In This Episode
Abdul reflects on a year of COVID-19 and discusses what’s in the COVID-19 relief package. He then talks to Dr. Joia Mukherjee, Chief Medical Officer at Partners in Health, a global health non-profit organization operating in the US and abroad, about what it will take for America to lead globally on COVID-19.
Dr. Abdul El-Sayed: It’s been a year since COVID-19 brought our country to its knees, and over 530,000 people have lost their lives. President Biden signs the historic 1.9 trillion dollar COVID-19 relief package into law, ensuring childhood tax credits and $1,400 stimulus checks. And the president announced that every adult would be eligible for a COVID-19 vaccine by May 1st. This is America Dissected. I’m your host, Dr. Abdul El-Sayed. And this has been the longest year of my life.
Dr. Abdul El-Sayed: Do you remember where you were this time last year? That week before lockdown, when things felt normal, the sun was just starting to pick out from a long, dry winter. There was an excitement in the air. But a bigger, more ominous looming threat was in the air, too. Something that was increasingly being referred to as the novel coronavirus, back then. I remember reading about the strange new flu-like illness that was spreading in Wuhan, China, in December of 2019. But the threat didn’t really hit until those last few weeks of February, when I started to appreciate that this was going to be the big one I’d always heard about med school. And yet, as late as March 8th, I was on the campaign trail with Bernie Sanders. In one of the last things I did before lockdown, I got to speak in front of a rally in my hometown of Ann Arbor, packed with 10,000 people there to see AOC and Bernie. I was planning to launch my first book during those days, Healing Politics, which came out on March 31st. We had a 39-stop book tour planned with stops all over the country. It was not to be. But only a week later, on March 13th, we launched this season of America Dissected, focused entirely on coronavirus. We’ve been going ever since. And as people were trying to figure out what was about to happen, Sarah and I moved in with my in-laws. Emily was then two years old, and her daycare had just shut down. The only way Sarah and I could work was with the support of my mother-in-law, who graciously took care of Emily while Sarah and I worked side-by-side desks in their basement. That week, to take my mind off the blur, I picked up Michael Lewis’s book, The Fifth Risk, where he argued that the most dangerous part of the Trump presidency wouldn’t be the things we saw, but the myriad things we didn’t see—pieces of the American government machinery that we don’t always pay attention to, but are critical for our safety and security. Public health is one of those things. As an epidemiologist and former health commissioner, I know that public health is as much about preparation as it is response, and we were not prepared. Watching the Trump administration’s buffoonery at the outset of the pandemic was like watching a high-speed crash in agonizingly slow motion. Nearly everything they did, they did absolutely wrong: from denying the pandemic, to politicizing masks, to getting ahead of the science. It’s been a year, and though the man who got us into this high-speed crash is no longer behind the wheel, we are still facing the consequences. We’ve lost over 530,000 mothers, sisters, brothers, daughters, sons, cousins and friends. Millions more survived, but will never forget. Millions more than them have lost their livelihoods, they’ve spent the last year on the teetering edge of poverty, if they haven’t already been engulfed by it. Structural racism has tag-teamed with the virus to leave Black and brown communities even sicker and poorer than they already were, even as billionaires made a collective trillion dollars, the biggest winners of the so-called K shaped recovery. This pandemic taught us that it takes more than money to weather a storm. It takes collective trust, will and purpose. The living manifestation of our mistrust was then the President of the United States. That meant that for most of the past year, Americans suffered this pandemic 5x worse in terms of death than the rest of the world. Meanwhile, our broken infrastructures riven by racism, inequity and insecurity failed further and further as COVID-19 put an unprecedented strain on already crumbling systems. But that’s been the last year and this, this was last Thursday:.
[clip of President Biden] This historic legislation is about rebuilding the backbone of this country and giving people in this nation, working people, middle class folks, the people who built the country, a fighting chance.
