<Benjamin> COVID 19, created an enormous disparity, particularly for communities of color.

<Eliseo Perez-Stable>For Blacks, Latinos and American Indian and Alaska Natives, the excess deaths were quantifiable in both sexes clearly, compared to Whites or Asians.

There was also excess impact in Native Hawaiian and Pacific Islanders.

<Hancock> We know during the pandemic that African Americans were three times as likely to die from COVID than their White counterparts.

Over 200,000 children have lost their primary caregiver due to COVID, and 65% of the children who've lost their parents are Black and brown.

<Spero Manson> Access to resources such as housing, water, food the opportunity to shelter, to access testing and vaccination present the most adverse circumstances for Native people.

That explains the disparities that American Alaskan native people experienced with respect to COVID 19.

<Seciah Aquino> We actually shouldn't be surprised that communities of color that have been systematically disenfranchised over the years, experienced those disproportionate rates of infection and deaths.

<Georges Benjamin> The reason people of color were much more likely to get COVID was because of exposure.

If you were a bus driver or you worked in a hotel, or you were a sanitation worker, you had to go out and keep our society going, and therefore you were much more likely to be exposed to the virus.

So it wasn't about race, it was about occupation.

<Yolandra Hancock> It was a Friday in April, the data came out showing that African Americans were disproportionately infected by COVID hospitalized due to COVID and dying from COVID, and then we opened up.

No more stay at home orders, mask requirements went away in the majority of the country, and for me as a Black person and as a physician and a public health professional, it was a slap in my face.

<Georges Benjamin> We've always known about health inequities, but what COVID-19 did was raise that visibility of those disparities, so nobody can say they didn't know about it.

Funding for this program is provided by the Medical University of South Carolina Changing what's possible.

The Unites States Department of Energy and Allen University.

♪ <John King> Welcome to Exposing Disparity: COVID-19's Long-Term impacts.

I'm John King, thank you for your time.

We have an amazing, diverse group of experts with us today to look at one of the most glaring issues of the pandemic, the disparities in the number of cases, the severity of infection, and the long-term impacts of COVID-19, and why those differences fall along racial and ethnic lines.

Let's jump right in to the conversation.

Again, fabulous panel.

I'll call you all COVID heroes, people on the front lines who helped us understand who saved lives in the process.

So let's go back to the beginning.

Sandra, you are a frontline nurse, critical care nurse in Queens, New York, the first case is in Washington.

Then there were some cases in California.

Everybody in the country is thinking, what is this?

Is it limited to the West coast?

Is it coming to us?

Take us back to when you first saw it and then the moment when you realized this is exploding.

<Sandra Lindsay> That's right, John.

I work for Northwell Health, the largest private employer in New York State, and in March of 2020, I served as the director of nursing for the critical care division at one of our large tertiary care hospital, Long Island Jewish Medical Center, right in the heart of Queens, and I remember on March 7th, we admitted our first patient diagnosed with COVID-19 to our intensive care unit, and we were very, very careful to make sure we don't have cross contamination, but by March 13th, I remember very well because it was Friday the 13th, we were talking about expanding our ICU capacity from the already 48 beds that we had to add an additional 12 beds, because the volume of people that were coming in from the community requiring our care was just out of control.

So we opened that additional, intensive care unit on March 14th, 2020, and by Monday, March 16th, it was a different place.

All the beds were filled with predominantly people of color, mainly Black men, just gasping for air, even on ventilators.

That made me very, very scared.

The staff donned in personal protective equipment from head to toe, were just running around, and I could see the fears and the tears in their eyes, <John King> The fear and the tears, those early days haunting to think back.

And Dr. Kowalik, you are the Chief Public Health Officer in the city of Milwaukee at that moment, you had already declared racism a public health emergency because it was a priority of yours, and you're among the first to raise the flag saying, whoa, yes, this is bad for everybody, but it's especially a crisis in communities of color.

What did you see?

How did that play out?

<Jeanette Kowalik> Yeah, thanks, John.

So since we made the declaration that racism is a public health crisis for the city and the county in 2019, our level of awareness was heightened.

So we knew that gathering data about race and ethnicity was extremely important to be able to slow the spread of COVID-19.

So we also had our first case on Friday the 13th in 2020 in the month of March, and from that point on, once we started collecting data, you know, interviews with patients and whatnot, we were able to start collecting some pretty solid data on race and ethnicity.

Um, and we had very reliable data early on.

By the end of March, we started to see a trend.

We started to see that most of our cases were in the middle, uh, or urban part of, uh, the city or the county.

African American middle-aged men were being hit the hardest.

That got picked up by national media, and from that point on, then other jurisdictions started to look into their data and to be able to confirm they were seeing the same thing.

One point for us though is because we had prioritized that data collection, we were able to convert that and make sure it was available through a public facing map, but many other jurisdictions didn't have the ability to do that.

They were still working on collecting data, and if you know anything about science and data, you can't make connections if you don't have reliable data or valid data.

So, the fact that we did that, it was really important and it really helped to ring the alarm of who is being hit hardest, not just international travelers, but it was impacting communities of color in real time.

