You’re listening to a press conference from the Harvard T.H. Chan School of Public Health with Nancy Krieger, professor of social epidemiology in the department of social behavioral sciences and director of the interdisciplinary concentration on women, gender, and health. This call was recorded at 11:30 am Eastern Time on Monday, May 11.
Previous press conferences are linked at the bottom of this transcript.
NANCY KRIEGER: I am very grateful to be speaking with you as journalists. I just want to say that the work of journalism and reporting on what’s going on with the COVID-19 pandemic and its social antecedents and consequences has been absolutely vital. I am in awe of how journalists have been bringing data to the forefront, often before standard health agencies would do so, and so I just want to start with an actual thank you. I think that the work of the Fourth Estate here is being absolutely superb in keeping the public informed and in an effort to try to keep things safe and to try to prevent further harm.
So that’s where I start and what I just want to say first around the study with The Globe is that this actually was a true collaboration with The Globe, because as an epidemiologist who’s been involved for a very long time in
working with health departments cancer registries and other such agencies to improve monitoring of health inequities. I’ve been aware for quite some time of ways to make the day to talk to tell the stories that need to be told about the inequities and distributions and inequities means, by the way, very explicitly differences in health status between social groups that are unfair, preventable, and avoidable. And so these count, what we’re seeing with regard to COVID-19 so what I was aware of, was that there were not adequate data being reported about the health inequities for COVID-19 in this country, not only the CDC website, but also at many of the state and local levels as well.
So what I did was reach out to The Globe because I saw that they were getting data from the Massachusetts Department of Public Health that were not easily being released. And we work together, whereby they as they report in the article, were able to obtain the data and then my team and I actually analyze them. And what we did in this particular study was to use the technique that others are also beginning to use, but we’re the first to do it at the local level in terms of city, town, and also zip code. And we did it just for Massachusetts whereby we looked at what the rates for, and I emphasize rates not counts. I’ll come back to this. What the mortality rates per 100,000-person years were for the period of two-week intervals, starting in January through the middle of April, and compare that to the historical average for the past five years. So 2015 to 2019. And to simply look and see what was the total H standardized mortality rate in the 2020 two-week period versus the comparable period for 2015 to 2019.
The point about using rates and not counts is that rates are per 100,000 person years. It takes into account the age structure of the populations being compared. And it takes into account the size of the population, and it takes into account the time interval. If you just count deaths, obviously a bigger place could have potentially have more deaths with the exact same death rate as a smaller place just because it’s larger. If you have a place that has a lot more older people, compared to a place with a lot more younger people, but the same size population it could have more counts of deaths, just because of the differences in the age structure. So when you’re comparing rates across time, across place, and across social groups, you need to use H-standardized rates and these have hardly been reported anywhere in any of the publications or websites that have data from the national to local level that you’ll find in the US right now. Rates are core to epidemiology. It’s about population distributions and these are the distributions. It’s the cases by the in relation to the population from which they arise. The denominators. What we did in our study was that we could quickly look with their data at the residential address that included the zip code and city, town. And then we could make measures of the city, town and the zip code characteristics.
We looked at ones that are particularly important for understanding health inequities. These include first the percent of crowded households. Household crowding is a function of a lack of living wage combined with a lack of affordable housing. It’s not a fault of the individuals themselves. Secondly, we looked at the percent of the population below the poverty line. Third, we looked at the percent of people that are people of color and also we looked at another measure that I’ve helped develop called, which gets at racialized economic segregation, because the geographic distribution of people is obviously not random. Neighborhoods are sorted in relation to economic conditions and also who lives there in terms of racial ethnic population. That composition has a long history in relation to easily traced back to the historical redlining in the 1930’s. I’m happy to speak more about that.
We have two studies about to come out. One in the American Journal of Public Health. That will be out later this month, probably April 21st, online advanced access, looking at historical redlining in New York City in relation to preterm birth. And another paper that will soon be out in the American Journal of Epidemiology on current cancer stage of diagnosis in relation to historical redlining. I bring that up because I want to be emphasizing that this population distributions of areas, city, towns and zip codes within them is historically conditioned by the systems that we have in this United States that involve in equities around both racism and class structure and where people live and where they work. And this has everything to do with who’s at greater risk of dying from COVID-19.
