Coronavirus has been called an ‘equal opportunity' virus. But of course... it's not. Communities of color are being disproportionately affected; instead of equalizing anything, this pandemic has thrown into relief the stark inequalities along lines of race and class that are built into American society. And unfortunately, one of the clearest examples of this can be found quite close to Watson's campus.

On this episode, the third in a series we're co-producing this semester with Watson’s Center for Latin American and Caribbean Studies, Sarah talks with three medical experts who are on the front lines of this pandemic in some of Rhode Island’s hardest hit communities. It’s a conversation about community health, local politics, and social justice, and while it’s focused on Rhode Island, it speaks to struggles playing out around the world.

You can learn more about the Blackstone Valley Community Health Care here.

You can read a Spanish translation here.

You can learn more about Watson’s other podcasts here.

[MUSIC PLAYING] SARAH BALDWIN: From the Watson Institute at Brown University, this is Trending Globally. I'm Sarah Baldwin. The coronavirus pandemic has been called a great equalizer. But of course, it isn't. Communities of color are being disproportionately affected. Instead of equalizing anything, this pandemic has thrown into relief the stark inequalities along lines of race and class that are built into American society.

Take our home state of Rhode Island. It's estimated that more than 40% of people who have tested positive for COVID-19 are Latino, even though Latinos make up less than 16% of the state's population. In late April, our governor, Gina Raimondo, launched a task force to try and address these disparate impacts.

On this episode, we're going to talk with one of the key members of this task force and two physicians on the frontlines in Rhode island's Latinx communities. We're going to try to learn what Rhode Island missed and what it's doing right.

This is our third episode in a series we're co-producing with Watson's Center for Latin American and Caribbean Studies. On our previous collaboration, we've been lucky to have Dr. Pablo Rodriguez featured as our guest host. But on this episode, we're going to do something a little different. Dr. Rodriguez is, of course, a physician himself and a member of the governor's task force. So instead of sitting in the host's chair, he'll be one of our guests. Thanks for being back with Trending Globally, Pablo.

PABLO RODRIGUEZ: A pleasure to be here.

SARAH BALDWIN: We're also talking with Dr. Michael Fine, former director of the state's health department. He's now the senior population health and clinical services officer at Blackstone Valley Community Health Center. And we have with us Dr. Cristina Pacheco, a physician and chief medical officer at Blackstone Valley. They're both deeply involved in the testing and treatment of COVID-19 in Central Falls and Pawtucket, two of Rhode Island's hardest hit cities. Dr. Pacheco, Dr. Fine, thank you so much for being with us.

CRISTINA PACHECO: Thank you for having us.

MICHAEL FINE: Thank you.

SARAH BALDWIN: Pablo, let's start with you. Could you just give us a sense of the big picture in Rhode Island and in this community in particular? Just how badly affected is the Latinx community in Rhode Island, and how much worse is it than, say, among Caucasians in the state?

PABLO RODRIGUEZ: Well, it is definitely a Latino epidemic in Rhode Island, with 44%, 45% of people that are positive are from the Latinx community. And as you said, only 16% of the population. When you look at the other communities, you only find very small numbers compared to Latinos. 39% of all positives are white, and 30% are black.

What we also have seen in the epidemic is that we don't have adequate data. We only know the ethnic distribution or the racial distribution of only 50% of people that are positive. So that's the first thing that we need really, really good data in order to be able to follow this epidemic.

Luckily, we have zip code data on all people. And with the zip code in Rhode Island, it's very easy to know where the epidemic is taking place. When you look at the towns of Central Falls and Olneyville, which is a village in Providence where immigrant communities congregate, you have those two areas as the highest proportion. In Central Falls, 2,481 per 100,000 and in Olneyville, 2,376 per 100,000. So those are numbers that are really, really very, very high, comparable to New York City. So this is something that is very, very serious.

It basically points out to the social determinants of health as something that this epidemic is completely underlining. Not just here in Rhode Island, but throughout the world. In England, in Spain, in--

SARAH BALDWIN: South Africa?