Dr. Abdul El-Sayed: The contrast with Trump and his ideology of zero-sum racism and division couldn’t be more stark. It’s hard, even painful, to reflect on what might have been, had we had that kind of leadership from the jump. Last week, President Biden signed a1.9 trillion dollars—that’s 1,900 billion dollars—COVID relief package into law. It provides major support for direct COVID-19 relief, including vaccine deployment, school reopening and state and local funds to replenish coffers that had run dry because of COVID. It provides subsidies for health insurance for people who lost their health care or were priced out. Most directly, it offers $1400 checks to most families. Of course, there’s still a lot more I wish the bill would have included: more money for families, and raising the minimum wage to $15 an hour. Nevertheless, as Joe Biden put it, the package has the potential to be a big effing deal. It sets us a pace to put a final end to this pandemic in the US. And yet, let’s not forget that this was a global pandemic. In that respect, folks were asking if Joe Biden had what it took to meet this moment with a Rooseveltian response like the New Deal. Last Thursday, Biden and Democrats answered with a resounding yes. But we could and should do more. Roosevelt took on the Great Depression with the New Deal, and then he led America through World War Two. The New Deal is what made American leadership in World War Two even possible. FDR saved America, and then led America to save the rest of the world. And if this bill rescues America, it doesn’t quite rescue the rest of the world. Today, we talked to Dr. Joia Mukherjee, Chief Medical officer at Partners in Health, a global NGO that has been critical to delivering COVID services and relief, not just abroad, but here at home. She talks to us about what it takes to save the world after the break.
Dr. Abdul El-Sayed: Our guest today is Dr. Joia Mukherjee. She is the Chief Medical Officer at Partners in Health and someone who has been focused on equity when it comes to this pandemic, whether it is in the United States or globally. Dr. Mukherjee, thank you so much for taking the time to speak with us today.
Dr. Joia Mukherjee: Thanks Abdul.
Dr. Abdul El-Sayed: I’m honored to have you and grateful for your work. The pandemic is really, frankly, reshaped the thinking about how we think about resources and health and disease, or at least it should have. In some respects, right, the US bore this pandemic worse than any other country in the world except for maybe Brazil. What does this tell us about the role of more than just money in shaping who gets sick and who doesn’t? What are the other resources at play that we may have been missing in the global health equation?
Dr. Joia Mukherjee: Yeah, so that’s such a great question and I’m sure that all of us as public health people and medical people will be writing this history for many years to come. And we’ll find out a lot of things that we don’t know yet. But what we do know is that despite the greatest expenditure per capita in the world, the United States does not have the best health outcomes. And that is because of at least two things. One is very obvious, I think, to anyone, which is the massive inequalities in, the as we call, the social determinants of health. So policies of racism, red-line, red-lining, the poor quality of infrastructure in inner cities, and all of this, which are driven by policies of racialized capital, are really seen in health outcomes. And so that’s just, we see that, this inequality is one of the reasons that we are so totally unprepared. But the second thing that I’ve really come to realize in my work in the US since COVID hit is that we don’t have a health system. Right? We have a system of care that will maybe treat you if you’re sick, if you’re insured, but really doesn’t try to keep you well. Really, primary care clinics have little or no connection to hospitals, and neither has a connection to what’s happening in the community. And in countries all over the world where I’ve worked, you see this connection between community, health center, and hospital, and the system of care is there to do case investigation, contact tracing, resourcing the sick, the poor, and having a system that makes sense. And I think what’s been really shocking to me is to see the fragmentation. So you’ve got a system that’s very fragmented, and a society that’s deeply unequal. And I think responding to pandemics in that setting is extremely challenging.
Dr. Abdul El-Sayed: What’s fascinating is that I was talking to a friend and trying to explain something similar, and the only metaphor I could come up with is of a sandwich. If you’ve ever had a sandwich, you kind of want some good bun in that sandwich, right? You can’t just have all the meat. And our health care system has nothing except for the meat in the middle, which is that health care part of it. But none of the actual prevention, none of the integration, none of the thought about what happens before you ever get sick, or after you get sick and get discharged from the hospital. And without that, right, we have we have fallen into this situation where we come up with this medical marvel of the vaccine that we can’t figure out how to deploy with any degree of accuracy, equity or efficiency because we don’t have the rest of the sandwich. And one of the bigger failings, I think, is our failure to connect dots between what’s happening globally and what happens in the US. There’s a big effort, of course, to vaccinate everybody the United States, and because we’re the richest, most powerful country in the world, we command a tremendous level of power when it comes to who gets vaccines and when. And we’re failing to do that equitably in the United States. But we’re certainly failing to think about how we vaccinate everyone. And where the rubber hits the road on this is that every warm body that remains unvaccinated is a opportunity for the virus to take on a set of evolutionary capacities that makes it resistant to vaccines, at large. Can you speak to why we still don’t have a plan to vaccinate all 7.80 billion people in the world? And what it would take for us to do that thing if we decided we wanted to?
