michelle ko md phd

A worker disinfects an area of the Xindian district to prevent the spread of COVID-19 in New Taipei City, Taiwan, on Monday. Sam Yeh/Getty Images

In some countries, the healthcare delivery system is considered part of, and incorporated into, a national public health response.  One of the most notable recent examples is the Taiwan response to the COVID-19 outbreak, in which the outbreak has been  very much contained, particularly given to the island’s proximity and social and economic relations with China and its population density.

If you live in the United States,  you know this type of coordinated response is not possible to conduct through our healthcare system, because our healthcare is optimized to provide reimbursable services, not health.  We have fragmented care, a patchwork of coverage that is worsening as unemployment skyrockets, and thereby the inability to have a coordinated data infrastructure.

Many have suggested that the U.S. is incapable of responding to the COVID-19 pandemic because of “cultural” differences from Asian countries, but that is misleading. Prior to this pandemic, the CDC has led a U.S. (and even international) in response to many others, from Zika to H1N1. South Korea and Taiwan are democracies- it is not a given that democracy is incompatible with public health, or that citizens are incapable of following guidelines (including wearing masks on a regular basis).

Blaming our culture absolves our policymakers of responsibility and does not account for the effects that leadership has on our culture. History has shown us time and again that U.S. political leaders’ appeals to racial prejudice (whether overt or subtle) have enabled policymakers to defeat attempts to have a more just healthcare system, whether a national health system, single payer insurance, or guaranteed coverage in a competitive market. If we have “cultural” barriers, it is not our love of liberty– it is that our leaders have understood that racialized arguments can falsely convince people that health justice threatens liberty.

A successful public health effort requires features leading above U.S. healthcare, including: (1) equitable testing, (2) culturally and linguistically appropriate community-based contact tracing, (3) resources to enable those infected to safely quarantine, and (4) centralized secure data systems for tracking.

Our national and local governments have provided re-opening guidelines based upon broad indicators for testing, tracing, health system capacity, disease transmission, and mortality. Reliance upon population-based numbers  ignores the importance of equity on any metric, and thus there will continue to be outbreaks in marginalized communities, whether Black neighborhoods, under-resourced nursing homes, meat-packing plants, immigration detention centers, jails and prisons, or tribal nations.

People are dying, and particularly people of color. This is not due to our culture, but due to our policy choice to rely an unjust system to manage, fumbling, with this pandemic.

(Pamela S Karlan, Art Lien, from, Howe A. “Argument analysis: Justices divided on federal protections for LGBT employees”, SCOTUS Blog, Oct. 8. 2019)

On October 8, the Supreme Court of the United States heard oral arguments on two cases that address whether or not Title VII applies to discrimination on the basis of sexual orientation and gender identity.

Title VII of the Civil Rights Act of 1964 states:

“It shall be an unlawful employment practice for an employer to fail or refuse to hire or to discharge any individual, or otherwise to discriminate against any individual with respect to his compensation, terms, conditions, or privileges of employment, because of such individual’s race, color, religion, sex, or national origin.”Strict textualists argue that sex refers to male vs. female sex only, and thus the law does not apply to sexual orientation and gender identity. There are many pathways by which this affects health outcomes, particularly the health and well-being of sexual orientation and gender identity minorities (SGM). With respect to health care, how do civil rights protections for SGM communities square with Department of Health and Human Services rules that protect healthcare entities and providers on the basis of conscience and religious liberty?In our paper published in JAMA Network Open today, we describe primary care provider experiences of bias, harassment, and discrimination in a deeply underserved region of California.  SGM providers described severe actions taken against them by colleagues, staff, and healthcare administrators, including threats to licensure, denial of hospital privileges, and loss of insurance contracts. As a result, SGM providers have left the region, or remain highly guarded on their status.This is a limited exploratory study- we cannot make any claims as to how widespread these actions are, whether in California or other parts of the country.  We note that this raises several critical policy questions that affect healthcare workforce, physician supply, and ultimately, efforts to address healthcare inequities for SGM communities:

Do Title VII protections apply to SGM individuals?Do Title VII protections apply to physicians, particularly in states like California where they are not actually employees?Do HHS regulations protect healthcare entities with conscience and religious objections, who choose to say, deny admitting privileges to SGM providers?

Harvard Science Center, Photo: Michael Gritzbach

(where pre- med dreams go to die….or not)

Federal District Judge Court Judge Allison D. Burroughs issued a ruling on October 1 concluding that Harvard, in its undergraduate admissions policies and processes, does not discriminate against Asian Americans.  The case was brought by Students for Fair Admissions, led by anti-affirmative action activist Edward Blum, and will likely be appealed as far upward as necessary, to the Supreme Court of the United States.  SFFA is calling for an end to considerations of race and ethnicity in higher education admissions.  We wrote about the case, the role of Asian Americans, and the implications for medicine and health equity for an upcoming issue in Academic Medicine.