This article is part of an ongoing collaboration between the Colorado School of Public Health, the Denver Museum of Nature & Science, and the Institute for Science & Policy. Find all of our previous COVID-19 webinars and recaps here.
COVID-19 has illustrated structural inequities in the American healthcare system that have persisted for centuries. Black Americans are dying of the virus at a higher rate than whites, despite making up a smaller percentage of the population. Majority-minority communities commonly lack access to testing sites and other medical resources. Black, Latino, and Native Americans are likelier to suffer from preventable illnesses and pre-existing health conditions, leaving them at greater risk during an epidemic. How did this come to be? And how can policymakers, scientists, health practitioners, and citizens help address these long-standing public health trends and move toward a more just and equitable system for all?
We spoke about these topics and more with Fernando Holguin, MD, Director of the Latino Research & Policy Center at the Colorado School of Public Health and Professor of Medicine-Pulmonary Sciences & Critical Care and Director of Asthma Clinical and Research Programs at the University of Colorado School of Medicine; Cerise Hunt, PhD, MSW, Director for the Center for Public Health Practice and Assistant Professor in Community and Behavioral Health at Colorado School of Public Health; and Spero M. Manson, PhD, (Pembina Chippewa), Distinguished Professor of Public Health and Psychiatry, Director of the Centers for American Indian and Alaska Native Health, and the Colorado Trust Chair in American Indian Health within the Colorado School of Public Health
FERNANDO HOLGUIN: I'm an ICU physician and one of the things that struck me as really interesting and really odd was when I walked into the unit just a few a couple of months ago, we had six ICU units just dedicated to COVID patients. I've never in my whole life been in an ICU where everybody shared the same disease, and most of the patients were Hispanics. And certainly that speaks to our data at UC Anschutz Medical Center. Of the first 200 hospitalizations, only 20% of them were white. Whereas, more than 30% were black and almost 30% Hispanics. Hispanics and Blacks accounted for more than two thirds of the cases, which is really quite striking considering that Colorado Hispanics comprise 22% of the population and Blacks 4.8% of the population. So, a huge overrepresentation of the disease burden.
We started seeing that data coming in early on from New York. You can see that the same thing was happening. The New York Department of Health and Mental Hygiene shows that both African Americans and Latinos are most likely to be infected and are also more likely to be hospitalized and are unfortunately more likely to die. And recently, an article was published by The New York Times showing that compared to whites, Blacks and Latinos really represent about two thirds of the cases.
Compared to whites, the Blacks and Latinos that are most affected are working, younger age populations. So this is not that elder Latinos or Blacks are being more infected, it's actually the working population that seems to be at higher risk.
The virus doesn't discriminate, but governments do. I think a lot of the issues that relate to what we're seeing - why Blacks and Latinos are being impacted more seriously about this disease – is less about genetic susceptibility or biological security and has to do with the consequence of structural and systematic racism and inequalities in our society.
The CDC has acknowledged some of these factors. If you go to the website, you can see certain explanations as to why certain ethnicities and race groups have increased burden of disease related to COVID. For example, these are just some of the ones that I think are worthwhile to mention in our discussion today. Many members of racial and ethnic minorities live in neighborhoods that are further away from groceries and medical facilities, so they have to go out and walk. Many live in multi generational households, often with many people in very close living spaces. They are more likely to leave in densely populated areas with higher outdoor air pollution levels. There's actually some very interesting data showing that air pollution may be a risk factor driving mortality rate. And we can talk about that as well. And then, you know, residential racial segregation leads to a variety of adverse health outcomes and underlying health conditions, such as practices like redlining and structural racism which plagues our community.
And there are many work circumstances. The majority of Black and Latino workers are in frontline jobs that, for the most part, cannot be done remotely. So as you've seen before, there's a lot of mobility in this group and exposure. Although Hispanics account for 7% of the total employment, they constitute 53% of the agricultural workers in this country. And don't forget that people like Blacks and Hispanics are critical workers that make everything happen from hospitals to groceries being stocked. They're the ones that are being impacted most.
