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AARON CAIN: Welcome to Profiles from WFIU. I'm Aaron Cain. On Profiles, we talk to notable artists, scholars and public figures to get to know the stories behind their work. Our guest today is Elaine Hernandez.
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She's a sociologist, health demographer and assistant professor of sociology at the Indiana University Bloomington College of Arts and Sciences. But those titles, sociologist and health demographer, are not meant to be looked at separately. Hernandez strives to blend those two disciplines and examine ongoing social issues in the sphere of public health, specifically the disparities seen between various social groups when it comes to health care. By specializing in social motivations, Elaine aims to understand who receives different kinds of health care, who distributes it and what are the systemic sources of bias and discrimination. Hernandez completed her undergraduate work at Notre Dame and received a master's in public health and doctorate of sociology from the University of Minnesota. Recently Elaine Hernandez virtually joined me over a Web conferencing in the WFIU studios. Elaine Hernandez, welcome to Profiles.
ELAINE HERNANDEZ: Thank you so much for having me, Aaron.
AARON CAIN: You are a medical sociologist. And it seems like another example of one of those fields that's way more than the sum of its two component words, medicine and sociology. So what is medical sociology?
ELAINE HERNANDEZ: So many years ago, I was a undergraduate student at Notre Dame. And I wanted to become a physician. And so I spent time doing an ethnography in the newborn intensive care unit. And I wanted to understand why is it that some of the families get such better care than other families in that newborn intensive care unit. And so while I really enjoyed learning about medicine, a part of what medical sociology does and actually medical anthropology - it helps you understand how it is that that patient provider interaction can shape the care that people receive. What sociology can bring to the table is how these broader social and structural factors can influence the care that people receive. And so this is really what got me started and what got me interested in medical sociology. And then from there, as you mentioned, the field of medical sociology is very broad. So, we could be studying something like the patient/provider interaction or we could be talking about the current events right now. What is it that is leading or contributing to the socioeconomic inequalities in health or racial and ethnic inequalities in health during the current pandemic?
AARON CAIN: Was there something specific that you witnessed or experienced during that internship that got you thinking along these lines?
ELAINE HERNANDEZ: When I was in the newborn intensive care unit there was a program called the Kangaroo Program. And this was designed for newborns who were preemies. They were separated into two separate rooms. And so for those who are very young, they're born very early, they were put in an incubator. And so we had no contact with them, but others were put in what was called the Big Kid room. And those babies were taken out of the incubators and they were put skin-to-skin. It's very common now. But this is a couple of decades ago. It wasn't as common. And so they were placed on your chest. That was essentially our job, which is a very interesting way to be an ethnographer. You sit in a room. You're holding an infant. And you're trying to help regulate their breathing, and everything. And then you can see what's happening within that big kid room. What became very apparent is that not all of the parents knew about this kangaroo program. They didn't all know that there was some sort of process where somebody could come in and could hold their baby. And they didn't know all of these other plans. Some of the parents were very knowledgeable. And they had so many tools at their disposal and other parents could barely get by. They could barely find the time to make it to the NICU. And so we could see just these vast inequities starting already in a NICU.
AARON CAIN: Were there instances where some of these parents who weren't aware that this was happening became aware that it was happening?
ELAINE HERNANDEZ: This is one of the quandaries for researchers. So my research now is not in ethnography. But it is problematic when you find yourself in these settings. And this is not the only time where you become a part of the research. And there were instances where we asked them about the kangaroo program or some other program. Then they wanted to know a little bit more. But in most of these instances people who were in some way socioeconomically or socially disadvantaged or structurally disadvantaged, having knowledge about these wasn't going to help the fact that they were just barely making ends meet.
AARON CAIN: Well, already I'm thinking about some of the things that are particular to medical sociology because you mentioned the pollution of one inserting themself into the experiment, something you don't want in the sciences in general. And yet, hearing already just this much of your description of your own experiences, it seems to me almost like you want that level of being able to relate to what's going on, especially when talking about ethnography.
ELAINE HERNANDEZ: As an ethnographer you do want to keep yourself separate from the research. You want to be an observer. Obviously you have to have some self-reflection about the way that you are changing interactions in the space in which you're occupying. But when I'm teaching my students I really do try to encourage them to draw from both their own experiences. So I guess - now kind of flipping into my role as a professor - for instance, last fall I had a community-engaged learning class. And I tried to replicate this so that students who wanted to go into medicine who are pre-med, they have the opportunity to get into some sort of health care setting. And so we were actually in Jill's House locally which is a memory care facility, a wonderful memory care facility. And I really encouraged them to think both about their own experiences and then to pay attention to what they're observing. And I think all of that is the part of the process of learning. If you are doing an ethnography you would be giving a great deal of attention to your role and trying to be more of an observer.
AARON CAIN: So, let's go a little further back. Let's start at Notre Dame. When you were making this shift what got you thinking along these lines when you're at Notre Dame?
