Ep. 8: Sandro Galea, MD, MPH, DrPH, Dean of the Boston University School of Public Health. Topic: Social determinants of health, COVID-19, and racism in healthcare

Kathy: Hi everyone, and welcome to Episode 8 of the Smarter Healthcare Podcast. Right now, we are grappling with the COVID-19 pandemic and issues around race in America. Today we’ll be looking at the intersection of the two. Unfortunately, we know that being Black means you have a death rate from COVID-19 twice that of white Americans. A big part of that has to do with social determinants of health. Today, we are joined by Sandro Galea, dean of Boston University’s School of Public Health to talk to us about social determinants of health, what it means in the context of the COVID-19 pandemic, and racism in healthcare. It’s an important conversation we need to be having right now. Here’s our discussion.

Kathy: Dean Galea, thank you so much for being here today…and 2020 has been a year that’s really unlike any other that we’ve lived through. You recently wrote an article in which you called this year “The Great American Trauma.” We have all of these different events going on – we have coronavirus, the unemployment tied to that, racism, political divisiveness, these have all disproportionately affected people of color, and they’re all unfortunately connected and converging at this one period of time. So I want to start off this interview by broadly talking about the concept of social determinants of health. I feel like I’ve heard this phrase at every healthcare conference I’ve been to in the last year or so. Can you give us a background on what that means and why it’s important in the context of healthcare delivery?

Sandro: Thank you Kathy for having me, first of all, on the show. The – I think you’re right – that we are going through a period of what I’ve called The Great American Trauma. I think there are multiple traumas going on and I think one of them is obviously COVID, the pandemic itself, the other one is unemployment and the economic consequences, and the third one is a reckoning with decades-old, centuries-old, racial injustice, deep-seated structural racism. Now, I frame it that way because I actually think all of that ties into the social determinants of health. By social determinants of health we mean the forces that drive health that are outside of our bodies. So it’s not the biological determinants. Biological determinants would be our genes, the molecules in our body. Social determinants are the housing we live in, the transportation we take to work, the air we breathe, the water we drink, whether there’s gender equity, whether we are victims of violence, whether there are opportunities to actually live one’s life fully. And when we think about health, historically we have taken a very biomedical approach to health. Which means we have privileged the biological determinants. We tend to see health as something that happens in my body, in your body. And that approach results in a limiting. And in fact, we know now that the world around us matters much more to our health than does biology. The social factors matter much more than biology. So let me use an example. If you are born in a poor household and your parents have to work two jobs to keep you fed, and you grow up by yourself, and looking out for yourself, watching TV, you’re going to eat junk food, that’s what your parents can afford, you’re going to grow up obese, that instantly creates greater risk factors for you, it makes it hard for you to lose weight later in life. You then move on to a manual labor job where you’re standing on your feet, and by the time you’re in your mid-40s, you have extra weight, you’ve been on your feet all your life, and you need a knee replacement. Now, we can see the knee replacement as a biological factor, saying well, it’s osteoarthritis that resulted in a knee replacement, let’s worry about it biologically. But a social determinant’s perspective says what really drove the knee replacement was your misfortune of being born in poverty, the fact that you got obese in childhood because you had poor eating habits, the fact that you never got a good education, and as a result you ended up working on your feet all your life. So that’s a social determinant’s perspective versus a biological or bio-medical perspective. Now let me bring you back to COVID, because you asked me about COVID by way of starting it. I think that much of what we’re seeing in COVID should lead to a recognition that the social determinants are what shapes our health. Why is that? Well, the reason for our national failure at dealing with COVID, reckoning with COVID, centrally is that we did not have a healthy enough population and that we did not have a system in place to help us deal with COVID. Those are all social factors. Economic collapse results in a worsening of conditions for a large segment of the population. Particularly a segment of the population that is already underemployed and already socioeconomically marginalized. And the forces that have brought about a reckoning with decades- and centuries-old racism and structural inequities are fundamentally social and economic forces. This reflects a deep history of racism that has excluded segments of the population, particularly Blacks, from access to economic and social opportunity that they can use to advance and to be healthy. So the entire story of COVID is a story of social determinants. We can use that term, but I don’t think we need to use the term as long as we understand that that story is embedded in the social and economic realities of people around us.

