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Racial Justice Series: “Health Policy, Ethics, and Equity” SwatTalk

with Carolyn Rouse '87, professor and chair of the department of anthropology at Princeton University, and Maria-Elena De Trinidad Young '04, assistant professor of public health at the University of California, Merced

Recorded on Tuesday, March 9, 2021



Ted Abel Tonight is one of our SwatTalks in about racial justice and we'll focus tonight on health policy, ethics and equity. And in these SwatTalks in racial justice series, they're structured as a discussion. Really, we'll start the hour off with questions for Carolyn and Maria-Elena about their work and then they can have a chance to answer those. And then, as that discussion is continuing, everyone on the webinar, or there's 102 of us now, which is terrific, can post questions in the chat. And then I'll ask them to our panelists. Please, when you post in the chat, please post your name and also your connection to Swarthmore, your class year, or if you're a parent or otherwise connected to the college, that would be great. So this evening, we're gonna focus on the impact of experiences of racial profiling, surveillance, and deportation on the wellbeing of immigrants and others in our society. And to talk about issues about life expectancy and rural white communities and how that has declined and how that has impacted rights and freedoms. And in general, we'll talk about the connection between healthcare disparities and racial disparities and socioeconomic status disparities and their impact on healthcare. A very timely feature given everything that is happening right now especially with COVID. And as that pandemic evolves, now we see access to vaccines as being one of the other things that are unequal across our society. Let me begin by introducing the distinguished scholars who have joined us. Dr. Carolyn Rouse is a Professor and Chair of the Department of Anthropology at Princeton University, after graduating from Swarthmore with a major in anthropology and sociology, Dr. Rouse themed her PhD in anthropology from the University of Southern California. Her research, as we'll hear about, focuses on race and inequity and religion, medicine, education and economic development. And she's the author of several books including one that I think just came out or is coming out, "Developmental Hubris Adventurous Trying to Save the World." And we had a tremendous discussion as we were just starting with wide ranging literally from genetics and epigenetics to race and inequality. Looking forward to her discussion this evening. Dr. Maria De Trinidad Young is an assistant professor of public health at the University of California Merced. After graduating from Swarthmore with a major in Spanish literature, she went on to Berkeley where she obtained a Master's of Public Health and then to UCLA, where she received her PhD. Her work focuses on the impact of the U.S. immigration system on the wellbeing immigrants and their family. And she's contributed to the growing evidence that immigrants who lack citizenship or legal status face unique barriers to healthcare and wellbeing. She's been a voice particularly in the American Journal of Public Health and elsewhere, really, it seems like every other year, publishing an editorial on this topic and making her voice heard to try to address issues of structural racism and immigration policy. Thanks, Carolyn, and Maria-Elena for joining us this evening. Let me start with a question for Dr. Rouse. Dr. Rouse, what have you learned from studying the declining white life expectancy in rural communities?

