 Hello. I'm Phillip Cohn. I'm your sociology professor and here to talk about health disparities in general and make some connections to the COVID-19 pandemic. Brief lecture, I'll make some connections for you and see if you can take it further from there. There's my contact information. Feel free to get in touch. Happy to talk about all these issues with you later. What are health disparities? What do we mean when we talk about health disparities? Well, the Centers for Disease Control has a nice definition I like, which is that health disparities are preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health. So things that make you sick or injured or violently harmed or things that prevent you from getting the kind of health that you should be able to get on your own. All those things experienced by socially disadvantaged populations. So they're connected to wider issues of inequality and they are disparities in health. So we usually, we often talk about them in terms of health outcomes, things like mortality or being sick or being injured or having cancer or things like that. So health disparities. And you'll see in your daily life a lot of stories about inequalities in health and the health care system, things like a nursing home resident who deserved a better death than the one they had from coronavirus or how junk food makes us sicker or how Obamacare policy changed that the federal government did may have prevented deaths in the opioid epidemic, which we'll talk about a little bit more, or how we have a problem of maternal mortality that is women dying in or around childbirth in this country and different groups experience that at different rates or how preventable cancers may be on the rise in this case, a story about Alabama. So all these things are issues of health disparities and things that will come up in your daily life or around the news and so on. So that's kind of what motivates us today. For the framework, I'm going to use something called the theory of fundamental causes, which sounds in a way bigger than it is. It's not a theory of the whole universe, it's a theory about health disparities in particular. And it really tries to answer the question of the relationship between socioeconomic status and health outcomes. That is why is our general inequality in society so persistently associated with health inequality, inequality in things like illness and death. Now the context for this is that overall our living standards have been improving in the long run. Some of that is old changes like the introduction of water and sewer systems or improved nutrition, things like refrigeration, freezing and canning and all that stuff made a huge difference 100 years ago. A lot of improvements in medicine and medical technology and understanding of medicine and also in terms of education as the population's education has improved, we're better able to incorporate information, learn how to take better care of ourselves for example by smoking less or eating better. So you can see the chart there just in the very general sense in about 120 years our life expectancy in this country has gone from a little less than 50 to almost 79 years. The average person born today if nothing changed would live about 79 years. We hope actually things will get better during those 79 years but we don't know for sure. So why as things have gotten better is there's still such a strong relationship between health outcomes and socioeconomic status or why are our other inequalities still so strongly associated with health inequality. So the answer that the theory of fundamental causes gives us is that income and education which is sort of the building blocks of socioeconomic status bring more resources that are beneficial to health. So money, knowledge, prestige, power, and beneficial social connections. So who you know, who you interact with, who you learn from, who helps you and who you help. All of those things are resources that people with higher socioeconomic status have that people with lower socioeconomic status have less of and that improve their health. And the key thing that the key insight of this theory is that as the health system evolves and as our general health has improved socioeconomic status is still enabling those with more resources to have better outcomes than those with worse resources or fewer resources. So it's a moving target but this helps explain why we always have that gap. I'll give you some examples of that. When you look, here's a study that looked at people who were born in 1960 and asked what is the chance, if they made it to age 50 what's the chance they would make it to age 85 and it compared that chance by their incomes. And so you can see here it's by men and women and the population is divided into income fifths, the poorest fifth of the population, the second, the middle fifth, the fourth fifth, and the fifth, the richest fifth. And you can see that the richer men and women have a much higher chance of making it from age 50 to age 85. 