ELAINE HERNANDEZ: My dad went to Notre Dame. And so I was just one of the kids who you see on campus who is put in a little cheerleading outfit. My sister and I had a chance to see the campus and we're pretty young. And then when I got a little bit older I just really felt comfortable being on campus. And so that was my goal, was to get to campus and my dad went there. My mom lived in married student housing. They actually had my older brother who was actually born premature and was in that newborn intensive care unit. And so you can kind of see how Notre Dame was very much a second home, but then also being in that newborn intensive care unit where my brother was born and cared for and then he unfortunately did not survive. He was born too early. It kind of was coming full circle. My dad is a physician. And so I've always been very interested in medicine. I think that I just became very interested in the social sciences. I was very interested in how we can answer some of these other questions that I wasn't learning in some of my classes going into medicine and going into medicine.
AARON CAIN: So then, after Notre Dame, you got your Master's in Public Health at the University of Minnesota. And when you were working toward that you briefly worked for the Minnesota Department of Health in policy and communication. So when it comes to public health, what did you learn during that time about the relationship between academic research and state-level policy decisions about health and about health care?
ELAINE HERNANDEZ: Sure. So my early time in public health was really shaped by some of the events that were occurring. And so, getting my MPH, there were the anthrax scares. And then there was quite a bit of attention to emergency preparedness to prepare for potential smallpox outbreaks. And so that was very influential for people who were getting their MPH at that time. There was a great deal of attention in kind of understanding that. And so, at that time I did get quite a bit of time and training under Mike Osterholm at the University of Minnesota. And so, he's been quite involved now with the current pandemic. He's always been beating the drum and warning us about pandemics, and so that was a very kind of formative experience. At that time what was very clear and very evident is that we really lacked clear public health communication. And this is very evident with the anthrax scare because fear was disproportionate to the risk. And that was very evident that it was difficult to try to explain this to people. And so in the past two decades what's been really fascinating to watch is that we've really progressed in our ability to communicate to the public with regard to risk. Right now there are just so many moving pieces that we can see how it's very difficult to communicate effectively. But that definitely shaped some of my experiences. And it is one of the reasons why I went to work at the Minnesota Department of Health. I worked closely with the health commissioner and then worked at times with the governor in Minnesota in trying to shape and understand how policy is developed at the state level.
AARON CAIN: Now, you mentioned that the ability to communicate improved. Does that mean that the communication improved?
ELAINE HERNANDEZ: It's very tricky because I do see that in comparison to where it was two decades ago the CDC has made efforts to work with risk communication specialists. So, for instance, one example is Peter Sandman and his partner Jody. They worked very closely with the CDC and with others, and so you can see that the guidelines are there for the CDC. The problem is, as this pandemic has unfolded, people haven't necessarily followed those guidelines that they have outlined.
AARON CAIN: Why do you think that is?
ELAINE HERNANDEZ: To a certain extent - and I've said this any time I've spoken about the pandemic with people - I returned to probably what Mike Osterholm would say in classes. And it was a bit frustrating at the time because we would talk about, “well, this is one scenario that would play out if we have a pandemic.” And then we'd say, “well, this is another scenario.” And he would kind of throw up his hands and he would just say, “these are just models,” you know, “I don't necessarily believe in these models. And life is a lot more chaotic and it's only as informative as the information that you're putting into those models.” And, as a student, when I was receiving my MPH it was very frustrating because you would want some definitive answer because you were there to learn. And at the start of the pandemic it all clicked. It became very clear that he was right that models are simply models. And we saw that at the very beginning of the pandemic when none of our models accurately predicted what was going to happen because there is so much unknown in the way that people are going to behave. And so, I think that to a certain extent there is going to be a level of chaos. And I think they then you have to be able to react and you have to be nimble and you have to be able to react to whatever is happening presently. So, to a certain extent, whenever I've spoken to people there are going to be problems that occur, even with the best laid plans. And there's so many reasons why that is, particularly in the United States. We have - most of our public health is actually dictated at the local level, so, at the community level, because they are best able to understand. If you think about the public health that's occurring, it's trying to ensure that you have clean water, trying to ensure that your food is safe. All of those - we have regulations, but most of what's occurring is at the local level. And then you have states that are going to help you with other kind of population level issues. And then you have the federal government like the CDC giving guidance. What ends up happening is that even though you have this decentralized system that can be really helpful most of the time, it can then be problematic when you have to come up with a system for everybody to operate. As others have written, we've had really a patchwork pandemic. And it's not been equal. We essentially have 50 different countries reacting to a pandemic in the United States.
AARON CAIN: And so that's what you mean by a “patchwork pandemic.”
ELAINE HERNANDEZ: Yes.
AARON CAIN: It seems to me that we have kind of a paradox that's inherent here, because we need to keep people as informed as possible. And yet it sounds like we can't always trust models straight away. We need to diminish panic and we need to make sure that we have consistent instruction. And to do so might be short sighted. I mean, how do we negotiate some of these contradictions?