Dr. Joia Mukherjee: All it would take us money. It really is not a complicated thing. And we know that for a fact, because when the movement for HIV treatment access swept across the globe in 2000, ’99, when we have had highly active antiretroviral therapy in the US and Europe since 1996, so four years of zero treatment in places like sub-Saharan Africa, parts of Asia, lots of Latin America. We know that once we had the money, we were able to do it. And today, 27 million people are on treatment. They’re getting that treatment through the public sector and that money has gone to build good health systems—not perfect, and there’s a long way to go. But no one thought we could do that either: patents, it’s too hard to make it, the transfer of technology, only we American companies, Big Pharma can do it. And we learned that to be totally wrong. And now the same excuses are being made to protect the profits of pharmaceutical companies, which is: it’s complicated, it’s mRNA, it’s different. But billions of vaccines are made every year in other countries to vaccinate kids against measles and polio. And we can do that. So all we have to do is have the will to train and tool up these massive factories to make this new vaccine, and make billions of doses of it. And what it would cost—I mean, Public Citizen has estimated that it would cost somewhere around 25 billion to do that. This is chump change, right? That’s a week of our war machine. And so it’s just a political decision that we’re making to protect private profit over the public health, and to protect what we consider to be American security. Which, to be clear, I think for many young people who’ve grown up in the never-ending war, you know, there is no guarantee of our security based on how we’ve constructed the world today. I mean, when I was a young person, we were far more secure, and that was in the height of the Cold War. And so what we’ve done in this constant war against Black and brown people, and Muslim people, is to make us all less secure. And the thing that would give us security right now is turning these swords into plowshares and putting money into health and vaccination and COVID control. And that’s just a political choice. And we could make that political choice.
Dr. Abdul El-Sayed: So we just passed a 1.9 trillion dollar COVID relief package, which is a good package, right?
Dr. Joia Mukherjee: It’s a good package. Could be better, but it’s good. We’ll take it.
Dr. Abdul El-Sayed: That’s right. Could be better, but it’s good. And that is 1,900 billion—that’s what 1.9 trillion is, right? 1,900 billion. And you’re saying that it would cost 25 billion of that to vaccinate the entire world, and yet we’re choosing not to do that. What could possibly be on the other side of keeping us from doing that? What could possibly be—
Dr. Joia Mukherjee: Racism, I think, it’s racism. I mean, to me, the longer I do this, the more I think that if we didn’t live in a world where we saw Black and brown people as less deserving, less worthy of technology, less worthy of health care, we could do it. I mean, I just, I just can’t see any other reason, because even from a, from a purely profit motive, it doesn’t make sense. Right? If the global economy right now, any of us sitting here at any minute are wearing clothing from four different countries in the world. Right? We’re all part of the global economy, whether we like it or not. There is no other way, other reason except that we see people as other than human. And that was never more apparent since probably the civil rights movement, never more apparent than under the Trump administration. But it is what we do globally. I mean, for many years as the Chief Medical Officer of Partners in Health, I’ve watched kids die of starvation, and in the 21st century, like that’s absurd. That doesn’t need to happen. And we just don’t have the political will. And if we had a level of hunger in France as we see every day in Haiti, you better believe there would be massive aid going to that. And so I’ve become more and more convinced that if we don’t really try to deeply deconstruct racial capitalism—as many Black thinkers, African thinkers, Black feminist thinkers have asked us to do and have done—that we’re really not going to get to the bottom of it.
Dr. Abdul El-Sayed: You know, when you raise this question of the impact of racism, I’m reminded of the fact that racism, it is deeply devastating to the people who are the victims of it, but it also hurts the racist. And the challenge that we have is that we don’t see the consequences of the fact that we are globally connected and our failure to look out for others is fundamentally a failure to look out for ourselves. And, you know, we talked about the variants the very top, but this is a direct example of what can happen if we allow racism and greed to keep us from acting globally when we have the capacity and the power to do it. Because it just takes one variant that can slip through our vaccine-mediated immunity, and we are almost back to square one. Right? It’s not to say that the whole pandemic would hit us together, would be some residual immunity, certainly, but it is to say that it would vastly delay our capacity to to bring this pandemic to heel. Some argue that there are global approaches to taking this on, Covax is one of them. Can you tell us about what Covax is and if it’s enough?