Carolyn Moxley Rouse '87 Thank you, Ted. And thank you to everybody who's here. This is a wonderful opportunity to share with the Swarth community questions about racial disparities and where we are with this. So, yeah, so I guess I'm going to just start off with a story and it may seem like I'm not quite answering the question but it's because the question's a little complicated. So I had always been interested in racial health disparities. And then the 1990s, I was making a film about community workers in California. And I had worked with this woman, African-American woman who was working with these African-American homeless kids in LA, and we went and filmed them and they were talking about their aspirations, I want to become a mortician and I want to… They had all these dreams, right? And I was so familiar with this because of my work with African-Americans. African-Americans have tended to be very aspirational. And you can, if you go to a church, you will hear that, you will see that, there's a lot of community support. The idea of you have to be your brother's keeper, your sister's keeper. And then I drove up with my film partner to a rural place in California called Susanville. And again, this was in the middle of the '90s and we were filming basically the same kinds of populations of teens and there was a meeting about trying to teach them about reproductive health. And they asked them, what do you want to do? And there were no, the students the kids couldn't articulate a dream or an aspiration. And then I heard stories about, I heard the story of a woman who lived in a trailer with her Vietnam vet husband, who was a drug user and their 15-year old was a product of rape. And she had been this owned by her family and she was depressed but didn't have the language to articulate it in this community health, (mumbles) trying to help her. And then my friend and I drove to this little town with a population of maybe a hundred, maybe less. And there was this iconic red, what is it? Little shop in the middle of town. And we were saying, hey, we're here, we're studying health. And she said, oh, you should go meet this woman over here. She's had to foster over 36 kids because of the drug use, meth. I'd never heard of meth. I feel like I was so naive and we went over and talked to her and she said, "Oh yeah, my neighbor, he came over and yeah it was beating the dog." And he'd killed over and died, he was a chained up dog. And then he was tested and the body was tested and had HIV, or AIDS. He died of AIDS. So the whole family was tested. They all had HIV and they all ended up dying. And this was a tiny little town in rural California. And I came back and I called my sister who's an economist. And I said, "White people are in trouble." I mean, I didn't know, this isn't something that we were studying at Swarthmore. We were studying Charles Murray and his whole analysis about black people and their inferiority, cultural and otherwise. And a lot of the talk was about empowering black people and a lot of the focus, but what about white people? But of course, I'm still interested in white people. So I went on and have done work on race. But around 2015, I was in Ireland with Angus Deaton, and he'd just, he and Anna had just published their paper on declining white life expectancies. And they were sort of trying to wonder, they were wondering why, right? They're trying to come up with answers and it was all sort of rational actor answers, the idea that, oh, it's because their parents have less income so there's just as not, the people aren't just as motivated because it's a sort of a rational actor that they're not inspired. And I thought that's not it really. I mean, anthropologists struggle with some of the basis of utilitarian economic theory and the idea of the rational actor. So I said, I'm going to go back.  And then my primary interlocutor happened to be listening to (mumbles) when he was talking about Angus Deaton and Angus Deaton (mumbles) had in my work. And so she called me and she invited me to this County in California to do field work because she said, "Yeah, you gotta come here." And sure enough, I needed to come there. So, and let me just be clear. I think a lot of people are disinterested in whiteness and health and in some ways maybe rightly so. I'm not asking anyone to pity these folks, many of them are from upper and middle, middle and upper middle-class homes and they fell down the economic ladder and some of them are racist and you know, they're not perfect people. They're not objects of respectability or people but that's not, our humanities, we all have, we're all human and I think that if we care about the least of us then that's a very important thing. But that said, people ask me why study them? They've had all these opportunities. In fact, some of them have inherited enough money to buy a second home in this area and rent it out. So it's not as though they are without resources, but they're passively suicidal. They're killing themselves by drinking a lot, drugs, just basically not taking care of themselves. But I'm interested because of the American narrative of progress. And the idea that we thought somehow what we were doing was taking us into this direction of better health, more wealth, I guess, more happiness. And these declining life expectancies indicate that there seems to be something wrong with the narrative or maybe we're not getting something right. And to me as an anthropologist, this is really fascinating. And so, just to move on to shorten this, basically again, it may sound tendential and not directly addressing your question but we really do have to go back to the industrial revolution, and a time when we had built an economy of things around the idea that a person's value and income should be based upon the production of things. And we also had a society that exploited people who've produced these things, right? But people still have in their heads that that's the right kind of society. So we have an economy of things but we don't have economy of care. And so these people are still invested in that economy of things. And they think that we need to return to that economy of things, and they have not processed the fact that this is an economy built on exploitation, and it's an economy that's going to destroy the environment. So I'm really fascinated by this kind of, all of the care work that could create a new economy in this area, there's a lot of caring that's going on. People taking care of sick people, mentally ill people. We could create a different kind of economy, but again, they're still invested in that old economy and their racism also as part of that, too, right? So they feel as though, when their parents were middle and upper middle class, the structures around them supported parents who were alcoholics, right? And drug users, because women weren't allowed in and immigrants really weren't here, in Blacks, and right. But when women gained rights and immigrants started to moving in and African-Americans with desegregation, they had to compete and they don't like that competition. So they're invested also in a system where, because they really think the cream rises to the top, and the only reason why African-Americans or people of color are gaining on them economically is because the government is supporting them. So they want to get rid of the government. And so they want their independence and their freedom. And it means freedom from the Affordable Care Act, that means freedom from all of this things that would actually help them because they really think that then the cream will rise to the top and that will be me. And it won't be those immigrants, it won't be those Black people, it will be me. So it's a combination of a lot of things that I connect to the way in which we think about what an economy is, which is a cultural construct but it's also these investments in a particular type of economy and social system that is long, that should be long gone. That does not promote the health of the population. It promotes the health of a group of people. And so they're caught up in this. And so they're quite proud of the fact that they don't want the government to tax them on cigarettes. They don't want people to come in and tell them not to drink. They don't want any kind of oversight of public health. They want to be quote unquote free, of course they get government support at the same time but it's all because of this sense that they're entitled in a way that other people aren't. So again, they're not to be pitied but I think it's a really important thing to note that in a society of great abundance, you can have these declining life expectancies, completely challenging our narrative about progress in this country.