<John King> - and, so Dr. Bell, as you're dealing with it here in South Carolina, again, in learning, this is not the west coast.

This is not just the cold states.

This is everybody.

It may come at a different time, but it's here for everybody, and you hear Sandra, and Dr. Kowalik saying that you see it more in the Black community.

Immediately, you also have to deal with, as you're trying to get data and you're trying to help everybody and get to understand this, this misperception, misinformation, that there is some genetic predisposition among Black people.

That's why it's happening.

<Linda Bell> Yes, that, that misperception was important for us to address because we recognize that health disparities had previously existed.

What they were learning in other jurisdictions about those most susceptible were those with existing underlying conditions, and so, and just knowing about race, genetically, race or ethnicity, those are really social constructs.

You know, the, difference in human beings on a genetic level is really very, very, very, very small.

So that it is not really race that was making people of color more susceptible.

It was how they were treated because of their race.

These are societal treatments that put people at a disadvantage, and that's what led to the existing disparities that people of color were at higher risk of complications because of limited access to care historically.

They were more likely to have poorly controlled high blood pressure, poorly controlled diabetes, more likely to be obese because of poor nutritional factors.

And so we were able to anticipate the impact on community of colors because we have a higher proportion of African Americans in the Southeastern and South Carolina, and so we were able to anticipate that these communities would be harder hit, but it was important to convey that it is not race that is making them more susceptible.

These are things that we need to address as a society to improve access to care, to improve living conditions, and, um, access to preventive, personal protective equipment, testing, vaccinations and things like that, that would better protect that community so that it was not race alone that was making them susceptible.

It was things that we could control from a societal perspective.

<John King> ...and, Dr. Alier, in those early days, your wheelhouse was emergency medicine.

So you're thinking, how do I get the paramedics ready?

What if we need?

Protective equipment?

That's your day job, if you will, but then you become an ambassador because of your bilingual skills, because of your trust to the Latino community.

When it comes to misinformation and misperceptions back in those early days.

What jumped out as most important to you?

<Arnold Alier> Well, it was just...a total lack of, of information.

So, in South Carolina, although we do have Spanish cable channels, we don't have any local TV channels that give the local Spanish news.

So there was just a dearth of information.

And then when the Spanish media...approached us, small Spanish radio stations, um, they were just asking basic questions.

There was so much misinformation that had made it through social media translated into Spanish that people didn't know what to believe.

So one of the additional barriers that we had, in addition to the fact of exposure, because, um, many Latinos in South Carolina work service jobs...as many other communities of color, and then access to care, because many do live in rural areas, now there's the compounding problem of language.

They just did not have the information at their fingertips to make the right decisions or to know what to do or who to trust.

<John King> Who to trust becomes a giant issue, or will be throughout this conversation.

Dr. Christensen, you are at that moment, back in the beginning, March, 2020, the head of the Navajo Area Indian Health Service.

So walk through the early days and the specific unique challenges you face with the Native American population.

<Loretta Christensen> Yes.

You know, we serve the American Indian / Alaska Native population every day.

And so we're really aware of what their health status was, their vulnerability, and we knew we had to address everything very aggressively, but most important to echo what's been said is communication.

We had to deliver a single message.

It couldn't be the tribe, and then the federal, and then the urban.

So, we unified very, very early, and we communicated sometimes multiple times a day, same messaging, defining what was coming, what was COVID, what's virus, all the basics, but we needed the people to understand this.

So they would come with us and let us take care of them and support them, and then we had the added challenge of building trust.

You know, there's a long-standing history of the American Indian / Alaska Natives in the government with mistrust, with the boarding schools, with taking of land, with all of the inequities that have gone on for many, many years.

So how you now say, please trust us.

<John King> Nice.

>> And so we worked very hard with tribal leaders, our federal urban leaders.

We talked together, we, we, we did shows together on the radio, bilingual radio, live Facebook, anything we could do to get out to the people in the communities.

We used every one of those things to build early trust so that they would seek care, seek testing, and work with us to get through this what we felt was going to be a horrible pandemic, and unfortunately, we were correct in those.

<John King> And to that point, you felt it would be a horrible pandemic.

You knew that because of the preexisting inequities and disparities that if something terrible came along that community's going to get whacked.

< Dr. Christensen>It was going to affect us deeply.

<John King> Dr. Christensen, thank you.

Thank you to all of our, I'm going to call them COVID heroes.

They're our experts, but they're COVID heroes.

Let's take a pause, dig deeper before we continue the conversation.

As we've heard, racial disparities are nothing new.

Most experts agree many of their root causes are deeply, deeply embedded into our way of life.

We'll hear more now about these social determinants of health and how they're actually predictive, not only of our well being, but also of our ability to withstand a health crisis.

♪ <Benjamin> We talk about the social determinants of health, meaning those things in society that help you become more healthy or impede your health.

So access to transportation, education, housing.

>> The history of the United States would indicate that there are structural factors that have been baked into society to create inequities, whether we use the term structural racism or discrimination, to explain that.

