What Becomes of Us: Health Disparity in Pandemic

On today’s podcast, Editor Brandy Schillace speaks to Josh Mugele. a disaster and emergency medicine physician who is working to build an emergency residency in Northeast Georgia.

A headshot of Josh Mugele against a dark gray background. He wears a sportcoat and blue shirt with tie, has a beard and salt-and-pepper hair. He smiles at the camera.Medicine is actually his second career, after he worked Silicon Valley during the dot com boom. He attained his doctorate from the University of Michigan and completed his residency in emergency medicine and his fellowship in disaster medicine from Indiana University. As a disaster medicine physician, Dr. Mugele worked in Liberia during the Ebola epidemic, studied the effects of the earthquake in Kathmandu, worked in New York during the early days of the COVID pandemic, and was a member of a FEMA Urban Search and Rescue team. From his startup days in Silicon Valley, Dr. Mugele remains an entrepreneur at heart. He designed and created his own disaster medicine fellowship and is currently working on creating an emergency medicine residency in Northeast Georgia with the hopes of training the future generation of emergency medicine physicians.

Today, he joins me to speak about healthcare disparities made evident (and worsened) by times of disaster—especially relevant for our present outbreak of Coronavirus, COVID-19.

Josh on Twitter: @jmugele


BRANDY SCHILLACE: Hello, and welcome to the Medical Humanities Podcast. I’m Brandy Schillace, Editor in Chief. And today I’m here with Dr. Josh Mugele, a disaster and emergency medicine physician who has been working to build an emergency residency in northeast Georgia. And I wanted to bring him on today to talk a little bit about the way crisis makes health disparities worse and also how it makes them more visible. Which is part of what we’ve been talking about in a series here on the podcast. So, welcome and thank you for joining us.


JOSH MUGELE: Thank you very much for having me. I appreciate it.


BRANDY: Do you wanna tell our listeners a little bit more about what you do? Because I don’t know that every one of our listeners is going to be familiar with what it means to be an emergency medicine physician.


MUGELE: Sure. So, the bulk of my job is to work as a doctor in an emergency department. So, especially in the U.S., we take all comers into the emergency department, and we’re the bulk of all acute care that happens. So, we do get a lot of what we classically define as emergencies: the gunshot wounds and the car accidents and the strokes and the heart attacks. But the emergency department really serves as a safety net for a lot of people in the U.S. as well. So, people who have an acute illness, whether it’s a simple cold or pneumonia, or they’ve run out of their blood pressure medicine or anything that kind of is an acute presentation of an illness, often it shows up to our department because they either don’t have access to primary care, or they can’t get into primary care in a reasonable manner.


BRANDY: Right.


MUGELE: And so, that’s what emergency medicine is, and that’s where I spend the bulk of my time. I’m also in education, and one of my jobs is to create an educational environment for new emergency doctors. And so, that’s what I’ve been spending most of my time on recently.


BRANDY: Well, and I know, too, in addition, that you have a fellowship in disaster medicine. And I think that’s something that people probably haven’t heard of before and yet seems really critically important at the present time. So, could you say a bit more of that, too?


MUGELE: Sure, yeah. I mean, disasters, so it’s not a formal field per se. So, there are people who are specifically trained to work within disasters, but there’s a whole breadth of what disaster medicine, disaster management are. And I think what most people envision disaster medicine is, is kind of the response phase of disasters and how when something bad happens, whether it’s an earthquake or a pandemic or a war, the special skills that are needed to take care of the patients and the victims of those disasters. But there’s a whole lot of work in disaster medicine around preparedness, around policymaking, around interacting with hospitals and public healthagencies to make sure that communities are prepared for disasters and are trained to know what to do when a disaster strikes. And the same in a healthcare organization: how does our hospital know what to do when we get a large influx of very, very sick patients?


BRANDY: Right.


MUGELE: So, that’s what I was trained in, and I’ve done quite a bit of work at various points in my career. What it’s kind of ended up being is, is when something big happens, such as the COVID pandemic, I try to put myself in a place where I can be of help with that. So, for example, during this COVID pandemic, when they were having need for volunteers in New York, I went to New York to volunteer at one of the hospitals in Harlem.


BRANDY: Right. That’s actually, I do wanna talk about that, but I wanna go back a little bit earlier because I know that you also worked during the Ebola epidemic. And I was wondering how you would compare those two experiences.