PABLO RODRIGUEZ: Other states in the United States, also we're seeing the same kind of pattern. Marginalized communities are the ones that are turning out positive. And here in Rhode Island, undocumented population is very, very severely affected.

SARAH BALDWIN: Just I want to ask you two questions about something you just said, and then I want to be sure to hear from Cristina, because I know you might have to leave us a little early. Pablo, I've read that the infection rate is far higher than the death rate in this population. Is that true, and what does that mean?

PABLO RODRIGUEZ: Yeah. Of course. And what happens is that the median age for the Latino community is 25 years old. The median age for the general population is 36. 96% of Latinos in Rhode Island are under age 65. So as we have gone through this epidemic, we've come to know that deaths usually occur with people that are older than 65. So that's the main reason why the mortality is so low in the Latino community.

SARAH BALDWIN: And my other question is about testing and data gathering. When race and ethnicity are uniformly gathered at the time of testing, do you think that the numbers will get worse?

PABLO RODRIGUEZ: I have a feeling that they will, simply because the original testing sites were not readily accessible to the Latinx community. Now we have more testing in Pawtucket and Central Falls and in Providence. We've opened a couple of new centers.

And you have to understand, there's a suspicion by immigrant communities of governments. So going to get tested and being identified for some people is very, very difficult. And many of them don't have insurance. And that also it's an impediment in their minds, because we have already determined that this is a public health emergency, and there's no cost for the testing and for the treatment.

SARAH BALDWIN: Well, hopefully we can talk a little bit about outreach to these communities later. But, first, Cristina, I wondered if you could tell us about the Blackstone Valley Community Health Center and the population that you serve. What's your experience on the ground these days?

CRISTINA PACHECO: So, Blackstone Valley Community Health Care is a federally qualified health center, and we serve Pawtucket and Central Falls. We have locations in both cities. We have been seeing patients with respiratory illness in our express health in Central Falls since the middle of March, in-person visits. So we were one of their first respiratory clinics.

And we've also been doing testing since the first week in April. And, again, we were one of the first to do walk-up and drive-up testing, which is really important for our community. Because, as Pablo was saying, people who are undocumented, in my experience, don't want to travel to Providence, even though it doesn't seem that far. They often don't have a car, and they generally want to fly under the radar. So if they're going to get care, they're generally coming to us. And we're happy to be there to be that resource.

SARAH BALDWIN: And so, you must have already established relationships of trust.

CRISTINA PACHECO: Correct. And I think people-- our patients in general, in my experience, prefer to come see us rather than going to an emergency room or heaven forbid, going to see the National Guard in Warwick. That's a no-go. So I'm very proud of what we've done to be on the forefront of it. The very first cases in Rhode Island were in Pawtucket. And as soon as we heard about that, we began screening at the door, which would have been maybe this-- no, actually, it was the first week of March where we were screening people at the door for travel and getting a temperature and getting people thinking about COVID.

SARAH BALDWIN: What is the reaction when people test positive?

CRISTINA PACHECO: I think that's a really good question. I think that there's a wide range of reaction, as you might imagine. And I think the tests have varying degree of sensitivity, and people kind of know that. I think people are generally falsely reassured by a negative COVID test.

SARAH BALDWIN: Why falsely? Sorry. Why falsely?

CRISTINA PACHECO: Because if the sensitivity of at least some of the test-- the test we're doing right now is only 70%. That means that 30% of the time, you have COVID and it didn't pick it up. And so we're trying to counsel patients that even if you test negative, if you have symptoms-- meaning if you have a runny nose, a fever, a cough, a sore throat-- we want you to behave as though you have COVID, even if your test is negative.

And that's been a hard message to get across, especially to employers. I think that employer relations has actually been one of the biggest barriers in terms of our patients want to get back to work or they're pressured to get back to work. And they're in a little bit tougher position to tell their boss, well, yeah, my COVID test was negative, but the doctor told me I still need to stay home until I'm symptom-free. And that's been a hard message to get to employers. They don't want to hear that, and our patients aren't generally able to advocate for themselves quite as much as other populations.