ELAINE HERNANDEZ: I think that that's a very important point. And some of what my recent research - what I've been looking at with colleagues is how do people make decisions in the face of medical uncertainty. And most of the time we don't have this level of collective uncertainty. So, I often have used pregnancy as an empirical example. Not everybody is going to go through pregnancy at the same time. And so you have the opportunity to talk to a friend or to a sister, and you can say, “well, what did you do when you were pregnant?” But now we just have this significant collective uncertainty. And so nobody knows who to turn to. And I think that you're right that it's very difficult to convey that uncertainty and to offer, at the same time, reassurance. And I think that the best step forward, when you have this level of uncertainty, is to really be honest about it. And this is what some of the risk communication specialists are telling people: that we can't tell you with precision what's going to happen in August or what's going to happen in September. But we do know that there are steps that we could take to mitigate the spread of the virus during the pandemic. And we can look across different countries or across different locations to see what has been effective. We can't tell you in every situation that if you wear a mask or if you wear a face shield or if you engage in a specific behavior that your risk is going to be zero. We can give you assurances that if you engage in this behavior, and this behavior, and this behavior, your risks are lessened. And I actually think that that sort of communication, where you provide some level of certainty, you don't see that there is zero risk and you don't give assurances that the model is going to tell you exactly what's going to happen between now and December. But you do just tell people how to behave. I think that that level of certainty would be really reassuring to people right now.
AARON CAIN: I keep thinking of the phrase, “the beginning of wisdom is ‘I don't know;’” grappling with uncertainties and not seeing in binary, or black and white, or really definitive answers to things. So, in your own life, if you look back to from Notre Dame until so far, do you find comparable examples of you going from a certain young person to a more open-minded person comfortable with ambiguity? And, if so, how does that square with trying to give the most equitable and the most accurate public health guidelines possible?
ELAINE HERNANDEZ: That is a difficult question because I do not always practice what I preach. I would say that in my own life I seek certainty at all costs. And I see that both in gravitating toward research as a field of study, also in reaching out to trusted friends and family and other people in my network. So I most definitely do not practice what I preach with regard to this. I think that, though, over time what you learn, it's somewhat easier to describe this if you can imagine a picture and you have some event that's occurring in your life and the ball is a certain size. Let's say it's the size of an orange, or something pretty small. As you get older you just have enough life experience that your life experience is maybe the size of a basketball, or something. So that orange is just a small part of your entire life experience and so you, in retrospect, can look back and you can see that when I was twenty-five everything was this orange. That was all of the life experience that I have. Now I have something much larger to draw from and I become a little bit more okay with that uncertainty. If we just think about over your life course, you just have more experience over time.
AARON CAIN: But when it comes to dealing with something like a public health crisis, uncertainty isn't actionable. It's very hard to immediately act on uncertainty to say, “okay, everybody go out there and immediately be flexible and be ready to roll with whatever comes, because that's going to change.” That's hard to put into action at times of crisis.
ELAINE HERNANDEZ: And this is where if you see what epidemiologists or people who study population health - so my training is also in health demography. And we're looking at this collectively in kind of the population health. The goal of public health is to avoid putting the onus on the individual in every instance possible. So if we look at the reasons why life expectancy has increased in the United States - and really around the world, but just looking at the United States over the last century - the main reason why we have these increases in life expectancy is because of public health. And it's boring. I tell this to my students all the time. Back in my day it was E.R. or we could think of House or we could think of Scrubs or we could think of any number of medical stories that are really exciting and sexy. Public health is anything but. It is boring and it's boring to talk about cleaning water unless you go back and you talk about Jon Snow removing the pump and preventing outbreaks. But that's essentially what public health is and then developing vaccines. It's really not that exciting. But this is what we kind of have to go back to. And most of the time of public health is working correctly, you don't know about it. It's happening because people are creating a structure to protect you so that your decisions are not going to influence your health in any way. That's all taken care of and you don't have to think about it. That's why it's so incredibly stressful right now, because for our entire lives we haven't had to think about in most instances, is our water clean? Is our air clean? Now we have to think about all of these different factors that we really haven't had to think about. And for most people alive today we haven't had to deal with a pandemic like this and this level of uncertainty. And now what's frustrating is that we're putting those decisions on individuals. And we see this right now, even with school decisions, where these decisions in my opinion should be made among government officials, or these should be made at a higher level rather than having parents put in this very precarious situation where they're really making impossible decisions about what to do with their children.
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AARON CAIN: You're listening to Profiles from WFIU. I'm Aaron Cain. I'm speaking with Elaine Hernandez, a health demographer and assistant professor of sociology at the Indiana University Bloomington College of Arts and Sciences.
In your career so far, you've done a lot of investigations of social inequalities in health. What are some examples of these inequalities in health and how do they emerge and persist across so many generations?