There is a piece about reparations in the New York Times Magazine, a phenomenal paper that's worthwhile reading, but one of the things [the author] ends up with is is really kind of a bleak future considering today already more than half of Black adults are out of work, Black businesses are withering. Just 12% of Black and Latino businesses owners who applied for the small business loans received the full amount requested, so even in the aid package, we see biases and racism practices applied to the groups are being affected the most. So, unfortunately for these racial and ethnic groups, it is a hard road ahead.
CERISE HUNT: My focus is going to be really looking at how COVID has impacted the Black community, and Fernando has done a great job really teeing this up. What we know about the Black community on a national level is that we make up about 13% of the country's population, but account for 22% of the deaths according to the CDC.
So this is a result of what I'm going to refer to as some pre-pandemic realities. We've talked about this, this shouldn't be alarming. This shouldn't be surprising. And this is due to the long-standing systemic health inequities that have put members of the Black community at increased risk of getting COVID-19. And so, I know our title is talking about inequality. But in order for me to authentically talk about the Black community, I got to address inequity, the injustice, the unfairness as Fernando has already stated.
We know the disparities, and need to look at the inequities that are perpetuating a lot of groups of color. What's foundational in the inequities is racism. And I love Dr. Camara Jones, who’s with Morehouse School of Medicine and is the former American Public Health Association president. She has done a lot and is a tremendous public health scholar on anti-racism. She's given us a framework to really think about contextualized racism in a system as restructuring opportunity and assigning value based on the social interpretation of how one looks, which is race. So that's what we're talking about right now, this system that has unfairly disadvantaged some individuals and communities and unfairly advantaged other individuals and communities.
When I think about racism, which is really going to be a lot of my focus, it's rooted in the foundation of the United States of America, beginning with the enslavement of Africans in 1619. And if we really think about most of the Black experience in America, it has been endured under chattel slavery. That was 244 years and ended in 1865 and in this time, we got to remember, Black folks were thought of as property. We weren't thought of as a human. And then after slavery, then we go into the Jim Crow laws, that collection of state and local statutes that legalized racial segregation, which is a common theme. We heard segregation already in Fernando's talk. For about 100 years, we were in this Jim Crow period from post Civil War until 1968.
And what we need to understand is that those laws denied Blacks the right to vote, get jobs, get education and opportunities. Think about redlining. And, you know, the New Deal, all of these government programs that were supposed to uplift the economy, uplift folks - the Black community, because of racial restrictions, was denied these opportunities of things such home ownership, which leads to wealth, which leads to accumulation of wealth.
So when we think about how we got here, we have to know our history. And then, the Tuskegee experiment, which was sanctioned by public health from 1932 to 1972. Men were recruited for the syphilis study, were not given informed consent, and they were not given an adequate treatment. So now here we are with COVID. Now we want to start going to folks’ door, going door to door - we have contact tracers, we have folks that we want to get antibody tested and all these different things - there's a lack of trust.
And so, like I said, when we're thinking about our interventions and being culturally responsive, we have to understand that trust is reality. And so I would just like to say it's not because of one's race that this is happening. The viruses aren't going after Black people, as already been stated. It's because of inequities and racism which leads to poor health and greater exposure to the virus. When I think about COVID-19 and that blacks are more likely to become infected, we're exposed more. We have those frontline jobs which are now deemed essential, but these frontline jobs have low pay and can't be done from home.
What we also know is that the Black community, once infected, is more likely to die. Blacks have a higher rate of underlying conditions such as diabetes, asthma, high blood pressure, and this extra burden of chronic disease makes COVID-19 more dangerous. So then my next question is: Why is the Black community overburdened by chronic disease? What's the explanation? And we have to take into consideration the physiological aspects of racism. There has been an increased acceptance in medicine of a concept called weathering, pioneered by Dr. Arlene Geronimus of the University of Michigan School of Public Health. In her research, it holds that the stress and the living as a member of a community of color in itself takes a toll on the body. So when we're talking about that experience of racism and discrimination and prolonged exposures to the indignities and dangers of discrimination, it's weakening our cardiovascular and immune systems and that leads to a deterioration of the body.