So in this study, what we found, comparing the 2020 rates in the two week time periods compared to the historical average of 2015 to 2019 was that, in the last time period that we looked at the first two weeks of April, which was the most recent data that we could get, the rates everywhere were surging but they search much more among people communities with higher proportions of people of color below the poverty line and crowded housing and with adverse racialized economic segregation. The report gives you the numbers. I don’t need to say them again, I’d be happy to send you additional follow up. We have a link to the working paper which gives all the detailed tables. So you can see more data than you ever might want to see. That will give the background to the graphs that The Globe produced. So these are the descriptive data, but they’re descriptive data that tell a powerful story. And then the question that you have to ask when you see data like this is why? Why do we see these distributions? These distributions when we’re getting at total deaths. And by the way, the other thing I’d like to flag is the reason we looked at total deaths.
And not just what are called COVID-19 deaths is twofold. One, the work is fast progressing understanding what counts and who counts as a COVID-19 death. There’s new papers being published every day about different ways in which the virus SARS-Cov-2 is actually attacking different organ systems and people’s bodies. People are understanding now what should be called a COVID-19 death, and that’s going to probably continue to change over time with greater knowledge. This is a standard technique, especially when the case definition is changing, to look at the total surgeon mortality compared to the year prior for the same time period. And that also, of course, by the way, takes into account any seasonal or temporal concerns.
So I can stop there for questions about the particular study, or I can offer a little bit more interpretation and perhaps maybe I should do this regarding why we see the trends that we do. Noting that this is science happening quickly in real time. But It’s very clear that you have to break down what the cascade of events is who was exposed, who is vulnerable to becoming infected exposed who if, in fact, it actually becomes ill, who becomes seriously ill, who dies. And this has everything to do with the conditions in which people are living and working and what their health status is at the time of being exposed and potentially getting ill. And I think a key thing to make clear is that although the initial introduction of the SARS-CoV-2 to this country came from people who could clearly travel and take airplane flights.
What’s happened since is the domestic transmission that absolutely breaks down where there’s greater concentrations amongst people that are being exposed because they are essential workers who need to work. They are predominantly lower income people of color. There are people who do not have paid sick leave. They are people who have been not provided with adequate personal protective equipment on the job. And they are people who are the ones that we’re seeing also living in likely more crowded conditions again because of problems of affordable housing and what the wages are. And that’s, and then, these are people who are, also even before SARS-Cov-2 turned up, were compromised and health status by the persistent health inequities that we have in this country. And these comorbidities, particularly in relation to different kinds of chronic disease, our problem and that seems to be intersecting to increase the risk of death.
And this is a separate question also from the nursing home situation here in Massachusetts, which we can come to later. But the last thing that I would like to flag that’s really important and understanding this notion of comorbidity and pre-existing conditions is that typically it’s been framed in the media again looking at national averages national averages are only that averages in a really big country. That age 60 that people are talking about. Age 60 doesn’t always equal age 60.
There is well documented research about effectively what you consider to be accelerated aging or let’s put it this way, premature morbidity and mortality by economic position and race ethnicity in this country where the same diseases, particularly cancers of many types also cardiovascular disease. The two leading causes of death occurred earlier ages and populations that have been subjected to economic deprivation and to racial discrimination. So to be age 60 in one population group that’s been more privileged is not the same as being age 60 in another group that has not had this privilege. And therefore, you’re also seeing is not only the fact of COVID-19 deaths it earlier ages amongst these groups so that I think is very important background to give to the data that we share in our paper.
MODERATOR: Thank you, Dr. Krieger. First question.
Q: Thank you, Doctor for doing this. Appreciate it. I’m curious what needs to happen to change this, and can anything happen quickly enough to stem this tide that’s happening?
