When we think of people engaging in unhealthy lifestyles, we are quick to blame the offender. What we often fail to recognize is that not everyone has the same opportunities. In this episode of EJB Talks, Stuart Shapiro delves more deeply into the area of health disparities with professor Dawne Mouzon, a medical sociologist specializing in health disparities across vulnerable populations. Dr. Mouzon sheds light on why some populations, particularly black Americans and Latinos, are more susceptible to infection–not just from COVID-19–and why their health outcomes are not as good as those in predominantly white or more affluent communities. She also expresses the importance of delving into why some other countries have had much better outcomes managing COVID-19 and why the U.S. should take steps to make universal healthcare a priority.
Stuart Shapiro
Welcome to another episode of EJB Talks. I’m Stuart Shapiro, the Associate Dean of Faculty at the Bloustein School. And the purpose of this podcast is to talk with my colleagues about issues affecting people in New Jersey, the United States, and the world. Today we’re returning the topic of the health impacts of COVID-19, particularly the disparities in those impacts across race and across socioeconomic status, a topic mentioned a few episodes ago by Dr. Sabiha Hussain in the RWJ Intensive Care Unit. I’m talking today to my colleague Professor Dawne Mouzon, an expert in health disparities. Dawn, thank you for joining us.
Dawne Mouzon
Thank you for having me. I’m happy to be here.
Stuart Shapiro
Can you tell us a little bit about your research on health disparities?
Dawne Mouzon
Sure. Generally speaking, I study physical and mental health disparities among populations of African descent. So, I study the negative health effects of racial discrimination–goal-striving stress, poverty, and intimate partner violence. But in addition to studying those traditional risk factors for poor health, I study how protective factors, like social relationships, religious involvement, racial identity, and coping, shape physical and mental health among black Americans. And I also spent a lot of time understanding and communicating information about the heterogeneous nature of black communities in terms of ethnicity. So, how African Americans may differ from Afro Caribbeans and from those with direct ancestry, and also how the black immigrant experience in the U.S. is both similar to and very distinct from, the experience of African Americans in this country.
I came into the field of health disparities because my paternal grandmother died of a preventable illness related to poverty at age 38, which made me passionate about finding ways to end premature death among historically marginalized groups.
Stuart Shapiro
When we think about people being in good health, you know, when we have the sort of lay interpretation of that, we think, oh, that person has a good diet, they don’t smoke, they don’t drink. They go see good doctors. But a lot more goes into people being healthy. How do socioeconomic factors play a role in how healthy a person is?
Dawne Mouzon
So I’m really glad you asked this question because it’s one I hear a lot, and it’s a common topic I discuss with students in my class. My short answer is that yes, each of those factors matters individually, but I really see those factors as being inextricably linked to each other. So, good health, a good diet, and healthy behaviors are shaped by socioeconomic factors. So I’m trained as a medical sociologist, and we often talk about constrained choices that many low-income people and people of color face. And a common explanation that people give for health disparities is health behaviors. If only those people over there would do better, if only they would eat better, if they would value their health more and so on. But that assumes that every person has the same range of healthy opportunities available to them. And we know that that’s simply not the case.
And that’s where socioeconomic factors come into play. So if you think of neighborhood socioeconomic status; you live in a low-income, under-resourced neighborhood, there’s likely no full-scale supermarket where you can buy fresh produce. So you don’t even have the option to buy fresh fruits and vegetables if you wanted to. You have to rely on small neighborhood stores that largely specialize in canned goods and box goods. And likewise, in that same under-resourced neighborhood, it may be unsafe for children to exercise in the park, or they may not be safe sidewalks on which to walk or run. So in both of those cases, healthy choices are constrained and oftentimes not within one’s reach at all. And at the individual level, socioeconomic factors like income, of course, determine whether you can afford to buy healthy food, or instead need to rely on cheap and unhealthy food. So you may know it’s in your best interest to buy ingredients for an arugula salad, but if that costs $10 for one or two people, and you can buy a frozen family meal that’s more filling for $6, your choices are constrained. The unhealthy choice is more within your reach. And if you’re struggling to keep your lights on, you can’t afford a gym membership. So your exercise choices are constrained as well.
So when I hear this question, my main response is, your own personal socioeconomic resources, coupled with the resources available within your neighborhood, help to shape the extent to which people are able to make healthy choices regarding diet, exercise, smoking, drinking, and so on. And I alway emphasize in my courses and in my research, that it’s imperative to consider social context when investigating health inequities, because otherwise, it’s just a slippery slope into simply blaming people for their poor health outcomes.
Stuart Shapiro
Yes, and that’s such an important misconception to correct. I mean, even the Surgeon General of the United States a couple of weeks ago was talking about how people need to take responsibility for their health. And if we ignore the factors that you’re talking about, we sort of, say to the government, okay, well, you don’t have to deal with this problem it’s a personal issue. It’s not a structural issue. If we admit it’s a structural issue, then we have to do something about it. Am I sort of getting that right?
