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'I'm dispirited' seeing people of color affected by COVID-19: Q&A with Dr. David Wohl

Tina Vasquez May 14th, 2020
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Across the United States, workers at meat and poultry processing plants are becoming infected with COVID-19 at work. Some of them are dying. These are primarily immigrant workers, many of whom are undocumented. The pay they receive for keeping Americans fed is minimal, forcing their families firmly below the poverty line. The companies that employ these workers skirt labor laws in order to avoid providing them with health insurance and other benefits despite a full-time workload that often veers into overtime.

President Donald Trump has ordered processing plants to remain open during the COVID-19 pandemic. The companies that own these facilities appear to be suffering no consequences for their lack of transparency regarding outbreaks and their failure to protect workers, who are treated as “essential and dispensable,” as Prism reported in our three-part series about COVID-19 outbreaks in rural central North Carolina poultry processing plants owned by Mountaire Farms, Tyson, and Pilgrim’s Pride. This lack of care and concern is making itself clear at nearby hospitals, where Dr. David Wohl, a professor of medicine at UNC-Chapel Hill and an infectious disease specialist, is seeing a “huge” proportion of Latino community members tied to processing plants test positive for COVID-19.

Wohl spoke to Prism twice over the course of the last week, discussing the parallels between the HIV epidemic and the COVID-19 pandemic, the issues related to testing in North Carolina, and the partisan divide over the response to the novel coronavirus. Our conversations have been combined, condensed, and edited.

Tina Vasquez: Your area of expertise is in infectious diseases and you’ve been conducting HIV-related research for more than 20 years. Are there any lessons that can be taken from the response to the HIV epidemic and applied to the COVID-19 pandemic?

David Wohl: There are parallels. Just like we want people with HIV to know their status, we want people with COVID to know theirs. The big thing we’ve been trying to push for decades is making sure people get tested and they know their status. With COVID, a small minority of people who are infected know they’re infected. Right now in North Carolina, if you’ve been following guidelines and you’re an otherwise healthy 35-year-old with a cough and a fever, you don’t qualify for a test. It’s very weird. We should test that person, this should be information we want to know. We need to be testing more people. HIV specialists have become COVID-19 specialists and uniformly, we have been saying that more testing is needed.

The pace of transmission is of course very different than HIV, but there’s a reason communicable infectious diseases settle where they do. There’s a reason why in North Carolina, the first cases we saw were related to travel and now we are seeing outbreaks in rural places like Lee County and Chatham County where there are poultry plants and farms. There’s a reason why Ebola is in places with poor healthcare infrastructure. People are in situations where they cannot protect themselves and that’s where the virus finds its niche. People who can’t protect themselves get infected and people who have the privilege to protect themselves fare much better.

Vasquez: African Americans have died disproportionately from COVID-19. In New York City, it was low-income Black and Latino people who were hardest hit. In northwestern Oregon, Latinos are 20 times as likely as other patients to have the virus. In central North Carolina, we’re seeing Latino communities overwhelmingly test positive for the coronavirus. Talk to me about these disparities. Why are communities of color at the epicenter of the pandemic?

Wohl: It’s very complicated. There are multiple layers as to what we’re seeing with disparities related to race and ethnicity, just like everything in medicine. I’d honestly be more surprised if these communities weren’t  the hardest hit, given the history of medicine in our country. I’m dispirited to see more severe cases of COVID-19 in communities of color. It can be a lack of access to earlier care, biases during care that might be overt or covert, or comorbidities because as we know, being Black in this country sets people up for comorbidities related to poverty, stress, lack of resources, and a whole host of others that conspire to keep people less healthy⁠. If they’re less healthy because of these factors, COVID-19 takes advantage of that.

Something that was very disappointing to me was when⁠—because of these disparities in who is getting sick from COVID-19⁠—the [Centers for Disease Control and Prevention] released guidance for testing asymptomatic people of color because they are disproportionately affected by the virus, and then the guidance was changed entirely. The fact that [mention of race and ethnicity has] been removed is a shame. It could have been a useful leverage point to expand the testing we should be doing where it would have the most benefit.

Vasquez: Poultry processing plants in central North Carolina have stopped releasing information about their outbreaks, though some never did in the first place. Based on the information from county health departments, we know that COVID-19 cases in rural areas are on the rise. Can you say anything about the outbreaks that are emerging from poultry processing plants in central North Carolina? 

Wohl: Looking at the characteristics of folks getting diagnosed with COVID-19 in our area, in the beginning we saw that this was really people who were coming in from out-of-state, folks who traveled and returned. Things have shifted. We’ve seen this with other epidemics and outbreaks. Viruses don't have a brain or a mind of their own, but they find niches. Given we've had weeks of lockdown and social distancing and quarantining, if you're a virus, where can you spread? You can spread in areas where there are people next to other people. So prisons, jails, nursing homes, factories, farms where people work elbow to elbow, these are places where we're seeing transmission. At processing plants, poultry workers are in a situation where transmission can be much more efficient. When I look at the proportion of people coming in [and testing positive], and the proportion of people hospitalized with COVID-19, the proportion of the folks who are Latino is huge. It's really quite striking compared to before.