ELAINE HERNANDEZ: I would say that a consistent theme in my research is looking at the role of education as a stratifier in the United States. And really, when we think about the opportunities that we have over the life course, so many of them stem from educational attainment. And over time, an educational degree has come to mean more. And, in fact, completing a graduate degree has come to mean more if we think about your prospects on the job market. But even something like - I tell this to my students at Indiana University all of the time - that education stratifies your social networks. It's stratified who you are friends with and who then - and we know that who you know is going to help you get a job. It's also going to help you on the marriage market; if you do choose to partner with somebody or to get married. And so we can see how education stratifies all of these life opportunities. And a lot of this influences the way that people behave, but also the environments, the institutions where they find themselves. Are you in a place where you have access to health care, or are you in a job that you do not have access to health care? And then, if we look at this, we can see that educational attainment really sets us on diverging paths that then lead to a different life expectancy. So people who complete a graduate degree or a professional degree may live on average a decade longer than people who, for instance, don't complete high school. And then we also see differences by gender, and then by race as well. But we can't see how education is really stratified in the United States, and that's not even talking about some of the racial inequities in health. Essentially what education is in the United States is - this is kind of our social class system. If we're thinking about how this is reproduced over time, you can envision how parents make - and again I tell my students that you want to be born to parents who are both very well educated. You want to win the ovarian lottery, because that's going to set you on, again, the same path. And we know that the early education is one of the reasons why parents across the country right now are really grappling with this decision of what to do with school. We know that early education is very, very important for children in kind of setting them on a path to their socialization. But then, also getting them into schooling and on a specific path over their life course. And really what's most influential for them is their parents’ socioeconomic status. So that leaves out a great deal of other inequities. But that's just one of the major stratifiers in the United States.
AARON CAIN: While taking education as an example, then, what are some of the things we can do to maybe rectify those inequities?
ELAINE HERNANDEZ: Most definitely we want to think about universal access to early childhood education programs and ensuring that, in some way, we make them equitable. And we see these inequities exacerbated right now with the thought of schools closing. Schools are - in many ways, even though they are imperfect, they are an equalizer because we do ensure that people are able to at least access schools. I think that funding schools would be really important. Funding early education, as well. Ensuring that the teachers and the students have what they need at their disposal so that they can learn in a healthy environment. I think all of those would be really, really sound investments. And what is fascinating is that scholars, and economists in particular, have looked at if you invest one dollar in early education today, this is going to pay off in the thousands in adulthood because people are able to get a job. People are not going to be in the criminal justice system. We're investing in them. A dollar now is going to pay off greatly it down the road. We're going to get really a big bang for our buck if we invest in early education for kids.
AARON CAIN: Now, you'd mentioned before about one of your mentors at University of Minnesota talking about various models, the case you mentioned, plugging different variables into models for something like a pandemic. Given what you just said about ways to address inequities in education to help with the similar disparities in health, given that, yes, early education is so important and yes early education right now in terms of an environment might be physically dangerous. At this time, so let's imagine then that we've had to close things, our early education has gotten about as inaccessible as it can get. What will that do to us in about 20 years' time, do you think?
ELAINE HERNANDEZ: So, I have a colleague here in the department of sociology at IU. And I study health inequalities. and she studies educational inequalities. And the parallels are uncanny. And so, right now she has been writing about - and we spend a great deal of time talking about what these educational inequalities will do, both for your outcomes more broadly, but then specifically for health outcomes. The optimistic answer is that this will be a relatively small blip on the radar for kids of parents who are privileged. I think that even if it is a relatively small blip on the radar kind of this life course of education that kids are receiving, I think that even if that is the case we will still see inequities and we'll still see some kids who are just going to fall behind and may be behind for an entire year. It's really hard to quantify those differences. I think that the more pessimistic response, if I were to be putting confidence intervals on this, perhaps, is that this is going to perhaps change the entire way that education is delivered; that we will have these widening inequalities that will just continue over time. What I do see on the horizon is that people are talking about inequities, both educational and then, from what I do, health inequities in a way that I've never seen happen. I would have to scream from the rooftops to try to get people to listen and talk about health inequities before the pandemic. And my friend who studies education would have to scream from the rooftops to try to get people's attention about these inequities. But people are listening now. And I really hope that this will translate into some broader acknowledgment and change and ways to kind of address these inequities.
AARON CAIN: I'm probably biased because I was taught from a pretty early age that Mother Nature tends to bat last, but hearing what you just said makes me think of almost perverse upsides to a pandemic, which is that a virus reveals weaknesses. If only in the immune system, eventually antibodies can be developed to resist such insidious infections in the future. It will lay bare shortcomings in the human body as well as, perhaps, the public health system, the body politic. Anything you can mention. I realize it's kind of a dark and overly poetic way of looking at it. But do you ever think about things in terms of the poetry and some of the weird, big picture ways, just to make sense of something like this? Because it just seems like when you're dealing with a pandemic, every new day brings its new inconceivable thing that we couldn't imagine happening that is suddenly the new normal.