Dr. Joia Mukherjee: Yeah, no, it’s not enough, but it’s great. I mean, so when I referred to the AIDS pandemic—our last huge pandemic, there were other pandemics too, like Ebola, which affected more than one country—but when we look back, it took eight years to get the fruits of science to people who are suffering. And at that time, there were 8,000 people dying a day in the world from HIV. So it was a massive failure of imagination and delay. What Covax did, which is remarkable, was to say: even before we have a vaccine, let’s make sure we have a platform for sharing that knowledge. So the Covax facility was set up before the vaccines were even authorized by the FDA. And so that’s remarkable. There was an equity plan from the beginning. The problem is that it relies on voluntary contributions from wealthy countries. So, of course, under the Trump administration, they weren’t going to put anything into Covax. Thankfully, the Biden administration has, and that’s a game changer. But what we believe at Partners in Health, but also there are many organizations and people supporting what’s called the people’s vaccine, is that just waiting for charity from the companies—the leftover doses, the small amount that’s not getting paid for by the US, Canada, Europe, etc.—that’s not sufficient or fast enough. That we have to really make sure that these vaccines are mass manufactured in India or elsewhere and that they can get out the door as quickly as possible. Covax provides maybe, maybe about 20% of the coverage that we need. And so, and part of it is the production capacity of the groups that make these vaccines is just not large enough. So if they can’t meet the global demand that we have, then we have to move that production to someone who can, and transfer that technology, and look at it as we’re truly in this together, we’re not just: we’ll, we’re in it together for our country, and then the left over, the spillover of the wave, will go to you. And that’s what’s happening now. So I, I, I’m a fan of Covax, but I agree with what Dr. Tedros said just this week, that it’s not nearly enough.
Dr. Joia Mukherjee: We’ll be back with more of my conversation with Dr. Mukherjee after this break.
Dr. Abdul El-Sayed: We’re back with Dr. Joia Mukherjee. One of the insights—we sort of talked a little bit about this early—of this pandemic is that there is a level of collective will that has to happen if you are going to be able to react to a major public health threat like this pandemic. And we just haven’t had that. I mean, it’s a little bit better now under this new administration, but we really haven’t had that. We just saw a couple of weeks back that governors of states that have been captured by the right in this country are prematurely opening up. Not for the first time, they’ve already done this before and it didn’t work out very well last time. And now we’re doing it in the presence of these extremely threatening variants. And other countries with far fewer resources have had the collective will. I mean, some of the countries that have done best when it comes to this pandemic have actually been West African countries that have gone through either scares when it came to Ebola or the full pandemic. What does that tell us about the kind of political and or cultural resources that we lack—and you all at PIH have done a lot of work trying to take that on through contact tracing efforts, et cetera—what have you learned about whether or not it’s possible to build that, and how critical it is as an ingredient to effective and efficient public health?
Dr. Joia Mukherjee: Yeah, well, so I came of age during the Reagan era, and I think, you know, and my grandparents were beneficiaries of the New Deal, and so I think what we’ve seen in the United States is 40 years of austerity being shoved down the throats of Americans as liberty, the conflation between democracy and capitalism, and the gutting of our social contract as citizens of the United States. And so I think both parties have done too much to cut the social safety net away from Americans, and to make it seem weak to be getting help from the government, and that is somehow bad. And that is based on neoliberal capitalism, the idea that the market will fix all our problems. Well, I think Texas is the perfect example to show that it won’t. That if you leave energy solely up to the private sector, people will live in the dark. Literally, people’s pipes will burst, people will not have heat. And we run health care like that. We run the school systems like that. And so the regular things that we would consider as part of public good, what brings us together as a society, that basic social contract, is really disrupted in the United States compared to many other countries in the world. And of course, it’s disrupted around the, along the lines of race. And so what we have to do, and this is why I am encouraged about the 1.9 trillion dollar American Rescue Plan, because I think we have to rebuild the sense that government is truly for the people, and not for the corporations, not for tax breaks, not for giving more and more money to the top 1%. And if we can convince Americans again, like my grandparents were convinced during the New Deal, that government is going to help you, then there’s a different view of government. And I think where we see political will is governments have to do something for somebody. There is a demonstrative act that comes from governance, not just: oh, we’re going to stay out of your business, not tax you. That’s not governance. And so I’m encouraged by the space that has been created for the Biden administration to govern. But we have to understand that that’s rooted in voter activism, that’s rooted in people getting to the polls. If we didn’t have Ossoff and Warnock as you know, 49 and 50 in the Senate, it wouldn’t happen. So I really think that we have been sold a bill of goods based on a very narrowly-construed economic ideology of neoliberalism that has abandoned for in the United States and sown the seeds of division that then can be fed by our own racism, by bigoted policies. But the economics, or the dismantling of governance, I think has been happening over 40 years.
