Expert Interview: Racial Disparities Amid COVID-19

Drug Topics®: Hi, this is Gabrielle Ientile with Drug Topics®. Today I'm going to be speaking with Dr. Cheryl Wisseh, PharmD, MPH, and zone 5 director of the National Pharmaceutical Association (NPhA) about their commitment to racial equality and dismantling racism within healthcare.

This interview was prompted by the joint statement that was made by 14 national pharmacy organizations that came out in support of protests for the end of police brutality. But the protests also represent how many different sectors, including the healthcare sector, must actively work towards ending racism within their system.

To start out, would you highlight some of the key messages from this joint statement and what the statement means to your organization and NPhA?

Wisseh: So some of the key messages and coming directly from this statement is the unity within the organizations that were standing in unity to advocate for the dismantling of systemic racism that have historically marginalized and oppressed Black Americans in this country.

So advocating for measures that eliminate these inequities that result from this discrimination and systemic racism, and working together to provide opportunities to address healthcare disparities, in every facet of our profession, including patient care, pharmacists, pharmacy technicians, continuing education, student pharmacists’ education, workplace practices, pharmacy school admissions, leadership opportunities, and even the organizational policies.

So it's a multifaceted approach from all of these organizations to dismantle the system, if you will, using different tools, initiatives, and intentional training and programs to look at this and finally move forward with it and create a generation of pharmacists that will be better equipped to fight this kind of second pandemic, and advocate for equity and actually create a more equitable world.

Drug Topics®: So what do you see as the importance of pharmacies and pharmacists in addressing racism in health care and supporting the Black Lives Matter protests?

Wisseh: It has to do with our code of ethics as pharmacists. And 1 of the tenets in our code of ethics is that a pharmacist serves individual community and societal needs.

Pharmacy and public health do have an intersection in their shared goals to promote the health of individuals, communities and society overall. Racism in all its forms – structural, institutional, interpersonal, or even internalized – is a public health issue. Since it has negative impacts on the health of individuals and communities of color and society overall, then that means it becomes a pharmacy issue, because pharmacy has that shared goal with public health.

And there's another tenet within our code of ethics that also says, as a pharmacist, we seek justice in the distribution of health resources. Delving a little bit deeper into structural racism, for instance: in order to understand structural racism, you need to know that American society in and of itself has racial discrimination built into the foundation. That includes all of the social structures and systems, so housing, education, employment, wage, earnings, credit approval, entertainment, media, and most importantly, healthcare.

Over time, you have this discrimination that is compounded within these systems and leads to that reinforcement of discriminatory beliefs and values that are discriminatory and then an equitable distribution of the resources that are within the system.

In thinking of all of that as pharmacists, we're seeking justice like that tenant says, in the distribution of healthcare resources, since structural racism also affects the healthcare system, we need to address these forces of structural racism. Because it places 1 group, which is white Americans at an unfair advantage, and then Black Americans and other non-Black People of Color at disadvantage.

For instance, you have the example of the medication availability and pharmacy deserts, so you have the literature in pharmacies showing that there's limited access to community pharmacies, the actual establishment, services, and commonly used medications based on racial segregation. In recognizing that there's this unearned privilege that in this system, pharmacists must empathize with the plight of Black Americans and strive to truly understand what it means when it is said that all Black lives matter because for centuries, there has been human suffering on the part on Black Americans in the United States, and that also leads to another part of our oath that we take as pharmacists that I will consider the welfare and humanity and relief of suffering, my primary concern, so it kind of is built into our code of ethics and our oath and we should aim, and must live up to that oath, when we take it, because we do take it.

Drug Topics®: I just wanted to swing back around to the systemic structural factors. I know you did a great job of explaining that I was just wondering if there were other examples that you wanted to bring to light?

Wisseh: Definitely. There is quite a bit I actually wanted to talk about with that.

In general, those systemic and structural factors are the social determinants of health (SDOH). So these are the conditions, those environments, that populations of people are born, live, work, play, worship and age – and this is the definition of course by Healthy People 2020 – given by that framework.

In a nutshell, they're tangible and also intangible resources that can affect the quality of life and health outcomes. Depending on which side you fall on those tracks, whether it's privilege, or it's disenfranchisement and lack, they can be life damaging, but they can also be life enhancing.

In regards to thinking about that systems approach, the social determinants in of themselves, include your economic stability, your education, the social context, the community context in which you live in, health and healthcare as we've been discussing, the neighborhood, and just that overall built environment, and to tie it back to structural racism, is shaped – the social determinants in of themselves what we see in people's lives – those conditions are shaped by how money is distributed, how power is distributed, and resources just throughout the communities and within in the world.