ELAINE HERNANDEZ: I would say that we're still in the thick of this. And I still wake up. And I'm not going to lie. I study health inequalities because I have really dedicated my life to finding approaches to remedy them and to ameliorate them. So that's my objective. I want to do the best research that we can to try to ameliorate inequalities. And so, for those of us who study these inequities it can be very overwhelming to see them now laid bare. Because if you were to ask a population health researcher, a health demographer, a medical sociologist, anybody who's familiar with these inequities - so I have also been serving for the Indiana State Health Department, the maternal mortality review committee, which is just really another major health issue that we have right now. And I tell everybody that the reason that we see these higher rates of both infant mortality in Indiana - but in the United States - and then also maternal mortality, is because we have these population health problems. And so, pregnancy - what obstetricians and gynecologists have talked about is that pregnancy is really the first stress test on your body. And so it's a canary in the coal mine for other problems that we've seen over the life course. And so, this is one of the reasons why black patients suffer much higher rates of mortality and infant mortality. We knew that this was the case. And so then it's almost like a tsunami. The pandemic is a tsunami that's coming across the population. And we're just seeing everything happen collectively and so everything that we knew or that we would expect is playing out in precisely the way that we would anticipate. And it's happening all at once. I always try to stop and grieve and think about the fact that these are real people and these are real lives that have been changed. I don't think I'm quite over that hump to think about what are the positives in looking at the Black Lives Matter movement and seeing, just, this kind of collective spirit, and in looking at the kids and thinking they're going to grow up in such a different world than I ever would have anticipated for children right now. And I do think that over time there will be a lot of positives that emerge from this. One positive that isn't directly related to health inequalities but an acknowledgement that we have to pay attention to climate change, because some of what we are seeing right now is what will happen with climate change if we do not take very big steps to remedy it.
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AARON CAIN: Elaine Hernandez: health demographer and assistant professor of sociology at the Indiana University Bloomington College of Arts and Sciences. You're listening to Profiles from WFIU.
Another thing that did not seem to be quite as big of “a thing” before the pandemic was telehealth. Now I should come clean that I'm speaking to you right now, you are in your office, far away, and I am in a recording studio. And so we're already proof of that. This interview itself is being conducted remotely. But telehealth is something that - this is its moment, and it seems to have some upsides and some downsides which I'd love to hear your take on, in general. I'm also wondering what role it might play in moving forward in addressing something like health inequalities.
ELAINE HERNANDEZ: My colleague and I - we actually wrote something about this this past April. And we wanted to think about what are some of the positives of telemedicine and what are some of the negatives. And this is my colleague Tania Jenkins and she's out at the University of North Carolina, a fantastic colleague. And, on the upside, you're right. It can be more accessible. So, for instance, I had a tick bite this summer and I had a rash. And so I had to speak with a physician. And I went and had my blood drawn and they said it was positive for Lyme disease. And so one of our great local infectious disease physicians here actually had a full telemedicine through the health system point with me. And he was incredibly methodical he listened to me. It was a fantastic visit. It was great. And then you have to take a step back and realize, “well, I have all of these privileges.” I have a job. I have health insurance. When I speak with the health care provider and I tell them I am a professor, they treat me in a certain way. I am white. I have so many of these privileges that when I enter that encounter, it's very easy to forget about those - some of the downsides of telemedicine is that it could accentuate that mistrust that we have between the patients and the providers. And so, when I'm talking to the provider they have to trust some of what I'm saying. And they have to trust. So, just, for me, I show them a picture. And not to mention the fact that we have challenges in diagnosing Lyme disease in people who are black patients or people who have different-color skin. And so, we can just see how telemedicine can in many instances undermines that trust that you could get when having an interaction with somebody. In that instance, when a physician or a healthcare provider is seeing a patient, they may be more distrustful. And then the patient might also mistrust them for whatever reason. And so, this is where we could see implicit or explicit biases, which we know are already occurring in the health care setting, and then in the clinical encounter, really playing out and accentuated ways in that telemedicine encounter.
AARON CAIN: Now what's an example of something that could be exacerbated in terms of a previous bias in telemedicine situation?
ELAINE HERNANDEZ: So, actually, when I was getting my MPH I worked with a great researcher Michelle van Ryn. And this was at the V.A. Medical Center. And a part of what she was doing is studying these unconscious biases. And so, this is back before people were talking about unconscious biases. And it's really difficult to study unconscious biases because of the patient/provider confidentiality. It's difficult to get into that kind of clinical encounter and to kind of measure this. And so, one of the things that you can do is you can give people a clinical vignette. And then you can measure their unconscious biases. And, understandably, what people are saying now is we need to move past these unconscious biases. It's more than just unconscious biases. We have to think about systematic racism, and we have to think about this kind of structural racism. But it is informative to be able to measure and to understand that these unconscious biases are occurring. So, if we do this clinical vignette, a few of the examples that are really useful - one would be pain seeking. So if somebody presents at the emergency department and they, “say my back is hurting me.” And on a scale of 1 to 10 it's a 7 or it's an 8. It's very high. That is something where - you can't really measure pain, you have to go on what the patient is saying. And so the physicians are going to be on average more trusting of a white patient than they are of a Black patient. And they're going to assume - and then also low socioeconomic status. They're going to make assumptions about those lower socioeconomic status patients or those Black patients. And they're going to say, “you know, I think you're drug seeking.” And we see this play out over time at the population level. We see that they're much less likely to prescribe pain medication, even when, on average, they have the same levels of pain compared to white patients. So that's just one example of how that could play out.
AARON CAIN: And is the difference, then, just the remoteness? That because you're not in the same room with someone you're not connecting with them more as a person? They're more escapable, in a way, and so you can retreat into your biases?
