This is something new for us. We hear a lot of stories, many relating experiences outside our own that open doors to broader understanding of the many lives that make up the American experience. Today’s author, Fatima Adamu-Good, is an occupational therapist and writer with 15+ years of experience in research, diversity advocacy, urban design, quantitative analysis and cultural competency. As an advocate for diversity, equity and inclusion, she has collaborated with local and national leaders in the healthcare and non-profit communities to address systemic racism in clinical practice, delivered presentations on the detrimental effects of implicit bias in the academic sphere and published articles highlighting the experiences of people of color as they strive for success. She is currently an adjunct professor in occupational therapy at Thomas Jefferson University in Philadelphia, Pennsylvania.

Fatima told us this story in passing, and was kind enough to write it up. Thanks also to Stephanie MacKay for edits.

A Look at Clinician-Experienced Racism

One morning in early April of 2020, an occupational therapist walked toward the room of the newest rehabilitation patient at a skilled nursing facility in Southeastern Pennsylvania. She mentally reviewed information from the patient’s hospital chart*; race: White, gender: male, age: late 70s, weight: 185, height: 5’ 9”, past medical history: unremarkable, the reason for admission: fall with hip fracture and subsequent replacement. The therapist grabbed a rolling walker conveniently located next to the doorway, prepared for a standard intake process; this was the latest fall/hip fracture patient in a line of the many seen in a facility devoted to geriatrics. Upon entry, the patient seemed fatigued but well-oriented to his surroundings. He peered skeptically from smeared glasses and said, “Whoa! What’s going on with that hair?!”. The therapist, taken aback, reached up to touch her afro, styled the same way it was every day. The next morning, her supervisor informed her that the patient had requested non-African-American rehabilitative and nursing staff because he “had difficulty understanding the instructions” of African-American staff.

That therapist was me.

What are the economic consequences of the above anecdote? There is a financial cost to attitudes and policies colored by racism as the 2020 Peterson and Mann report on the economic impact of inequality makes clear. African-Americans currently make up 12.8% of the country’s population and the cost of their exclusion from higher education access equates to $90-$113 billion from 2000 to 2020. Such encounters as the one I experienced undermine remedial initiatives that increase the quality of care for African-American patients. The percentage of African-American physicians is currently 5%, less than half the overall population share. The avoidance of preventive care services accounts for 75 percent of national healthcare expenditure and reduces economic output by $260 billion a year. Efforts to increase national figures for African-American doctors, such as the $100 million contribution to historically black medical colleges by former New York Mayor Michael Bloomberg, could also reduce economic opportunity barriers while buoying GDP.

A 2020 cross-sectional survey in the Journal of Family Medicine found that twenty-three percent of the 71 physician participants reported a patient directly refusing their care due to race. It concluded that physicians of color experienced significant racism while providing health care in their workplace and were likely to feel unsupported by their institutions in which they practiced. Another study, in 2007, of minority medical students, showed a correlation of racial bias with burnout and depression symptoms in 48% of participants. Before its 2008 apology, the American Medical Association failed to address 100 years of the racial inequalities African-American physicians faced, and excluded them from vital organizational conversations. African-Americans are underrepresented amongst the management that determines patient-handling policy, the business people who fund these measures, and the professional staff that control who enters educational institutions and higher-wage occupations. The aforementioned structural imbalances need to be remedied to ensure that income gains fostered by the growing share of African-Americans physicians, and the companion better health outcomes for their patients, are not eclipsed by sidelining and burnout.

The CDC reports that deaths from the Sars Cov-2 virus in racial minority groups are more than 50% higher than in White or Asian persons residing in the United States. This surge in deaths has a resonance with another set of findings with economic roots and ramifications for an entire demographic category. The 2015 Case and Deaton paper chronicling a marked increase in mortality for middle-aged non-Hispanic White working-class people identified educational attainment, access to mental health services, and availability of stable work as life and death determinants. Louisiana, one of the ten U.S states with the highest African American population, demonstrates a microcosm of a larger pandemic pattern: African American Covid19-positive patients had a higher prevalence of conditions manageable via preventative healthcare services such as obesity, diabetes, hypertension, and chronic kidney disease. These patients were also three times more likely to have Medicaid insurance than white non-Hispanic patients. The Affordable Care Act (ACA) has made a dent in the country’s uninsured numbers and could be critical in addressing inequities in care-access; between 2013 and 2016, the ACA’s expansion of Medicaid lowered the uninsured rate for non-elderly African Americans from 18.9 percent to 11.7 percent.

