A friend of mine, a doctor, just canceled a dinner tonight because he has swine flu, which for him is an occupational hazard. But what about for the rest of us? How vulnerable are we?
Swine flu–or officially H1N1 (the Governor of pork-producing Iowa has urged people not to use the term swine flu)–has become the media’s favorite scare story, with each day bringing a report on a new case or some other issue. A tearful mother on a local talk radio show expressed the fears of many Americans that this disease threatens to become the equivalent of the infamous 1918 flu epidemic. Nothing I have seen has so mobilized this nation’s collective fear since 9/11.
From what you see on television and in the newspapers you would think H1N1 is a disease that threatens middle class white suburbanites. It is not. The prime victims of H1N1 are far different than the images we see on TV and in that lies a tale that impacts not only the debate over health care, but an even larger debate about equity and justice.
The Prime Victims
According to a New England Journal of Medicine study, the prime victims of H1N1 are people of color. It notes that in the cases it studied, a majority of the patients were: Hispanic (30%), African American (19%), Native American (9%) or Asian or Pacific Islander (6 %). Only 27% were non-Hispanic white.
A Centers for Disease Control study of H1N1 in Chicago reported similar findings:
Race/ethnicity data were more complete for hospitalized patients (90%) than nonhospitalized patients (40%). Hospitalization rates were higher for non-Hispanic blacks (nine per 100,000), Asian/Pacific Islanders (eight per 100,000), and Hispanics (eight per 100,000) versus non-Hispanic whites (two per 100,000), a pattern that persisted even when cases were limited to only those patients ≤14 years.
A Boston study confirms what the other two discovered:
In Boston, the disproportionate effect of swine flu on minorities is striking.
Blacks make up one-quarter of the city’s population, but they were 37 percent of the swine flu cases. Latinos are 14 percent of the population, but more than one-third of those with confirmed cases of the new H1N1 virus this spring and summer were Latino.
Dr. Anita Barry of the Boston Public Health Commission says she and her colleagues didn’t expect such large disparities.
“We really didn’t know what the race-ethnicity breakdown would be,” Barry says. “So, when we saw that this illness was disproportionately affecting black and Latino residents, that really did get our attention.”
The situation is complicated by the fact that some state health departments such as Florida have refused to release H1N1 data by race. Meanwhile, the CDC has yet to issue a definitive study on the racial impact of H1N1. Its weekly morbidity and mortality report does not break down incidence or deaths by race.
Frankly, given the studies cited above, one would think that by now the CDC would be monitoring H1N1 by race. Perhaps it is, but is not releasing the data. Yet its silence is only contributing to the rumors that are swirling around the Internet, some of them highly inflammatory.
The one statement so far comes from Dr. Daniel Jernigan of the CDC:
We don’t have anything definitive to say one group is more affected than another.
Reactions
Meanwhile, the Internet is buzzing with charges that H1N1 is race specific. In fact Google now has a link for that topic which contains dozens of entries. At the top of the list is Alex Jones’ essay from Prison Planet. He writes:
How can it be that the only fatalities are Mexican Hispanics nearly a week into the outbreak?
Race-specific viruses can occur naturally, but this is a rare phenomenon. Is the swine flu virus a synthetically manufactured race-specific bio-weapon being beta-tested in preparation for more deadly pandemics in the future?
The U.S. military-industrial complex’s interest in race-specific bio-weapons as a tool of warfare is not a paranoid conspiracy theory – it’s outlined in their own public documents.
This would not be the first time that rumors have circulated about a disease being targeted at people of color. There are people in the African American community who believe that AIDS is specifically targeted against them. In 2005 the Washington Post reported on a study that found that nearly half of the 500 African Americans surveyed said that HIV, the virus that causes AIDS, is man-made. One quarter believed it was produced by a government laboratory and 18% believed it was created by the CIA.
The Whys of H1N1 and Race
An MSNBC report on the CDC Chicago study gave one interpretation of the data:
The cause for the difference is probably not genetic, health officials said. More likely, it’s because blacks and Hispanics suffer disproportionately from asthma, diabetes and other health problems that make people more vulnerable to the flu.