ELAINE HERNANDEZ: If you're thinking about controlled substances, pain medication, anything that physicians are more cautious about in interacting with the patient, they're going to be on a heightened alert if they can't see you. And some of these interactions are not occurring face to face either. Some of them are occurring by telephone. So there's going to be a lot of questions. Am I talking to the right patient? What you see in all of these institutions - we see this in our criminal justice system and in policing, the way that we police people different depending on their race and their social position in our society. So, we're just going to police people differently if they come in for pain medicine if they are high socioeconomic status and if they're a white patient compared to other patients.
AARON CAIN: Are there any specific times you remember seeing this kind of bias happen right in front of you?
ELAINE HERNANDEZ: So, again, it's difficult to get access to that clinical encounter. What I've done is I've spent a lot of time in clinics over the past decade. And I've spent a lot of time interviewing providers. And so, arguably, you could say this is only one piece of the puzzle and we have to take this to triangulate. But if you're talking about some of this with health care provider, one of the clinics that I was in - again, this is with pregnant patients - the providers were saying, “well, in our community health clinic we have to ask everybody each time they come in, are you drinking? Are you smoking? All of these health behaviors each time they come in.” Because the grant that they had - and this is what the provider was telling me - the grant that they use requires that they need to have that information. Now the other clinic that I was in wasn't a community health clinic. It was a university center. It was higher socioeconomic status women. It was maybe mentioned in the very, very first appointment. “Do you drink? Do you smoke? OK. We're not going to worry. We're not going to talk to you about that. We know that you're not drinking. We know that you're not smoking.” And so you can just see, even in that encounter, that the people are just - their bodies, their actions, their behaviors are just policed so much differently.
AARON CAIN: You teach courses that help prepare pre-med students for medical college admission tests. So what sort of conversations are you having with them as they prepare to begin the long, arduous process of becoming physicians?
ELAINE HERNANDEZ: My students are just some of the best students. I mean they're not all perfect (laughter) all of the time. They impress me with their questions. They impress me with their desire to tackle some of these world problems. And I was really sad that we had to leave the classroom in March. That was very hard. I've kept up with some of them because I've been writing letters of recommendation. And so, in that capacity, and then even just finishing out the semester, what they're writing - medical schools are requiring - some of them are requiring a statement on the pandemic. And it's something that they can write about and they can say, you know, “I had an internship, but because of the pandemic I can't participate.” But what a lot of them are doing is using this to talk about how they are ready to dive in and to solve some of these problems. And it's very inspirational. And I think that what I tell them, both the undergrad, the premed students, but also the graduate students - because I've had some interactions and grad students coming to me and asking, “what do I do? I care. I want to become involved. I want to find a way to remedy some of these problems.” And so I just tell them, “get the skills now that can then be transferred into different settings because this is just one pandemic, right? You have to think about this long term. The skills that you are getting right now are going to help you prepare for whatever emerging infectious disease we have down the line.” This is sometimes hard to hear, hard to tell people. But we're living in an era of re-emerging infectious diseases. So it's HIV/AIDS. It's Zika. It's now the SARS. It's MERS. It's the current COVID pandemic. We kind of separate that SARS-CoV-2 from the first SARS epidemics in the early 2000s. And so this is going to be something where you have to get these tools to help us down the road.
AARON CAIN: But this is something that's always been intrinsic to the nature of viruses: that they go away. They change. They come back wearing slightly different clothing. And they'll be perhaps a bit more benign or perhaps way more deadly. Is this something that we have always had to be prepared for but we're just realizing it now?
ELAINE HERNANDEZ: I think that that's a really good question. The way that demographers and public health researchers have talked about the 20th century is that at the beginning of the 20th century people were more likely to die of infectious diseases, or because of infectious diseases. But with the rise of bacteriology and other public health efforts, along with vaccines, we see this decline. And people are more likely to die of chronic diseases. Now we may see a flip, and these are called epidemiological transitions. We may see a flip again here. But what's actually really interesting, and I think that your point is kind of hitting on here, is that many of these chronic diseases may actually stem from infectious diseases as well. So, some of these cancers - I mean we know that viral infections can predispose you for certain types of cancer, just as an example. But it may be the case that for other bacteria, or the way that your kind of microbiome develops as a kid, that all of these are actually set much earlier in life, and that these viruses or bacterium are - actually now we see fungi - that these could be kind of shaping your health more broadly. And then to add to that, we have to think of antibiotic resistance or antifungal resistance. All of these are going to continue to be issues. And so when we say re-emerging infectious diseases, it's really reemerging infectious diseases as the leading causes of death in the United States, and in many other countries, with the caveat that we don't necessarily know the etiology of some of those chronic diseases.
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AARON CAIN: You're listening to Profiles from WFIU. Our guest today is Elaine Hernandez, a health demographer and assistant professor of sociology at Indiana University in Bloomington.
One of the other bits of research that you've done recently was the effect of in-utero exposure to the 1918 influenza pandemic on infant and child mortality in the United States. Now, this is a subject that's come up a lot in the advent of the novel coronavirus pandemic: comparisons to 1918, 1919. These viruses are pretty close cousins when you think about the ones that originally were H1N1, and how that became H2N1, and various mutations that will completely change the effect of the virus on the human body when it emerges years and years later, when it will have some of the building blocks of the initial virus. And then you compare that to a novel virus and the devastation that it can wreak, because it is completely unfamiliar. What is your take on that? What lessons have you taken away when you comprehend, when you approach this novel virus? What takeaway do you have from the lessons of 1918, 1919?