In other, heartening, news, there has been a marked increase in African-American applicants to medical schools since the Covid-19 pandemic began. If the face of healthcare is more representative of the communities most in need, it equates to increased traffic through a clinic’s halls and consequently an increase in revenue along with quality care. Many potential African-American patients avoid utilizing preventative care services for fear of discriminatory treatment. A Stanford study reported higher communication levels between African-American male patients and doctors of similar ethnicity, extrapolating conclusions to indicate better cardiovascular health outcomes for such patients by 19%.
When an incident of overt or covert racial bias against a clinician does occur, current institutional methods of redress are lacking.

Any ameliorative strategies to address the racial inequalities created in our centuries-old simmer, fueled by bias and frustration and detailed in this research note are rendered toothless if framed as ethical issues or limited to philanthropic gestures. Much of the literature reviewed for this article framed the racially biased patient phenomenon as an ethical dilemma, left to be either addressed or more often ignored by White senior physicians, clinicians, or administrative staff. Targeted and purposeful investment is critical in order to achieve the best economic outcomes framed by years of research that repeatedly concludes that income inequality and race have wide macroeconomic consequences. The Covid19 pandemic has made it clear that all these factors are intimately intertwined. Now’s our chance to restructure a society-wide foundation offering broader economic opportunity while building resiliency and better health outcomes for those who have been excluded and underrepresented.

The scope of the pandemic-related public health crisis has brought many societal inequities into stark relief, none more glaring than the impact of racial disparities on physical and economic health. I have experienced the drain that racism has on institutional resources and the quality of healthcare first-hand. My supervisor chose to reassign the White male patient to the caseload of a less-credentialed therapist simply because they were White and not because they were more qualified to treat him. As a daughter of Nigerian-American parents, I was taught to excel at everything I do, for better or worse. Can you imagine the sense of betrayal at the realization that my good faith efforts to learn these valuable skills, years spent hunched over textbooks working six and seven days a week to pay for graduate school, were put in jeopardy by racism?

A 2016 survey of 400 White medical students and residents found that 50% believed that African Americans felt less pain due to thicker skin. I sometimes wonder if patients, colleagues, or superiors presume the same about me, that I am impervious to physical, psychological, and emotional pain. I do not have thicker skin, but I am angry and weary of institutional injustice that disproportionately hurts so many, which this pandemic can no longer let us deny. Feel my anger, know my anger, respect my anger. And join me, even in the smallest of gestures, to collectively channel that anger towards meaningful change. I am hopeful that more of the collective will begin to understand that to hinder one is to hinder us all.

Further reading/References:
https://www.msn.com/en-us/news/other/surge-in-african-american-medical-school-applicants-drive-to-action-by-covid/vi-BB1dslXB

Bloomberg Gives $100M to Historically Black Medical Schools

https://www.census.gov/library/stories/2018/03/graying-america.html
Hospitalization and Mortality among Black Patients and White Patients with Covid-19. https://www.nejm.org/doi/10.1056/NEJMsa2011686

https://www.aamc.org/data-reports/workforce/interactive-data/figure-18-percentage-all-active-physicians-race/ethnicity-2018

Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proceedings of the National Academy of Sciences of the United States of America. http://pnas.org/content/113/16/4296.abstract
Does diversity matter for health? Experimental evidence from Oakland. https://siepr.stanford.edu/research/publications/does-diversity-matter-health-experimental-evidence-oakland
Williams, D. R., & Rucker, T. D. (2000). Understanding and addressing racial disparities in health care. Health care financing review, 21(4), 75–90.