So, the social determinants are somewhat of like a playing field, if you will, and on the social determinants, this foundation, health disparities are built on this. Health disparities, or those inequities, are in and of themselves built by the structural inequity that comes from structural racism and other structural biases. These domains include race, and then it could be ethnicity, it could be gender, gender identity, or class or sexual orientation, but it always is a systemic disadvantage between 1 social group when compared to the other social group with whom they coexist, so you juxtapose power and privilege with lack and disenfranchisement.

Drug Topics®: So now with the social determinants of health, we're seeing amid COVID-19, that minorities are being disproportionately affected and infected by the virus. Can you talk a little bit about the impacts that we're seeing on minorities?

Wisseh: Sure. COVID-19 has had a major impact on minority health and well-being. So first would be hospitalization. As of June 2020, the confirmed hospitalizations from COVID-19, in those hospitalizations that were reported, 33% of them were African American, and 22% were Hispanic and Latino. But Hispanic and Latinos are minorities and makeup only a fraction of the entire US population.

In regards to deaths, while Blacks themselves make up 13% of this overall US population, they account for 24% of COVID-19 deaths, so definitely a disproportionate number of deaths.

In regard to cases, Blacks, Latinos, American Indians and Asians account for a disproportionate number of cases in the United States. And to think about it in regard to how the United States sees health - these are minority health disparity population, so you see a lot of disparities in these populations anyway. How they fare with within each other, non-Hispanic, American Indians, or Alaskan Natives have a rate that is 5 times more non Hispanic white persons in regards to cases and exposure. Non-Hispanic Black also have a rate that's approximately 5 times that of non-Hispanic whites and then Hispanics, their rate is about 4 times that of non-Hispanic whites.

Then recently in the news, in the literature, there's data that suggests that because Asian American data is kind of aggregated together, there's fear that we don't necessarily know how those numbers are being reported in Asian Americans. This circles back to the social determinants of health because this affects health and well being. Because they can have these ameliorating and damaging effects on health and wellness outcomes, we can talk about this inequitable distribution of social determinants of health being the why we're seeing what we're seeing COVID-19.

So, a couple of points that I want to make, that minority populations first of all carry a higher burden of chronic illnesses such as hypertension, which is the number 1 underlying medical condition of COVID-19 hospitalizations. Other underlying conditions include overall cardiovascular disease, metabolic disease include diabetes, respiratory disease, asthma and COPD.

Minority populations are also likely to live in racially segregated areas that lack greenspace, increased exposure to environmental pollution, crime, and more food deserts and swamps. They lack access to health care providers. I would say even more so, I argue that they lack access to also culturally competent and culturally humble care. Anyone can argue with me about that, but I think that that's something that's definitely lacking. And I can say that because you've seen that a lot of Black families have come out and share the experience of losing a loved one that was not appropriately either triaged or even tested in the beginning of this pandemic and was at home subsequently to die from COVID-19 because maybe there was an implicit bias on how their symptoms were being viewed.

Minority populations are more likely to be essential workers. This increases exposure to the virus. Minority men, especially those that are Black and Latino, are disproportionately represented within the prison population, the male prison population. This is another area where we're seeing cases being high, and in this case, race is now compounded with the exposure of living in close living courters.

Since minorities are more likely to rent and own, so thinking about housing with those social determinants of health, they may not own their own home and may not have privilege to non-essential roles or working jobs, and may have lost their jobs and will be facing homelessness during this pandemic because the moratoriums on evictions and on foreclosures that were set by different states, some have expired this week, and if not renewed, then the proceedings may go forth. Now you have a population who already is predisposed to have a disproportionate rates for all of these reasons that I just discussed, but then now being put out potentially on the street and not having anywhere to live. It affects the education attainment gap as well, because these homes that lack internet access, their students that live there who may not have had access to their courses, or their classes and it's likely they may not even return to school in the fall.

Then you have to think about multi-generational homes, which, when you think of culture and minority populations, you may have Grandma, the parents, and the kids living in the home. When exposure comes into the home, how do you adequately isolate or quarantine in the lack of housing for those who are homeless?

Then finally, 1 point I like to touch on would be the Affordable Care Act (ACA). We all know that the Affordable Care Act is now on the chopping block. This was legislation that increased the uninsured rates of Hispanics and Blacks across the United States, whether it was because of the adoption or expansion of Medicaid or other programs. I think that if this legislation is overturned, it will be an epic failing of human rights because I strongly believe, outside of NPhA talking for myself now, but I strongly believe that equitable health care is a human right.

That's what you're seeing with COVID-19, and how those social determinants of health and the inequitable distribution the social determinants of health are affecting health and wellness outcomes.

Drug Topics®: Dr. Wisseh, thank you so much for joining me today and your continued work during this time as well.

Wisseh: Thank you so much for having me. I enjoyed speaking about this and I appreciate you giving NPhA the platform to discuss these very critical issues at hand.