77% chance in the case of women, 66% chance in the case of men, but down in the poorest fifth it's much lower. Only about 30% of them are expected to make it from age 50 to age 85. So a very big difference by social class in life expectancy in this case of people who made it to age 50. So people with higher family incomes live longer and the reasons for this are their better living conditions, their better health care, and their better health behavior that's partly facilitated by their resources and including education. Here's another one specifically about health behavior, smoking. People who smoke obviously are at risk for lung cancer and other health problems and you can see here a very strong gradient on education. So people with graduate degrees only 37% of them smoke and as you move down the education ladder you get the people all the way down with GEDs, the general education degree, 36% of them smoke. So very strong education gradient and we see this with a number of other health behaviors also. So we assume part of what's happening is through the process of education people learn better health behavior but also who they interact with, the circles they go into the other resources they have access to are helping to promote these better health behaviors if you have more education. Here's a long run disparity where we can talk about infant mortality and race especially specifically blacks and whites. So infant mortality is the death of a baby between birth and age one. So you can see in 1850 a 340 out of every 1,000 black babies born were estimated to not make it to their first year so about a third versus 217 of the white babies and you can see this tremendous progress really for both groups since 1850 to 2017 which is not too surprising but you also see that race gap persisting all the way along so it was 340 to 217 in 1850 all the way down now to 11 only 11 out of every 1,000 black babies don't make it to their first year tragically but that's still more than twice the five out of every 1,000 white babies that don't make it to the end of their first year. So as infant mortality is declined that gap has persisted and that's really what the theory of fundamental causes would predict and we can look at the specific mechanisms that drive this for example the living condition differences between blacks and whites things that contribute to their overall health including nutrition and health care and the occupations that they work in and so on and then discrimination in all various forms of life they're from everywhere from where people live to their education to the health care system and so on. So we can we can look at that the influence of those factors all the way through time even as the situation has gotten better that the gap is persisting it doesn't mean it inevitably will but it's just what we what we have seen so far and so we're not surprised if we keep seeing this. A more recent concern has been the dramatic until this year with the coronavirus epidemic the dramatic opioid epidemic that we had in the last 20 years or so in this country. This map shows where there are the most opioid overdose deaths in the population and you can see they're very concentrated especially in Appalachia and other economically distressed areas sort of places where the industrial economy has has collapsed or shrunk or disappeared so you see those other areas in the upper midwest for example. So that's a case where the resources available to people at the local level in their geography are contributing to their worst health so it's that having lost jobs having less opportunities and then also having had opioids introduced for example when people get injured on the job and all of that has snowballed into a massive epidemic of addiction to opioids whether prescription drugs or heroin or fentanyl other legal drugs fentanyl could be prescription too. Okay so that's a that's a taste of a few different health disparities and things that we look at by education by income by race and by geography. So that sort of sets us up a little bit to talk about what's going on now with the the COVID-19 pandemic the coronavirus and that we're dealing with now and the reason why you may be watching this video. Just a little bit of background the coronavirus is a group of diseases that affect humans and other species okay so we have this group of viruses some of them are very mild and some of them are quite serious like the one we're dealing with now. This one is the novel coronavirus 2019 was discovered in Wuhan China in late 2019. We now call the disease that that virus causes COVID-19. There's a couple of references there you can follow so that just for background what we're talking about and the key thing when we're looking at disparities in how this disease spreads and the impact that it has is to think about the mechanics of how it works I'm not going to get into it in great detail but basically like other coronaviruses we assume this one spreads through droplets in the air very small when someone coughs or sneezes or touches the surface where it has droplets on or transfers virus from from their body to something that ends up in somebody else's hands and then into their into their mouth or something like that. We don't know for a fact but it seems also that there's good evidence now that it's also spread among people harsh and so we don't know for a fact. We do know for a fact we don't know how much that it is spread by asymptomatic patients that is people who show no symptoms to some degree there are people with no symptoms you can't tell they're sick but who are nevertheless transmitting the virus and also sometimes rather than just a literal drop of liquid that flies through the air sometimes error lots slides droplets more like tiny particles that float in the air so that's one reason why those two things are reasons why we think this is very contagious and spreads a lot when people are just sort of close to each other. Okay now why is this disease so bad that has become a global pandemic? Well it's a novel it's brand new it's a novel coronavirus so no one is immune to it it's highly contagious that is if you put people together and one is infected and the other is not it's very likely that the disease transmits from one to the other that issue of the asymptomatic transmission so it's spreading