www.cdc.gov/nchs/fastats/white-health.htm

https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=3&lvlid=61

https://www.census.gov/popclock/

https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/413324

https://www.bls.gov/cps/cpsaat11.htm

https://www.cdc.gov/404.html

https://journals.stfm.org/familymedicine/2020/april/serafini-2019-0305

Closing the Racial Inequality Gaps: Long-term Economic Effects of Racism – Dana Peterson and Catherine Mann, Ph.D.

https://www.cdc.gov/404.html

‘Deaths of despair’ are rising. It’s time to define despair

www.statista.com/statistics/200970/percentage-of-americans-without-health-insurance-by-race-ethnicity/

This morning’s report on consumer confidence from the University of Michigan graphed the share of respondents reporting income gains as the reason for improved personal finances by income tercile. Although the trendlines remain sharply down for all three, the top tercile is climbing, with 44% mentioning income gains in early February, while the second and third continue their slides, with only 17% of the third tercile mentioning gains, the lowest level since 2014. Fifty-four percent of the top tercile reported their finances have improved, compared with 23% in the bottom third.

And that partisan divide just keeps growing. Overall the index slipped to 76.2 in early February from January’s 79; was basically unchanged at 86.2 v. 86.7 for current conditions; while expectations fell about 4 points to 69.8.

Within that, after rounding, the overall index among Democrats was unchanged at 90, down 1 point for Independents to 76, and down 6 points among Republicans to 64. Little change in current conditions among Democrats, 86, but Independents rose 5 points to 86, which cancelled out the 7-point fall among Republicans, 92. Same old unchanged for Democrats in expectations, 92, while Independents fell 5 points to 69, as did Republicans, but to 46.

Given his thinking that the new round of relief payments will reduce stress among those with lowest incomes, Richard Curtin found it “more surprising” that the outlook fell among consumers, but it’s far from a unanimous decline.

It was encouraging to see solid gains in manufacturing & construction in the most recent payroll numbers, occupations listed as more stable, and therefore safer. Back in spring the idea was to get such work rolling again, while skipping the stop at a bar on the way home. We’re hitting the reset button on that.

That may help get the pandemic under control, but it is going to hurt minority workers, as shown in Friday’s jobs report. The Household survey is jumpy, but the number of employed men rose, while the number of employed women fell. Within that both White and Black men gained jobs, as did White women, but Black women lost jobs, as did both sets of Latinx workers, and Asians, not broken out by sex. Gains were large enough to lift employment-population ratios for White women and Black men, while losses were enough to cause declines for Black women, Asians, and for Latinx men and women.

In 2019 women held 29% of manufacturing jobs and, within that, 39% of medical manufacturing and animal processing, 46% of sporting goods & toy manufacturing, and a little over half of textile manufacturing. Asian workers had a 7% share, but 29% of computer equipment; Blacks, 10%, and close to 20% of auto and pulp manufacturing; and Latinx, 17%, including 40% of fruit and vegetable preservation. Both Black and Latinx workers have close to 20% share in tire manufacturing, and 22% and 35% shares in animal processing plants.

Manufacturing employment is still down 4% over the year, less than overall employment’s -6%. We sometimes include a graph of the three-month average of manufacturing withholding in a classic Midwestern state. Here’s what that looks like these days:

Alexander Morse, researcher at Rockefeller Institute, reports CO₂ emissions will fall 5% this year. CO₂ has fallen by 20% in Wuhan, while microscopic atmospheric debris fell by 71% since March 24th in India.

Neither Morse, nor we, are suggesting this is the solution to our ecological problems, or that we focus on anything outside health and relief right now, but such a dramatic reduction is important knowledge.

(Pioneer 10’s images of Jupiter, from NASA, where everything is free.)

For the future, we could try carbon-cost programs. Some estimates of social costs per ton run to $400: The Obama administration estimated between $42 to $62 per ton; the Trump administration between $1 to $7 per ton.

So let’s turn to the states, where initiatives have generated about 50% of growth in renewables. And not a zero sum: Between 1970 and 2017 a witch’s brew of pollutants fell by 73%, while GDP grew by 270%.

