 Hello, I'm Philip Cohen here to talk today about the COVID-19 pandemic and health disparities. You can see my contact information there, feel free to get in touch with any questions or issues you have with this lecture. So before we can talk about the pandemic and health disparities, we have to know about health disparities. Health disparities, this definition from the Centers for Disease Control, are the preventable differences in burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by socially disadvantaged populations. That is their differences. It's an inequality and they're preventable. So it's something in our social system, our social life and health care health system that creates a disparity in the experience of disease, injury, violence, or opportunities to achieve good health that is preventable. You can see a few headlines here, nursing homes, junk food, opioids, cancer, and so on, all things that might be the subject of a discussion of health disparities. Key theoretical perspective for sociology of health disparities is the theory of fundamental causes. This explains why the relationship between socioeconomic status and health outcomes is so persistent. The interesting thing about this is health care health has improved dramatically over the last century and a half or so. We've had rising living standards, we had huge improvements that came just from water sewer and prove nutrition, but also medical technology, and also education and health related behaviors things we learned about like us will see like smoking and so on where things that improved the public health that improve the health of the population. But even as a life expectancy as you see here improved, the socioeconomic status is still very strongly associated with health. So the theory of fundamental causes helps to explain this apparent paradox. Why is there still a strong relationship between health outcomes and socioeconomic status. So, the, the, what the theory of fundamental causes explains is that in an income and education or what we call socio economic status or SES, bring more resources, money, knowledge, prestige, power and social connections. And those resources help protect people from a lot of different health problems, even as society and medicine change so sort of wherever we are in society whatever is the story of our overall health conditions which are apparently improving. We still have disparities that occur along the lines of income and education or socio economic status because of the resources that those qualities provide. In other words, in any given social situation being able to achieve the benefits of the society in terms of health are dependent on the kind of resources that you get from income and education. So, that's fundamental life expectancy and income. This figure shows the probability of surviving from age 50 to age 85 for different income groups, looking at people who were born in 1960. In the poorest fifth by income, poorest fifth of the population, about 30% of men or women lived from age 85 after they got to age 50. It was around two thirds or three quarters higher for women than for men as we know. So this, this following people over time clearly showed the survival in the sort of second half of life was much greater among people who were richer people with higher family incomes live longer because of better living conditions, better health care and better health behavior. This goes back to the theory of fundamental causes. So part of this is about accessing good health care and part of it is about the benefits of education and other resources that allow people to have better health behaviors to live a lifestyle or to engage in the practices that enable people to have better health. Smoking is a great example of this smoking and a lot of other harmful behaviors are more common among people with lower levels of education. You can see the gradient, the education gradient for smoking is very strong where among people with graduate degrees only 3.7% are current smokers that increases up to about 20% for people who have only graduated high school and over a third for people who have a GAD education as their high school diploma. So this is just one example of a very clear health behavior that we know is associated with health outcomes that is a very strong relationship to education. Social economic status is not exactly the same as race of course but we know that they go together that is members of minority groups and minority communities have lower social economic status on average. And one of the things that we see is that the health disparities that occur by race or ethnicity are very similar to what you might expect by socioeconomic status. And sometimes the data we have in the United States is based on race or ethnicity instead of education. I'm not that the race ethnicity is not important in itself but we kind of go back and forth between these two, depending on what the question is and what the data allow us to look at. This is an example looking at infant mortality over a very long period going all the way back to 1850. And you can see that infant mortality has declined drastically which is great this is modern society this is what we expect. But nevertheless the gap between white and black infant mortality has persisted. So it's still more than two to one, the black white difference in infant mortality actually a greater ratio than there was in 1850. So we can look at the different causes of this having to do with living conditions, which is associated with economics obviously overall health. We'll talk about some of that today the access to health care and the various forms of discrimination that prevent people having access to those things that might then might improve their health and also creating the sort of stress and hardship that is associated with various health problems. So even within black and white groups or in this case also Asian Pacific Islanders and Hispanics and American Indians, we still have an education gradient that is that socioeconomic status difference works within the racial ethnic groups in this country also this education is apparent within each group. Again, this is infant mortality. And you can see that in each group those with the least education this is the women the mother giving birth. Those with the least education are most likely to have to lose an infant have an infant die in the first year of life. Those with a higher levels of education are the least likely to experience infant mortality. But you can also see that that does not at all negate the differences by race