And then we also know that there's less access to health care. In 2019, the Colorado Health Institute reported that although the Affordable Care Act has provided Black Coloradans more access to health insurance, it is not guaranteed that they receive services, treatment, or equitable care. So here we go, there's that buzzword: equitable care. They are less likely to report seeing doctors and specialists, and are more likely to visit the emergency room for non-emergency visits. So then we got to go into the trust of the healthcare systems, and are they going to receive the quality care.
We also know that access to care is not the only barrier. Studies have found that implicit bias on the part of healthcare providers often results in poor treatment of Black patients. So I would even say when we think about bias in the treatment of Blacks, we have to go through all of our systems because we know in order to eliminate these inequities, we're going to need a multi-systemic approach. So we need to think about our school systems. We can talk about the school-to-prison pipeline and fear of if teachers have Black students. Racial bias is real and we need to tackle this and address this.
And then there's also the myths that lead to inadequate treatment in the Black community, such as one that Black people don't feel pain. There's been studies about pain assessment and treatment recommendations and false beliefs about biological differences between Blacks and whites, and this was led by Dr. Kelly Hoffman at the University of Virginia. And this work really reveals that a substantial number of white lay people and medical students and residents hold false beliefs about biological differences between Blacks and whites and demonstrates that these beliefs predict racial bias and pain perception, treatment recommendations, and accuracy. It also provides the first evidence that racial bias and pain perception is associated with racial bias and pain treatment.
So this mistrust in the healthcare system has multiple factors. And so I do want to stress that we've done our own work within the community, where we partner with the Colorado Black Health Collaborative. The community was telling us, our provider doesn't listen to us. It's like they don't hear our concerns. So we have to really understand that we are delivering services that are culturally responsive, that we are being inclusive to the needs and we're listening to the community.
Race is not a determinant of COVID-19. I can't stress that enough. It's racism. This COVID 19 pandemic and a rise in police violence and killing underscores that racism is a U.S. crisis, and I'm so grateful that there's so many people that are watching it today, because in order for us to stress this crisis, we need all of our attention right now. I don't care what sector, not only in our public health and health care systems but education, housing, justice, our behavioral health and employment systems.
So even with this bleak history and the challenges, Blacks have persevered when faced with continued continuous efforts and injustice.
SPERO MANSON: I'd like to begin my remarks by sharing with you an observation that was shared with me in mid-February when I last visited Alaska and it was as follows:
“Once more, darkness descends upon our people and this land. It bears many names: smallpox, flu, measles, typhoid, TB. Today, a virus. Suffering and death always follow, though your traditions shine brightly, casting light to guide the way. We struggle to survive. By these traditions, now armed as well with medicine and science, weapons of the Western world. The challenge is how to bring both to bear on this danger so we may live on.”
That is from an Athabaskan Elder, translated into English. He lives in interior Alaska. And I think these powerful words of this particular elder underscore this novel virus sweeping across our country is reawakening fear, pain, stigma, and loss of past outbreaks of infectious diseases among American Natives and Alaskan Natives. It amplifies the fractures in the social fabric and exacts a terrible toll by exacerbating the health disparities that place.
This special population has added risk. You've gotten some of that, largely through the eyes of the Navajo Nation in the Southwest, and the Lakota of the Northern Plains, which have garnered the largest attention in the media. Most of this attention has emphasized the challenges, namely, their vulnerability, the heartbreaking battle to constrain the contagion and the lack of resources to care for those afflicted by the virus and the mounting consequences for individuals, families, and communities.