ELAINE HERNANDEZ: I started this paper prior to the pandemic and never expected it to become so real and such a part of our daily lives. And I often thought about what was it like to live during the 1918 pandemic. One of the first lessons that I think we can all learn is that we look back on the mistake and scoff and say, “we would never do that again. I can't believe the people wouldn't wear a mask.” And here we are in reality. We're grappling with so many of the same problems that we had in 1918. And so I think that the first lesson is that we really need to look and listen to historians, and medical historians in particular, to understand how history is repeating itself in so many different ways. I think, as a public health researcher, that means that we are going to be studying the ramifications of this for really a lifetime. It could be for other future pandemics that emerge, depending on how we control them. And this is not just because of mortality, but also because of morbidity. Because we know that if we think about mortality, mortality is the tip of the iceberg. But underneath the iceberg we can think about the illness and everything that's going to be happening and causing disability for people as they go forward, as well as the other kind of short-term problems that they have in trying to get back to their daily lives. And then people have brought up questions about what are some of the long-term effects of being infected with the virus? We really just don't know. We're going to be studying that for a long time. And then that is kind of what led me to study these in-utero effects of the 1918 pandemic. So, this is based on research. And it's a field called the developmental origins of health and disease which really states that a lot of these processes that are occurring in utero can affect the way that people develop. And so if you are exposed – so, for in our paper, the three specific processes that we're looking at in terms of physiological processes, one is stress, which is a very big and important factor affecting in-utero development of the fetus. The second is undernutrition, and then the third is just infection with the virus. And so, we also know that those are intertwined, that it's difficult to separate those physiological processes. But we can get very creative about kind of separating some of those. But when we look at those three processes we know that those can have effect on the developing fetus. And, in fact, that's what we find in our study, too.
AARON CAIN: Wow. So they can aid and abet each other, too, though. Stress can probably make a growing fetus more vulnerable to disease as well. I mean, is that what you mean by it's difficult to separate them?
ELAINE HERNANDEZ: Right. So it can change these physiological pathways. And so, it's difficult to separate them because, in most instances, when you have undernutrition it's also a stressful event as well. And so it's difficult to disentangle: is it the stressful event, or is it the undernutrition that's causing these physiological differences in the developing fetus? And that's really difficult to disentangle. There are some scholars who've gotten very creative and actually use Ramadan as one way to look at this because Ramadan, you would assume, is not as stressful but you still see undernutrition. And so fetuses or individuals who were in utero in the first or second trimester during the month of Ramadan, they had different rates of illness or of morbidity later in life. And we can see these kind of measurable differences later on, compared to people who were in utero, maybe in the third trimester, during Ramadan, or who were not in utero during Ramadan. So we can get really creative about kind of looking at this. What we find in our research is that individuals who were in utero during the 1918 pandemic, we find evidence that there was culling, which means that during the first and second trimester, that more fetuses died in utero. And what we end up seeing is that the remaining cohort is smaller. But then we looked at were they more or less likely to die during childhood, so we can compare them. We use something called sibling fixed-effects model which allows us to get at some of the causal interpretation here. It's almost like a twin study design, so you're comparing twins., but this is a sibling fixed-effects model. And we find that the surviving fetuses, those who were exposed in the first and second trimester, were actually less likely to die in childhood. So that gives you some kind of information about what was happening in utero, that it was probably the weakest fetuses that died during the 1918 pandemic. And then the surviving cohort is smaller but healthier and less likely to die during childhood. And this is in the early 1920s up until 1930 when rates of child mortality were higher.
AARON CAIN: Given your research into 1918, do you have any projections, any gut feelings about what it might do to us socially, about how it might affect us psychologically moving forward, when you consider what it did or didn't do in the wake of the influenza pandemic of 1918?
ELAINE HERNANDEZ: I think that's a very interesting question. To answer that, I would look to the way that people have compared this pandemic to the HIV/AIDS pandemic because many people spoke about how, in the epicenter, when San Francisco was dealing with outbreak in the very early months, that they responded much differently. They had this - what we call a collective memory. They remembered what happened during the HIV outbreak. And I think that that really changed the way that they behave, because you see the physicians, a number of them were profiled at that time, and they were talking about the pandemic. You didn't see that in New York, which is interesting because New York was also an area where they were hit first. I think that it's difficult to predict. I do think that for children this will most certainly have an effect. I can't say which period is most formative. But this is going to make a big difference for kids and I think even for those who go into the classroom if they're going to be wearing masks or face shields or socially distant. I mean, that just completely shifts the way that they're engaging with each other. I do think that they're - kind of circling back to one of your other questions there, too - I do think that we will have some positive social changes. After 9/11, because people were not able to get into Manhattan or into New York to work, they were able to work more remotely. And what we saw is the companies allowed them to have what's called a flexible work arrangement. And that was the start of these kind of flexible work arrangements that we have. And so I think that we'll start to see that and in many ways that means that life is more accessible for people who were not able to travel, for people who had a disability, for people who had young kids at home, whatever the setup they have. In some ways our lives will become more accessible and more open. And I think that that is a positive that can occur and could potentially allay some of these psychological effects that we're seeing.