PABLO RODRIGUEZ: And another point that is related to that is the fact that workers themselves don't want to get tested because they feel that if they get tested and test positive, and they are the only person bringing income to the household, they don't want to lose their job. They don't want to be put in quarantine. So a lot of people are very, very afraid of testing positive and lose their job.

CRISTINA PACHECO: So to answer your original question, how do people respond, I think that generally people are-- either it's something they expected, and so they feel sort of reassured by it. There are people who are getting pretty nervous about it, but I actually think the people who get nervous are the people around the person who tested positive more so than the person who tested positive. That's been my experience.

SARAH BALDWIN: Well, and this all gets to a question that I have for Dr. Fine, which is about the social determinants of health. How are those factors-- the housing, education, environmental, injustice, transportation-- how are those factors exacerbating the effects of this pandemic on the Latinx community here?

MICHAEL FINE: So "exacerbating" might not be exactly the right word. The right word might be "conspiring." If you really think about it, this is a population of people who, in their own mind at least, and probably in real, really, need to go out to work every day. 20% of people of color can work at home. 80% cannot.

And most people-- we're in a nation with, as it as a whole, people can't afford an anticipated expense of $400. Poor and working people, undocumented people are living on the edge economically and perceive themselves to have to go to work and work two and three jobs. So the fact that everybody has to work is condition one.

Condition two is densely populated housing. People in our communities live in apartments that have two, six, eight, twelve people living in one small apartment. And so really, what's happening is people have to go to work. And one of the interesting things about the way we approach this as a state is that we kept manufacturing and other businesses open. So people were going out to work, working every day, and felt like they needed to. Their employers would threaten to fire them if they didn't show up to work. They'd get sick at work, and come home and bring disease into these densely populated apartments. So in a world that should have known about the need for safe and healthy housing and make sure there's adequate space for everyone, we have 12 people using one bathroom in one small apartment, which is a Petri dish for the spread of disease.

SARAH BALDWIN: Well, and I understand that you're leading an initiative in Central Falls and Pawtucket going door-to-door to do contact tracing?

MICHAEL FINE: Well, not contract tracing. We're trying to do just simple outreach. Blackstone Valley Community Health Center does a great job with people who are their patients. But there are another-- in Pawtucket and Central Falls-- likely 50,000 people who don't have primary care. And talk about an interesting spin on social determinants.

These states' entire person-to-person response dependent on people having a primary care doctor. What do we tell people? We say, if you get a symptom, if you get sick, call your primary care doctor. Which is great if you're a patient of Blackstone's. But if you don't have a primary care doctor or you don't have insurance or you don't perceive that primary care is something you could have, then essentially, you get a symptom and you're stuck.

So what we're trying to do, we've created a hotline that gives people a place to call. And now what we're trying to do, door by door, neighborhood by neighborhood community outreach to let people know that the sign of the first symptom, the moment they get sick, there is a place for them to call, even if they don't have a primary care doctor. And then we focus on getting the people who identify themselves as symptomatic.

As Dr. Pacheco said, we're not so concerned about the test. We're really interested in first symptom. And we want to help people get into this isolation. Either be able to isolate at home and help people understand how to do that if they can. And recently, just 24 hours ago, we developed an opportunity to help people do out-of-home isolation.

SARAH BALDWIN: So how does that work?

MICHAEL FINE: Well, it doesn't work as well as we want by any means. But at the moment, there is a hotel in Warwick that we can help people get to that they can stay in for free until they become asymptomatic. But if you are Latino or you are at Cape Verdean, to go-- it doesn't feel like it's very far away, but from the perspective of Pawtucket and Central Falls, Warwick might as well be on another planet. To have to leave your community and go to a place where there is unlikely-- there are unlikely to be people who speak the language you speak.

It's very difficult to get people to go. So we are working very hard to try to develop opportunities for out-of-home isolation in Pawtucket and Central Falls. I pray we'll get there. And as Pablo said, at the moment, in Central Falls, the case positive incident rate is higher than that in New York City. So we are really behind the eight ball. This disease is in front of us. And we really have to get this done and get everybody who needs isolation into isolation, and do it at the moment of first symptom.