MUGELE: It was interesting because I happened to be in Liberia, in Monrovia when the first patients from the northern part of the country that had been infected with Ebola started making their way down to the city. So, I hadn’t been to Liberia for the sake of working with Ebola, but I happened to witness the, kind of firsthand, some of how the hospital responded that I was working at, how the hospital responded, how the city responded. And then I kept in touch with a number of my colleagues there as the epidemic really ravaged the city. And then I was able to work a little bit with my hospital at the time in the U.S. and with the state infection control that I was in at the time to prepare for that. And I think at the time, a lot of the bad things that were happening with Ebola I attributed to Liberia being an incredibly poor country and not having good healthcare infrastructure and not having a lot of trained healthcare workers. And the toll that it took on the city and on the country, I kind of attributed in a large part to the poverty.


And when it really didn’t hit the U.S. very hard, and we somewhat felt prepared for it, in my mind, I think, attributed it to the kind of lack of resources in that country versus ours. But now that COVID has essentially run rampant in our country, I see a lot of the same parallels, not necessarily in the disease itself, but really in how miseducation has spurred the spread of the disease and how lack of resources has really affected the healthcare infrastructure and how we just weren’t prepared for it, and we weren’t able to adequately respond to it for a number of reasons. And I see a lot of parallels kind of on a macro level to what happened to Liberia during the Ebola epidemic.


BRANDY: I think that’s really an interesting take. And I’ll say this, because one of the things we’ve done lately is we’ve spoken to people like Alice Wong, who’s a disability activist there. We’ve spoken to Oni Blackstock, Dr. Oni Blackstock.


MUGELE: Mmhmm.


BRANDY: And it’s become very clear that some of the, we sort of rest on our laurels, right, on the idea that, oh, well, we’re a big first-world nation, and these things don’t happen here. And now they have.


MUGELE: I think we assumed that money equaled preparedness. You know, we are rich, and that therefore, as a nation, we were prepared for this thing. And we really weren’t.


BRANDY: Mmhmm. Well, and I think the other thing that it has revealed is something we all know it’s true that not everyone in the United States is rich.


MUGELE: Right.


BRANDY: In fact, it’s a tiny percentage of people who are actually wealthy, and then you kind of have a struggling middle class and then you have quite a large group of people who are just under middle class and then plenty of people under that, below the poverty line. But we tend not to think about America that way, and that remains sort of hidden. And so, one of the things that we discussed in a couple of our other podcasts was how this is rendering invisible problems visible. Suddenly it’s like, oh! Well, this problem isn’t new; it’s just newly visible. And I wonder if you can speak to that a little bit, because I think the lack of preparedness, it’s also to do with the way medicine is set up and is accessible or inaccessible in the United States, wouldn’t you say?


MUGELE: Oh, absolutely. And I think for most of the country, it has absolutely kind of laid bare some of the disparities that were already there. So, COVID is killing black people at 50 percent higher rate than it is killing white people. And I think that’s shocking and horrifying. But Black people have been dying, you know, have higher maternal mortality and have a lower life expectancy generally even before COVID hit. And I think sometimes, I think we’ve known this, those of us who kind of are on the frontlines of healthcare, who work in the emergency department, who kind of see people who come into our emergency department who can’t afford their medications or who have not sought care for what they knew was a horrible cancer because they knew that it would bankrupt them to seek care for that or any number of stories that all of us could tell, I think a lot of us kind of were aware of this all along. And now it is just magnified. It’s on a much higher scale. And it’s becoming apparent in the news. It’s becoming apparent to the general population as well.


And, you know, it’s not just poverty, too. I mean, I think one of the things that’s astounded me most about the COVID pandemic is how much anti-science rhetoric and how much willingness there is to believe misinformation. And I think that’s the thing that surprised me as much as anything, as much as any disparities is how much misinformation is out there and just is exacerbating the situation. And we saw that in Liberia during Ebola, too. And again, I kind of wrongly assumed that America wouldn’t have that kind of issue, that we’re scientifically literate people here. But clearly, I think that has been another aspect that has just really devastated our country.


BRANDY: Well, and I think that, so, I deal a lot with grief and death studies myself, and I did quite a bit of work, I was interviewed on NPR and in The New York Times when the crisis first hit here, having to deal with grief. And they were talking about how, oh, it’s so difficult to grieve. And I said, you know, one of the things that I think we are grieving that isn’t talked about is, we’re grieving a loss of an illusion. A lot of people have this very comfortable illusion that is just not true. And I do think that sometimes, in an attempt to preserve the illusion, you have people willing to believe all sorts of things that will keep that intact.