Ted Abel Thanks, Carolyn, it's striking and especially striking in the healthcare arena. And I remember hearing Elizabeth Warren during the primaries speak here in Iowa, about, with the answer to everything, but what was missing in many of that was this question about care. And I mean, it's missing in all, a lot of them, in all the politics really, they're set up to have these massive solutions but at the end of the day, what builds society is individuals caring for each other. And that's something that cuts across all of it. But it's interesting to hear that perspective. I see that we're getting a couple of questions but let's let Maria-Elena tell us about her work and that your discussion about health at the end and the Affordable Care Act is a good transition to that, that's thanks to Carolyn, where Maria is focused on the relationship between the health status and racial profiling surveillance and deportation in immigrant communities, and she's focused on that in Latino and Asian immigrants in California. Dr. Young, could you tell us a little bit about your work in that area?

Maria-Elena De Trinidad Young '04 Yeah, hi everybody. I was gonna say, good afternoon, it's still pretty much afternoon over here. Good evening to my East Coast friends. It's wonderful to be here and to just get to have a Swarthy chat. And it's really just so fascinating Carolyn what you shared. And I think a really great bridge into the work that I've been doing is thinking about the role of government, right? And it's so fascinating to think that, of the populations that you've been studying, this perception that the government is giving a leg up to immigrants. My work really focuses on trying to understand how immigration policy shapes public health and it really come from the perspective of thinking about how immigration policy actually bolsters structural racism, and how immigration policies and it does perhaps the very opposite of what the individuals that Carolyn has worked with might suggest but actually really is very involved in perpetuating inequities that disadvantaged immigrants and really can be a real risk to their health. So one of the big challenges today that immigrants living in the United States face is that they're navigating lives, going to work, going to school, accessing healthcare in a patchwork of very complicated, often contradictory government policies at the federal state and local level. So some of these policies are actually inclusive. So for example, in California, we've enacted policies that expand rights and eligibility for public services of people regardless of legal status. So if you're an undocumented child in California, you can sign up for Medi-Cal which is our state Medicaid program. If you're an undocumented immigrant, you can get a driver's license. So there are some of these policies particularly at the state and local levels that are trying to integrate immigrants, provide them access regardless of their citizenship status but on the whole, a lot of the policies that we've seen enacted really over the last 30 years in the United States, are largely punitive and exclusionary, and target immigrants with surveillance using legal status as this line of watching and excluding immigrants, really focusing on profiling them and just very much leads into just racial profiling immigrants and then ultimately resulting in the deportation of lots of immigrants. So in my work, I really wanted to understand how did these policies, what do they look like in people's lives? And so with colleagues at UCLA, I've been working on a multi-year study where we've conducted a large survey here in state of California. We did a film survey of 2000 Latino and Asian (mumbles) born adults to ask them about their experiences with policy and then also 60 in-depth interviews with specifically Mexican and Chinese  immigrants in Southern California to get a little bit more of the rich stories behind what we were seeing in the data. And I want to talk a little bit about what we found specifically in that survey. So the survey was really asking people very targeted questions about potential forms of exclusion that they might experience under this patchwork of policies. So for example, we asked people, had they been denied a medical interpreter at a doctor's visit? And that's something that's protected under California state law. We asked people, have they experienced wage theft? That's something that should be protected under a federal and state laws, but specifically when it came to issues of immigration enforcement and policing, we asked people a whole series of questions about whether or not they had encountered immigration officials in their neighborhood. If they had been asked to prove their citizenship to a law enforcement officer. If they had been racially profiled or if they or somebody else that they knew had been deported. And the idea was to try to understand all the different ways in which people's lives intersect with this system that we've created, this system of immigration enforcement, which again, I argue is really a system of structural racism. And I'll highlight just a couple of key findings and are happy to take more questions about it. So, first I think one of the things that's really unique about this study is that we included Asian immigrants. And when you look at the researcher, just, I think even, I mean, most of you are sure, reading the New York Times, when you look at immigration enforcement deportation, the stories largely feature Latino immigrants. And that makes sense that that is a large group and are very much targeted but there's very little knowledge about Asian immigrants and how they might be sort of racialized by our immigration enforcement system. So our first sort of general findings were to a certain extent confirming what we already knew about Latino immigrants. They reported high levels of surveillance and profiling. So for example, 10% of our participants, Latino participants reported that they had ever been asked to prove citizens, their citizenship to a law enforcement officer. That's one in 10, that's pretty high up. 15% reported that they'd seen immigration officials in their neighborhoods. So this sort of confirms what we already knew that Latinos are living in an environment with enforcement. But we also found really what I would say are significant non-negligible levels of exposure to enforcement amongst the Asian respondents. So for example, when it came to racial profiling, amongst Latinos, 15% reported that they'd ever been watched, sort of surveilled by a law enforcement officer and 15% reported having been racially profiled. Among Asians, 5% reported having been watched but 10% reporting reported having been racially profiled by police officer or a law enforcement officer. So, these are numbers that I think haven't really been in our conversations about policing and immigration enforcement and I think are important to highlight. And then finally, when it came to deportations, 45% of Latinos reported knowing somebody who'd been deported. This is pretty consistent with other national surveys but we also found that 10% of Asians knew somebody who had been deported. So again, I think these are numbers that it means, need to bring into the conversation and understand how our system creates different forms of racial inequities. And then I'll just end with, when we took this survey data together and did all the kind of fun statistical modeling stuff, I think really the key finding that emerged is that it's not necessarily person's exposure to any one of these experiences that shaped health but it's their overall cumulative experience. So where participants reported greater numbers of these experiences, had higher chances of reporting worse health and also had higher chances of reporting emotional distress. But I think this is really important too because often the way we talk about enforcement, we sort of focus in only on one topic, just deportations or just racial profiling and it's easy to forget that these are all specific mechanisms that together function to create a system that's our risk to wellbeing. So I'll leave it at that and take more questions later.