We know that this virus has deeply penetrated tribal communities. Indeed, as of mid-May of this year, American Indians comprise 18% of the COVID-19 related deaths and 11% of the SARS-CoV-2 cases compared to only 4% of this population in Arizona. That's 57% of cases compared to 9% of the total population in neighbors to the south, in New Mexico. And 30% of the cases compared only 2% of the population in our neighbors in Wyoming to the north. So within the same timeframe, the Indian Health Service reported nearly 6,000 positive cases in IHS, tribal, and urban Indian health care facilities.
Indeed the infection rate among the Navajo has surpassed the state of New York, the center of the pandemic here in the United States until recently, with over 2,700 cases for 100,000 people compared to 18,000. Today the Navajo Nation has the highest per capita incidence of COVID-19 infection in the U.S. despite draconian control measures. And of course, you may or may not realize that within the greater Denver metropolitan area, the two largest tribal communities represented among our native residents include the Navajo and the Lakota people of South Dakota.
This situation is even worse among the smaller tribes in New Mexico, particularly. The virus presents elevated risks, as Fernando and Cerise have noted, for Native peoples as well who experience substantial health disparities. We suffer disproportionately the high prevalence of many of the health conditions that place us at greater risk for serious illness and death including diabetes, heart disease, asthma, and obesity. The Indian Health Service is the primary vehicle through which the federal government fulfills its responsibility to provide primary health care services to us. However, the Indian Health Service has been chronically underfunded to meet the healthcare needs of Native people. Across the country, for example, 25% of healthcare provider positions are vacant with 30% vacancy within the Navajo Nation as of 2019. The Indian Health Service budget only provides $4,000 per capita for health care spending. That's less than half of what is spent for federal beneficiaries in the general population, and covers only 16% of the estimated funding needed to address the needs provided by the IHS federally operated and tribally operated and urban health care facilities.
Now the Indian Health Service Clinics are located predominantly on or near reservations in rural areas. In Colorado's case, our two tribal communities in the Four Corners area the Ute, Mountain Ute, and the Southern Ute, which makes those clinics essentially unavailable to the urban American Indian and Alaska Natives. Whereas residents of today's cities represent more than 72% of the total population of American Indian and Alaska natives. The underserved nature of these programs located across our cities is widely documented.
As that Athabaskan elder’s remarks are about above, American and Alaska Natives are no stranger to epidemics. The current crisis is just one in a long history of deadly viruses to plague Native peoples. The arrival of Europeans in the late 1400s and beyond, introduced smallpox bubonic plague chickenpox, measles, diphtheria, influenza, malaria, scarlet fever, typhoid, tuberculosis, and pertussis - diseases to which we Native people had no natural immunity. The consequences were just devastating, killing an estimated 90% of the population at that point in time with lingering effects that can reverberate in today's world in the form of social and cultural dislocation, historical trauma, and major population migrations.
Infectious disease-related mortality contributed to enormous social cultural upheaval among American and Alaska Natives. We've seen throughout each of those infectious epidemics entire families, even tribal communities decimated. Many survivors experienced major long lasting disruptions and dislocations. Not unlike today, "blame the victim” beliefs are created as explanations for the vulnerability of Native peoples in the ravages of these epidemics and to our difficulty in weathering the consequences. From the late 1800s to the early 20th century, we look at media accounts. We saw words like “dirty” and “illiterate” regularly appearing in newspaper accounts of the spread of smallpox, TB, and influenza among American and Alaska Natives.
And before one dismisses these attributions as belonging to the distant past, we only need cast back to the 1993 reports of Hantavirus in the southwest United States, which was initially known as the “Navajo plague.” The mouse droppings associated with transmission were linked to descriptions of reservation dwellings as “filthy, squalid, and unhygienic.” In the past, and today, this unfortunate history deeply colors Native peoples’ views of the virus. We fear the social and cultural disruptions that history has shown to be close companions of such outbreaks. Seldom the masters of our own fate, we were often subject to the external forces imposed upon us by the federal government.