Dr. Abdul El-Sayed: Yeah, I, I certainly and profoundly agree. This governing approach is actually unfortunately been consensus for a long period of time. And it’s required us to break that consensus, and yet the biggest challenges that we have the doing that even now, right, that the bigger that—the things that are not included in the $1.9 trillion package are things that that consensus rooted—not just among Republicans, but also among some Democrats—has interrupted our ability to work. And so I think there’s a responsibility to appreciate the fact that politics shapes culture. Culture doesn’t simply shape politics. And when we accept a certain level of truth to be an uncontested truth, right? That poor people are poor as a function of non-deservingness and lack of hard work rather than as a function of circumstance.
Dr. Joia Mukherjee: Or as a function of policy. I mean, not only sort of passive circumstance, but the active policies that have impoverished people.
Dr. Abdul El-Sayed: Right. That’s exactly right. As a function of redistribution from the bottom upward, right? Then we miss the opportunity to act. And it hits us hardest, and it hits those same people—the poor, the marginalized, the oppressed hardest—in moments of crisis like this. And so I think that there is this moment where we have to take stock of the cultural and political resources we did not have, and why it meant that we were 5x as likely in this in this country to die of COVID-19 as the global average. And rebuilding that has to be a major priority of the post-COVID era. I’m wondering, if there’s one lesson from your work abroad that you wish Americans could program, right, could learn and not just learn, but learn deeply, we could program into our DNA as a country, what would it be?
Dr. Joia Mukherjee: I think that societies function best if people protect one another. That the individualization, the every man for himself, is just not a healthy way to live. It leads to more extraction, destruction of the environment, it leads to more COVID. And that part of the functioning of our society, of our government, really has to be a level of interdependence. And that means that the most marginalized people need to be protected, and they need to have more protection. They need disproportionate share of the resources. And I just think, this is why I’ve been trying to say, what are the what are the social theories, what are the things that we can look to to understand our place in this world? And I think it is theories around mutuality, theories around listening to the voices of the marginalized and the oppressed, and those really come from, you know, Black feminism. And some of the things that would really say: let’s center our world around caring for one another, not just about the capital. And I think there are countries that are doing that. And if you look at countries like Rwanda, they had an exquisite COVID response. Or Vietnam, where over the last 30 years they have built health care that’s relatively equitable, that’s tax funded, and that is a form of wealth redistribution. And they’ve had very, very few COVID deaths. But there is a sense that people are—you can’t just keep saying we’re in this together, but not materially making it so. And I think that’s, we don’t have a society of being in it together, materially or sort of morally.
Dr. Abdul El-Sayed: Really appreciate you taking the time to share your experience, your perspective with us. And that was Dr. Joia Mukherjee. She’s the Chief Medical Officer at Partners and Health, operating in 12 different countries around the world, gratefully here in the US as well. Thank you so much.
Dr. Joia Mukherjee: Thanks, Abdul.
Dr. Abdul El-Sayed: As usual, here’s what I’m watching right now. As Dr. Mukherjee and I discussed, it would cost us a mere 25 billion dollars to vaccinate the whole world. To put it in perspective, 25 billion would have only added to 1.3% of the cost of the American Rescue Plan. Or to put it another way, 25 billion is 1/26th of 2021’s budget for the Department of Defense. As we’ve discussed, it remains critical that literally every single person in the world gets vaccinated. Any warm body that is susceptible to COVID is an opportunity for the virus to mutate, creating a variant that would slip our vaccines entirely. Will the US rise to the challenge? Nevertheless, the American Rescue Plan is critically important for Americans all over the country struggling through this pandemic. To help us understand how it will offer more Americans health care. Here’s our DC Diagnosis with KHN’s Emmarie Huetteman.