Much of this focuses on, the policies that led to residential segregation and the generation of wealth.

>> So if we want to break that a little further, think about race, class, zip code, our age, um, immigration status, all of those are predictors of, of our health.

And so, when you don't set up a culture of health because of these barriers that exist in communities, then when higher need times come, then it's harder to implement those different points of action.

<Benjamin> So we were innovative by having drive-through testing sites.

Well, the problem is, if you're not feeling well and you don't have a car, um, and you have to take two buses and walk three blocks to get to the testing site, you're much less likely to go get tested than someone who has, um, got a car, and of course, in our country, that falls along, um, um, income lines, that calls often along racial and ethnic lines.

<MANSON> If you're American Indian Alaska native, our households are typically multi-generational households, much more likely to be impoverished.

So for example, if you are currently employed, and you are exposed to COVID-19, the suggestion that you should isolate for 10 days to two weeks and thus jeopardize your employment, as rare as that opportunity is, is a major uphill battle, access to, uh, telecommunications in many of our rural, uh, and native communities.

Let's just take Navajo for example.

Uh, just slightly more than 30% of Navajo households have no active telephone.

<Benjamin> And so with COVID, we saw the social determinants explode, as a multiplier of people's ability or inability to, um, protect themselves from this, this terrible virus.

♪ <John King> So let's dig deeper with our experts on how those social determinants impact what you can do, and obstacles to providing good care.

Dr. Bell, let me start with you in the sense that the pandemic hits and everybody's saying, what's the plan?

But there can't be a plan, right?

Isn't that part of the problem, the challenge of these social disparities, that what might fit for one community simply won't work in a community that does not have the infrastructure and the history?

<Linda Bell> Well, there can be a plan, but the plan has to be adopted to be relevant for each separate community because it's not a one size fits all, and when we think about the social determinants of health, maybe a clearer way to think about that is actually social vulnerability, and something that we did is we looked at existing maps of social vulnerability, and an interesting phenomenon with COVID that you typically don't see with the respiratory illnesses is that you could see the same disease rates across our populations, but when you looked at the death rates, they mapped parallel to the areas of highest social vulnerability, and when, so you look at what's underlying in those communities that have high social vulnerability, and it is access to care, access to adequate transportation, but other factors that people don't often anticipate.

It's a minimally adequate education.

It is economic security.

And those are all things that translated more into social vulnerability to a respiratory illness that we hadn't seen before.

So flu and other things did not behave like that, but with COVID and these contributors of the underlying health conditions contributed so significantly is what we saw in much higher death rates in communities of color.

<John King> So, Dr. Christiansen, take that into your world where these disparities and the determinants are so acute in the sense that you've said you felt on your own sometimes.

So the government has a plan, the government's trying to help, but you sort of knew from the beginning you were going to have to take that and tailor it.

<Loretta Christensen> Absolutely.

We have to adapt and innovate all the time.

And we had to look at what's in each community and what they needed.

And for us, our, our vulnerabilities were based on, if you can imagine today, 30% of homes not having running water.

So how do they do hand hygiene?

How do they clean?

How do they disinfect?

Multi-generational homes, we had COVID positive families and houses, not COVID positive people.

And then how do you isolate?

So we had to innovate how we would get people into isolation and get them to a place that was safe so they could heal.

And then food desert.

14 grocery stores in 27,000 square miles, you didn't want people to go out, you didn't want them to congregate.

They had 14 stores to go to, number one.

Then you bring in economic instability.

How are they going to pay for 14 days of food to isolate?

So we had to create solutions and framework for all of this that was going on.

And we do this all the time, but with COVID, it was just so many cases, so many families that it had to be very adaptive and very just well thought out to, to, to work in our community, and each tribal community, of which they're 574 federally recognized tribes.

<John King> As this is all playing out and the experts are trying to learn every day, sometimes having to say, today, a little different than yesterday, because you've learned new information.

Dr. Kowalik, I know your area well because of what I do at my day job.

There's Milwaukee City, there's Milwaukee County, then you move to Waukesha.

I talk about this all the time in the terms of red and blue, and who's going to win the state for the presidency, or win the state for the Senate.

When did, sadly, you first see, oh, my challenge is even more complicated by politics.

<Jeanette Kowalik> I would say early April of 2020.

There were protests, I think, yeah, that first week of April in the suburban jurisdictions about the public health orders.

The state still had a public health order that crossed over all jurisdictions.

That was pulled back in May of 2020.

That was a whole thing, the Supreme Court ruling at that time, but the city of Milwaukee, we still had a public health order in place regardless.

So once that was repealed in May, our city order took effect.

The issue was the other remaining 17 jurisdictions in Milwaukee County 11 of which have health departments representing them were not willing to use public health authority to provide some protections.

So there was a lot of conflict between us because from my perspective and philosophy in making sure that we were protecting those that are most vulnerable, that we needed to have this order.

As noted, the service workers, the transportation challenges, the poverty that we had the most diverse race and ethnicity population of all jurisdictions in the county, we had to provide these protections, but because of this pressure from outside jurisdictions and even other counties, it was very difficult to maintain the line.