So Native people are suspicious of the promises of aids that have been provided. As a result, communities emphasize self governance and tribal sovereignty. But I want to close on the same note that Cerise did, that despite these challenges there are enormous wells of strength and resilience in Indian and Native communities in which scholars, healthcare professionals, advocates, policymakers and funders have a unique and collective opportunity and obligation to join Native peoples in bringing to bear past and present lessons from public health to battle this virus. It's not only an opportunity but I believe it's also a moral imperative. We need to recognize that the broader world of which all of us are apart, and to which we can contribute, and this is the challenge we are capable of meeting in the world.
KU: What are some of the ways that we’re seeing biases come up in medical treatment around COVID-19? I’m thinking of the clinical trials for vaccines, for example.
FH: One way that people tackle these very serious problems is to enhance diversity in healthcare. So if you're someone of a minority racial or ethnic group, and you get treated by a doctor or a nurse or a health care provider that shares your cultural beliefs, you're always going to be in a much better place. But I do agree that research-wise, representation is key. There's a letter that was just recently published in the New England Journal of Medicine that actually shows that, for example, the remdesivir trials which is one of the major antivirals - only one or two percent of the people in those trials are either Black or Hispanic or in minority groups. So there's a huge underrepresentation.
SM: It's had a long history in terms of the National Institutes of Health biases with respect to clinical trial research. Initially, it excluded not just racial and ethnic minorities, but women too, and exclusively focused on males, largely white males. That's been addressed in a number of different ways today under the rubric of the science of inclusion, which is a very robust field of inquiry that holds great promise for making a difference and addressing some of these omissions. But we see them today, not only as Fernando just mentioned in the current trials, but we see urban and rural differences, and we have the same kinds of biases at work in these trials. And so I think that we still have a long way to go to recognize and to address these kinds of biases and how we approach such science.
CH: I would just add to this about ensuring that our workforce and researchers are trained around these arenas. This needs to be infused in all aspects of curriculum. It needs to be ongoing and continuous education around biases but then also partnering with community on research. We hear about community based participatory research. There really isn't, to me, in my opinion, any excuse of why there's not that partnership with communities, authentic engagement establishing the relationships, building the trust. Fernando was spot on. We need to diversify and ensure that we are engaging and bringing researchers of color into this process.
KU: How do you rebuild trust, particularly if there’s this history and decades and hundreds of years of mistrust?
SM: Well, I'll take the first shot. First off, it means being present and putting yourself in the place of others and being able to suspend judgment about a variety of assumptions that many of us have. All of us have assumptions, but it's the importance of recognizing what those assumptions are, how they may affect what you see, and what you look for, how you suspend the judgments related to that and being there continuously throughout that process and lending your skills to understanding the circumstances and to advocating on the part of solutions that are best promoted by local key stakeholders.
CH: I totally agree with that, and what I would add on to that is mobilizing and community. That's why we formed the Colorado Black Health Collaborative. It was to say that, you know, we're tired of seeing injustice within our community. If we really want to invest, you know, and really promote and advance equity in the Black health, we had to mobilize and come together ourselves. In 2009, that's exactly what we did. And as we're doing this, we're establishing trust, we're creating those mechanisms. We have a mechanism. So, as a community we can vet researchers as they're coming through the process to say this is trusted and it can be that bridge and that link between community and also research.
As Spero has stated, being present, continually being present - we don't parachute in and parachute out. All of that is really simple. How do you build a relationship with anyone? It takes time. It's not all about me and what I need and what I desire. It needs to be mutually beneficial. And at this point, benefiting the needs of community. What are the desires, what type of research will community members want to engage in? So it's really taking that time to be authentic and how we're broaching and being sensitive to concepts. We know how to build relationships. We know what it takes. It’s just putting it into practice. It's so easy to say, I just don't know, I just don't know. You know. Now, we need to break through that and really take the time and establish those relationships.