ethnicity, so that for example the the college graduates black women who are college graduates have higher infant mortality rates than white women who've only graduated from high school. So here's just one example where you can see both the race ethnicity dynamic and the socioeconomic status dynamic and in both cases what we're looking at is conditions where the situations where the conditions of life of health and health care and economic status and discrimination and all that that entails are producing very disparate outcomes by race ethnicity and education. So we're still building up to the pandemic, the current pandemic. And one another example I want to give that goes to helping to understand sort of the social context that produces very disparate health health outcomes is the opioid epidemic. And those the opioid overdose death rate in all the in all the US counties, and you can see it's very high it's clustered in the Appalachian area of and and some places up in the Northeast, and then some areas where it's our poor areas in the West, especially American Indian areas. These opioid overdoses are very concentrated in places that are economically distressed places that have been experiencing de industrialization the loss of the economic base, a shift of the declining resources available to state states and governments for things like education and health care. So this economic maladies that have gripped these areas have fed into the opioid epidemic in those areas so it's another case of where it's sort of this is the geography of socio economics that is producing health disparities. So just quickly, why is this pandemic so bad. Well it's a novel coronavirus that's what it's called, which means that we don't have immunity to it. Nobody in the world does probably, or did when this pandemic started so there was no immunity virtually no immunity. It's highly contagious if you're in close contact with someone else who's infected it's very likely that you'll become infected. The problem of asymptomatic transmission makes it hard to isolate people who are infectious. So it's sort of always one step ahead of us infecting people who don't appear to be sick. And then of course this all only matters because the disease is bad it makes people very sick, not everybody but but more than other infections such as seasonal flu. So people experience more negative effects including eventually mortality than we do for a lot of other infectious diseases those are the things that make this bad. I show this because I want you to see that the United States is in a fairly unique situation here out of the roughly one million deaths in the world, over 200,000 have been in the United States by far. Greater than our share of the world population and more documented coronavirus deaths than any other country in the world. So now let's talk about COVID-19 a little, and specifically how it spreads when we understand a little about how it spreads, then we'll be able to understand something of how the disparities that we see emerge. So it's spread through interpersonal contact people being near each other, and the droplets that come out when somebody coughs or sneezes or exhales strongly for example yelling speaking loudly or singing, and by aerosolized droplets that are that are that are not droplets that sort of are wet and fly through the air but tiny droplets that can linger in the air. So it's whenever people are near each other, and the longer they are together, and the closer they are together and the less ventilation and airflow there is around them like indoors versus outdoors. This is how the pandemic spreads. A key thing also is that asymptomatic patients patients who don't know they're sick can be infectious and spread the virus. So essentially what we're going to find is that people who are separated from others are least likely to get this disease and people who are close to others are most likely to get it and then we'll also see that the outcomes are partly dependent on the kind of healthcare that people have. So some of the dynamics of how this has evolved in the United States. One, one, one institutional setting where we've seen outbreaks that help us see how this epidemic works and also how we have failed to stop it are settings where people are close together, especially people who have possibly compromised health and not good health nursing homes are by far have been the worst on something like 40% of all deaths from coronavirus have occurred in and around nursing homes over 77,000 people in the United States have died. I'm either nursing home patients or staff who work in the facility so just devastating, including in small towns and rural areas where often the epicenter the local epicenter in many rural counties has been a nursing home. I also have seen shockingly large epidemic outbreaks in prisons among both prisoners and staff over 200,000 infections and 1265 deaths as of a recent count by the New York Times. Here's a list above me a list of some of the specific cases 3000 people tested positive in Avenue State Prison in California 2500 in San Quentin in California just thousands of people in prisons and prisons are churning people are coming and going from prisons and so the epidemic is coming in and going as prisoners come and go and as workers come and go. So these have been a big, a big driver in our country and then similar situation occurs in factories we have a lot of people who are close together, working hard breathing all over each other for extended periods of time. We've seen some big outbreaks in places like meatpacking plants, especially you can see there, the meatpacking a Smithfield planted South Dakota the Tyson foods plant and Iowa over 1000 cases each, and many many other examples of outbreaks in factories. So all these are cases where close together breathing on each other and then it's worse when people have health impairments or health problems in addition. We see places where we might see health disparities along the lines of what we saw discussing earlier that might be coming up in this pandemic, physically concentrated places like nursing homes and factories and prisons places where people have health status that puts them at greater risk of negative effects of this disease which is a respiratory illness. So people who have for example asthma or high blood pressure or compromise immunity of some kind are greater risk of having a negative outcome if they are infected. So a lot of what we see is people who are exposed in and around their workplaces health care workers obviously the most obvious people