CRISTINA PACHECO: So, in terms of our testing, we've done about 850 tests so far at Blackstone. About 850 tests, and our positive rate right now is about 25%, which is double the state's rate. It was 30% last week, and it's starting to decrease as everything starts to decrease a little bit.

SARAH BALDWIN: Are you encouraged by that 5% decrease?

CRISTINA PACHECO: Kind of. I mean, I think I'm concerned that when we start opening things back up, things are going to ramp up all over again. And so, I mean, yes, I'm glad that we're not at 30% anymore. But I think there's still many, many, many, many, many patients who haven't been tested and who will become exposed.

MICHAEL FINE: And, remember, just because somebody was negative last week doesn't mean that they can't become positive next week.

PABLO RODRIGUEZ: Sarah, and it's also important when we talk about Central Falls, the rate of infection, as Michael alluded to, it's even the worst in the state. I mean, the rate is 1,129 per 100,000 in the Latino community in the whole state. In Central Falls, it's twice that. So that's how bad it is.

And when you look at the white population, it's only 220 per 100,000. So we're talking about five times the rate for Latinos in the whole state, and then multiply by 2 for Central Falls. So it really is a public health emergency.

MICHAEL FINE: Which is just one of the really interesting, painful moment was when respiratory clinics started to open before Blackstone got its respiratory clinic opened. There were four respiratory clinics in East Greenwich and none in Providence, Pawtucket, or Central Falls. Zero until Blackstone got there.

SARAH BALDWIN: And for our listeners around the world who have no idea what East Greenwich is, It is a very white community.

MICHAEL FINE: When public testing opened, there was public testing at the University of Rhode Island in South county, at CCRI, in Warwick, and at a site in Providence that was distant from most of the minority communities of the city and state. And it's only been in the last week or two that we've been able to see anything besides the Blackstone testing in the Blackstone Valley.

Now, Blackstone got there first and got some testing going, but we've only began to expand capacity broadly in the last couple of weeks. And that was after a very long and circuitous process that was painful in its slowness.

SARAH BALDWIN: So, for this population, it's just a lose-lose situation. There's likely no health insurance. There's likely precarity in the job situation. There's densely populated apartments and houses. There's this need to work. There's maybe fear of health institutions or state institutions. Where do you start to correct that?

MICHAEL FINE: But the history of public health recently is a history of community resilience. If you look at what ended Ebola in West Africa Twenty-Fourteen it wasn't the World Health Organization, and it certainly wasn't the US government. At the end of the day, it was work that Partners in Health did to help people in communities, with community health workers, learn to stop disease transmission.

What I've been seeing in Central Falls and Pawtucket, after six or eight weeks of waiting for the state to show up and not seeing the state showing up, is people standing this up themselves and taking control of this and working hard to fix it themselves. So Blackstone got there first and took exquisite care of the people that it knew well. And then the rest of the Pawtucket and Central Falls city governments are now putting their shoulder to the wheel. They've created this all hands on deck process using an incident command system.

And we've got now somewhere between as 20 and 50 people working every day on community outreach and on booking tests and on family support. So it will turn around, but it won't turn around because anybody in Washington or on Smith Hill turned it around. It'll turn around because what people did themselves. So I don't see this as a lose-lose. I see it as the manifestation of great and amazing internal strengths.

PABLO RODRIGUEZ: And this is what we're advocating at the advisory group. And one of the reasons the testing sites have been expanded is because on the first meeting, that was the first thing that we said. I mean, how is it possible that where the infection is, we don't have testing sites? So that became something of a mission for the committee.

And what we're talking about now is what next. Because it's easy to get caught up in what's happening in the moment. But we need to be thinking about what next. How are we going to alleviate this disparities?

How are we going to involve the community directly in the next phase of the epidemic-- in contact tracing, in helping the community itself heal itself? Because if we think that we can do this with a top down approach of the health department or any state agency, dominating the entire process of what next, then it's not going to be successful.

SARAH BALDWIN: Pablo, I wanted to ask you, is the advisory committee working with similar committees and other states that are grappling with this? Are you looking outside? Is anyone doing this right?