FH: I agree and I would say that from the academic perspective, research into the community is not always “we know what's best for you.” It’s not that we're going to come so we can use your data and prove a hypothesis using your population and then once we get the results, walk out of there. People in our communities are really tired and disappointed with academics coming and saying, you know, you guys are really bad shape over here and then walking away and offering no long term solutions.
And part of that is actually enhanced by the funding cycle. People come with very good intentions, and they start to work on the community, but then the grant’s thrown out and then the projects don't have self sustainability and they die out. And that creates a level of distrust in the communities to academics that's very pervasive and it continues today.
KU: What are some ways to reach folks to avoid them feeling isolated?
CH: First, find out why they are choosing to be isolated. As academics, we need to go into the community with cultural humility and really try to remedy the past hurts. So whenever there's any resistance when I'm engaging in community, I really need to understand the why. Not to say, oh this community is too hard to work with and they just don't want to work. I need to take another pause, take a step back, especially if we know that these communities are overburdened with disease. We can no longer say that community is too tough and just jump on to our favorite communities, they like to work with us, they like to partner with us. We have to really take the time and make sure that we are learning and getting an understanding of why folks are not engaged and really try to remedy the relationship and walk in that humility to build that bridge with the community.
SM: This is one of the great dilemmas for people from our respective communities in which our lives are collective by nature and our identity is not just personal, but it's social as well. It revolves around the development of that identity, its reinforcement, its maintenance through family and extended family matters. If you look at our healing traditions in Native communities, they're virtually all collective by nature, focused on mobilizing and targeting social support in the context of a variety of symbolic frameworks to repair the rifts through emotional, psychological and spiritual aspects of our lives.
And so something that requires us to isolate through mitigation practices such as today, really are an anathema for Native people. One of the interesting things seen in the Southwest is particularly how physicians from the biomedical world are now working with traditional healers from tribal communities to develop ways in which mitigation practices can be appropriately incorporated into the ceremonial and ritual practices to enable them to move forward and to provide the value that they have historically in our communities. And that's why I think, going back to the Athabaskan elder, the notion about bringing the weapons of the Western world together with our traditions in Native communities is a wonderful example.
FH: I would say that one of the major problems, at least for the Hispanic community, that drives us to terrible isolation is issues related to migration and legal status. As you know, a large portion of Hispanics are undocumented. And even many of them that are documented, are not coming out. That actually is creating a vicious cycle in which people are getting sick and not coming out and then they’re not able to get help at a timely fashion. So there are a lot of dangers and make isolation a real problem for Hispanics.
KU: What is the role of integrating traditional knowledge with Western information and what are some ways that we can support and bring those things together when it makes sense?
SM: I’ll address it through an illustrative example. There are several Southwestern tribal communities, for example, that are finding new ways to underscore and to develop social supports. A great example is among Pueblo youth and their outreach to elders about mask wearing. There's a very high prevalence of wearing masks in many American Indian and Alaskan Native communities, because we value elders and we have done an enormously important and successful job of communicating to our younger people particularly that wearing a mask is not so much about protecting yourself, but about protecting your elders. You have a basic essential critical obligation or responsibility to ensure that that value is enacted in your day to day life. And so that's a wonderful example of how to bring a mitigating practice together with synchronous cultural values.
KU: Is there a danger that past injustices will be codified through machine learning protocols and algorithms, those that seem to be data driven on their face where they reflect past discrimination and treatment? How do we avoid that?
FH: I would say that anytime that you're dealing with data or metadata analyses, of course, the data is going to be biased by the inherent structure which carries all the biases and racist practices of policies and other things. The data are the data, so I think they're going to tell stories. Where we can potentially make a difference in how you appraise that information and really acknowledging its limitations. But I don't think that you're going to be able to potentially change that information because already exists. It's the way you evaluate it and move forward, in my view.