at risk but also service workers, people whose jobs put them in close contact with the public, and then workers who work at work instead of working at home as I am doing right now, people who can't work at home are just at greater risk because they're out interacting with more people just in order to have a livelihood. So we see how the inequality in work is translating into inequality in working at home which puts people in a safer position vis-à-vis the pandemic, but instead of working out and about which is where people are at greater risk. So we put this together to show some large occupations or occupation groups of occupations, and you can see these higher paid occupations, computer and math occupations, lawyers, architects and engineers, managers, science occupations. Those higher paid jobs that pay over $1500 a week have very high rates of people who are currently teleworking. People who are working at home because of the pandemic, the Bureau of Labor Statistics has been asking this question. People who are working at home because of the pandemic, and so in these occupations like computer and math occupations, I'm over 60% of people say yes I've been working at home at least some of the time, because of the pandemic. All the way down at the bottom of the income scale here down around $500 or $600 a week. I'm in pay food service jobs health care support personal care building and grounds workers. These are not jobs you can do at home and these people are not doing those jobs at home so under 10% of them are working at home people have these occupations, they have less money, and they have jobs that put them at greater risk, they literally are out doing their jobs that involve interacting with other people jobs like truck driving and driving buses and working in sales and office support jobs and so on. Working class jobs are just putting people at greater risk, and it's the middle class and higher status jobs that are allowing people to stay home where it's safer, and where they're just less likely to get infected by the pandemic. An occupational disparity boils down to what we can see an education gradient in working at home. So I do this to draw to go to harken back to the discussion earlier about smoking or about opioids, where we know people who are in have harder economic times, people who have a less education are more likely to have behaviors which are not necessarily things that they're choosing as in this case that put them at greater risk for health problems and create health disparities. So when you look at that occupational distribution of who can work at home, you see this very strong gradient by education in the percent working at home where 50% of people with advanced degrees, such as me, are doing their jobs at home at least part of the time, and all the way down to workers with less than a high school education, only 4% are able to work at home. So just like smoking, this is a case where the behavior in this case working outside the home that puts people at risk is concentrated among people who have less education. Now, this is not all happening in a vacuum as far as our government and our government policies. And particularly we have a very serious problem that workers who literally are sick have to go to work or they will lose their jobs. So we have a problem with with trying to stop the pandemic that we're literally pushing people into the workplace when they are sick. 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. 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 care for. 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. So unsurprisingly, when you look at the kinds of occupations people have, the kind of health conditions they have, the type of work they're doing, and the lack of protections that a lot of people have at work, you can imagine we're going to see some disparate impacts of the coronavirus epidemic. This shows how extreme those differences can be. These are the COVID-19 death rates. So these are deaths out of every 100,000 people in each age and race ethnic group have died from the pandemic. And you can see that in each group, people with older age are more likely to have died. So that's that's what we know about how the disease works. It's more harmful to older people. But the disparity between black, Hispanic, especially black and Hispanic versus white death rates is very large when you look within the age groups. And especially it's a little hard to tell the figure. That's why I called it out that where the rates are lower the people under 65 so age 18 to 65. That's where the disparities are the largest in terms of death rates where black and Hispanic individuals have death rates of five to eight times higher than white people of the same age group. So very disparate impact in that case, which I think we can trace back to not only pre-existing health conditions at someone, but also those conditions of work and the inability to work at home. And yes, if you're looking in shock at these numbers, that number for black people over age 85 is 1600 out of 100,000. That means 1.6% of all black Americans over age 85 have died from coronavirus. So just absolutely astounding, devastating and terrible death rates at older ages, especially among black and Hispanic people. So what can we learn from the fundamental cause theory to help us understand the coronavirus pandemic? Well, poor resources, so the kind of jobs and education and money and where people live all that affects the living conditions, lower education and also discrimination affects what kind of jobs people have. And these things put people at different amounts of risk. On top of that, the workplace policies such as sick leave as we saw leave some people more vulnerable or the ability to work at home versus having to go out and work with the public leaves different groups more vulnerable. We saw big disparities there. And then poor health care or lack of health care affect the outcomes once people are affected. And you don't have to look any further than the president and his associates to see that they have, they were reckless and took all kinds of risks and got infected and then have had great health care to help them deal with the outcomes. So the disparate impact is partly by do you get it and partly how sick are you or how healthy are you at the time you get it and then what resources including health care resources do you have to deal with the infection to deal with being sick. All of this affects disparate black and Hispanic impact of the pandemic as well as other disparities such as education and income.