Kathy: And we’ve seen with COVID that in New York there’s some predominantly Black neighborhoods in the Bronx and Brooklyn where the death rate was twice as high as in white neighborhoods. Are there particular reasons as to why that was the case?

Sandro: Yeah, so we know that in – at least at the moment, as we are recording this – that the rate, the mortality rate from COVID among Blacks is more than twice what it is among whites in the U.S. And the way to think about that is to think about two different sets of risks. There is the risk that you’re going to get COVID, and then there’s the risk that if you get COVID you’re going to become really sick with COVID. Because of course, most people who get COVID, they’re not particularly sick with it. The first risk of getting COVID is determined by the likelihood that you are to be in contact with other people. And if your job is one that you can not do from home, it’s not a white collar job, it’s a job – you’re an essential worker or you have to take public transport, you are going to be more in contact with other people and that is going to make you more at risk of getting COVID. Now if you have COVID, and you have underlying diseases, underlying morbidity, and you have a greater burden of poor health, which is what characterizes people of color, and people with lower socioeconomic needs in this country, then you’re likelier to be sicker as a result of COVID. So there is no question that there is a greater risk of mortality from COVID among people of color, centrally among African-Americans, Blacks, and that I think is due to these two different sets of risk. Greater chance of getting COVID, and great chance of being sick from COVID if you get it.

Kathy: And then there are probably some of the – I mean you touched on some of the economic reasons: people of color are more likely to have to go to work, they’re more likely to take public transportation. I think that seeing some of our response to this – even mask wearing seems to be very political right now – are there other factors like that that contribute to how our response has affected people along racial lines?

Sandro: Yeah, I think you’re asking a very big question, and I think there have been – almost everything around this pandemic has fallen along racial lines. Because racial lines are indistinguishable from socioeconomic lines. And it is impossible, it’s been simply impossible to protect yourself from a highly transmissible virus without actually having the socioeconomic means to sequester yourself, to self-isolate. And those socioeconomic means go with – they highly correlate with race, and with dimensions of identity. So as a result the entire story of COVID has been one of race in many respects.

Kathy: And do you think our response would have been different if it affected non-marginalized groups in the same way that it has affected marginalized groups?

Sandro: That’s an excellent question. I don’t know. I would like to think not, but I fear the answer may be yes. I do think that at the beginning we reacted to COVID without knowing which group it was going to affect, although several of us, myself included, have been writing since the end of February that this is going to affect marginalized groups more. So I think we did know that, and in many respects what we did not do is take the extra steps to protect marginalized groups, to protect populations that we could have guessed are going to be more affected. And did we do that? In some small extent we did, but not overwhelmingly, no.

Kathy: Now let’s talk about some of the racial protests that have happened in recent weeks. In some respects these, you would think that they’re events that are completely different from the pandemic, just happening at the same time, but I think in many respects they are intertwined with each other. How have the protests and the civil unrest that we’ve seen in our country impacted both our pandemic response and has it affected outcomes at all?

Sandro: It does not look like the protests at a very physical level have affected outcomes. It does not look like there has been that much new transmission as a result of the congregation about civil unrest, largely, I think for two reasons: One is that many of the protestors were careful wearing masks, social distancing, and also because these protests have been outside. And we now know that transmission outside is much less likely than is transmission inside. That’s number one. But at a more important level I think the protests put front and center - put race front and center in the conversation, where it should be. Where it should have been all along in the middle of COVID. So the fact that race obviously in this case emerged because of the police shootings of unarmed men and women, but it is a larger story about race than that – it is a story of race, as we just discussed, that really informs everything about COVID. So I think the civil unrest elevated the importance of race to this story and insofar as it does that I think that’s really important.

Kathy: Over the last several days we have seen a big increase in the number of people who are testing positive for COVID. From a public health perspective, do you think that there are certain things that we really need to focus on right now? What are the most important things, do you think, in our response?