NANCY KRIEGER: So one, I think that I can offer some views as a social epidemiologist. But note that there are people that have expertise in communications because communication needs to be improved and also in doing the place-based health interventions that are required, but what I can say that our data do show or that there needs to be attention paid to these communities which are being most afflicted. That means attention in terms of pop up testing, making sure that testing is available in these communities, making sure that the testing is available in the right languages, is in a way that is non-threatening that dresses, the fears of people, particularly if there are people who are undocumented status. That being tested is vital. That if people are tested are being tested and found to be positive, if they are living in crowded housing, to make additional facilities available as is occurring, for example, at the hotel in Revere right now where people can go if they can’t self-isolate within their own households. That’s really important. These are all things that are in the realm of policy to do. to make sure that if people are in any group that is considered to be an essential worker that it is also equally essential that their job provide personal protective equipment.
Q: Thank you.
MODERATOR: Next question.
Q: Hi Professor Krieger. Is there a chance that COVID, like diabetes and obesity, as society kind of addresses it, becomes something of a disease of the poor or the marginalized, not that this has fully happened with diabetes and obesity? But I think the trends are in that direction. You know, with an infectious disease. I don’t know if that’s even possible, but just wondering your thoughts?
NANCY KRIEGER: Well, but it is very possible with infectious disease. I can tell you to off the top of my head, tuberculosis and HIV AIDS. And what’s important around HIV AIDS is that it had similar trends around what happened with class dynamics in this country and others where it started out amongst more affluent people and then quickly became concentrated amongst people without the resources for adequate testing and adequate control. So there’s a different conversation because it’s a different kind of transmission, but with tuberculosis, absolutely.
Tuberculosis, as you look at the history of tuberculosis, you will see, and it’s killing many people millions or every year around the world, is concentrated amongst people who are with fewer economic resources. So yes, this could potentially happen with COVID-19, but the thing is, getting back to the issue of both transmission and the nature of these essential workers who actually do also enter end up interacting with the people who are otherwise more protected. It’s not clear to me that it’s going to be quite so simple to keep it totally contained. So, but there will be two different things that play out. One is, again, what is the extent of exposure and who is exposed and who becomes infected versus how severe will the illness be? And the thing about how severe the illness will be is that if that is intersecting people’s pre-existing health conditions, then that will lead to a worsening mortality rate amongst people that are already badly off even if everyone is similarly infected. So it’s important to break your question down into the different components of who gets infected, who becomes infected, and who dies if they become ill.
Q: Very good, thank you.
MODERATOR: Next question.
Q: Professor, I have a question about kids. Currently we saw quite a lot Kawasaki disease cases occurring, New York, and we also say it has happened in other states and countries. And some kids with these tested positive for the coronavirus. And so my question is, how can we protect the children in this special situation and do we need, like a much wider test for kids?
NANCY KRIEGER: You ask a good question and that’s actually one that goes beyond my particular expertise in terms of the new data on what is going on with children. Our study was looking at just the COVID cases, all cases combined across all years, but we age standardized. So we did not specifically focus in on what’s happening amongst children. The deaths are much lower among children right now, but I know that there are worse and reports about children, and about what needs to be done with testing. I also know that there are reports of different kinds of testing modalities that may be easier to do. For example, the ones that are based on saliva. But that you’ll need to speak to somebody else to get the requisite answers. One thing I’m extremely clear about as a scientist speak with the topics on which I have expertise and then refer those questions in which I don’t
Q: Okay, thank you.
MODERATOR: Next question.
Q: Hi Dr. Krieger, thank you very much for doing this. I do, would like you to address the nursing home situation. I’d like to know how it figured in the data that you were looking at and also how you feel about the decision of at least the state of Massachusetts and in Cambridge, as well, to spend a lot of effort on testing in nursing homes and assisted living facilities?
NANCY KRIEGER: Sure. So in the data that we were sent, we did not have specific information on nursing homes. We did have addresses, but I would be a little loath to quickly interpret those in that way. And that could be a subject of a more detailed investigation. I am aware, however, that, for example, the state of in Seattle King County, which is an excellent health department that has been doing work framed around health equity, racial justice frame for a while. They now have a dashboard up which allows you to separate out the cases that have for both infection, the testing and also for mortality, that and hospitalizations, that allow you to tease out, who was a case that was based at a residential or home or qualified nursing facility.