Having orders, not having orders, a lot of it boiled down to who was your boss.

If your mayor or village president supported you having an order, you had an order.

If they did not, you didn't have one.

So that made it very difficult even for me to appeal and maintain support from my council members because they were looking at other jurisdictions and wondering, well, they're not doing it.

We're losing business across these jurisdictional lines.

You need to reopen, you need to make some kind of concessions.

<John King> I want everybody else to jump in on this.

I don't want to put any words in your mouth, so just forget I'm here for a second after I finish this, and just talk among yourselves about - how does that impact what you do and the care you're trying to give when you might have conflicting voices?

I'll give you an example.

I work in Washington where you would see the President of the United States say one thing, and then Dr. Fauci come up and correct him, my words, correct him, and then he would step back and the president would say something and either Dr. Birx or Dr. Fauci would come up and say something different again.

When people are getting mixed messages from the leadership, number one, how does it impact how you do your job?

And number two, how is it received by the consumer, by the patient, by the sick, worried person who's looking for help and doesn't know who to trust?

<Loretta Christensen> Well, for our community, it was a vitally important, as I was saying before, communication, and we were the filter, and that's absolutely critical in your communities to be that filter because there's so much information out there, it will confuse everybody.

So we would take that advice from my colleagues at the CDC and NIH and FDA, and we would distill it down to a message our people would understand, and then they, they trusted us.

So we were able to use that built trust to continuously update them and be very, very transparent, which was also very critical.

<John> You were on live television getting your vaccine.

<Sandra Lindsay> Yes.

<John King> The first person.

<Sandra Lindsay> Yes.

I felt like it was a civic responsibility to get vaccinated, and to help to get us out of this crisis.

<John> But you took flack for it.

<Sandra Lindsay> I did, mm-hmm.

I got reprimanded on social media about being stupid, being a guinea pig, just being used, I'm being paid for this.

<John King>Everybody else, please jump in on how much it complicates your job when there's this, I'm going to call it dust, turmoil, flack - the politics flying around when you're trying to save lives.

<Linda Bell> I wanted to say something about the data.

There was such a hunger for the COVID data, and we used that data to educate, but communities, it would've been very helpful to also look at the data to make decisions about policy changes, because it has been mentioned that in, you know, in certain jurisdictions when restrictions were lifted, certain areas were able to maintain mask mandates and others did not, and we saw that in South Carolina as well, but you could actually map out by the jurisdictions that had mask mandates that were still locally enforced and that were not, and the data showed where those interventions worked and where they did not, I mean, they, they aligned very well with the...relief of the ordinances, and so the data was not used as effectively as it could have been by policy makers.

<Jeanette Kowalik> So if you recall, the CDC updated their community transmission maps.

So there was an old map and a new map that was being used to drive a lot of policy making decisions, which is really confusing for many in positions of power, and positions of authority to make decisions.

I know we were still using the old guidelines because we felt those were more stringent.

However, the other point was once the CDC started removing actual objective measures on distancing and grouping and all of those things, that made it extremely hard for our legal counsel to support various sections of our ordinance.

And honestly, for us, we were like, okay, we don't care if we get sued because that's what people do.

They're going to sue you.

They're going to try to jam this up in court.

We're going to just move forward and try to do what we can to protect the public.

<Arnold Alier> With the Latino community, we had, I think, the benefit of filtering out the noise and keep the message unified and simple, because they were hearing so many different things.

and they would ask me, well, what do you think?

And we try to keep from the controversy that was being really surrounded in Facebook and other social media just to keep the message on point, and even using the existing data that we had, either from early on or continuing on that this is the reason we need to do this because we're - our community is still in danger, and case in point, we had some communities that were very small, but had a high concentration of Latinos because of the industry there, and their positive numbers were just astronomical because they didn't have access to care readily.

They were exposed because they work a service industry, but at the end of the day, they didn't have the message, but once they got the message, we were able to at least make the numbers trend downward.

So I think it's using the science and the data that we have, but keep the message as simple as possible without making it so complicated, and then taking that message and making sure that it's consistent.

<John King> Being consistent, using data, trying to push the politics to the side as much as possible.

We'll continue the conversation.

The misinformation and disinformation conflicting messages that came from reacting to science in real time.

It did, yes, fuel skepticism and distrust of public health officials, the swirl of confusion, dramatically complicated communication during the pandemic and underscored the fact there's no one size fits all response to a public health crisis.

One silver lining though of this communication breakdown was the reemergence of, or re-energizing, you might say, of grassroots organizations advocating for the well being of their local communities.

We'll take a look now at the integral part they played in turning the tide of disparities.

♪ <Yolandra Hancock> We recognized that no one was going to come and save us in terms of the African American community, and we had a two-fold mission.

The first was to provide relatable, reliable, trusted information.

The second was to provide direct services, going out on the street to make sure that folks had access to vaccines, personal protective equipment really being there to support the needs of the community.

<Manson> The Indian Health Service was very critical, and they were an early disseminator of those resources, far more rapidly, frankly, than many...counties and many states themselves.