SM: I believe that self reflection is really key to all of this, I'm impressed by the fact that in training, medical students and residents for the most part are well versed in the assumption that science is objective and omniscient, and that it proceeds without bias when done well. I submit that in fact, there's bias in everything that we do as human beings. And our challenge is to develop the tools by which to recognize what our own biases are, how they may affect our observation of the world around us, and then subsequently perceive it. And I think that is an ethical process. I think it is learnable, but we all too often do not undertake that challenge. And there are all kinds of ways to enact that and lots of examples I use with my medical students and residents.
CH: When we're thinking about these aspects, we want to look at structural racism. We've talked about training and education, but within our organizations, what's key is assessing how is racism infusing our policies, practice, procedures, and our values? If we want to be an anti-racist organization and we hear folks that are saying that, then what I want to know is, have you assess your practice? Where is it infused? Are we having this anti racism work infused in every area? Is it in your value statements? And so these are the different things within our organizations that can address some of those past discrimination and harms that have worked within communities, and that leads to the continual ongoing learning and education.
But you don't know if you do not assess: where are our gaps, where are we falling short. Even when we think about our engagement with patients, we should be doing assessments. We should learn and hear from our clients. How were you treated from the moment you walked into the front door to the time that you were seen by your physician? And we should aggregate that data by race and ethnicity to see if there's some different trends. So those are all tangible practices that we need to do. But we don't want to just collect this data. What's key is after we collect the data, we engage in some sort of practice to go through some sort of organizational change. So one of the key things is we're going to have to stop, pause, and assess and not assume that we're all doing the great work because these assumptions are what has led to these inequities. People are well intentioned, but they are causing harm. So we need to hear from community.
SM: I can't help but notice in the chat that several participants have now offered reparations as one way to address this, and I strongly disagree. I disagree because we American and Alaska Native people have several centuries worth of experience in reparations from the federal government. First off, in the form of the treaties. We found that those treaties shrunk in size and shape in terms of the obligations to the federal government to us. We also found that reparations in the late 1950s to a number of tribes, which led to their termination, actually gave the federal government the opportunity to wash its hands for the responsibilities to Native peoples, that reparations allows one to say, I've dealt with this, I no longer have a responsibility in that regard, I discharge that obligation. And I believe that what we need is an ongoing acknowledgement of that obligation in a reciprocal fashion that keeps us engaged and moving towards solutions without that kind of engagement, which I think reparations, for example, undermines. I don't believe that solutions are likely to occur.
KU: Are there good examples of that ongoing engagement that you could point to or that you have ideas about?
SM: Yeah, in some respects, they're specific to American and Alaskan Natives particularly federally recognized tribes going back to the first President Bush. They required what was called government to government consultation, recognizing that tribes have domestic dependent sovereignty status and the federal government has a responsibility to engage us in to consult with us about a full spectrum of different kinds of policies and practices that affect our lives or hold the promise of affecting our lives. So we're engaged. That doesn't mean that reparations aren’t occurring simultaneously, but they're a necessary but not sufficient condition to achieve the kinds of goals that I think that we share.
FH: I think my colleagues have a lot more experience than I do in terms of reparations. But I would say that, whereas there has perhaps been a lot of discussions and engagement with the Native American community, it seems to me – and this may be only my opinion - but it seems to me that that discussion hasn’t even happened for the Black community in this country yet. It hasn't even started. And so I think there's a lot of work to be done.
CH: I will completely agree on what that conversation would look like. We’re still at three carts and a mule. We still haven't even got that. So I'm just saying that that conversation has not moved forward within the Black community.
KU: What are we learning now, in respect to taking in historical examples that we can learn from, that can help us make ourselves a little bit more prepared, even to deal with COVID-19 which is still here, but also future pandemics?