So it is possible for states to report the data out that way to Seattle King County absolutely is. And you can just go to their county website and you’ll find it under their new tracker that they have. It takes into account also race, ethnicity. So why I personally do not know the reason why Massachusetts is having as many problems as it is apparently with regard to what’s going on in the nursing homes. I have not personally studied that. I have read the accounts concerning the issues of the lack of sufficient personal protective equipment, lack of the appropriate staffing.
These are all policy issues. These are not issues about the workers per se. This is about the management and the funding and also the pay rates because what I am aware of from one other colleague who actually has done a lot of research on what goes on in nursing homes is that often employees are not paid adequately to have that as their sole job. Therefore, they work at other places that increases the risk of potential transmission moving from one facility to another. So it’s if this is a place where mortality is occurring at excess rates, then absolutely there needs to be more testing and also betters procedures for the workforce to help take care of the people that need this care vitally and also to take care of the workers themselves.
MODERATOR: Did you have a follow up question?
Q: If you know what it had on your data? I mean Massachusetts has reported that something like half of the deaths in the state are occurring in nursing homes and, right, so does which does report separately for long term care and the other the rest of the population? Something like one in three of the deaths are occurring in nursing homes and assisted living so I just wondered if this show up in your data that you saw?
NANCY KRIEGER: What shows up in our data is that we did one set of analyses that are in the working paper. You can see the graph there.
That is age stratified. So there’s still H standardized, but we did it within three age strata. Zero to 64, 65 to 79 and 80 plus. And you can get the biggest rise the of those of the surge of just access all-cause mortality is among the 80-plus, but it’s going up in the 65 to 79 as well. But the point is that’s happening in the context of the communities in which people live and that’s what our data capture.
Q: Okay, thank you.
MODERATOR: Next question comes from email that. He is curious, in particular about household crowding. Do you have a breakdown of how prominently household crowding played into the cases you looked at and the level of household crowding that you looked at, etc.?
NANCY KRIEGER: So household crowding is a really important variable. It’s easily available from the US Census, you can get if the decennial data and from American Community Survey. I want to emphasize that crowding really means crowding. So that if you look at the question that’s asked about household crowding in these surveys, you exclude you count the number of rooms, but you exclude things like bathrooms, hallways or foyers or balconies and porches. So what that means, but you count things like kitchens. So if you have a one bedroom apartment that has one bedroom, that has one living room one dining room and one kitchen that counts is four rooms and the only way that that place would be considered to be crowded is if it had five or more people living in it. So that’s a lot of people.
So what we did is we looked at that variable crowding, and what it shows is that there’s a very, if you’re in the high crowding quintile the top 20 percentile of households for crowding, then yes there is a mark surge of what the mortality is. And that makes sense because household crowding as part of the mechanism of transmission. It’s where people are being exposed and can’t self-isolate.
Q: Do you take age, the age of the people living in the household into account as well for crowding? Do they, are children considered the same as adults?
NANCY KRIEGER: Yes, in the census definition it’s the number of persons, independent of age, that are occupying that set of, and this is about occupied housing units, by the way. So, this does not include a measure of crowding within institutions, for example. So it doesn’t. If you’re in an institutional facility, including, for example, a jail or prison. This doesn’t count. This is not a crowd of that, this is a count of occupied housing units.
MODERATOR: Okay. Thank you. Next question.
Q: Thanks for doing this and appreciate the extensive overview. That was really informative. Um, your study in some respects reflects known disparities in health and life expectancy multiple studies going back several years and data that goes back decades. Disparities based on race income and geography and so forth. Is it fair to say that scientists in your field, and even the federal government knew that this was likely to happen with COVID-19?
NANCY KRIEGER: I have not personally seen the pandemic preparedness plan that was apparently issued in 2019 so I do not know how that document did or did not address health inequities in relation to pandemic preparedness, so I can’t answer that question. Did people who were social epidemiologists and others who are active in concerns around health equity have a clue that once the pandemic started happening this could be a problem? Yes. And you can see that reflected in initial blogs that started appearing, probably of all fairness, like beginning sort of March. So I would say that, I mean, I have not seen a ton of public writing about that before that. And that was again in more a blog format.