So we looked to our leaders in our respective communities, our traditional healers, our spiritual guides, our respected elders, and those were our trusted sources of information.

<Seciah Aquino> The Latino community there was much misinformation coming their way, and so they were looking for the truth, and part of any information that's coming their way from the government is processed through a layer of, um, mistrust.

So for us, it became about opening up that door of discussion.

<Yolandra Hancock> And we sort of served as translators.

That was our relationship with the federal government, is to hear what they were telling us to do, hearing what was happening in the country, and then being able to go out into the community like, listen, this is what's happening.

This is on the real, this is what's going on.

<Manson> We have a deep-seeded sense of responsibility for one another, and you would see all of the public media campaigns use those core values to translate, um, into action for preventing or addressing, uh, COVID 19 in the pandemic.

<Yolandra Hancock> In order for us to address health disparities in this country, the expectation that the solution is within the federal government is wrong.

I honestly don't think that we would've made the progress that we have made in terms of COVID-19 numbers, cases, hospitalizations and deaths, had it not been for the work of our organizations.

♪ <John King> So let's dig deeper on the critical importance of the grassroots organizations and the reemergence, the re-energizing to provide help.

So city public health officials, statewide, public health official walk through this same conversation in terms of the value because your agency's understaffed, your agency's understaffed, you don't have enough boots on the ground, but you do have these grassroots organizations.

How important is that in sort of getting an army that's organized in the community and does the communication have to be both ways?

<Linda Bell> Public health could not control this unprecedented pandemic alone without the community-based organizations and without the faith community.

So, in terms of that trust, if community members said, you know, I don't know you, but I know my pastor, I know my minister.

And so, the faith community reached out to the public health department, sought to be educated, and then communicated, not only communicated to their congregations, but actually set up pop-up clinics, made the faith community sites for vaccinations, and so there are just multiple examples of how community-based organizations stood up to, to shore up the public health response, and the another important part about the education is making these partnerships, is that we often go into communities and say, we want you to know about this threat.

And sometimes it's, it can be insulting.

It's like, we understand the threat, you're coming back with the same message, but as has been said, you don't understand.

We need, we need to educate you about, we have priorities.

I don't have paid time off to get access to what you're recommending, and so my priorities are my children are hungry, I may lose my job, and so we understand the threat, but this most immediate threat is more important.

So we had to listen and learn from the communities and respond to that, bring the services to them so that their other threats were addressed.

And so this, collaboration is what we, we really need to focus on an ongoing basis is that it's not just the public health department that can fix these societal problems.

It is that we need to listen to and we need all of the community members to help address the social determinants of health ultimately.

<John King> And so, as you were engaging Dr. at the grassroots, when the gift, the miracle of the vaccine came, the challenge was getting it to where it was needed most, and sometimes the sites, the organizations, the online programs, platforms, portals didn't do that quite right.

You were part of this vaccine strike team effort.

Walk us through that, why it mattered.

<Arnold Alier> Right.

So we early on knew that where some of the greatest needs were in some of the communities that were disproportionately affected, the Black community and the Latino community, and so, because of my contacts now with the relatively small Spanish media but there were lots of them, and they would contact me and say, Hey, can we have a vaccine event here?

Or who can we send here?

And of course, they would contact locally, the church or a business leader, small insurance companies, small grocery stores, bodegas, and they would sponsor a vaccination event.

We also had bilingual community health workers that went out and just basically pounded the pavement.

They knew where the Latinas were, convinced them this was the right thing to do.

And again, just keeping the message simple.

This is the vaccine, this is what we have.

And, and by setting the example ourselves of being the first in line when it was available to go ahead and get vaccinated.

<John King> And to that point, Dr. Kowalik, talk about how it helpful it was in, especially in the early days of COVID, or when they're trying to then now spread vaccines or maybe the PPE becomes more available and you need help on the ground, getting it the right places and listening to the community about where it is needed most, and that, my follow up to that is if these organizations were so important and energized or re-energized in the middle of this, are they still on alert, because there will be another one, sadly?

<Jeanette Kowalik> Thanks John.

So health officers serve as community or chief health strategist for communities.

So what that means is whether it's an emergency situation addressing obesity, violence, whatever public health topic that we're providing the data, providing the information and allowing the community to lead, giving them the resources, giving them the information so that they can address whatever their issue is at hand.

Health departments are responsible for creating community health assessments and community health plans.

And as a of that, there's supposed to be very strong community partnerships.

So a lot of these entities that are referenced already, faith-based various advocacy groups community, you know, youth serving organizations, you can go down the list, but if you're doing that health assessment process justice, those relationships already set up.

You already know, folks, you're already working together.

Unfortunately, because of the state of the Milwaukee Health Department, which is why I was, I became commissioner in 2018, a lot of those relationships were fragile and in the process of being repaired.

So once the pandemic started, we were really behind the curve on re-establishing many relationships.

So we really had to like be responsive to the community's dissatisfaction and anger about how the pandemic was playing out from our Black community, from our Hispanic or Latin community, our Muslim community refugee groups.

