast Alicia.

Alicia: Thank you. It's good to see you both.

Eric: So before every GeriPal podcast, and before we dive into this topic, we have a song request. Who has the song request for us?

Monica: I do.

Eric: What'd you got Monica?

Monica: It's a song called Seriously.

Alex: And why did you choose this song? What is this about?

Monica: This is the hypothetical thoughts of President Barack Obama about his presidential administration and its legacy and potential impact that led to what we see as far as Donald Trump, being able to step into that space and what he might be thinking nowadays in his wisdom and his eloquence. Whereas most of us might just be cursing. He might say things a little differently. So it's a beautiful song that This American Life asked a song writer and performer to do for that episode.

Alex: Yeah, magnificent. Leslie Odom Junior sings it, who was Burr in Hamilton in the original version. I am not Leslie Odom Junior but I will try to do my best. Let's see what happens.

Alex: (singing).

Monica: Very nice.

Alex: That's a great, great song. I have a little more at the end, but people, I encourage you to go to YouTube and check out that video. It's powerful and really particularly in this moment and we should speak to this moment with what's happening across the country in reaction to George Floyd's murder and check in with both of you about how things are on top of the COVID epidemic and impact on minority communities, which is the topic for today. Monica, maybe we can start with you. How are things in Chicago?

Monica: They're more quiet today, but it's been rough. We've not had as much as I think other cities have had, but it has still taken its toll. And the two are related. I think it's not a coincidence that we're seeing the reaction to George Floyd in the time of the COVID epidemic in this country. They're interconnected. The COVID epidemic has created such an economic crisis, has created so much uncertainty, so much worry, death, destruction and so much of a disproportionate impact amongst the African American community that the whole country is mourning and feeling vulnerable in particular marginalized populations.

Monica: And then we add on top of that, this long history of police brutality that has been heightened in the past several years with a pass from our federal government that many would say are just fanning the flames of racial violence. And so what we see, this huge reaction to a situation where people are willing to risk their lives to stand up and have their voices heard. I've not ever seen anything like that where the stakes are so high for people coming out and having their voice counted and yet they're willing to do so. It's been a challenge.

Eric: I want to thank you for sharing that. And I think people are not only risking their lives from going out there and protesting and the risks of that, but the risks of this being in a COVID pandemic is just... I don't even know how to describe it. Alicia I want to turn to you, how are things from your perspective right now?

Alicia: I think as we start talking about COVID many of the things that Monica and I, I suspect, will point out will be very similar. We'll talk about many similar risks, we'll talk about many similar challenges. And I think that what happened with murder of George Floyd is one of the ways in which the black experience, African American experience is actually quite different from the experience of other minorities within the United States. It's just not in any way to suggest that other minorities are not dehumanized. We only need to look at ICE and the cages, those children over the summer to see that.

Alicia: But nonetheless, there's something about the incredible violence visited over and over and over and over again on African Americans by police that really stems from this very long history. And it's one of the ways in which I think it's really important, particularly for Latinos, not only those with a lot of light skin privilege like me, but Latinos of every shade to know that this is quite distinct, it is horrendous, it is a level of dehumanizing and fear of the African American person that is really quite extraordinary and shocking. And I think that I've been reflecting a lot upon that.

Alicia: And I also over the last week or so, and I also completely resonate with that some of the economic and other problems created by COVID are going to feed all of this. And we can talk more about that. But I think that the most important thing for is to hold out the... To shine a light on this specific thing. And for all of us, to stop and say, "No, it's this one, it's black lives matter." That we need to say. So thank you for giving us the opportunity to talk about this because it's very difficult to just go about one's daily life and not have a moment to honor them.

Monica: One of the things that we're doing at The University of Chicago is trying to create additional spaces for our students and our house staff to grieve and mourn and to have a shared sense of community. So we're going to be having some candlelight vigils and other safe spaces because the constant caregiving in the time of the epidemic is exhausting. Is exhausting in a way that residency isn't ordinarily where you're putting your life more at risk and the extra shifts. And then for persons of color to then also have to deal with this additional emotional exhaustion, it's really taking a toll on many of our trainees. And so for those of us who are in medicine, we have to think not only about the patients who are coming in into our healthcare system from these communities, but also the people who are taking care of those patients.