FH: People need to understand that epidemics are apolitical. These processes only respond to public health interventions that are based on evidence, and that highlights the social and structural inequities that exist not only in this country, but in many countries. And unfortunately, when you look at the historical records from the 1918 flu or even from other plague epidemics, the same type of mistakes get repeated again and again and again. Things become highly politicized. There's a lot of misinformation happening now with the internet, even more rapidly than in the past. But clearly we have to be conscious to the fact that we, Dr. Manson mentioned, we need to care for our communities. One of the problems that I have is that I know that the United States cherishes individual freedom quite highly. Something that's very valuable to society. But we have to think about collective freedom as well. If I don't protect my neighbors or my neighbors get sick, what does that give me ultimately? So we have to think more collectively as a society, sometimes perhaps more than our own individual health when we're dealing with problems like this.
CH: My view in this, in what we're taking away, is that history is repeating itself, that we're not making much change. And so I imagine that when Dr. King was assassinated, folks were moved and what what happened afterwards is that there wasn't much change. And so my concern is, if we're not conscious, history will repeat itself again. We have folks that are talking about racism and structural racism, we have all these statements, which can be deemed as performative if we are not intentionally thinking of how we're going to change our practice. So I'm more hopeful that this isn't just a moment of time and after COVID, we go on to the next aspect and communities of color who have been historically marginalized - all of these groups have a history of marginalization in the United States - does not continue to move forward for the next 100 years. So that's kind of the way I’m seeing it. I’ll call it out: make the changes and do something. We’ve got to do the work.
SM: My view on this is that expertise and knowledge does not reside within the world of science alone. There are many different locations of relevant expertise and knowledge that we need to be open to identifying, soliciting, and engaging and then integrating into the ways in which we battle these kinds of infectious disease epidemics.
And I think there's some wonderful examples. What it requires is that we be open to those possibilities, and that we explore actively where that knowledge and expertise lies and engage it in mutually beneficial and meaningful terms. And I don't think we've been, historically, particularly adept at doing that.
KU: What is one thing that you do to maintain resilience?
CH: You know, I'm all about self care, because in this time in this season really taking the time to refuel, disconnect because there's so much this going on. I mean, think about all that is going on with the civil unrest in the United States, global unrest. As someone who has gone and done all their education in predominantly white spaces, it's been my community. We’ve got to allow for different groups to engage and come together and not be concerned about that because my engagement with the black community being connected to the Colorado Black Health Collaborative, that connection to my community, allows me to refuel and replenish. It gives me the space to kind of identify with other scholars, with other community members to really refuel me. I think that that's important, just to band together. Because in Colorado, in Denver, we don't have a Black neighborhood. And so creating those space for Blacks to come together, strategize, just heal with one another in the shared experience.
FH: For me, resilience in the community has to do with the value of your identity in a community. And I think that comes, in the Hispanic community, from a lot of family centeredness. Even though they fare worse in terms of having access to health care, and having higher risk of chronic diseases, they often have better outcomes in terms of survival and origins compared to even vocations. So there's an incredible amount of resilience among the expanding community, which is a shared cultural background, even though it's very different in many different aspects of groups. I think that's where resilience comes from. Personally, I think my resilience comes from being inspired by the stories of my patients and their struggles and I learn from that every day.
SM: I think I've spoken repeatedly about what I believe are many of the strengths and soft assets and the sorts of resilience in Native communities. Personally, I'm very blessed to be able to live on a ranch about 75 miles southeast of Denver. That was a decision I made 20 years ago about brining work life balance into my professional and personal worlds. Like Fernando and Cerise, I'm able to integrate my personal and professional lives so that everything I do personally really echoes in my professional life, and vice versa. So Fernando's point about family-based and family centeredness of the Hispanic community is also true. I had my daughter and son in law and three of my four grandchildren here for five days for horse camp in which we let the broader world go by and we rode together across the ranch every afternoon for three to four hours. I just returned from a trip to Alaska with my oldest son, who's a U.S. Marshal, who's been at this strange interface between law enforcement, social justice, and many of the racial and ethnic tensions that arise himself being American Indian and a US Marshal. He is challenged by these kinds of tensions. So I agree, it's family based from my point of view.
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