Dawne Mouzon
I think you’re exactly getting that right. And that was a very disappointing moment for many people who study the things that I do. And there were lots of think pieces written about that. Because, yes, really, there’s no room for policy intervention if we can just blame people for making bad decisions. As opposed to looking to the range of decisions they have available to them. And I think you hit it right on the head with that one.
Stuart Shapiro
So turning to our current crisis, COVID-19 has clearly hit hardest upon racial minorities. I saw one number this past weekend that in New York, black people were twice as likely to die as white people. And that’s controlling for everything else–controlling for income, controlling for all that other stuff. What is your best explanation for this?
Dawne Mouzon
Well, there are so many explanations. I say probably the leading explanation right now has to do with the fact that people of color, almost across the board, have disproportionately high rates of chronic conditions, which are often comorbid and co-occur together. The CDC lists 10 risk factors for COVID-19, including things like asthma, diabetes, obesity, heart disease, and kidney disease. And blacks and Latinos have the highest rates of those conditions, leaving them especially vulnerable not only to acquiring COVID-19 in the first place. But these health conditions also mean that their recovery rates are lower than those of whites. And poverty and racial discrimination at the individual and institutional levels leads to cumulative stress over the life course, which we know also impairs the immune system and raises the risk of illness. So all these risk factors translate into higher vulnerability for acquiring COVID-19 in the first place. But besides that, biomedical risk factors, there are a bunch of other risk factors that predispose people of color to COVID-19. And I would characterize those as largely social rather than biomedical. And I won’t talk about all of them, but I just want to talk about probably two of them. Housing inequality is one of those factors. So we know that population density is a major risk factor for COVID-19 in the form of crowded living conditions. Both in terms of housing structure and housing composition. So given the long legacy of racial residential segregation, blacks and Latinos are far less likely to live in single family homes, and far more likely to live in apartment buildings and high rise complexes that involve more unavoidable daily human contact with neighbors. And to compound that issue, because of poverty, people of color tend to have larger household sizes, often in what we call vertical living arrangements, with multiple generations in a single household. So in those circumstances, it becomes harder to contain the virus. If one person in the household catches it, and because many of these households are multi generational, older family members become most vulnerable. And there are many others I can name but I’ll just name one more in the interest of time. The second social respecter is that blacks and Latinos are largely concentrated in low-wage jobs within the service industry, for which working at home, or even taking paid sick leave is not a possibility. And these are problems because they pose at least two additional risk factors for acquiring the virus. So for those in essential jobs, they have increased contact with the public. And because there’s no paid leave, they’re less likely to stay home when they’re sick, because they need the income, quite frankly, to keep their lights on. So those factors increase the risk of acquiring infection in the first place.
Stuart Shapiro
Yes, it’s sort of a double whammy there. Poor people, particularly minorities, are both more likely to get sick in the first place, and then less likely to get adequate care once they get sick. Let’s go through these, and you’ve talked a fair amount about them already. But I want to go into a little more detail. Let’s talk about the first of these prongs and think about what we can do about them. In terms of making it less likely that people get sick in the first place, what can we do in terms of prevention to protect the most vulnerable members of society?
Dawne Mouzon
I think–in order to sort of affect any real and lasting change, and building what I think should be a goal for all of us, which is a more equitable society–I think it would really require a drastic reorganization of our society’s current arrangement. So this is just a pie in the sky thought. But for those with the most resources would just have to be willing to give up a little bit more. So the 90 to 99% of us remaining have more equal access to health and economic opportunities. And we see this type of economic organization and other wealthy democracies. But the question, of course, is whether we, as a nation, have the political will to execute that level of redistribution. But on a more realistic level in the short term, (laughing), that’s my pie in the sky hope.
Stuart Shapiro
(laughing) But you’re allowed to have that.
Dawne Mouzon
(laughing) Thank you. I’m going to hold on to that. I think we can definitely increase our efforts to provide a basic living wage to workers. And it’s only seemed like one to two weeks of this pandemic for people to reach total economic devastation. So Americans need more financial cushion in their budgets in order to be able to withstand any economic shock, whether individual individual level shock, like having a car that broke down or collective shock, like we’ve seen with COVID-19 in the form of massive job loss. And I think we can also provide universal health care like our other wealthy democratic peer nations. I’m not alone, hopefully, in thinking healthcare should be viewed as a basic human right, not something that only some people deserve.
Stuart Shapiro
So that turns to the second prong and sort of making sure we care for people better. Can you expand on that a little bit?
Dawne Mouzon
I mean, I think that, you know, given the enormous job loss we’ve witnessed in the past few months, I think it makes sense that American’s health coverage not be tied to their places of employment. So we’ve seen millions of people who lost their jobs due to the virus, but also as a result lost their health insurance. So I share the belief of many others that we need to design a system in which employment and health insurance are not inextricably linked. So that’s one factor. I also think we need to ensure that there’s universal free testing available to everyone, regardless of insurance status or citizenship status and that these sites are available in all communities. We all have shared risks, so we cannot afford to leave any communities behind. I think we’re slowly getting there. But there are miles to go, so to speak, before we sleep. I think we need more rapid testing. So people diagnosed as positive with COVID-19 can self-quarantine and contact tracing can be initiated as quickly as possible. And we need these rapid results, especially for people with pre-existing conditions, so that accessible pathways to care can be developed so that these vulnerable residents don’t fall through the cracks.