Vasquez: In reporting on the outbreaks in poultry processing plants in North Carolina, I learned that if a company like Mountaire Farms does not want to disclose the number of people testing positive in their facilities, then in turn the local public health department cannot cite specific numbers emerging from the facility because it’s protected health information. But during an unprecedented public health crisis, it seems strange that no pressure is placed on companies to be transparent about the size of outbreaks in their facilities. Does this lack of transparency trouble you, especially because workers say they can’t make informed decisions about whether or not it’s safe to go to work?

Wohl: I think the public health apparatus of the state is really responsible for surveillance and communication. I think they're trying really hard to amass data that tell us what we need to know. When you start getting to the granular level of a particular business or operation or employer, it gets trickier because of the issues regarding privacy. So I don't have a ready answer. I do think that connecting the dots, you can know that if you're seeing more cases in areas where there are these plants, then you know there's a problem.

But your point about individuals being informed so they can make informed decisions is an important one. Of course we all have an obligation to help each other and to look out for each other, and certainly if you’re an employer you need to watch out and make sure you do everything possible to keep your employees safe. If [your business is] considered essential and people have to work, you have to use evidence-based approaches towards protecting people. That's an obligation, and I don't think anyone can defend abdicating their responsibility to protect workers or coworkers or family members.

Vasquez: Can you tell me how testing is working in your area? In reporting, I relayed the story of an uninsured poultry plant worker who went to Chatham Hospital and received a bill for $500 after being tested. Based on interviews I’ve done with workers, there seems to be a lot of confusion about where to get tested, if everyone can get tested, if you have to be insured to get tested, and if testing is free. What can you say about how it takes place where you are?

Wohl: Access to testing differs depending upon where you are and how much money you have and the usual things that are operative for health care in the United States of America. Testing is no different, so we do see that there are some differences in access to testing. Fortunately, testing in North Carolina is increasing. That’s great. Testing for many people, and most people I would say, is probably free. When we do see instances of someone getting charged or seeing these large bills, it's often somebody who comes in to get tested and they're sick and they get sent to the emergency room, and the emergency room then charges them for their services. That's pretty standard. I don't think anyone's going to come into a center, get tested, and get a bill for $500. They're going to get a bill for $500 for going to the emergency room and getting a chest X-ray and that sort of stuff. Making this clear and disseminating correct information is important. We don’t want people to think that if they come in and get tested, they will get a $500 bill.

Here in central North Carolina, services are available from federally qualified healthcare centers, like Piedmont Health. UNC has certainly taken on a lot of the testing role and health departments are doing testing. But we need more testing, lots of it. There are a lot of people working together to expand testing and not only that, but trying to expand care for people who might be more symptomatic. We're certainly not there yet, but there are some really good partnerships forming. And I think we have to work with the state, work with our healthcare entities, work with our federally qualified and community health centers, and work with the industries to really try to ramp up testing.

Vasquez: As testing expands, [the number of confirmed] COVID-19 cases will of course increase, but it may alarm people to see the numbers rise. Should people prepare themselves to see an explosion of cases in North Carolina?

Wohl: Testing is really tricky that way. The federal government certainly is sensitive to this, and so is the president, who said something along the lines of: "If we do more testing, it's going to make us look bad." Now that, of course, is not really what we should be thinking about. Knowledge is power, and I think we want to find out how many people are infected. So yeah, it will make us look bad if looking bad is having more cases. I think we're doing the right thing by testing more people, identifying them, counseling them, getting them to stay home, getting them not to infect other people, and being able to link them to care so that we can prevent them from going to the emergency room and getting a $500 bill. And better yet, preventing them from getting sicker and ending up in the hospital.

Vasquez: Given that the numbers are increasing, do you have any concerns now that North Carolina is opening up? 

Wohl: My concern is we're going to stop social distancing. The virus doesn't care if you're next to somebody plucking a chicken or if you're next to somebody at Starbucks. A virus only knows you're susceptible and jumps from somebody who's positive to somebody who's negative. So it doesn't matter the color of your skin, it doesn't matter what the walls look like around you. It matters that you're next to somebody. This is infectious disease 101: If you have someone susceptible next to somebody who's infectious, there's going to be a problem.

Vasquez: On a different note: I did not anticipate that a pandemic would become partisan and that efforts to contain the virus would be so polarizing. In North Carolina, we have armed white men protesting at the state capital and people are refusing to wear masks and obey stay-at-home orders because they say it’s “tyranny.” Does this bleed into the work that you do? Are there ways in which this willful ignorance makes the job of healthcare providers more difficult during the pandemic?

Wohl: The way that news moves on social media or the very nature of social media gives a disproportionate voice to a minority opinion. It’s a real curse of the platforms we use to learn about each other and learn what’s going on. What I can say is that the number of people hospitalized with COVID-19 on any one day in North Carolina far exceeds the number of people amassing at the state house, complaining and waving flags. The “personal liberty” argument doesn’t make much sense here. They can go out and get infected with COVID-19 and infect other people, whether they want to or not. Their exercise in what they’re calling “personally liberty” has very serious implications for all of us. If it’s your right to leave your home and you spew infectious droplets onto another person and make them sick, didn’t they have the right not to be infected by you? Public health is more important than someone who just really, really wants to go to a basketball game.

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