even when people don't know they're sick especially they're perfectly healthy seeming and they move all around in the population instead of sort of being oh I feel terrible I'm going to just lie here still and have and be sick that's a much better for containing a disease and then the reason we care so much about this is that it really does have relatively high mortality we don't know the rates exactly but we know it's pretty high compared to other viruses going around so you can see the chart here that shows really from the end of January with very low numbers there's rocketing up of deaths associated with COVID-19 now up over 160 thousand deaths the United States which has the worst epidemic of any country in the world is up to about 40 000 deaths as I speak and so we have a very serious problem with COVID-19 here so let's talk a little bit about disparities the epidemic interestingly started in richer parts of the country so it's not like other things where you would expect poor people from our previous discussion would end up immediately worse off this disease started in coastal metropolitan areas especially Seattle San Francisco area New York and from there it spread throughout the country also hopping to other metropolitan areas like Detroit Chicago New Orleans Los Angeles and it is now spreading throughout the rest of the country so about 80 percent of counties have had a coronavirus cases now and you can see if you look closely at the chart there's a lot of places where there's a dark county in the middle and some letter counties around it so it's sort of someone has flown to a particular city Columbus Ohio or something and then it's spread to the suburbs from there so that's sort of the path it has taken not really affecting the poorest areas first so interestingly starting in richer places some of the counties outside New York are some of the richest parts of the country we've had some very specific outbreaks and here we start to see some inklings of the disparities in this outcome nursing homes have been tremendously hard hit places where people can't move to get away where we don't have the resources or they're not aware that they have an infection until it's too late and where the patients are very vulnerable to this particular disease so New York state has produced this list of of nursing home deaths in counties in New York and you see several thousand people already have died in nursing homes in in in New York state um in a way similar although a very different population obviously has been prisons some very big outbreaks as I speak now the largest outbreak in the country is at the Marion um prison a state prison in uh Ohio with 1800 prisoners infected another big one in the cook county jail in Chicago and many other in prisons and jails where captive populations in close quarters um get infected and the the staff either can't or doesn't take the steps necessary to isolate people and keep the disease from spreading and then we see a third case which is also in a way similar factories where people have been are stuck together in small spaces for long periods of time also breathing a lot sweating and so on in the case of meatpacking there's a large Smithfield plant in South Dakota's had about 800 cases another meatpacking plant in really Colorado and many other situations like that where they've had outbreaks that are um at particular workplaces so you can see here populations that are vulnerable in some sense because of the kind of job they have because of the place where they're confined either because of uh the criminal justice system or because of their health that leaves them vulnerable to the spread and then in the case of nursing homes especially to the negative outcomes um of being very very sick um so let's talk a little bit about how we get disparities in the coronavirus uh specifically so the physical concentration is one key issue um another big issue has been workers who are exposed to eat to each other a lot but also especially when they're exposed to people who are already sick and this is um the healthcare workers especially doctors and nurses and um and nursing assistants and other workers in hospitals but also service workers people who work in um restaurants and grocery stores and make deliveries and any kind of service provision that involves being close with other workers and especially being close with members of the public and then in that category to expose workers are really anybody who can't do their work from home like I'm doing now in my home studio delivering a lecture a lot of people's jobs simply don't allow that or they don't have the resources or the liberty to do that and so their job puts them at risk um and then the other kind of disparity we have is even separate from who gets infected is for how badly people are affected once they once they have the disease it's a respiratory disease um so it it affects the lungs and so people who have asthma or other breathing problems a high blood pressure um which makes it difficult to recover from lung infections any kind of compromised immunity so then that affects their immune reaction to the disease um and uh or age that simply um a lot of these things accumulate in older in older people so if you take people who have any kind of health any of this categories of health problems in the first place and you add the disease the impact will be worth so it's not only who gets it but how bad the impact is um I'm going to jump into this video now to talk about the problem of paid sick leave the CDC came out with clear instructions to prevent the spread of COVID-19 and at the top of the list is to stay home when you're sick but a lot