Sandro: I think we’re getting at a point in the pandemic where we need to recognize that we can not keep the economy and the country shut down forever. There are too many significant social and economic consequences – if kids do not go to school, they’re going to fall further behind, and that’s going to have particular implications for kids who are – lower socioeconomic status kids who do not have the luxury of easily accessible digital home learning. So we do know that by keeping retail shut down, hospitality shut down, transportation shut down, we are affecting jobs, principally jobs that were taken by people who were already marginally employed and in deepening social and economic decline. So it is important that we open up the economy. But doing that should not happen glibly, and it certainly should not happen without paying heed to the due caution that we need to exercise in order to open in a measured way and take the risks well into account. That means opening but observing social distance, wearing masks, not congregating in large groups inside – all of that fundamentally goes towards mitigating the spread of the virus, saying, we are going to open, yes, we understand there’s going to be some more cases, but hopefully those cases will be among young healthy people, we want to make sure that those people are not transmitting their cases then to elderly people. So that means opening but opening with testing, contact tracing, isolation of people with cases to prevent cases from becoming clusters, becoming outbreaks.

Kathy: Now let’s talk about how we start to solve these problems and recover from this trauma that 2020 has brought us. It’s obviously not going to happen overnight. Are there some areas in which you’ve seen a positive impact as it relates to social determinants of health?

Sandro: Well perhaps the biggest positive impact with respect to social determinants is the elevation of social determinants to all conversations, the fact that we are talking about social determinants, in the context of a pandemic. Which, when it started, the conversation was entirely a biological conversation, about the virus and properties of the virus. Now we understand that what really matters for the consequences of the pandemic are the social determinants – that is a positive, that is important because we need to change the conversation to begin to say that what drives health is not our biology. What really drives health is the housing available to us, whether we have access to fair wages, whether there is gender equity, whether we are living in a neighborhood that allows us to exercise, whether there is clean air, whether there is safe, affordable healthy food – that’s what really drives our health. And I think COVID is helping us see that more clearly. It is very hard to say what is the silver lining behind a pandemic that has killed hundreds of thousands of people. That is a very hard thing to say. But from point of view of learning collectively, if we can learn that health is socially determined, that what we do collectively as a society determines our health, hopefully that will educate us so that we do things that improve our health. Because ultimately, we all want better health.

Kathy: For healthcare leaders, I think a lot of this can seem overwhelming when we’re talking about these big issues like social determinants of health, like racism in healthcare – it seems like too big of a problem to solve. This has been going on for too long, this problem is bigger than I am. For those healthcare leaders, what do you think are some of the first really tangible steps that they should be taking to affect positive change in their organizations?

Sandro: Well, I think there are several areas which healthcare leaders can take. Number one, I think healthcare leaders need to understand that their control over health is relatively limited. That if you are running a hospital, you can make sure you restore sick people to good health, through your doctors, through your nurses, and that’s fine. But ultimately, people’s health is triggered by and it’s shaped by their environment. Let me use a metaphor: A metaphor is, supposing you get a splinter in your arm. You get a splinter in your arm, and you get an infection in your arm. Well, you can go to your doctor, and your doctor can say, you have an infection in your arm, let me give you antibiotics. And they give antibiotics and it gets worse. If you never take out the splinter, you are still going to keep getting worse. And we need to make sure that we move our healthcare away from saying simply let’s just keep using antibiotics to treat this, to treat the infection and to say, what’s the splinter? Let’s remove that. And that is the places we live, the places we work, the places where we play. Now a lot of that is outside the remit of healthcare leaders, I understand that. It’s outside what many healthcare leaders do, but healthcare leaders have an important voice, and if they embrace that charge, and they speak to that charge, they can be part of the solution.

Kathy: Now let’s jump ahead to 2025 – what do you think will be the big lessons that you hope we will have learned from this year?

Sandro: I think the big lessons are COVID is a story of two things – it is a story of underpreparedness, of underpreparedness of the system, of our public health system at the national, state, local level, and because of underinvestment in that system, and number two, it is the story of an unhealthy country. A country that has been structured with much poorer health than it could be, because we have neglected the underlying social and economic conditions that drive health. That is the story of COVID. And of course in the latter part a large part of it is about race. If we can extract those two stories and elevate those two stories, we will as a world be better for it.

Kathy: And do you think we will have made progress by then?

Kathy: I do too. Well thank you so much, this was a great interview, thank you for your time today.

Sandro: Thank you for having me Kathy.

Kathy: Thank you for joining me for this episode of the Smarter Healthcare Podcast. You can follow Dean Galea and the Boston University School of Public Health on Twitter @sandrogalea and @BUSPH.

You can also follow me on Twitter @ksucich or @smarthcpodcast. Feel free to get in touch with comments or guest suggestions.

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