Dr. Abdul El-Sayed: Tell us a little bit about how this law now changes the experience of health care costs for the average American.
Emmarie Huetteman: So these changes to health care have been called by experts some of the most significant changes to the affordability of private insurance since the passage of the Affordable Care Act, with the caveat that they only last for two years. Now, the federal government is going to use subsidies heavily throughout this law to make private insurance more affordable for more Americans by giving them more money to pay their premiums. It’ll be especially beneficial for the unemployed, as well as lower and middle income Americans who kind of fell through the gaps of the Affordable Care Act before, and have been suffering in particular for not having that aid from the government in the time of the pandemic when they’re struggling to afford their premiums in many cases. For the unemployed, this means that they’ll get some eligibility for subsidies on the exchange, where they didn’t have them before. They’re also get more benefits from the government in the form of the coverage of their COBRA premiums, actually. For unemployed workers, recently unemployed workers who are on the, who used COBRA to get their previous employer’s health care plan and in the past would have probably paid up to their full premium on their own—a pretty pricey bill in many cases—they’ll get full coverage from the government through September to cover their subsidies. And then in the case of many lower and middle income Americans who may have gotten little to no help under the previous law, they’ll get some subsidy help to both afford new new plans, in some cases get lower deductible plans that’ll make their coverage more affordable going forward.
Dr. Abdul El-Sayed: We know that millions of people either lost their health insurance entirely or found health insurance unaffordable. What proportion of Americans who, you know, lost their health insurance or were priced out of their health insurance, what proportion will get will be benefited by this package?
Emmarie Huetteman: It’s a little hard to say precisely, in part because we’re still assessing how many people lost their employer-sponsored insurance during the pandemic. And there are many different situations that apply to them. Generally speaking, estimates say that nearly 15 million people lost their employer-sponsored health care because of the pandemic. But at the very least we can’t say this will make health insurance more affordable for millions of people. The Kaiser Family Foundation has estimated that there are about 15 million people who are uninsured right now who would be eligible to enroll in the exchanges, most of whom would be eligible for subsidies under this new law. And the CBO has estimated that on the COBRA expansion alone, they—actually, the CBO scored a less generous version of the bill than the one that passed—in the end, the one that passed will cover 100% of premiums for people using the COBRA plan. Before the CBO had estimated on the less generous plan that it was going to be about 2.2 million more people who would be eligible to enroll in the program. So we can expect with a more generous proposal, there might be more people who are enrolling as well. There is one caveat, actually, which is that actual enrollment may be limited by the fact that this is a temporary benefit. So not everyone is going to be motivated to change their insurance plan for a couple of years unless they’re already having a lot of trouble affording insurance and know about the benefits now available.
Dr. Abdul El-Sayed: That was Emmarie Huetteman, she is a journalist with Kaiser Health News, for today’s DC Diagnosis. In the next few weeks, we’ll be doing an episode on the experience of getting vaccinated. I’ll be sharing my own, but I really want to hear about yours. If you’d like to be featured, send us an email with a voice memo of your vaccine experience to email@example.com. That’s firstname.lastname@example.org. Also, if you like our show, I want to invite you to subscribe to my newsletter, The Incision. I take on some of the biggest issues of this moment, like the seven policies the filibuster could kill, or why the royal family’s racism is a lot bigger than Meghan Markle, or which vaccine you should take. Spoiler alert: it’s the first one you can. Sign up at Incision.substack.com. And don’t forget to pick up your America Dissected swag today. Our Science Always Wins hats are back, along with our super soft sweats and tees and we’ve got some kids tees. Crooked.com/store. And we’re always trying to make our show more accessible, so we’ve gone back and uploaded transcripts of all our episodes, available at Crooked.com.
Dr. Abdul El-Sayed: America Dissected is a product of Crooked Media. Our producer is Austin Fisher. Veronica Simonetti mixes and masters the show. Production support from Tara Terpstra, Lyra Smith and Alison Falzetta. The theme song is by Taka Yasuzawa and Alex Sugiura. Our executive producers are Sarah Geismer, Sandy Girard and me: Dr. Abdul El-Sayed, your host. Thanks for listening.