The list is long, but what we did, instead of taking it personally was, okay, you want to vent, let us know what's going on.

This is our constraints.

We're going to give you resources.

We're going to provide you with information.

We're going to set up regular touchpoints, whatever we needed to do to make sure that they had what they needed to be able to serve their communities more efficiently and effectively.

That's what happened.

Another point that I want to mention related to one of the things that federal government did well was providing the pandemic response money.

So, in the gap of receiving all of those millions and billions of dollars, we received funding from local foundations to provide money for housing, transportation, medications, you name it, to be able to meet the needs of various community people.

So that was super helpful for us.

While we were waiting for that windfall of federal money to add more staff, address the PR needs, all of the other things that we were lacking.

Once we got that money, that ARPA money, we were able to do some good with it, but giving money to the community so that they could be effective.

<Sandra Lindsay> I just want to add that in addition to the committee to reaching out to the health departments, they were reaching out to organizations as well.

We found that a lot of the community leaders, faith-based leaders in our areas were reaching out to us at the hospital level and saying, well, we need information.

We have all these people, our population coming to us, congregation for answers, and we don't have answers, and so we formed a community group that is still in existence today because we are going to need them going forward for when that next crisis and, just to do health better, to be proactive, and this was all formed over Zoom, like everything else, and recently had them the community leaders for a meeting in person, and it was really great to see how engaged they are, how much they want to continue to partner with hospitals.

I am talking faith-based leaders, barbershop owners, hairdressers, just everyone in the community will recognize that it's going to be through our efforts, the people who live in communities who are going to make health better for all of us.

<John King> And so Dr. Christensen come in on that point, because you're in the federal government.

<Dr.

Christensen> Yes.

>> Which you would say the most distance between the grassroots on the street community organizations and Washington, DC.

What did you learn, number one, globally and then to the specific challenges you've mentioned.

<Loretta Christensen> So there's always going to be someone in charge of resources, but the messaging to hands-on care that you're doing, it has to be tailored to the community that you're serving, whether it be tribal IPOC communities, it matters who's giving that final messaging to the people on the ground, the people that are receiving the services, and I learned that, definitely, readiness, public health readiness is essential to this country.

It certainly is essential to the American Indian/ Alaska Native population, and I recommend that at the highest levels to have agreements in place to have these rapid contracting methods in place ahead of time.

So we're not searching for them, creating them and writing them, but that we have it all set so that we're ready to go when the next problem comes along, because then it filters down and it makes things on the ground more facile.

It makes us be able to move much quicker and respond very immediately to the needs of our people in our communities.

<John King> Hopefully the communication stays in place during the lull, so when needed it can be ...engined back up.

Let's continue the conversation.

COVID-19 presented itself as a mystery, and one of its lingering mysteries is long COVID, which scientists and patients alike continue to grapple with.

Let's turn now again to Dr. Eliseo Perez-Sable, Director of the National Institute on Minority Health and Health Disparities for a summary of where we stand with this iteration of the virus, and its quite frightening potential scale.

♪ <Eliseo Perez-Stable> Unknown yet, long COVID is, continues to be a challenge.

The latest data indicate that as the virus continued to mutate, the likelihood of developing long COVID decreased.

Also that if you are vaccinated, at least with three doses, you're less likely to get long COVID, but if you look, do the math, you say, well, disproportionate cases in people who are of color, so they're likely to have disproportionate long COVID.

Uh, the, the indicators are that that's the case, but I don't think, if you ask me right now, what's the clinical definition of long COVID, I don't think we have full agreement yet on what that is.

Does it begin when you feel symptoms at four weeks?

The WHO says three months.

Uh, I don't think we have a definitive answer.

And in also from observation in other sort of post-viral syndromes that have that, that have occurred is they, they attenuate with time, and then there's a much smaller proportion of people who, stay sick for, you know, for years.

Except, we never had an infection that was, you know, getting...at one point we reached a million cases a day in doing the omicron phase.

So if you have that many people getting infected, 3000 people dying, all these people, you know, *there were going to, even if only 1% ended up with long COVID, that's 10,000 people a day.

♪ <John King> So let's get back to our great experts for that big question.

What is long COVID as defined now anyway?

And where are we heading in this conversation?

And Dr. Kowalik, if COVID itself obviously punched harder, hurt harder in communities of color, reasons to believe that long COVID will as well, correct?

<Jeanette Kowalik> Absolutely.

So it was always a concern of mine, not just focusing on reducing deaths, but also the disability that could be tied to having COVID.

So as time, you know, we're here in 2023, you're hearing... more and more about long COVID and about how many people are struggling.

They can't work.

They're out of the workforce.

They need accommodations.

How are they able to receive a diagnosis or treatment?

We know that there's no consensus on what a diagnosis of long COVID is at this point in time.

You have a WHO definition, a CDC definition.

This reminds me of maternal mortality and morbidity, how there's inconsistency in how we measure things, but we know that the disparities for Black women and maternal mortality morbidity are just astronomical.

Why are we dealing with this in this country?