of American workers don't have that option 27% of private sector workers don't get paid sick leave and that's going to make this pandemic a lot more problematic than it needs to be over 30 million workers in the US don't get paid sick days that's not the way it has to be the US is one of only two OECD countries without federally mandated paid sick leave so taking off can mean you can't pay your bills and calling sick can get you fired so what does that mean when there's a highly contagious disease circulating like right now it means people who are sick may be going to work and risking infecting their coworkers their customers the people they teach or the people they and it gets worse those 30 million or so people without paid sick leave they're most concentrated in low wage jobs and in industries that are the most likely to involve the risk of contagion restaurant workers hotel workers people who work in transportation travel and tourism less than half of americans doing restaurant leisure and hospitality work have paid sick leave and for the bottom 10% of wage earners overall only 30% do with the coronavirus crisis we're going through today paid sick leave isn't just the right policy for workers it's essential to our public health thank you to Elise gould from the economic policy institute she's talking about the policy problem there that the law does not require people to get paid sick paid sick leave from their employers and so you end up putting workers at risk and the people that they work with the bureau of labor statistics does a survey where they ask one of the questions they ask people is do you work at home could you work at home and using that question can you work at home they broke it down by occupation education and race ethnicity and I have that for you here that shows us that the more procedures occupations people with higher education and in terms of race ethnicity especially Asians and whites are most likely to be able to work from home so managers and professionals sales and office workers much more than blue colored jobs of transportation that's driving trucks and production factories and service hands-on service jobs and construction and so on and then a huge education disparity in this issue of can you work from home people with college degrees over half of them have jobs where they could work from home they they say they could work from home if they needed to all the way down to about five percent from people whose jobs have less than a high school degree so when you get this instruction of you should stay home you should work from home or we're trying to keep people working from home we immediately have this vast inequality that opens up in terms of who is working at home and who is out there interacting with people putting themselves and others at risk and then the race ethnic breakdowns sort of go along with those occupation those map to those occupation and education disparities so that's not that's not too surprising I'm going to talk a little bit finally about the black-white difference the disparate black impact African-Americans have been affected dramatically more especially than whites from what we know so far it's very early days as far as the data that we have available but we can start to see based somewhat on geography but also some places are reporting their data out by race who died what was the race of the people who died here's just five places Washington DC Chicago Louisiana New York state and then New York city specifically sort of going up in places that have had more and more serious outbreaks and you can see in every case blacks are much more likely to have lost their lives from coronavirus than whites are in all these places and there are a few others that are collecting this data as well so we're seeing this disparate impact we want to talk a little bit about why we would what what what and what about this fundamental cost theory would help explain that okay so the poor resources especially regarding living conditions would already have conditioned blacks to have worse health than whites so they're more vulnerable to the impacts remember that Charleger showed you was deaths not infections so those are the people who actually died and that means most likely they had some kind of health problem going into it the lower levels of education and discrimination in terms of what jobs people have whether they have jobs and benefits or flexibility or ability to work from home and all those things that we were just talking about racially unequally distributed by race the workplace policies themselves where where do they work for an employer that allows flexibility that all that provides sick leave and so on so there's racial disparity in that also and then the healthcare system itself the earlier healthcare or lack of healthcare because we still live in a country where a lot of people don't have health insurance affect outcomes not only before they get sick but when they also when they get sick so the hospital they go to the doctor they go to when they when they already have the coronavirus COVID-19 the disease so these are all reasons why we would expect the lack of resources in this case associated with blacks compared to whites that blacks have versus whites will have created this disparate impact in terms of the impact of coronavirus and this is just a taste of one particular disparate impact in terms of the difference between blacks and whites but as this epidemic unfolds through this country and around the world that gives us a taste of the kind of things we're going to look for to understand this and many other disparities that we're likely to see thank you for listening