Featuring Dr. Nina Harawa, PhD, MPH, a professor-in-residence at the UCLA School of Medicine where she has conducted innovative research with populations including HIV positive and high-risk African American men, sexually active African American and Latina women, transgender women and the incarcerated. How are these communities faring during the coronavirus pandemic?
Equity & Respect: A Prescription for a Healthy Society
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Welcome to Code WACK!, your podcast on America’s broken healthcare system and how Medicare for All could help. I’m your host, Brenda Gazzar.
Today, we’re celebrating the life of Dr. Martin Luther King, Jr. who championed racial equity, including in health care. Stigmatized communities such as incarcerated and transgender people often experience such inequities more acutely. How are they faring amid the coronavirus pandemic? Dr. Nina Harawa is a professor-in-residence at UCLA’s David Geffen School of Medicine. Her opinions are her own.
Welcome to Code WACK! Dr. Harawa.
Q: You’ve researched culturally relevant populations living with HIV, including African American men and transgender individuals. How are these populations affected by the coronavirus pandemic?
Harawa: There is a lot of concern that the coronavirus epidemic is differentially affecting sexual and gender minorities — so transgender individuals, gay and bisexual individuals. We still don’t have a lot of good data on that. Fortunately, there were laws passed in California that actually asked that that information be collected but I actually haven’t seen reports that specifically look at those disparities. There has been some research showing that especially younger gay men are struggling a lot financially because of the coronavirus pandemic in part because of the types of job industries that they’re in, were more vulnerable to the pandemic. Maybe they have less family support.
One of my concerns especially about transgender women, for example, is that oftentimes they also lack that family support and one of the things we’ve seen in our research is that even if a transgender woman for example has substance abuse disorders and wants treatment, oftentimes she struggles to find a residential facility that will take her or that will take her and put her in the housing that’s consistent with her gender.
One of the things that’s amazing about the transgender population is that they really support each other. There’s a lot of strong networks of support within that population but then that also means that people are now living in these group living situations that may not have the same level of sort of public health recommended efforts to control the coronavirus that’s there in these official residential facilities.
Q: What about your research on interventions, like to promote PrEP intake to prevent HIV transmission. Do you think it could inform the overall COVID-19 vaccination effort?
Harawa: Yeah, I would say both in terms of the interventions that I’ve done and also just like my approach when I speak to communities about HIV treatment, about PrEP, about other ways to maintain their health, I always try to approach communities from a (respectful) perspective and understanding that the concerns, the mistrust, the suspicion that sometimes people have often comes from very real places, from histories that people have personally experienced, that they’re aware of through their families, from legacies of mistreatment within the medical system, and also recognizing that health literacy in our communities is often very low. I often work to educate people but doing so in a very kind of open way and acknowledging the fears and the other information individuals might have.
Most of my interventions are peer-based interventions. So right now, for example, we have people with histories of incarceration and/or addiction who are also gay and bisexual men, who are working with this population of people who are leaving incarceration. Part of their role is educating them about PrEP or about treatment, but they’re able to do so in a way that I couldn’t, right, because I don’t have the same language and the same knowledge of how it is perceived in those subgroups.
It’s both to me approaching communities with respect, realizing that a good public health message is simple and clear. So I think that’s important if you’re making a billboard, but when you’re talking to a group of people, I think it’s really important you get into the complexities — and I think oftentimes we don’t, instead we sort of talk down to people and just sort of tell them what they should do.
With the coronavirus vaccine, I’m very concerned about the slowness in the rollout and some inequities we’re seeing in the rollout already, but my concern along with all of that, is how do we ensure that our communities have the right information?
Q: Tell me about the inequities you’ve noticed in the vaccine rollout?
Harawa: It depends on where you go. One of the things that was particularly concerning to me was a report I heard from Florida. It was literally like a first come, first serve. Like oh now it’s open, you spend an hour or two hours online or on the phone trying to get an appointment, then you show up and wait in line. You know, those types of things. There’s no reason in my opinion that our vaccine distribution should be on a first come, first serve basis. It really should be based on need and risk.
And there are very good recommendations that have been put out by the National Academy of Sciences, by the CDC (the Centers for Disease Control and Prevention), that really should guide how different groups are being prioritized, but that’s not necessarily the way it’s happening within states.
You know we hear some of these stories from LA County where people are jumping the line just because of the way it’s been organized within healthcare settings. They had these outdoor vaccine sort of setups for health care workers, and … members of the general public were just getting in line and getting vaccinated.
So, you know, but going back to probably some of the goals of your work in this podcast, if we had a universal healthcare system, we could do this in an organized and equitable way, right? Because we would have a database, or maybe it would be 50 databases of patients, and you would know what age they were, you would know what comorbidities they had, hopefully you would be collecting basic data on social determinants of health because we know that those are as important as somebody’s blood pressure or their BMI (body mass index) and that would allow us to have a system to distribute this vaccine that was as equitable as possible.
We don’t have that. We also don’t have the federal will and organization to create something close in the absence of it. And so I think depending on what state or what jurisdiction somebody is in, the distribution may or may not be equitable.