So it's no surprise that we're going to see the same thing when it comes to long COVID.

Some of the data that we're seeing now is that the majority of people with long COVID are women, White women, and that we're seeing that because of access to care, private insurance being able to go to a clinic and someone at least documenting or listening to what that individual is going to or going through, but we know that as people of color, that oftentimes we're ignored and dismissed, and there's a lot of harm that can come out of receiving healthcare in this country.

So we shouldn't be surprised that the data that we're seeing about long COVID is not a true representation of what is reality.

We can assume that there's underestimates of long COVID and communities of color right now and what is being done.

So, there should be some hard questions that policymakers are willing to answer by providing some types of assistance to people that are living with long COVID.

We know ADA, the Americans with Disabilities Act provides some support, but what about financial support for people?

What about insurance coverage for people?

Because they're going to need a lot of support, and as someone with an autoimmune condition, it is not cheap to manage your disease and to be functional and to eliminate flares, you have to have a good health insurance policy and you have to have money.

<John King> I agree completely with what you said about we're lucky if you have healthcare, a lot of people out there who don't, and it could be astronomical.

So, Dr. Bell, from a state perspective, then, if there's no sure definition at the moment, and of course there isn't.

It's going to take years for that to figure... the wake if you will, of COVID and what is really long COVID and what might be something else, but if you don't have a definition from a state policy perspective, what do you have to do?

And does the idea that in...some of the political conversations, people just want to close the chapter, COVID is over, let's move on.

How does that impact the challenge?

<Linda Bell> This is a multifactorial condition because the COVID virus was able to damage almost any organ system in the body.

So while one person may experience an underlying heart condition as a consequence of COVID, someone else might have lung disease.

Someone else might have persistent brain fog or something like that, and so one of the, one of the concerns on the table now is that who will take care of these, the variety of these problems, and an issue that we see, again with access to care, especially in a state like South Carolina, where the majority of our counties are medically underserved areas and our health professional shortage areas.

So what will happen to the people who will take care of them from a subspecialist perspective or even an access to care perspective?

And we've talked again and again about the disproportionate effect on minorities, and so the long-term consequences, not just of the health effects, but of the economic impact, because something else that we saw in communities of color is that they were impacted at a much younger age.

We saw more strokes in younger African Americans.

There was a condition, MIS-C, multi-inflammatory syndrome of children, and far more African American children were affected by MIS-C than were Whites for currently undescribed reasons.

So the long-term consequences that we'll be looking at from the complications of COVID, long COVID and whatnot, will be access to healthcare for these long-term conditions, the economic impact from people who are the breadwinners of their family, and so this will, again, we need to, to continue to look at the social determinants of health and how to fix the societal factors that are not just healthcare related, but how to help people with their social circumstances so that they don't suffer the long-term impacts, not just from a health perspective, but from a quality of life perspective.

<John King> And so then, Dr. Christensen, in your world, how do you best do that?

<Loretta Christensen> Well, you know, it's a very challenging problem and it, it may be the worst wave of COVID yet, because COVID, when you're, <John King> That's pretty stunning.

When you're tested and you're treated, we see it, it's a point.

We can diagnose it, we give the medicine.

This is very different.

It needs to be definable in some way.

You know, what happens to disease issues across this country when there's no diagnostic tool or no specific way to say somebody has or doesn't have it.

So I fear there's going to be a lot of people that won't get the proper care.

As far as screening for it, we do definitely support and promote that, but I fear people don't recognize they have the symptom and they never come in for care and they just languish, and they're just going to suffer without any intervention or any support.

So I think it's going to be a huge challenge.

I think it has to be in everybody's mind when you see somebody that has had COVID, are you having these symptoms?

And there's a lot of 'em, and they're very diverse.

And then as far as funding, no, we haven't targeted funding on the treatment and sustaining care of people that are diagnosed with long COVID.

We've done research, we're doing, you know, clinical trials.

We're doing all those things very well, but then are we going to forget then?

Or is it going to dissipate, and then we haven't taken our opportunity to help people?

<John King> From that perspective, as someone who understands the frontline, when somebody walks through the door, they don't feel well.

Maybe they don't know why they don't feel well, but they walk through the door.

I don't feel, well, how is the system dealing with this idea?

Does this person have long COVID?

Is it something completely different?

Is it a combination of things when you don't have a agreed upon national or international definition, how do you work through it?

<Sandra Lindsay> So in the absence of a definition, it's hard.

We're seeing patients come in who neglected care during COVID, during the height of the pandemic and even after, who were still fearful of coming into our hospitals, and so they're coming in sicker requiring more resources, and again, in the absence of or in the presence of current staffing crisis, requiring more and more resources to get them healthy again.

So...it's really difficult, and to Dr. Bell's point, it's not just the symptoms of health, the shortness of breath or the fatigue that they could rationalize to something else and not recognizing that this is long COVID, it's all those lingering social factors that we often don't talk about as well.

<Jeanette Kowalik> I honestly believe that leaning on a community as being a trusted resource that...will be the path for someone to move into receiving some kind of care or support.