Stuart Shapiro
Obviously, everyone talks about testing, and that’s going to be a key component. My view is that testing is necessary, but not sufficient to get us there. We have to have it. But it’s not by itself going to get us to where we need to be to recover from this. Ideally, eventually, we’re going to need treatments, and we’re going to need a vaccine. And I’m guessing most of these issues of disparities, what we’re going to have to really watch out for is treatments and vaccines are developed as well.
Dawne Mouzon
Right, I think we have to be attentive to the potential for inequities at each stage of the process. So we were just talking about testing. But also in terms of being sure that those pathways to affordable and accessible care are made available to our most disadvantaged and marginalized populations. And the New York Times, actually, the CDC recently released a statement saying that healthcare providers should be made aware of the potential biases they may be perpetuating in the clinical encounter. And I think that was largely in response to some of the media coverage about black patients specifically, seeking testing and being turned away and then later dying. So we need to be careful to attend to, not just once we eliminate, hopefully, testing disparities, but that we are also aware of unresponsive to disparities regarding treatment, follow up, and so on. So all across the path.
Stuart Shapiro
Yes, the turning away for testing is just it’s appalling. And, you know, to some extent, I’m sure it’s unconscious bias. But it’s there and we need to be aware of it. There was also data, I saw that when African Americans complain about pain, they’re less likely to get medications than more affluent and white patients. If that’s what happens when we have a treatment for COVID, you know, this is not gonna go away.
Dawne Mouzon
Right? Yes, we’ve seen that in terms of pain. We’ve seen that in terms of maternal and child health. You know, black women going for, you know, labor and their symptoms and their complaints being disregarded. And we even saw this with Serena Williams. I talk a lot about this, and other medical sociologists talk, about diminishing returns to health. So, you would think the idea is that once even the most disadvantaged group, once you reach a certain socioeconomic level, then health disparities should go away. But if you’re Serena Williams, and you’re still having access to care problems or quality of care problems, then you know there’s there’s a problem there.
Stuart Shapiro
Right. I mean, that takes away the argument that, oh, it’s just income.
Dawne Mouzon
Exactly. So we need to be attentive to socioeconomic disparities and certainly design policy for that. But we also have to realize that racism also comes into play and compounds the issue further.
Stuart Shapiro
Right. So obviously, COVID-19, we’re still in the middle of it. We don’t know exactly how it’s going to play out. A lot of people have guesses and ideas. But we can already start to, I think, hopefully, draw lessons from it. If we were to take lessons from this awful experience, what would you like them to be?
Dawne Mouzon
That’s a great question. I really hope that as a nation, we begin exercising the humility to learn from other countries. Not just about how they’re managing the pandemic, but more broadly in terms of how they organize their societies. So, since we’re talking about health here, the most obvious solution is to find a way to provide universal health care for all. It should be a basic human right, full stop. We need to raise the bottom on population health for people of color and low-income people so they don’t develop chronic illnesses prematurely at the rate they do. There are some studies showing that for black people specifically, they develop chronic conditions on average 10 years earlier than whites. And so premature death matters not just for the families who are left behind, but also in terms of lost productivity to the economy, and in terms of the ability to pass down intergenerational wealth. So I think that matters. But even beyond health, I think what we’re learning here is that, what many of us knew all along, is the social safety net in the U.S. is woefully inadequate. People who were put out of work had little savings to get by. There are still millions of Americans waiting to be approved for unemployment. And the federal government provided a one-time stimulus of $1200 dollars. But if we learn to exercise the humility by looking at other countries — we can look at our northern neighbors, Canadians who became unemployed, because of COVID-19, are now eligible for $2,000 per month for four months with an additional payment, I think of $300 per child. And even college students in Canada are eligible for $1250 per month for four months. So having this sort of steady, short-term economic transfer will keep Americans from becoming housing or food insecure. And because health care in Canada is not tied to employment, those who lost their job don’t have to worry about being unable to afford care. So I think that’s one important thing we can learn from this terrible exercise.
Stuart Shapiro
I like that you used humility there because certainly, you know, the only things we’ve been the leaders in the COVID-19 crisis is the total number of cases.
Dawne Mouzon
I totally agree.
Stuart Shapiro
I mean, I don’t know that that’s where it’ll be when all is said and done. I think the developing world is going to have a horrible time. But right now, that’s where we are, and nd that’s not where we should be. Thank you very much, Professor Mouzon, for coming on today. This has been I think, very educational, and very helpful to our listeners.
Dawne Mouzon
Thank you for having me. It was a great time.
Stuart Shapiro
I also like to give a thank you to our production team, Tamara Swedberg, Amy Cobb, and Karyn Olsen. We’ll be back next week with another talk from another expert at the Bloustein School. Talk to you then.