AARON CAIN: Now, you yourself are a parent. And at the risk of getting too personal, are there any effects, positive or negative, psychological or physical, that you're already noticing in your own children?
ELAINE HERNANDEZ: Most definitely. They crave more physical activity and attention with other kids. They miss their teachers. They miss their friends. They're close enough in age that they have bonded in ways that I never would have expected. And honestly that is one positive for me as a parent. We were recently visiting grandparents and they started to sleep in the same bedroom together. And now instead of whining at my husband and me to put them to bed they actually want to be with each other before bedtime. And it's a relief for us because it gives us a little bit of extra time. But it's also the most precious thing to see them together, and so close, and really helping each other - fighting, but also really helping each other. And I've heard that from a lot of other people, that siblings now that would have otherwise been separated into different groups and different grades or different daycares or preschools, they're actually much closer now. I think that that just personally I love.
AARON CAIN: You also teach several undergraduate courses in addition to teaching graduate students. Some of these courses include Health and Society, Health Behavior Analysis. You teach a course about American medicine and its inherent social problems. So I'm wondering about the trajectory of your students. First of all - maybe this is a pre-pandemic and post-pandemic sort of question that might have more than one answer - but I'm wondering what knowledge they're tending to bring to your class and what you really hope that they get from their course of study with you. What do you think the young students, young adults - whether or not they want to pursue medicine - what is it you want them to really get from these courses? What preconceptions do they have and what “post-conceptions” do you want them to leave with?
ELAINE HERNANDEZ: Right. Some of my friends have been using “the Before Times” and “the After Times” to distinguish. And I would say, in “the Before Times,” one of the most consistent comments that I would receive from students is that they want real world examples. They want to be able to apply what they learn in the classroom into the real world. And that's precisely what I want as well. And so, in many ways, that's where my students and I connect. We'll talk about a concept in the abstract, but then we'll spend a lot of time talking about how to make that real. And so, this is one of the reasons why I started this kind of community-engaged learning class. And it's because they come into my classes and some of them are EMTs. Some of them, they've already spent time - many, many hours or years - volunteering in hospitals. So, they can already bring something to the table. When I'm teaching them, I do everything possible to empower them, to really, really listen to what they bring to the table and also to learn about what's happening in southern Indiana. So, for the health behavior analysis class, I was teaching that a couple of years ago when the HIV outbreak was happening here in southern Indiana. And they had firsthand experience of friends who worked in clinics, or who were at greater risk because they were using opioids. And so, I think that there's a lot to learn. And there's so much that they can bring to the table. And I'm really grateful when they talk. I think in terms of kind of “the After Times,” everything that I've done to make life applicable in the real world is just going to be far more apparent in many ways. Especially in the start of the pandemic, I spoke with friends in a similar position to me who have a Masters of Public Health and were sociologists or demographers. It's just like everything just clicked. And we just said, “finally! Everything that we have been training for, everything that we want to do in the world we can - we know how to answer that question. We know how to help with this problem. We know how to connect these dots, and we know how to do this!” And so in some ways it's very invigorating, because now we can teach students, and we can actually say, “look, you learn this and it can help you right away when you leave this classroom. And you can go out and when you go into medical school you are well-prepared.” And I can't tell you how many students - I was one of the earlier professors who said, “you know, there's a chance they may close the university to help mitigate the spread or do some of this.” And some of them wrote back to me and said, “you know, we really didn't know what you were talking about. You're the only professor who said that.” But then they said, “but then we started to really listen to you because you kind of knew.” And I think that it's really useful because now they want to know everything. They're gobbling up all the information. And so I think these classes this fall are going to be great.
AARON CAIN: On some level that makes me amused. On some level that makes me sad. Because I think about students who have kind of a, shall we say, a distaste for the theoretical. And…careful what you wish for. Because now they see the everyday applications of this stuff in such sharp relief that, boy, I bet they rue the day they ever said, “gee, how does this apply to real life?”
ELAINE HERNANDEZ: (laughter) This is true, very true.
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AARON CAIN: Well, Elaine Hernandez, thank you so much for your work. And thank you so much for speaking with me today.
ELAINE HERNANDEZ: Thank you so much, Aaron. I'm very grateful.
AARON CAIN: Elaine Hernandez, health demographer sociologist and teacher. Elaine Hernandez is an assistant professor of sociology at the Indiana University Bloomington College of Arts and Sciences where she teaches and researches the structural forces that contribute to social inequalities in health. I'm Aaron Cain. Thanks for listening.
MARK CHILLA: Copies of this and other programs can be obtained by calling 812-855-1357. Information about Profiles including archives of past shows can be found at our website WFIU.org. Profiles is a production of WFIU and comes from the studios of Indiana University. The producer is Aaron Cain. The studio engineer and radio audio director is Michael Paskash. The executive producer is John Bailey. Please join us next week for another edition of Profiles.