And then I’d say that really started to crescendo as the data began to become clear. And because what this depended on is knowing the means of transmission. I mean, that’s really crucial. And that was only just getting figured out in terms of what the potentials for domestic transmission were going to look like. So I would say that it’s not these what we’re reporting is not surprising, the point isn’t to surprise. The point is to document for where there is need. One thing that stood out in The Globe article to me, for example, when the reporters were talking to people in different places that we indicated based on towns, city, town or a zip codes characteristics were given that there probably was a surge going on that may not have been actually correctly reported or understood or even perceived by people if it’s not actually publicized. Because then, here in Massachusetts there was a lot of attention, rightly so, for example, and Chelsea.
But that’s not the only community that looks like that. And The Globe reporters were able to use the data that we generated to actually talk to people in some other towns like for example Medford, like for example, Lawrence and identify surges that are going on that hadn’t previously been discussed, which is critical for the people that live there in terms of knowing one what is going on. Who’s being affected and to what steps need to be taken in terms of testing in terms of potentially contact tracing, in terms of the needs for personal protective equipment and the need for planning around what can be done around isolation. So part, again, this is not to say that this should be surprising, but if it’s not documented you don’t know you have a problem. It’s an age old adage no data, no problem. The way that you get attention to problems is by having the data to show they exist. So that resources can be mobilized to address them. That’s a core function of public health monitoring and the study that we did is in the tradition of public health monitoring for equity.
Q: Great. Thank you. Appreciate that.
MODERATOR: I just have a quick question. Sometimes we have been getting some questions about mass incarceration and how the virus has been going through prisons and the criminal justice system. How do you think those issues could be addressed? How do you think that mass incarceration could be changed in a way that would make it safer and healthier for those who are in prison?
NANCY KRIEGER: So again, this is where I would really recommend speaking to people in terms of concrete policy recommendations. I can speak broadly from a public health standpoint. And clearly, and there are many other issues around mass incarceration and health that go well above and beyond COVID-19 in terms of both who is incarcerated, who should not be incarcerated, and what the health issues are of what happens with mass incarceration, not only on the health of people that are themselves individually sent to prison and or jail. But also to their families and communities that are disrupted by this.
So there’s a much broader discussion to have about the health harms associated with mass incarceration. Here in this particular case it seems that there are two really key issues going on. There are what is happening to the people who are themselves incarcerated, in terms of crowding, lack of access to adequate sanitation facilities in terms of running water, in terms of private bathrooms – that’s not obviously not happening. And in terms of closeness of contact. It’s just not possible. What’s happening with personal protective equipment. What’s happening with, these are real concerns and there have been many issues raised at people, so many people that have been sentenced were sentenced to prison. They were not sentenced to death. And if this is going to increase the possibilities of death this is a real problem.
So that’s where I know that there have been judges and others that have been very involved in these in, engaged in these discussions along with different advocacy groups, but what can be done around personal protective equipment, what can be done around the improving the conditions and decreasing the crowding is a huge issue. But the other people that are being affected are the correction officers themselves and they’re the ones that are going back and forth, bringing it from the community into the prisons and back out again. And so there’s also a concern about what’s happening with their health and these have to be addressed together, which gets back to improving what the working conditions are as well as decreasing the extent of crowding.
MODERATOR: Okay, thank you. And I had another question. So in your analysis, is there one population that stood out to you that you were not expecting to see that was included or one that was particularly hard hit by the virus?
NANCY KRIEGER: I think what’s really important is that our results show the importance of looking at all the kinds of indicators that we did. And also, by the way, not as some people do just lumping them into one large index. So you see a very, you see this steepest excess surge in relation to percent of population of color, but you see very sharp surges in relation to poverty. In relation to racialized economic segregation and also crucially, the household crowding. So all of these things matter. And they’re part of getting a fuller picture.
MODERATOR: Looks like that may have been our last question Dr. Krieger. Do you have any final words you’d like to say before we go?