Alex: I want to thank you both for sharing these eloquent perspectives and reflections on the moment and what's happening now and wanted to add that as Alicia said, we need to focus and think about this issue ourselves, and do some deep reflection. I wanted to share a poem that's been widely sent around social media via posts by Shola Richards, that talks about privilege as a white person for people who identify as white. "I have privileged because I can do all of the following things without thinking, I can go birding, #Christian Cooper. I can go jogging #Ahmaud Arbery." And it goes on and on and on and on throughout so many experiences that people may take for granted that may put you at risk if you're African American living in this country. And the last line is, "I can be arrested without fear of being murdered, #George Floyd."

Alex: I read that today, I was blown away by so many things. I mean, just piece after piece, after piece in the news, it just keeps coming. And what a time this is when we're in the midst of this COVID epidemic and such fragile communities and tremendously disproportionate impact on African American and Latino communities.

Eric: I was wondering if we can actually talk about that and I mean, it's such a hard time because all of this is happening at once. There's so much that we could talk about here, but I do want to dive into this topic of these health disparities and COVID-19 outcomes and what you guys are seeing, why you think it's happening. So I'm going to turn to Monica first. Can you describe a little bit about what we are seeing?

Monica: Yeah. It was April 6th I believe, when some of the stories first started breaking around black, white disparities in coronavirus death rates. Chicago was one of the first cities. Chicago's one-third Latinx, one third white, one third black. And that day 72% of the deaths were amongst African Americans. And we saw similar numbers in Milwaukee, a few other cities. And those are striking numbers that Mayor Lightfoot said, here in Chicago, it takes your breath away.

Monica: It was a call to action for our city. Right away she formed a racial equity, rapid response team and the city and the state had been working to try and think about strategies to mitigate these disparities. Other cities began releasing other data. We have started to see disparities in other populations.

Monica: The challenge is that we do not have mandatory reporting by race and ethnicity. And so the numbers that are being released by the CDC, we don't know with complete accuracy how good those numbers are. There's some estimates that up to 50% of the data is missing for race and ethnicity. And so we're not going to be able to fully get our hands around which communities, which populations, where in the country we can track this virus and its impact on marginalized communities. If we can't know where it is. And so that's a huge part of the problem. And there are so many sociopolitical fights that we have in front of us in order to be able to really stem this tide. And that's one of the first ones.

Alex: I want to ask Monica, I've heard, read various explanations for why there's an outsize impact on African American communities. I wonder what your thoughts are and what you think underlies these tremendous disparities in rates of infection, rates of hospitalization and rates of death.

Monica: Yeah. So I think that what scholars have been saying since the start is what local and national data is now beginning to bear out. That it's not the brownness of people's or the blackness of people's skin that is increasing their medical risk, although certainly a disproportionate burden of disease is a contributor. Yes, it is the structural inequities based on race and ethnicity, what we call structural racism. That is the biggest driver of the disparities that we're seeing in COVID death rates and the mortality.

Monica: And so that means that in particular, that there are differences in who is exposed, who can get tested, who has access to treatment and where that treatment is. All of those are in such stark disparities in and of themselves that they each have a multiplier effect. There's individual risk and there's place-based risk. So that racism affects individuals, but it also affects communities and where they live, so that because of structural racism and redlining policies and residential segregation, there are many communities that disproportionately have a lot of crowding, poor quality housing, where they have lower scores for being able to socially isolate. There's more chronic disease, just all of these things that put people, if you're looking at a pandemic at increased risk for able to propagate infection.

Monica: And so there was a study that came out a few weeks ago, that were a national study of county level data that showed that the higher the proportion of blacks in a county, the blacker it was, the higher the rates of COVID deaths, the higher the rates of COVID cases and the higher rates of all of those things I just mentioned as far as uninsurance, unemployment, social distancing, crowded housing, those things. So there's the geographic place-based risk.

Monica: Then there's the individual level risk where someone who is because of all the structural differences and opportunity over time has had limitations in their education, how far they can go with their career, whether or not they're more likely to be incarcerated, and that's a whole story in of itself. You guys did a podcast on incarceration recently. And so their individual lifestyle, life span, life risk means that they're more likely to be an essential worker in a low wage job where they have to go to work and are being exposed where they're not being protected. If they don't go to work, they can lose their job, but then have no money potentially be homeless. The choices that people are having to make. Schools are shut down, who's caring for the small people in their home. And so there are the stars are aligning in such a way that the major things that are in play for what puts you at risk during a pandemic are all lining up around racial lines or lines for people who are populations that are marginalized.