Ted Abel That's great. Thanks, Maria-Elena. And one of the things we talked about before we got started was this idea of stress and stress is impact on one of the physiology and on psychiatry and on emotions. And those are differentially experienced by, if you're approached by immigration often or where your community is like, can really have an impact on that, for sure. We're getting a number of questions, which is terrific. Please, if you have any chime in, there also are some comments, which are nice too. So thank you all for those. And I wanna start with a question that we were going to talk about next. And one of the people in the audience, John Yuri has asked, and that relates to racial disparities in healthcare particularly related to COVID-19. There's an article in the New York Times, an op-ed piece to calling on the president to declare racism a public health emergency. And that piece points off, looks like we lost Maria-Elena. So here's one from Cynthia Gray. And she says, we used to have a caring economy who was underpaid. We have lost that caring economy as women entered the workplace. Do you have thoughts on how to reclaim or recreate or develop a more caring based economy?

Carolyn Moxley Rouse '87 Well, thank you for that question. So some people may react to that question as, oh, that's sexist question. There was care when their women were home, but she's raising a really important point which is that, we have an economy where we have often two breadwinners, let's say Princeton professionals, oh, should we go to...And so, it's actually increasing economic inequality. So you're having these communities like Princeton where you have two, a doctor and a lawyer lived together and are making tons of money and then raising the cost of housing and in the area. We really don't, so it's actually, it's not even just that we don't have care. People aren't, there's not somebody who's responsible for the emotional labor in the home but we also have these radical forms of inequality because we think that a family requires with two professionals should have two breadwinners. And we seem to be forgetting the importance of emotional work. And I personally experienced this when my husband died two years ago. And he had kind of gotten off the track because he had cancer and when he died, it was just, he was doing all of this emotional labor in my home that I was free to build my career as he's doing this and my kids needed it. So literally in the past two years, I've learned to text my children, like that wasn't a thing I had to do. And what would it have meant if he hadn't been doing that? And I, and so in this kind of rat race for more money, for more things, right? This economy of things is all about more, we have lost the fact that home life should be… So I think about how we're or hoarding labor. A lawyer who makes $2 million a year could choose to make half a million dollars a year and have three other lawyers and they could maybe have their weekends free and get home by five in the afternoon. But we don't think in those terms anymore. It's all about this kind of hyper performance and then massive amounts of money that go with that hyper performance, as opposed to thinking, why aren't we just sharing the wealth? And so that we have more people who feel comfortable and secure and safe, and with a safety net where they can do that very important emotional labor in the home. Taking care of elderly parents, taking care of people with disabilities within their home. There's all sorts of… So I agree, we hate to use that idea that, oh, it was better when, 'cause that's not what we're saying. What we're saying is we have to rethink this whole thing, I think, so.

Ted Abel Thank you. Maria-Elena, thanks, we're glad you're back and-

Maria-Elena De Trinidad Young '04 Sitting closer to the wireless, the Wi-Fi router now so hopefully that'll...

Ted Abel  Great, you teleported back to us, which is good.

Maria-Elena De Trinidad Young '04 Exactly.

Ted Abel We'll go back and jump to a question particularly for Carolyn. So we'll go back to this issue of declaring racism a public health emergency, as a question for you. And I think one of the, I was looking at this op-ed piece in the New York Times and the Black and Latino people make up 13 and 18% of the U.S. population, but they account for more than 50% of the COVID hospitalizations and thinking about Asian immigrants, as you mentioned and the virus has killed a disproportionate number of Filipino nurses is one of the things that this article points out and native Americans have been nearly twice as likely as white people to die from COVID-19. So how has have COVID-19 and its policy response, how has that impacted the immigrant community, for example, that you study in California?