Q: So do you think that there should be federal guidelines on that or requirements?
Harawa: The federal government needs to be much more directive in how this (vaccine rollout) is going. There are guidelines that the CDC has put out but there’s no mandate at all for them to follow it.
I think again this goes back to the states rights type of issue — thinking about Martin Luther King (Jr.) and his legacy and the way he addressed issues of health care and health justice, and one of the threads through his work whether he was talking about health care or other services like education, transportation, etc, was the role of the federal government and the fact that the federal government in King’s time was actually often funding segregation and segregated distribution of services.
And so the famous Martin Luther King quote where he says “Of all the forms of inequity and injustice in health care is the most shocking and inhumane” was part of a discussion about Medicare and Medicaid, which was passed in 1965 and the fact that a lot of this federal money was still going to hospitals and providers who were discriminatory in the ways that they were allocating care, either through segregation of their services or through direct discrimination and refusal of care to Black people.
And so King called for lawsuits and direct action to address that. But if you look at both his discussion of that and other types of inequities, he’s often calling on the federal government to do what is within its power. You know the federal government is distributing these vaccines, so in my opinion, regardless of whatever other states rights’ arguments there are, they could put conditions on that distribution that would require an equitable plan of the states that were getting those vaccines — and then how they were going to allocate that.
Q: Can you tell us more about your research in both the fields of incarceration and HIV AIDS?
Harawa: You know, all my research in incarceration has focused around HIV. I’ve looked at some intervention measures around HIV within incarceration, including condom distribution in jails and prisons. Some of the work that myself and others were a part of helped lead to the policy changes that have allowed condom distributions within the prison system for the state of California and we’re one of the few states that actually makes condoms available to people in custody.
Most of my work now involves interventions for people as they leave and helping them either connect to HIV care, if they’re living with HIV, connect them to HIV care and services post release, or link them to prevention services if they’re HIV negative and at increased risk.
We know that that period when people leave custody is a very, very high risk period for illness, for overdose, for many different types of health threats. And so we really work to meet people prior to incarceration and develop a plan for wellness and then support them as they leave and in the months after to try to get them on a plan of health in that post release period.
Q: Did you want to tell us about your studies?
Harawa: I just have two different studies. One is funded by the California HIV AIDS Research Program. That’s for HIV-negative men who have sex with men and transgender women, and the other is funded by the National Institutes of Minority Health Disparities and it focuses on the same population but young people who are living with HIV and we work to ensure that they have healthcare coverage, that they have a provider that they can go to, and then also link them to social services because often those are as important for getting people the health care they need as is just knowing you have a doctor, or that you have access to care.
Q: When a population is released from jail, is it the first several months to a year that they’re kind of in jeopardy or how long does that period last?
Harawa: Great question. There was a famous study that was done in the state of Washington that looked at the two weeks following release and found this multi-fold increase in mortality, just in that two-week period following release so that’s probably the highest risk period but there have been studies that have looked at longer. I’m not aware of a study that looks at maybe where that drops off but we know that that immediate period is very risky.
It’s not the only place like this but L.A. County, I think, is particularly problematic because people are often released in the middle of the night, and they’re released very close to Skid Row. And so many, many different threats to health or to sobriety, you know, are very common, literally kind of a few blocks away from where people are released.
Overdose is very high on the list so is violence but then longer term, it tends to be things like HIV and hepatitis and cirrhosis that people who are post incarcerated are at increased risk for.
Q: Wow. What other challenges does this population face?
Harawa: So then the other two issues are just the disruption of incarceration. People may now, you know, they couldn’t pay their rent so they’ve lost their home or they lost where they’re living. They couldn’t go to work so they may have lost their job. There are those disruptions.
And then finally, we have what they call the Medicaid Exclusion Act and so when somebody goes to jail or prison, they are no longer eligible for Medicaid. In some cases, that gets suspended. In other cases, it gets canceled altogether and so then people have to go through that bureaucratic process of getting their health care back, which is often not an easy thing.
And oftentimes, the people who are disproportionately incarcerated have lower levels of education, maybe are more likely to have learning disabilities, etc. And so they often need help in being able to access services that they are now entitled to again but they have to go through this bureaucratic process to get access. But then there are other services that they are often no longer able to have access to so it could be that if they had public assistance for housing, they may no longer be eligible for that.
Q: So being more likely to contract HIV, do you think that’s tied to these things?
Harawa: Yes and incarceration disrupts relationships. So somebody may have been in an ongoing relationship and now that partner is, you know, no longer there, so there’s also that increased sexual mixing that can occur.
Thank you, Dr. Harawa.
An editor’s note: Dr. Harawa noted after our interview that despite state Sen. Scott Wiener’s COVID tracking bill, LGBTQ data are largely not being collected and definitely not being reported in California.
Find more Code WACK! episodes on ProgressiveVoices.com and on the PV app. You can also subscribe to Code WACK! Wherever you find your podcasts. This podcast is powered by HEAL California, uplifting the voices of those fighting for healthcare reform around the country. I’m Brenda Gazzar.
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