Monica: And so you see this significant leap in cases and deaths for communities that have not been able to safely shelter in place. These are the communities that allow the rest of the country to safely shelter in place. But they're the ones who are hand delivering people's groceries, they're people who are driving the buses, who are making sure that power, it stays on our people's homes so that we can have Zoom calls.

Monica: But they are at risk and they're contracting coronavirus, and then they're going to, they get tested and there's all kinds of disparities in the kinds of tests that are available. Some that have a rapid turnaround, some that you have to wait five to seven days. By the time you waited five to seven days, you have either put yourself at continued increased exposure to people who live in your home where we know that there's probably not a palatial home where you're self-isolating just in case, but other people that you're exposing or you're back into the workplace and putting the public at risk and you've waited seven days where the disease had more of an impact on your own health. So you may present later to the hospital with a disease in worse shape.

Monica: So there are multiple reasons why you can catch the disease and die from the disease. If you have brown or black skin that have nothing to do with your medical problems. And so it's a combination of the historic weight of structural oppression that has impacted the health of a population, that has contributed to health disparities. In addition to the situational risks that people are then faced with in the setting of a pandemic that has caused these horrific numbers that we're seeing.

Eric: It just reminds me too, of a, I think it was a New England Journal article that just got published a week or two ago in Louisiana looking at that if you account for a lot of different things, actually race fell apart. So it's not like, "Oh, this coronavirus is just affecting black people because of how it affects their ACE receptor." It's not that, it is this larger picture is that right?

Monica: Race is a proxy for social issues. And so a lot of people are trying to, I think there's a movement to change the terminology because when we say race, there's a tendency for us to in our minds, think that it's really the person as opposed to the society. Again, it's not me, it's what society is doing to me that is making my health bad. And so yes.

Alicia: I think it is incredible how much we tend to biologies race in this country. I have also been asked, "Is there some biological reason why blacks and Latinos are more affected?" And you want to say, "What an interesting virus. It hits Hang Chinese, Northern Italians, people in Madrid, people in Paris, now people in Brazil and disproportionately African Americans and Latinos in the United States. And you want to think there must be some genetic thing in common?" No the genetic condition is being human. What is driving these epidemic is very much the social factors. And yet nonetheless, otherwise intelligent thoughtful people are saying, "Well, do you think that there's something to this? Could it be that there is a biological factor linked to race that is doing this?" And in my mind, it really boggles the mind.

Alicia: I also think that the discourse on chronic disease. As physicians, we certainly recognize from all of the data that among hospitalized patients age carries the most prognostic sign but that chronic diseases also carry prognostic information. Nonetheless, it is interesting for this, particularly as a Latino health researchers, because Latinos are dying at a disproportionate amount as well. Particularly whenever you look at age adjusted data, and yet Latinos tend to be much healthier in general, speaking on a population level, than both African Americans and whites. And in fact, particularly immigrant Latinos and yet it would appear to be certainly in San Francisco. And I'm curious what in terms of Chicago Monica, and yet immigrant Latinos are healthier than native born Latinos, and while certainly have very high rates of obesity and diabetes to have less other chronic disease.

Alicia: And so without getting too academic around this, what I think is important is to realize how so many of us reach for a biological rationality that avoids us having to contend with the social structures that have caused not only excess exposure, but perhaps excess mortality as well. So very interesting. I hope that was clear enough because it's really a complicated set of interlocking concepts.

Monica: You're exactly right. That is also happening here in Chicago, that we're seeing a second wave that is affecting the Latinx population as far as mortality. And it's an interesting case study because like you said Latinx populations tend to be healthier. And so there's not that chronic burden of diseases of I would say despair, but diseases of oppression. But yet they're dying at higher rates.