Maria-Elena De Trinidad Young '04 Yeah, I mean, so when COVID started, I started a small study that's quickly grown to talk to Latino immigrants in rural parts of California. So you see, Merced is located in the heart of the California Central Valley. So it's a rural agricultural region. And it's really powered by the labor of immigrants not just Latino immigrants is longstanding Yemen, Punjabi and Bangladesh and Hmong populations here in this region, just because of language, I've mostly focused on Latino immigrants. But I think, one of the big issues has been around having to work without a safety net for being able to opt out, and stay, opted out work and stay home. Immigrant workers have been at the frontline of keeping people fed and lionized, like essential workers as heroes, but it's not heroic, it's necessity. And you really see that here in the Central Valley, we've had some of the highest COVID rates here. And I think one of the things that to me is just so striking is when you talk to people and ask them about their concerns about COVID, everybody we've spoken to does their best to, in this situation, engage in social distancing, mask wearing, but can only go so far if they still have to go to work. People we spoke to were buying their own masks because employers wouldn't provide them for them. And a lot of the messaging around COVID is very focused on behaviors like oh, we need to talk to Latinos and make sure that they know what to do. It's like, no, they actually do know what to do but they are doing it in a context where they have no other choice, but to work. And so these sort of, I think there's been a good shift in terms of people's understanding that these disproportionate rates of COVID deaths and hospitalizations in communities of color are not just because of bad behaviors. I think there's been a good shift over the last year in that but I don't think there's been really a reckoning with the fact that people in this region do not want to get tested because if you get tested, you're human, you'll want to do the right thing. You will ethically stay home and lose two weeks of salary and you might be out, you might not be able to pay for your rent that month. And so people are not willing to even come forward and do certain types of testing or getting vaccinated because of fear of the impact on their economic stability.

Ted Abel Yeah, the other aspect of this is, we think of COVID in the treatments of people that wind up in the hospital and eventually in ICU and on respirators. But I'm at the University of Iowa, Carver College of Medicine and my colleagues here, they've really focused on just standard of care early on in the disease. And one of the challenges for example is that this loss of smell and taste means that when individuals COVID drink, they have like this dirt taste, some of them, and it's difficult to keep eating and drinking. And so there's small things about, like keeping hydrated early in the illness that can make a difference in the disease progression. And that's something that's really going to be impacted in a culture or a group of of immigrants where they have to work there, that's also part of their, they need the money obviously but it's also a part of their culture. And so they're not only not thinking about getting tested, they're not considering the fact that they would have to take, we'll get back to care, take care of themselves, right? And the little bit of care of of hydration and et cetera, is a small thing but it can make a bigger difference if it happens in the beginning of an illness, of COVID-19 illness. So there's that, that too. You don't always need access to the very, very high end medical care but what you need is the ability to focus on taking care of yourself.

Maria-Elena De Trinidad Young '04 Absolutely, right, just rest. I mean, being able to take time off work.

Ted Abel Right, that's absolutely right. One general question I had for both of you and I don't know is about this relationship. You talked about a very local community, Maria-Elena, and Carolyn, you did as well. One thing I wonder about is this interaction between local governments, state governments, and federal governments seems like clearly have this patchwork of regulation with some levels responsible for this and others responsible for that. But could you comment on that? And if there's part of that, if parts of that are a solution or parts of that are a problem.

Carolyn Moxley Rouse '87 I'm gonna hand that to Elena, go for it Elena.

Maria-Elena De Trinidad Young '04 You want me start? I mean, yeah so, I think it's such a fascinating question and this is really like, it gets at the crux of my research, looking at different varying levels of immigration policy. And I think that one of the benefits is that we can do things in local communities to expand access to try to undo some of those mechanisms and structural racism. So we see some of the, New York City, San Francisco, Los Angeles, have done programs to expand health coverage to undocumented immigrants, right? And so, I think those are really positive examples. I think, where it becomes really very problematic and we are now seeing this play out during COVID is that the federal government can often be at odds with what States are proactively trying to do to support their populations. And so I'll just give like one very specific example because I could bore everybody for like hours of other examples but, Trump spent, Former President Trump spent years trying to enact what's called the public charge rule. And this was regulation and federal immigration policy that essentially makes immigrants ineligible for obtaining residency if they use public benefits, right? So he spent years doing this, trying to gram this through the courts. It was blocked, it went forward and then COVID hits and people in States, even if State of California is trying to give cash assistance to undocumented families, even if they're doing local efforts to try to extend testing, you've got this federal messaging saying, if you use public services, you could be deportable. You could be ineligible for a green card. And so we see this time and time again, particularly in immigrant communities of these contradictions that essentially make state and local level efforts a lot less fruitful. And I think it really means we have to look at, particularly in immigration look federally to make certain changes.