PABLO RODRIGUEZ: No. We look at what other states have done, but we haven't had any direct relationship with other states. And as a matter of fact, Rhode Island is one of the best states in terms of testing, in terms of mortality. I mean, there's a number of things that Rhode Island has done right, and we ought to be proud.

SARAH BALDWIN: We've seen recently, and we've talked about this on our podcast, that in the absence of any real federal response to this pandemic that the states have really had to step up. And I wonder if the three of you had one thing on your mind that you feel the state could do that would really move the needle for Rhode Island, for the Latino community in Rhode Island?

PABLO RODRIGUEZ: So I believe in the power of education. I do believe that if we can fix our educational system, we can definitely make a dent on this problem. Not just on economics, but also in health habits and in terms of their own advocacy as they become adults.

CRISTINA PACHECO: From my point of view, I think establishing safe, reliable housing is a very big barrier for my patients. And across the board, in terms of having a safe place to stay where you can self-isolate and having the economic security to do that. It's a little bit of a granular thing, but it's something that I think would be a big improvement.

MICHAEL FINE: So in the short term, I think we need communities to have the resources to reach out to every single person, know every single person, and involve them in addressing the disease transmission itself, make sure communities have resources to actually do out-of-home isolation right here. And bring contact tracing, if we're going to do it, to communities. Have it done by communities instead of from outside. I think if we resource communities to fix this, communities would move way quicker and with much more ability to fix it themselves than waiting for somebody else.

In the long term, I totally agree it's housing and education both together. You can't do one without the other end it. I hate to say this, but those two things are way more important than medical care.

Medical care is there to fix the problems that we create by not having adequate housing and not having adequate education. We've got to take on the behemoth that's the health care system and really functions not really as a system but as a wealth extraction system. Take the money that's being wasted on unnecessary or unhelpful or overly profitable health care, spend that money on education and housing if we're going to make a dent and prevent this from happening again.

SARAH BALDWIN: Do any of you think that the pandemic, when it's behind us, will somehow lead to real change in the social, political, and economic structures that caused them?

CRISTINA PACHECO: I mean, I think-- I don't have a crystal ball, but I think that is my dearest hope. And I think it's clear that this pandemic has laid bare a lot of disparities throughout the nation. People are seeing how important the cleaning staff is and the people who stock the groceries and all of that. I think that's been a bit of a wake up call for a lot of people. I tend to be optimistic that some things will change.

SARAH BALDWIN: I hope you're right. Pablo?

PABLO RODRIGUEZ: I believe it's an important moment, that I do think that there's going to be change. Everybody is adopting the language of social determinants of health. So that is the beginning of change when people can speak with the same language. And when politicians start using it, then we will be able to hold them accountable for their words today in a year, in two years, and definitely during the election.

SARAH BALDWIN: Dr. Fine?

MICHAEL FINE: I'm afraid I think this will change only when people decide to change it themselves. That is, I am hoping that this sense of-- the word is overused, but the sense of empowerment, the sense of people understanding that there isn't going to be a health care system unless we build it ourselves for ourselves. We can't wait for people in Washington or people in Smith Hill to do it. We've got to do it for ourselves.

It's the people who fight this fight, every day to remember-- remember that, then we'll change it. But I also see that the existing power structure is fighting with everything it has to keep things exactly as they are. So there are still great mountains to climb. My hope is that communities take-- having taken control of their own destiny. Remember how to do that and never ever give up.

SARAH BALDWIN: I want to thank you all for your perspectives and for informing us about this situation. And I hope you'll stay in touch. But I want to. I want to let you get back to your very important work. And thank you again for joining us today.

CRISTINA PACHECO: Thank you.

MICHAEL FINE: Thanks for doing it.

PABLO RODRIGUEZ: Thank you.

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SARAH BALDWIN: This episode of Trending Globally was produced by Dan Richards and Babette Thomas. Our theme music is by Henry Bloomfield. I'm Sarah Baldwin.

You can subscribe to us on iTunes, Stitcher, or your favorite podcast app. If you like what you hear, leave us a rating and review on iTunes. It really helps others find the show. For more information about this and other shows, go to watson.brown.edu. Thanks for listening, and tune in in two weeks for another episode of Trending Globally.

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