Alicia: And I think a lot of the things that you pointed out come into play there as well in terms of the incredible excess risk associated with excess exposure and both individual risk, and as you so eloquently pointed out place risk. So in a study that was done here in the Mission which is a historical Latino neighborhood in the city, some of our UCSF colleagues, Dr. Dan Hadley, and others conducted a zero prevalence study, where they went and got swabbed for SARS COVID-2, within one census track in the city here in the Mission.

Alicia: And what they found was really pretty astronomical. What they found was that in this very diverse neighborhood where Latinos made up 44% of those participating in the study, they made up 90% of people who tested positive. 90 or 95 I'm misremembering that, and not a single, the other large number of people were white. They were white neighbors who live in the same census track, in the same small 10 block area, not a single white person tested positive. Everyone who tested positive was Latino, and I think there were two Asians.

Eric: Wow.

Alicia: And when they tried to find out, they asked some questions and they ask questions about, whether people were able to work from home. And of those who tested positive again, in the 90 percentile, they were unable to work from home compared to about 47% of the entire sample. So what we see here is that even when people share essentially the same addresses, they're level of individual risk is so different because of two things, having to go to work. And then the other thing that they also gathered data on was household size. And even in this very crowded neighborhood, the household size among Latinos was much higher because of multi-generational families or people living together among unrelated adults sharing rent.

Alicia: For example one of my own patients who unfortunately contracted COVID and was intubated for two weeks was just discharged this last week from our own ICU. She lives with her daughter in a room that they rent. Eight other unrelated adults live in the same flat. Together they share one bathroom, I'm sorry, two bathrooms, two small bathrooms, and a kitchen. Some of the men that live in that place had to keep going out to work. She doesn't work outside the home and got sick, and that's how she contracted COVID.

Alicia: So these issues are very clear. The issue of excess risk associated with the need to work and the issues of excess transmission associated with dense housing are crystal clear, particularly in our area which is a low prevalence area and where we can really see that.

Eric: Yeah. I feel like both the coronavirus pandemic and George Floyd's murder, they're opening up this box to this country about these inequities that we have baked into our system. And that we're seeing that now. I wonder when we think about the majority of our listeners are healthcare professionals. What's our role, what can we do? Or is this just hands in the air, it's baked into our system, I have no control over it. I'm just going to stick my head in the sand.

Monica: No, I mean, this is the fight of our lives. And this may be our last fight. Alicia I'm going to let you talk for a second.

Alicia: I think there's so much that as physicians we can do, both on the individual patient level, and I hope we can come back to that, but also as respected actors in our community and society. And I'll mention a few. And then I'll come back to Monica.

Alicia: One is this issue that Monica mentioned the issue of collection of data. There are two states that I'm aware of Washington state and California state that are doing comprehensive data collection. And that has been really important. It's allowed us to see things like, for example, how the very, very high, excess death rate among Pacific Islanders. So that has been super important for public health efforts. But most states have not made a commitment to collection of that data, and certainly the federal government has not.

Alicia: And here's something where we can work with our medical societies to say, or up beds, or however to say is we need this data and we need it for public health reasons, if nothing else. And I always say, we need real data, race, ethnicity, and language. And the reason for that is that if you know that many of the people who are positive are say Vietnamese speakers, well, then it doesn't take a rocket scientist to say, "We should be getting out education to the Vietnamese speaking community. We should be figuring out how to create testing sites for the Vietnamese speaking community. We should be making sure that physicians who serve Vietnamese communities are in dialogue and are helping out in terms of education efforts."

Alicia: But if we just collect data and say, "Race, well, what does it mean to be Asian? How do we know where to focus at the local level? Our health system efforts are public health centers." So number one, I think all of us should state, "We need data, real data, race, ethnicity, and language." Not only to document the disparities, but to guide us in our public health efforts. I have a few more, but let me stop there.

Alex: I just want to underline that point. Eric and I have been doing some palliative care consults in New York, at New York Presbyterian Columbia, so we can see their entire palliative care list, two thirds Latino. And the first three consults we did were with Latino families. And first one we did, we called every day for like three weeks with a translator. And so issues of language are really central to you as clinicians, as our listeners and Alicia I remember you wrote a terrific paper, you've written many papers about this. The one that stands out for me is the one you wrote with Yael Schenker. Who's now director of palliative care research at University of Pittsburgh about the use of professional translators.