Ted Abel Yeah, one of the people here, Erica Horseman, thanks for your question, which was related to this and helped inspire it. She works at the CMS, which I think is the center for Medicare and Medicaid services with the government. She is mentioning the new administration's goal of prioritizing more diversity and inclusion, but there's a lot to overcome there. And so Carolyn, could you comment on that interaction between local and state and federal governments in your areas of research and how that has impacted?

Carolyn Moxley Rouse '87 Well, I mean I just want to echo what she said. I think that health is pretty local. You know, I think Flint, Michigan is an example, right? Environmental exposures, what they do, where I work in a rural community, it's the fact that they can't keep doctors. The doctors come and then they deal with this really complicated population that doesn't have private insurance and they're gone within six months or a year. So continuity of care for a lot of these folks doesn't exist. And then the prisons drop people off. It's one of the cities in this County, it's the sickest cities in California and they just drop them off. And so you can imagine without any services. So you can imagine what happens within six months or a year. I went and with a team and there was a house that had been occupied by a man who was on meth with his two kids and nobody was taking care of them. So they finally evicted them and we were digging out and it was pretty heartbreaking to be digging out diapers and toys and it was just a pile of mess. And we were trying to help the person who owned it, who herself was sick and the neighbors didn't care. They're surrounded by people who have all sorts of addictions. So I was just talking to a woman there and they just got a grant to do home care visits, community care, the same kinds of care that you read about in Paul Farmer's work in Haiti with Partners in Health. And so Americans of course, think that they're just so much more advanced than other countries. And we literally need the same types in certain places, the same types of forms of NGO-based grassroots kinds of care in the poorest countries in the world. And so I agree with Maria-Elena that at the state level, at the national, they have to be attentive to these regional differences because they are significant. And again, the language differences are significant in different parts like Oakland, I'm thinking of, there's Chinatown in Oakland, or other types, Japantown and other places, these kinds of places need different types of care. So I completely agree with her that we have to have scaled up approaches, handling different levels of care and different kinds of approaches of care.

Ted Abel When you think about that and you think about the community health do, is the kind of increasing emphasis on tell the quote unquote telehealth, I don't have a more modern, we were talking earlier about how this makes us think about modems from our youth, but it's gotta be a better name than telehealth but is that something that you think would be helpful here or does that create more problems of its own?

Carolyn Moxley Rouse '87 I'm going to hand it over to Mari-Elena 'cause I think she has the best data on that.

Maria-Elena De Trinidad Young '04 So I haven't directly been studying telehealth. I have a great colleague here who's on my side who's been really jiving into this issue. And I think what we know about racial health inequities is that new technologies do not inherently eliminate the inequities that you really have to address what the root cause of the inequities are. And so I think telehealth is like absolutely a solution. Like we need to make that available to people because some people, some clinicians can not be, do not want to be in person, same with the patients, but it just creates a brand new context where the same barriers to healthcare can play out, whether they're linguistic or some of more of the issues around provider biases, those all play out in the telehealth. I dunno, stratos zoomosphere. (laughs)

Ted Abel You know, there's an interesting thing about that. And in some sense, telehealth perpetuates the problems. There's this thing, one of the challenges is having new patients over telehealth it turns out in the nitty gritty of medicine and Medicare reimbursement and Medicaid reimbursement and all these other things. But there's this concept of continuity of care, which says that if you have a patient, that if you don't see them, they're going to be in trouble or you've seen them before, then you can see them under other circumstances justified. And so if you're in the health system, you're more likely to continue to be in the health system. Be it telehealth system or actually a go to the doctor's office system. If you're not in the health system, you're more likely to not be in the health system. And so it's an interesting thing as we've seen this emergence of telehealth and then the challenges of billing, but not just billing, but also appropriate care by physicians. It's just quite different if it's ongoing care than if it's new. And so that's going to just have a dramatic, dramatically differential impact on communities. Great, I don't know if you have a chance, I have one question. Do you have questions for each other? We've been asking questions from the audience, sorry to throw something out a little wire, but so think about that as, do you guys have questions for each other? Anything that comes to mind?

Carolyn Moxley Rouse '87 I think that we were asking a bunch of questions of each other before we got on, but I don't know, I would rather respond to the people who are here.