NANCY KRIEGER: As I said, it’s been really crucial to have journalists providing legal interpretation of the data and also being the ones that are often getting the data as for many of the different COVID-19 tracking systems that have been set up. Whether working with The New York Times, The Washington Post or The Atlantic. So I really think that that’s very important. I also think it is really important for journalists to step back and frame the issues of who is at risk and who is dying from the standpoint of understanding what the structural determinants are. That sounds like jargon, but it’s actually really real.
It’s not a question of whether people are personally willing or not to wear personal protective equipment. If they’re working in jobs and they’re not adequately provided they can’t do that. What are the conditions at work? What particularly what are the conditions at work for essential workers? The reporting that’s happened. In The Globe, for example, about who’s been affected in hospitals, remembering that it’s not just the people that are directly providing health care, but also the janitorial staff, the shipping clerks. They’ve been at excess risk. So these are really important to frame the conditions in which people are living and working, which are well above and beyond individual personal decisions. That are affecting exposure and the ability to protect oneself against exposure. They are, whether you can have a job that allows you to work from home or not. Whether you have a job that has sick pay, that’s paid or not, let alone family leave, that’s paid or not.
And I think that one thing that COVID-19 is doing is exposing injustices that have long and known. But this is what every crisis like this does but and it’s doing it. For example, you could look at what happened with Hurricane Maria, or many years before Hurricane Katrina. Those did those in particular areas they were localized. They were devastating where they were, but they were localized. This is happening now across the entire country. And it’s revealing what problems are both in federal as well as state and local policies and resources that are available to people to live healthy and dignified lives. So I think it’s really important to step back and give that lens when reporting, that this is not about personal choices.
Yes, people behave. Anything that is alive is behaving. If it’s not behaving it’s not alive. But how people behave. What options, people have for how they behave has everything to do with the conditions in which they live and work. And that’s really crucial who depends on public transportation, who does not have a car, who is going to therefore be more likely to be exposed? These are really important questions to keep at the forefront of the journalism and to look at what’s going on with what the policies are about pay wages, conditions of work, who’s an essential worker what the personal protective equipment is ,what the policies are for people who can’t work because they’re ill or shouldn’t work because they’re ill.
MODERATOR: Um, I think we may have one last question squeaking in.
Q: Doctor, what you just said that will caused me to raise my hand. So many people are focused on how do we reopen, how do we reopen safely with what you said it that says to me, we can’t reopen safely unless we address this. Is that, is that right? And would that what you described earlier testing sites that people be comfortable going to treatment opportunities for isolation, all of that is part of reopening?
NANCY KRIEGER: Absolutely. To be clear that there is not a contradiction between public health and economic well-being, they actually go together and having possibilities of having us as a state not open up again safely, let alone the country, which is a much more complicated proposition and more waves of devastating infection and disease and death. Crashing out hospital systems is not a good idea. Crashing out the healthcare workers because it’s not like hospital systems and the healthcare systems are just a matter of money. They’re a matter of trained personnel and it’s really important that this is why, this is one of the many reasons people all around the world always end up inventing things called governments to try to address these kinds of issues in a systematic way that allows integrating understanding of policies across different sectors, so there’s not just an economy over here somehow and people’s health over there.
We live embodied. It’s all happening together and it comes together in our bodies. So yes, to understand what these inequities are, they have to be addressed as part of what counts for safe opening. Because otherwise, the infections will continue and the deaths will continue. And this is not anything that should be normalized back to an earlier question. This is because also, where this is different than, for example, diabetes, or cardiovascular disease is that this is a disease where, and it’s also different from example what some people were making as analogies early on well, a lot of people die of car crashes. Well, when a car crashes, it’s terrible and it can kill the people inside, more likely, it kills the pedestrians outside but then it doesn’t turn around again and kill the healthcare providers. This is a different thing. This is an infectious respiratory disease capable of being transmitted by asymptomatic people.
Q: Thank you, Doctor.
This concludes the May 11 press conference.
Michael Mina, assistant professor of epidemiology (May 8, 2020)