If you can see the western sky this evening, look for red giant Alderbaran blazing to the left of Venus.

If all is well, Pioneer 10, launched in 1972 & last heard from across 7.6B miles in 2003, is still heading out. Weighing <600 pounds, carrying pictures of a man & a woman, the solar system, and how to find us relative to 14 pulsars, it should pass Aldebaran in 2 million years. We know how to do this stuff. Analysis here: https://rockinst.org/blog/coronavirus-has-improved-air-quality-what-does-that-mean-for-climate-policy/ Cool graphic: https://www.space.com/nasa-satellite-air-pollution-us-northeast-coronavirus.html

The Washington Post’s Dana Milbank writes that one of the largest provisions in the relief bill, a $170 billion tax giveaway, “appears to be tailor-made for wealthy real estate investors like Donald Trump and his son-in-law Jared Kushner.” That’s more than the $100 billion for hospitals, and the $150 billion for state and local governments. While we are all wondering why the pandemic should allow these guys to write off losses from before the pandemic, as in 2018 and 2019, we thought we’d dust off another snapshot of shameless greed, our review of a NBER paper on pre-tax profits in tax haven and non-haven countries. graphs snapped from the paper.

According to standard explanations, the low and declining corporate tax rate around the world is the result of jurisdictional competition in a globalized world—offer a friendly tax environment or corporations will move. A new NBER working paper by Thomas R. Tørsløv, Ludvig S. Wier, and Gabriel Zucman (TWZ), says otherwise: multinational corporations (MNCs) are shifting an enormous share of their profits to low-tax havens without moving a single capital good. According to the authors, contrary to economic theory, “[i]nstead of increasing capital stocks in low-tax countries, boosting wages along the way, profit shifting merely reduces the taxes paid by multinationals, which mostly benefits their shareholders, who tend to be wealthy.”

A striking example of how this works: a couple of years ago, Google was booking close to $20 billion in revenues in Bermuda, a country it does almost no business in. That’s a striking example of how this sort of high-end tax avoidance works, but how big is it? TWZ attempt an estimate by scrutinizing the accounts of the havens. Their conclusion: close to 40% of MNC profits is shifted to tax havens. The biggest avoided jurisdictions are in the EU, and the biggest shifters are disproportionately based in the U.S.

One of the ways TWZ estimate the shifting of profits is by comparing corporate profits to wage bills by country. The average for non-haven countries is 36% (that is, pretax profits are 36% of the compensation of employees); for the U.S. it’s 31%. In Luxembourg, the figure is 258%; in Ireland, 242%; in Puerto Rico, 229%. Singapore and Hong Kong are around 100%. For some U.S. firms, profits are over 500% of the wage bill. None are this high because of massively high productivity; capital stocks are relatively low. Almost all the big profit numbers are from tax-shifting. Techniques include manipulating the pricing of intrafirm transfers (exporting to haven affiliates at low prices, and buying from them at high one); dummy loans from overseas affiliates, which produce big interest deductions in the home country; and locating valuable intellectual property offshore and paying high but economically meaningless royalties to the low-tax subsidiary.

The hits to revenue are large. TWZ estimate that tax shifting costs the EU 18% of its corporate tax revenue; the U.S., 14%; and developing countries, 7%. For the world as a whole, the loss is 10%.

All this movement of money plays havoc with macroeconomic statistics. For example, TWZ point out that the already-reported rise of the capital share of national income in the EU is probably understated. (They refer to estimates in a 2013 NBER paper by Loukas Karabarbounis and Brent Neiman, which found a steady decline in the labor share of national income in most parts of the world, with Japan and core EU countries (other than the UK) outdoing the U.S.) And reported current account deficits look worse than they should, because of all the accounting games. Adjusting for tax shifting, Japan, the US, France, and Greece would have had trade surpluses rather than deficits in 2015, and the U.S. deficit would have been reduced by a quarter.

Currently, most international tax disputes are between the high-tax countries; the low-tax ones get barely any attention. That doesn’t seem like a good use of resources.