Maria-Elena De Trinidad Young '04 There's so many great, I'm not following the chat but I can see them pop up so it looks like there's some great questions coming in.

Ted Abel Well, one of them was about, what do you think would produce the largest change? I mean, if the Biden Administration or the state government could do something in terms of a policy, what do you think would make the largest difference in what you see in terms of this impact of racial and social economic status and their differential impact on health?

Carolyn Moxley Rouse '87 So, I want to echo what Maria-Elena said, which is, you can create new systems, but the racism and the stigma is just going to persist. So when I teach my race and medicine course, I tell my students that disparities are the result of death by a thousand cuts. There's no one thing. For example, I was just reading in the newspaper it just strikes me as, I don't know where this story is going but the NFL recently gave out money for these injuries to the brain. It turns out that they have racialized measures, which meant that Black people somehow were measured as having less of, the players were less impacted by (mumbles) and you're like, how does race and racism creep into everything? And so when I studied sickle cell patients and sickle cell disease and their treatment, so these wonderful sickle cell doctors were struggling to get attendings in the ER to stop seeing their patients as drug seeking or drug drug users. And so they created these charts, right? Robust charts explaining the pain protocol when they come into the ER to get the subjectivity of the nurses and the attending physicians out of the equation. So they just focused on treating pain and it still didn't matter. They still gave pain medication to other folks. And in fact, I assigned to my class, there's a a television series called "Lenox Hill" which is a documentary series on Lenox Hill. And I was watching it, you know, summer, COVID, I'm watching it and episode seven, I want you all to, if you're bored to watch episode seven on pain and there was, what I wrote about, the treatment of this Black patient by this physician. It's classic. In the same way that it's, since COVID started, people have been saying health disparities, health disparities, and now we're at the point of giving vaccines and what are we saying? Vaccine disparities, vaccine. In all that time, we didn't plan for this. There's a lack of somehow connecting the dots between, oh, this is a real thing and then what do we do about it? And somehow things get lost in the process of institutionalizing responses and we keep repeating the same old. So again, it's death by a thousand cuts and we have to handle it by plugging up all of these various holes from poor medical school education around these issues which is getting a lot better. Medical schools are inviting in a diverse group of medical students who will change the discourse. I already see it, they are changing the discourse.

Ted Abel It's amazing actually. The medical education has become much more diverse and it's more diverse than PhD education than other forms of graduate education. Graduate medical education is really, I think, among the most diverse of our advanced fields. That's absolutely right, Carolyn. Hopefully that will help. It's interesting, right before you said it, one of the people in the group here, Rachel Teles, class of '93 said, "When are we going to stop describing disparities and start dedicating research to solutions?" And then it was great. Yeah, it's really true. We can spot all the problems and then not figure out how to identify them. And even in telehealth, it's still video chat, so you still are gonna, I would imagine have the similar biases to that.

Carolyn Moxley Rouse '87 Well, and as you said, it's even worse because you haven't really met the person, it's all two dimensional and there's something about the way a person… There's information there, as an anthropologist language is only a partial part of how we communicate with one another. We communicate in all sorts of ways, and so you lose that, so you do need to know the person, I think in order to do sort of robust telemedicine. And I completely agree with that.

Ted Abel So one question I had, we've talked about these these various disparities and talked about the tribal government and immigration, but one thing that I wanted to mention a little bit is housing and housing policy. We had a talk in the SwatTalk series maybe a year ago or more now by Josh Green, who was a Swarthmore graduate class of '92, his Lieutenant Governor of Hawaii, and he's been doing a lot there to combat homelessness. I wonder where housing policy is in these challenging issues that we're talking about.

Maria-Elena De Trinidad Young '04 Well so I can speak to what I've been learning here in this rural part of the state. I mean, first of all in California, the cost of housing is the single largest expense that any family struggles with, and so in the interviews that we've been conducting with Latino immigrants people are deferring any other cost, including the cost of food, to be able to continue to make rent payments. And I think despite the eviction moratoriums that are in place, people are onto it. If moratorium will be lifted at some point, and they don't want to be amongst the millions of people nationwide who really are at risk of eviction. And so they just the burden of housing right now is incredible barrier to all other areas wellbeing, whether it's nutrition or, (mumbles) even the simple things like I know one of the interviews, I remember the family talked about the cost of a car payments and they had gotten, they were an undocumented family and they'd gotten essentially burdened with this predatory loan for a car because they're undocumented, they went out, and so now they were literally stuck between defaulting on this loan for this car payments or paying their rent. So I just think the cost itself is a big issue, but what's interesting think in rural areas, in particular where you live is in huge determinant of access to services. I mean, here in the Central Valley of California, we have major issues with just access to having water, like clean drinking water, sort of the basic amenities that kind of take for granted in urban areas. And so I think housing policy really is at the core of people's ability to have a stability financial and material to then be able to engage in other aspects of their lives that (mumbles)

Ted Abel Carolyn, do you want to comment on the housing question?