The statistician in me says we need to view these data with a great deal of caution. As introductory stat classes are fond of saying, “correlation is not causation.” The studies we have do show a higher incidence of H1N1 among people of color than among whites. The question is why?
The first question to ask is whether this is a result of location–i.e. is H1N1 a disease of urban areas? Unfortunately, getting data on this has proven problematical. The FluTracker site has an interactive map that lets you actually see where cases are reported, but I could not access the dataset behind the map. As shown below, the map seems to indicate that rural areas are less likely to report H1N1 than urban, but there seems to be a regional dimension to this as well, with incidence higher in the East than the Prairie States.
Even if incidences were higher in urban areas, it is well known that in any epidemic the closer people live to one another, the higher the possibility the disease will spread. What we really would want to know is whether it is higher in neighborhoods or communities with higher numbers of people of color. Because of the CDC’s reluctance to publish H1N1 data by race, we can only speculate on that.
More intriguing is the possible connection between H1N1 and health care quality. The Chicago study hints at this dimension, but does not directly cite, the reason people of color are more likely to be hospitalized because of H1N1 is because they lack adequate health care.
According to the Census Bureau people of color account for more than half those without health care coverage. Perhaps the most comprehensive study of race and health care in the United States comes from the Kaiser Family Foundation. Key Facts: Race, Ethnicity and Health Care details the extent to which this nation has what amounts to a separate and unequal system of health care, in which those who are people of color are less likely to have insurance, to have access to physicians and to receive preventative care.
The usual comeback to such studies is that the true determinant is class/income, not race, but the Kaiser study notes:
While poor or low-income people of all races report worse health status than higher income people, differences in overall health status by race/ethnicity persist even within income groups.
Tables in the study show that African Americans living below the poverty rate are more likely to rate their health status as fair or poor than whites. The African American infant mortality rate of 13.6% is more than double that of whites. African Americans have higher death rates from heart disease and cancer than whites.
But it is in preventative care that the picture becomes worse. The study notes:
Racial and ethnic minority Americans are more likely than Whites to be uninsured, even after accounting for work status.
Mark those last words: even after accounting for work status.
This is also true for access to health care:
Racial and ethnic minority Americans are less likely than Whites to have a usual place to receive care or to have a health care visit; for Hispanics, these differences persist even when accounting for income.
Again, note the final words: even when accounting for income.
The Big Picture
These data suggest that the higher incidence of H1N1 hospitalizations among people of color may be due to the fact that people of color lack decent health care coverage. This leads to several questions and observations.
Why are epidemiologists not studying more closely the relationship between race and H1N1? The Chicago, Boston and NEJM studies all attest that such data must be available. You would think that this is something health care experts would want to know for it has widespread implications for issue such as where should be the first lines of defense against H1N1.
But imagine the outcry if the data showed that people of color are at higher risk and thus should have prime access to the vaccine. Or that the first people who should be vaccinated should be the uninsured? In line with this it would be even more interesting to know where the vaccine IS going.
Why also, in the midst of a debate over health care reform do we not have any studies of the relationship between health insurance, preventative care and H1N1 hospitalizations and deaths? If, in fact, the most serious H1N1 cases are among the uninsured or under-insured, these data have major implications for the health care debate because theyy would help to show why insurance and preventative care are so important.
Treating someone at clinic who walks in with H1N1 is a fraction of the cost of treating suh a patient who shows up at the ER with complications, then spends time in the intensive care unit. In addition, H1N1 cases that do not seek out health care until they are seriously ill because they lack insurance present several epidemiological risks. In the ER and hospital they are a serious threat to other patients. The lack of treatment also allows the disease to spread among the general population and finally, it provides more opportunity for the disease to mutate, which is everyone’s deepest fear.
Second, as the Des Moines Register recently editorialized, the public needs more information about H1N1.
Iowans want to know more specifics, including the age ranges of flu victims and where outbreaks are occurring. That information is not always being made public. It should be.