MUGELE: Yeah. And I was actually talking to my wife about this recently, how I think so many of us have just, you know, talking about the grief over the pandemic and our life has been disrupted as we know it and how devastating this has been to us and how much we suffer from this and realize that there are so many disparities out there. But that’s almost a privilege to have that suffering there because so many people and so much of our country has been aware of this for such a long time.


BRANDY: Mmhmm.


MUGELE: And it’s a privilege to be exposed to it for the first time during a pandemic, you know.


BRANDY: Right, yes.


MUGELE: It’s a little bit of a shock to be like, man, this is really a terrible situation we’re in. Whereas so many people in our country live in that terrible situation all the time anyway.


BRANDY: Well, for instance, someone saying, oh, I can’t believe that I’ve lost my freedoms to move freely where I want to and go where I want and do what I want.


MUGELE: Right!


BRANDY: And people with disabilities and people who are very, yeah, like this is life, you know! Where have you been?


MUGELE: It’s like man, the racial tensions in our country are astoundingly bad. And all of my Black friends are like, “Hey, where’ve you been?” [chuckles] This is like [inaudible; cross-talk] how people live.


BRANDY: Yeah, exactly. Because, right. And this is true. I mean, we have despite many strides which have been taken—and I don’t want to downplay the fact that many good things have come—we’re always on this precipice, this teetering edge of losing those rights.


MUGELE: Mmhmm.


BRANDY: And so, LGBTQIA+, individuals who are gender-nonconforming, who are nonconforming in other ways, who are disabled, who are racial minorities or fiscal minorities or minorities, all sorts of different aspects of this. The rights that they enjoy, we’re now seeing, in fear and panic, people wanna take more rights away. Instead of going, “Oh, they don’t have enough. We should expand access to medicine,” It’s more like, “Oh! Let’s take away even more from them.”


MUGELE: Right.


BRANDY: And I think that that’s, for my listeners who are in the UK, some of this is simply, it’s hard for them to get their head around. But it’s also a cautionary tale. The way that medicine is structured in this country means that my mother-in-law delayed treatment for colon cancer until it was almost too late because she was waiting to scrape up enough money to pay her premiums ‘cause her insurance isn’t very good. She has insurance, but it’s not very good. So, even having it does not necessarily mean that you won’t end up in all kinds of trouble. And so, it’s interesting to hear you talk about this from the perspective of someone who sees many of these cases coming into emergency rooms. I imagine you’re going to see more, am I wrong?


MUGELE: No, I think so. I mean, I think medicine is reflective of our society. And I don’t think we’re immune from anything, any of the disparities or any of the prejudices that society has. Maybe we like to think we are, that we’re better educated or have a more altruistic mentality. But I mean, the evidence is clear that we’re not. We have the same racial disparities. We have the same gender disparities. We just have all of the ills of society are evident in medicine. And I think as a lot of things change in our country and as a lot of the things that we fear are happening with, you know, like you said, some protected classes, currently as things get worse from them, I think that will be reflected in medicine. And they’re talking about repealing the ACA. And I mean, I trained during a time—


BRANDY: And for my, I’m sorry, for my listeners, the ACA being?


MUGELE: The Obamacare, the Affordable Care Act that essentially gave healthcare insurance to millions of Americans. And I think when I trained, I think the uninsured rate, there were about 60 million uninsured people, maybe 80. I can’t remember the exact number. And that got cut dramatically, and I think people started having a lot more access to care since then. But if we go back to a time when people don’t have insurance, that too, will predominately affect the poor, the working class, the minorities and immigrants and whatnot. So, I think we just have a horrible opportunity to see worse disparities coming down the road too.


BRANDY: Right. And we’ve just been talking about how a crisis makes healthcare disparities evident, ones that already exist. It also has the opportunity to make them worse, because, as you point out, if emergency room is already at capacity because there are a bunch of people sick with an epidemic or some other crisis, then the people who’ve been going there because they don’t have insurance are now going to be at the bottom of the list. It’s actually going to make things worse instead of better. And also because a lot of people lose their jobs as a result of a pandemic, and therefore lose their insurance.