Alex: For me for example, doing this consult, I took Spanish in college, I cared for a number of Spanish speaking patients as a medical student. My Spanish was pretty good at one point, but it's been a long time and I absolutely do not feel comfortable. I could talk to a patient about whether they have chest pain, but if I'm going to have a goals of care conversation with family members, I need a professional translator. And so to our listeners, just want to emphasize that, see if you have anything else you want to add to that [crosstalk 00:35:17].

Eric: There are limits too because there was a consult where Alex said, "Wait a second, I didn't say cirrhosis."

Alex: Yes, I did correct the professional translator on the phone.

Alex: I said kidneys, not liver. Can you correct that please with the family members?

Eric: And thank God Alex knew a little bit of Spanish.

Alicia: Oh exactly. And for many people we say people in the fair range, not very good and not none, know enough to be dangerous because unlike Alex, many people go out on their set by themselves, try to get by. And that cheats the patient of a better comprehension and much better satisfaction.

Alicia: I do think one of the things that has been happening in at least some settings, which have had very large number of Spanish speaking patients. They've taken a very interesting approach. And specifically Mass. General has taken the approach of embedding a Spanish speaking physician in with the team. And these are people who have volunteered to do this, they are people who are being obviously paid just as much as everyone else to do this, but they have taken on the role of providing language concordant care to the patients and to the families because language concordant care is even better than a care through an interpreter. But for most listeners and for most systems, the part that is absolutely non-negotiable is that professional interpreters should be involved in the care of these patients and their family members.

Eric: We also had Doug White recently on the last podcast talking about managing healthcare systems, managing scarce COVID treatments including antivirals for this. And it was part of his framework. They're trying to mitigate healthcare disparities in COVID-19 outcomes by in some ways, giving people extra weight or extra chance they're going to get this drug in a lottery system if they come from a disadvantaged area. So they're using the area deprivation index to assign people based on this index. Kind of, are you living in an area that is underserved or, what's the right word for it? I guess deprived.

Monica: Because this raised the increased risk-

Monica: ...we know, that they're going to be harder hit. And so it's like using a public health principle. We have seen that historically in this epidemic, those communities have been devastated and if they haven't been yet, they will be. And so we're trying to align need with resources. And so that's just a way of trying to implement that plan. And so you can do prediction modeling, you can do a lot of other things to try and figure out where the most need is going to be. And other cities and states are trying to figure out that for ventilator allocations, when new ventilators come online, because everybody has expended all the ventilators that are currently available are out in the field, everybody has them. So as new ones are being made and coming into the pipeline where are they going to go? And same for Remdesivir. As new packages are coming out, who's going to get them?

Eric: Because I think this even takes it a little bit further of saying-

Eric: ...if I got two people in front of me, person A and B. I'm going to give more weight in this lottery because I want to address social injustices at least by using basically socioeconomic status as a main indicator.

Monica: I agree. I agree. I mean, I really agree. I think that we have to, if we want to try to seriously get at equity and we have to think not just about fairness as to each an equal share, but to each according to need and to think about a distributive justice model of allocating resources, which means that we're understanding that certain populations have gotten to where they are because of the structural inequities. And so we're going to have to reallocate existing scarce resources in a way that looks at the least advantaged in society first in order to try and make sure that at the end, we have equal outcomes. If you give everybody the same share and people are not at a level playing field, then you're going to end up with people having unequal outcomes, it just perpetuates inequities.

Monica: And so we have to think differently if we're going to want different outcomes. And so, we just have to be ready for that and in all aspects of this. Getting back to your question, there's so much that each of us can do in our role as clinicians in how we deliver care, how we think about end of life care, how we are not just physicians, but we're civilians. We have a civic duty. We are living in times of tremendous crisis, so many different crises right now. And we don't have the advantage to be silent.

Alex: Yeah. I want to reflect back briefly on what you said earlier. This is the fight of our lives, of our generation. And I think back many of my colleagues at UCSF, maybe Alicia trained in the era of HIV and AIDS, and that was the defining condition and experience of their practice. And for us, that is going to be COVID without question, and how will we rise to this occasion? What will we do clinically? What can we do? I'm in complete agreement.