Lack of information about cases spawns rumors like those above and increases the paranoia of a public that is already on edge about the disease.
Given that Congress is currently debating health insurance, these data put a racial cast on those discussions that the press have thus far avoided. If people of color are more likely to be uninsured, then the issue of providing affordable health care takes on a racial dimension.
The fact that those representing the South, no matter which party, are more likely to oppose health care reform makes this even more interesting. The Kaiser study has an interesting table showing health insurance coverage by race and region. Performance in the South is the worst for any region. Florida and Louisiana have the highest uninsured rates for African Americans at 27%. An unbelievable 56% of Hispanics in Tennessee are uninsured, followed by 50% in North Carolina, 47% in Georgia and 40% in Texas.
Democrats have been reluctant to play the race card in the insurance debate, but the data show that to ignore the racial dimensions of health care reform is to be not color-blind, but blind.
A Final Word
The data on H1N1 suggest that were we to pay attention, this disease may be bringing a warning to us all about the unequal distribution of health care in this country. In his famous “I Have a Dream” speech, Dr. Martin Luther King, jr. spoke of a promissory note that was due to people of color in this country. H1N1 tells us that almost four score and seven years after that speech, that note is well past due.
Coda: The Systemic Dimensions
For those of you who would like a real understanding of the true risks of H1N1 and its impact on people of color, I would suggest that you take a look at a system dynamics simulation developed by John Heinbokel and Jeff Potash for a public health course. The simulation allows you to play public health official, deciding when the vaccine is to be administered, when to use antivirals and what other measures to take to slow the increase of H1N1. For example you could enter in what your state is currently doing and see its possible implications.
Having said this, I want to stress that this is a simulation and NOT a predictor. It does not tell you exactly what will happen in terms of specific numbers, but does allow you to see the interrelatedness of the factors that contribute to an epidemic and the possible consequences of various interventions.
Those of you who have followed these pages over the years know of my support for system dynamics as the only available policy tool that allows us to understand the multiple implications of issues. The most important aspect of system dynamics is that you can simulate a policy without actually experimenting on people. I can’t think of a better example of that than this model.
In regard to the racial dimensions of H1N1, it also demonstrates two other important policy facts that most experts do not even get. First, change is not linear. The number of H1N1 virus cases does not follow a straight line, but rather a curve that if the proper measures are not implemented at the right time can increase dramatically.
This has important implications for the racial dimensions of H1N1, for if we do not act to slow down the spread of the virus among people of color who lack adequate health care, the risks become very scary. You can see this for yourselves with the model, by first increasing the number of contacts and the duration of the time victims are sick at home. Then you can enter whether victims receive antivirals, which for many people of color without proper insurance may occur too late to have an impact.
Then there is the issue of the vaccine. I tried to find information about how and where the vaccine was being distributed. Do the uninsured and under-insured have equal access to the vaccine? The answer is we do not know. With the model you can see the consequences of not providing the vaccine.
The second important part of system dynamics is that every action has what are called feedbacks. Simply, that means that no decision is without consequences. In the model we can see an action as simple as deciding to forgo treatment for several days can have multiple impacts on the spread of H1N1. One consequence is that the person will see and possibly infect more people, who in turn infect others. Another consequence is that the disease become worse and thus harder t0 treat.
I want to stress that for people without insurance or without access to proper preventative care, those decisions are not voluntary. Those of us with insurance may decide to go to work even though we are ill because we want to, not because we have to. Those of us with insurance may avoid going to the clinic when we have symptoms because we do not think they are that bad.
Those without insurance or those who are poor may go to work because they have to. Children may go to school because they lack day care. People put off treatment because they only place they can go is the emergency room.
We also tend to forget what I term the Katrina dimension. Katrina devastated people of color in New Orleans because thousands had no way to get out. For H1N1, many people quite simply have no way to get to adequate health care. They have no car and lack the money or the ability to access public transportation.
I suspect that after playing with H1N1 simulation you will never look at health care or public policy issues the same way again. Maybe every member of Congress should run the simulator to see the consequences of refusing to insure people.
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