MUGELE: And the people who are most dependent on their jobs—the hourly workers, the people who live paycheck to paycheck—are going to be the ones who are forced to go back to work or forced to work maybe under dangerous conditions are more likely to contract the illness. But also, you’re right. I mean, they’re the ones who have to rely on the emergency department for their care. And so, are we at capacity? Are they gonna get more exposed if they come to the emergency department?


I remember during the early parts of the pandemic, a lot of the messaging that hospitals was giving to the general public, my hospital included, was that if you don’t need to really, really, stay away from the emergency departments so we can protect our capacity for the COVID patients. And what ended up happening was people just delayed care. And so, we were seeing delayed presentations of heart attacks and strokes.


BRANDY: Right.


MUGELE: And again, those are also gonna affect poor people, minorities, people without insurance, immigrants. So, it’s not just healthcare disparities in this one categories. The health care disparities across the spectrum are gonna be worsened as well.


BRANDY: Right. And I think we’ll be wrapping up here shortly, and I really appreciate you spending your time with us today. But I wanna go back one more time to that point you made early on, comparing the way you approached, the way you understood, the Ebola epidemic in Liberia versus the way that you’re seeing COVID play out. And I think it goes back to that sense of privilege that you mentioned. We ourselves, practitioners of medicine, myself as the editor of a journal, we are also sitting in privileged positions which allow us to make what turn out to be erroneous judgments, right? Where we think, oh, well, this is happening over there to them because of these reasons, not realizing that we’ve been blinded to the sort of gaps and negative things happening in our own countries, simply because it hasn’t [inaudible; cross-talk].


MUGELE: Right. We’re not humble enough to learn the lessons from more impoverished nations, I think. And I mean, another example is I studied the earthquake response in Nepal after the big earthquake outside of Katmandu. And they had phenomenal coordination between their hospitals and the hospitals and the government system. And I mean, it was this remarkable coordinated effort to care for all the patients of that. And I don’t think, you know, I haven’t seen a lot of American or Western experts go into Nepal to study how they did their response and learning from that.


BRANDY: Right. No, no. As a matter of fact, almost a sense, I read an article the other day saying, why aren’t people talking about how well African countries are handling COVID?


MUGELE: Right! Yeah!


BRANDY: They’re doing a wonderful job, but no one’s talking about it because it becomes [inaudible; cross-talk].


MUGELE: I was looking at the country by country chart of patient numbers of COVID before this call, and India is doing a remarkable example. And they’ve got a billion people in worse poverty than we do. And why aren’t we going to India and asking to study how they’ve done this? So, yeah, I agree. I think there’s definitely a blind spot, a little bit of [unclear], yeah.


BRANDY: And it’s a big one. I hate to say it, but the whole white man’s burden idea is still alive and well even though it should’ve died a horrible death a long time ago. There’s still a sense in which white and Western things are privileged over other nations and cultures who, as you point out, we could be asking them, hey, how did you handle this? Hey, how better might we serve our communities, our public? And the fact that we don’t is, I assume, partly why we have to have these conversations and also why you’re working to develop this disaster medicine ideas, why you’re working to develop your own studies in your residency for emergency medicine. So, you know, it’s the future generations that we’re hoping will do better than what we’ve done.


MUGELE: I certainly hope so. I mean, I think that is the point of education. And I think we owe it to ourselves to get better representation in how we educate our future generations, but also just being able to focus on these concepts. I mean, I was never taught about racial disparities or really any significant healthcare disparities when I was in medical school or during residency. And so, I think we have to realize that this is our country’s greatest sin. But it’s also healthcare’s greatest sin right now is that we have not addressed this in a meaningful way.


BRANDY: Mmhmm.


MUGELE: And we have to make this part of how we teach, going forward in the future.


BRANDY: Right. And starting from a position of humility, I think, is so deeply important and something that medicine is not always very good at, and I think, also something America’s not always very good at, so.


MUGELE: [inaudible; cross-talk] very good at that either. Doctors are truly not good at saying, hey, we’ve done this really, really poorly.


BRANDY: Yeah, and it’s important. It’s important to admit that there are problems, are often the very first steps towards trying to find solutions. So, thank you again for coming on, Josh. I really appreciate it. Again, this is Dr. Josh Mugele, and there will be a transcript of our talk today. You should be able to reach it from our blog post that will attend this podcast. And once again, thank you all for being part of the conversation.


MUGELE: Thank you, Brandy, I appreciate it.





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