Just relying on the health department or healthcare entities is one thing, but I think that personal touch of someone that may have been high performing, that now they can only do maybe like two hours worth of work, and just the sense of acknowledging that there's a sense of maybe shame and disappointment, of course, judgment from people in society of accusing someone, of being lazy or that it's all in their head or all of these things that we hear, but having that relationship, that personal relationship, that trusted relationship with someone at the community level, whether it be a faith-based organization, nonprofit advocacy group, I think that is what we will see.

<Sandra Lindsay> There's still this stigma around COVID, whether you had it or not, and so people might still not want to come forward to say, I had COVID and I'm still dealing with some issues, some brain fog.

I still get tired, et cetera.

So that's a really good point that we need to remove that stigma so that people can come forward and we can support them and help them through this.

<John King> We've talked about the social disparities, the inequities, the government response to the politics.

I just want you all now, to just have your time.

I won't lead you with a question.

I have a final thought and we'll just start with Dr. Christensen and move our way down through.

I'm going to call you COVID heroes again, because I believe it in my heart, but just a final thought on what you've learned or where we're going or what you think it's important or for anybody watching the program to think about.

<Loretta Christensen> Well, I think the lesson learned or most important, and that is inclusiveness.

It is collaboration, sometimes compromise, but nothing about us without us, and that really still resonates to this day.

We have to be at the table.

We have to include... our population all the way down through the communities to get the best chance at doing the best job.

<Sandra Lindsay> I would say we need radical changes.

We need to be more inclusive.

We need to look at the policies that divide us and make sure that those bring us more together than divide us.

I would also say that we need to do health better so that we are not so focused or spending more on healthcare, but if we're more proactive and engaged in our communities and do health better, then we'll have better healthcare.

<Arnold Alier> We can't really forget our, our frontline healthcare professionals, our first responders, EMS, fire and law enforcement.

As we went into this unknown.

And they faced it head on even often, and especially early on without the proper PPE, and looking at our healthcare professionals, frontline workers in the emergency room, in an ICU and everything... they went through.

It's like going through a war, and we had a lot of casualties.

So we want to thank them for their sacrifice and going forward as public health to remember them because they're the ones that are sort of at the bleeding edge of any disaster that comes our way, and we've got to remember to make sure we, we offer them protection, we offer them counseling.

Many other things that were kind of a second thought after we were about a year into the process.

<Jeanette Kowalik> Well, I agree with everything that's been said so far.

One thing I want to lift up is the policy wins that were made.

All of the excuses that were made about not doing certain things as far as student loans and eviction moratoriums and stimulus payments and SNAP increasing access to food programs and health insurance and telemedicine, and so many things that were done because of the COVID-19 pandemic, they worked.

So the fact that there's questions about continuing some of these things, or many of them were allowed to sunset is a little sad because we were able to move things forward quickly, and I think that's something we should embrace moving forward.

Another point too, about grieving.

I mean, we have all experienced a huge loss our way of life.

All of the lives that have been impacted, whether people are no longer here, our loved ones, people that have disability now from having COVID, all of the other chronic conditions that have developed as a result but just allowing us to finally grieve, ...and it - we had a moment where there was like, was the New York Times had listed like a hundred thousand people that had passed.

Where is that now?

It's like 1.1 million people.

But just we need to just honor that and just have a moment to sit with that.

The other side of it too, in closing is one opportunity moving forward is that we need to be more explicit nationally about boosting our immune systems and how do we take care of ourselves?

We need a unified message.

There were so many people that were popping up on social media as experts in pedaling products and medicines and vitamins and things like that.

It was a lost opportunity for us.

So helping Americans get stronger, helping us to build our immune systems up, what do we need to do?

<Linda Bell> I'll just close with just addressing the health disparities in the United States.

The most technologically significant country in the world in terms of medical care, and the fact that our proportion of the population, we had some of the highest death rates in the world in the United States, given all of the healthcare that we have to provide.

So when we look at communities of color, that means that communities of color in the United States were impacted as comparable to the developing world, and that's a tragedy that should be prevented in the future, and one way to do that is looking at everything like a dramatic change.

When we look at reimbursement models, healthcare providers generally do not get, they will provide care for what they're paid to do, and they generally don't get reimbursed for preventive care, and so if we need a diagnostic test for long COVID, and that's lacking, then we may miss the boat on being able to address long COVID, but the point is that it's much more cost effective to invest in things like early childhood education, transportation, community infrastructure that actually translates into healthier populations and a better quality of life than does critical care, end of life care where we invest the most in our money, and we'd be much better off and as a society if we invested our money in preventive care, in improving the quality of life before people need that critical care, and that would be a foundational aspect of addressing health disparities and improving the quality of life in the United States.

<John King> Dr. Bell, thank you, and to all of our great guests, thank you.

I learned a ton.

I hope you did as well from each other, and I want to thank our fabulous studio audience as well for being here, and I want to thank you for joining our conversation, Exposing Disparities: COVID-19's Lasting Impacts.

I'm John King, thank you for your time and take care.

♪