Alex: Other thoughts from either of you of what our listeners can do working in nursing homes, working in palliative care with patients who are dying in the hospital or patients who are doing telephone work with patients who choose to remain at home and maybe seriously ill with COVID or caregivers of people who are seriously ill or cared for by people who have COVID, but many of the caregivers tend to be from minority populations. Any other thoughts from either of you about what we can do?

Monica: I know there's so much Alex. We have like two seconds.

Alex: Lightning round. We sometimes have a lightning round at the end. This is our lightning round.

Monica: And now there's so much pressure. I think the most critical issues for people who are older and living in congregate housing. They're at the same increased risk as we think about our prisoners. And except that they can... Well, anyway. That we have to think about caring for them in ways that doing what we know we ordinarily would, but having an extra level of attention to those things that we should already know you're doing. So advanced care planning where we always know that we should be doing that, but we're not.

Monica: And so particularly for racial ethnic minorities for whom there has always been an extra level of concern that near the end of my life, things may not go as I may have wished if my life is in the hands of others or, I'm not able to make decisions if my family can't be with me in a pandemic, then I think that we all have an extra commitment right now to take a step back and say, any one of our patients could fall into the coronavirus abyss. And do they have advanced care planning in place? Particularly our elderly patients who are in a skilled nursing facility and to go back and check those extra boxes because that reality is much more likely to happen now than it was six months ago.

Eric: And Alicia?

Alicia: I know you have listeners from all over the country, and I assume with lots of very different points of views, which is great. And I wanted to just make two points. One of them is that we have to make work safer, we can make work safer. And we must do that. We know that the chicken plants and meat packing plants are dangerous. It doesn't take a rocket scientist to know that there will be outbreaks in the fields where people go and live in migrant camps in very congregate settings and go from one place to another. And we must make work safer to protect our patients, to protect people and also to protect the industries. We just must do that.

Alicia: The second issue is that I appreciate that there is a great diversity of points of views on immigration and what I think that as physicians, we all believe in effective public health, and it is very difficult for people to stay home when they have no money and must go out to work, to eat. And I think probably everyone listening knows that [inaudible 00:45:56] people have been excluded from every package of relief. And that may be congruent with people's views, but not when it comes to isolation and quarantine. In order for isolation and quarantine to work, people need to be able to stay at home. And there needs to be economic relief, wage for placement, sick leave given to everyone who is legally mandated to stay home because of coronavirus.

Alicia: And I think that is an area which where we can extend the cares to those workers, as well as to workers from small businesses and large industries. And we must do that. And there again I'm appealing to physicians to lead well, based on our knowledge of public health measures, not that separate, totally separate. We can have a conversation tomorrow about immigration, but let's make public health effective for all of us.

Eric: Yeah. It just reminds me of the podcast we did with Brie Williams, Adnan Khan and Eric Maserati-E Abercrombie, where Adnan made a great point of that this is not just about protecting the prison population, but it's also about protecting the community. These people don't just stay in the prison, they go in, out. And when you look at the largest outbreaks that we have in the US a lot of them are coming from these populations. So even if you don't care, which you should, I'm not arguing that you shouldn't care, but even if you don't care about these populations, it makes sense to prioritize them from a public health perspective. I just want to say we should care, and we should have empathy and we should have understanding, but it just makes sense from a lot of different perspectives.

Monica: And I'll just say one last thing that I have colleagues that have been looking specifically at the impact of people who are cycling through the jail population here in Chicago and the impact that that has had on the COVID pandemic. And it looks like that particular population is contributing significantly to the racial disparities that we're seeing in the city. And so their work is currently embargoed, will be released shortly. And so I think the more time we have, the more we're able to dig deeper into the data and find out exactly where our pressure points are as far as individual risk and place-based risks for this epidemic and within our vulnerable communities.

Alex: I want to thank you both so much. Alicia, Monica, thank you so much for joining us on our podcast.

Monica: Thank you so much for having me.

Alicia: Thank you.

Eric: Well before we end though, Alex, can we get a little bit more of that song.

Alex: A little bit more.

Alex: (singing).

Eric: Monica and Alicia again very big thank you for joining us today. And to all of our listeners out there for continuing to listen to our COVID podcast and joining us and caring. And to Archstone Foundation - thank you for your continued support.

Alex: Everyone thanks.

Eric: Goodnight everyone.



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