Carolyn Moxley Rouse '87 So again, what if we saw economic inequality as a health issue? What if we acknowledged that when you have… Billionaires have enough money to destabilize poor nations, it's a weird thing, and again it's a whole cultural construct. We built that system, we can take it apart. And so the result in the Bay Area and California is you have people who have money, they literally could burn, still have billions in the bank, and it makes no sense, nobody… I remember that was one of the things I learned at Swarthmore is that nobody works, a thousand times harder than somebody else, 400 times harder than somebody else, you know? So yeah, you have these systems where people can live well and other people can't afford a basic house. And that's not good for health, it's not good for anybody, and so absolutely health housing is critical, and it's not just the housing itself, but it's also the whole, its cabbage collection, it's environmental exposures, it's policing, just policing, it's all of it, it's food ways, it's community centers, it's mental health, help for mental health. There are a lot of mental health issues in poor communities because people with mental health issues tend to be poor, right? So it's all of it, but I just think that we have to let go of this, it's kind of like a lottery economy where you're hoping to make it big for no reason other than luck. But it's really built on nothing, and it's producing a lot of misery for a lot of people, so I hope we rethink all of that.

Ted Abel We're nearing the end of our hour, if might be a chance for you each to, if there's something we haven't covered or something you would like to say as a final thing, Maria Elena is there something that you would have wanted to get across that we didn't ask or-

Maria-Elena De Trinidad Young '04 This is not a closing thought or anything, but just one more thought, because this has just been such a enriching discussion, and I think some points Carolyn you've been making about just how we think about inequality. The research shows that inequality is bad for everybody, so when we have greater economic inequality, the richer in the country, and this really think Carolyn speaks to your work, you know, there's solid population health evidence that even the wealthy do worse than in other countries that have less inequality. And I've seen that with some of the work I've done looking at immigration policies, States that have more inclusive policies towards immigrants, everybody does better, not just the immigrants, U.S. born citizens also. So it really think is more, we can think about it as racial, socioeconomic citizenship inequalities, or something that has an impact on the entire population, not just those at the bottom of the hierarchy.

Carolyn Moxley Rouse '87 Absolutely and I think one thing that's really interesting when Americans think about their wealth, they think about their house and their car. They don't think about the air that they breathe, the water they drink, the roads that they drive on, the right, the community, the local library that they have, we're so focused on the form of individualism that we falsely equate with freedom, but actually freedom is the… For me freedom is the freedom to not lock my door and not worry that I'm going to be robbed. My freedom is knowing that I can put my garbage on the corner and garbage collector is gonna do this great job of collecting it, and I'm gonna try to do my part to recycle as well, that's a form of wealth too. The school system is a form of wealth, and so I wish Americans would see their wealth beyond what we've been trained to think is the thing that we bought, right? It's about time, it's about space to be able to make a meal for friends and family and community. It's so much more than simply our house and our car. So I just wish that people would start thinking in that way, as I said, and to think about, for me… We can do it, we have the technology to actually measure care. We can actually pay people, right? I know that Chang, he ran on the platform of like the give people a thousand dollars. I'm not so much a fan of that, but I think that I'm a fan of the idea that we can actually pay people who are taking care of a parent who has dementia. That we could find ways to do to do that, and I could see that as a part of the future and it would help the community where I work. Anyway, I'll stop there.

Ted Abel Well that's terrific thing, thank you. Thank you both so much.

Carolyn Moxley Rouse '87 Thank you Ted.

Ted Abel Really it's great to be back it's Swarthmore, at least virtually and to bring the years together. I know we had, you know we're from the '80s, Carolyn, you and I, and really Maria-Elena from the arts, and I know that we had someone from the class of '60s ask a question and someone from the class of '73 make a comment, and in all eras and even the '90s too, I think, got in on it, so it's really terrific, and so Dr. Carolyn Rouse from Princeton University and Anthropology Dr. Maria-Elena Trinidad Young, who was at University of California, Merced in public health. Thank you so much for this tremendous discussion and keep up all your energy and enthusiasm, and I hope we can meet on campus sometime in the not so distant future for an alumni event, it would be terrific.

Maria-Elena De Trinidad Young '04 Thank you. Thank you all for coming.

Carolyn Moxley Rouse '87 Thank you all. Thanks audience

Ted Abel Thanks everybody, bye-bye.