January 24, 2022. Communications Manager Katie M. Kanagawa interviewed Dr. Mathew Kiang, Assistant Professor of Epidemiology & Population Health, about his current research on disparities in excess mortality during the pandemic, especially around drug overdoses, his latest work on how we can better prepare for wildfires and power outages, and his participation as a faculty mentor in the AHEaD program's inaugural year.
Can you start by telling us a bit about yourself? How did you get here (to Stanford Epidemiology & Population Health)? Was there something in particular that attracted you to the fields of science, public health and your area(s) of study?
Sure — I took a bit of a scenic route getting here. My mom and I immigrated from a refugee camp in the Philippines to San Diego when I was pretty young. We were poor so when I was growing up, education wasn’t heavily emphasized and a PhD was not even a consideration. But, thanks to social programs like Cal Grants and Pell Grants, I was able to go to the local community college and eventually transfer to San Diego State University. There, a couple professors introduced me to papers about social inequalities, and I saw a lot of my own personal experience in that work.
So after piquing my interest, a professor suggested I go to graduate school so I could do applied work. Even then, research still really wasn’t what I thought I would be doing. I just really wanted to get some skills and then go work at a nonprofit or local department of public health. However, while I was getting my MPH at NYU, I found out I really enjoyed doing research, especially applied research, and eventually that road led me to the doctorate program at the Harvard TH Chan School of Public Health, where I began to focus more on social epidemiology. After graduating, I came to Stanford as a postdoc and now I’m here as an Assistant Professor.
Let’s turn to your research. I understand you are currently examining racial/ethnic and socioeconomic disparities in excess mortality during the pandemic, especially around drug overdoses. Can you tell us about the disparities you have encountered in this work, and how we (as researchers, institutions, and individuals) might begin to address them?
Long before the COVID-19 pandemic, the US was experiencing surging drug-related mortality — especially from opioids. Then, COVID hit and, early on in the pandemic, people were saying this would be the “great equalizer,” but I think it was pretty clear to those of us who study inequalities that some groups were going to be disproportionately impacted. I was especially concerned with people who use drugs and how a long pandemic-related disruption might impact their ability to get treatment or potentially exacerbate underlying social and economic factors that push people to use drugs in the first place. So I worked with the California Department of Public Health to better understand what was happening with fatal overdoses: were they accelerating or decelerating, what substances were involved, where were they happening, who was dying, that sort of thing.
What we found was that drug overdoses in California in 2020 were way up — something like 44% higher than in 2019. This really appeared to be driven by synthetic opioids, such as illicitly-manufactured fentanyl, but deaths involving other substances, such as methamphetamine and cocaine, were also up. In absolute terms, this was driven by the non-Hispanic white population, but per capita, the non-Hispanic Black population was experiencing the largest increases and nearly double the non-Hispanic white population. Similarly, those with only a high school diploma had the highest rate of excess drug poisonings — over seven times higher than those with a 4-year college degree. It’s worth noting though that excess fatal drug overdoses were a small number relative to all excess deaths or all COVID-19 deaths. So I’m not saying lockdowns killed people — instead, what I’m saying is that lockdowns need to include social and economic supports that make seeking treatment or continuing treatment as easy as possible.
I think addressing these disparities will require a lot of effort on multiple levels over multiple timespans. In the immediate term, we need to improve access to treatment and reduce barriers to care. We have highly effective medications for treating opioid use disorder, but it’s underused by people who use opioids and especially among people of color. It should be easier to get treatment than to get illicit opioids and we should accomplish that by having very low barriers to treatment. Right now, we know that the barriers and incentives are such that communities of color often get the more burdensome medical treatments (e.g., requiring daily office visits) while more affluent patients are able to get low-barrier medications that are also less stigmatized. There’s also a huge urban-rural divide in terms of physical access to treatment. All that to say, how we address the addiction and substance use crisis will look different in different areas. Interventions must be tailored to the local communities, optimally by local grassroots organizations that have worked in these populations and include people from that local community, with funding and support from higher level government organizations.
In the longer term, it’s worth noting that the inequities we observed during COVID-19 (not just in poisonings but across all deaths) did not just appear in 2020. They’re the reflection of long-standing racial/ethnic and socioeconomic inequities that have resulted from a history of oppression and structural racism. Addressing those root causes will take pretty radical changes ranging from providing stable housing, free medical care, and more economic opportunities as well as increasing destigmatization efforts around substance use, reevaluating our drug policies and recognizing how they can be unevenly applied to propagate racial/ethnic disparities, reiterating the importance of stable housing for public health, and reassessing the role of the criminal justice system as a mechanism for enforcing and intervening on what are public health problems and not criminal problems.
You are also researching power outages and wildfires and how we can better prepare for them. Can you please give us an overview of this research? What is the important problem you are working to solve and how have you approached solving it? What do you ultimately hope to accomplish with this work?
For most of the population, wildfires and power outages are minor inconveniences, but for those immediately impacted and for medically vulnerable groups, they can be incredibly dangerous. This is a fairly new line of research for me but, in general, I am trying to understand two related aspects of wildfires and power outages. The first is population dynamics; that is, where are people when these events occur, where do they go as they occur, and when do they return? The second is about medical and social vulnerability. So among this population that is there or moving over there, who needs the most medical help?
Information around population dynamics and medical and social vulnerability are helpful in informing strategies for resource allocation and shelter placement, and prioritizing interventions. I’m a part of an organization called CrisisReady, and we work closely with government agencies, nonprofits, and departments of public health to do this type of research with the ultimate goal of being able to provide them with real-time (or near real-time) actionable information as disasters unfold. We’re using a variety of data sources to try to do this work, but it is important to note that we are trying to involve the people who will ultimately use this information at every step of the research and development process so that when we finally create a tool, it will actually be useful and used.
You served as a faculty mentor for the pilot year of our department’s Advancing Health Equity and Diversity (AHEaD) summer research program for college students from underrepresented and historically excluded groups in the health sciences. What did you love most, or find the most rewarding, about that experience?
There was so much to love about it. From the big picture perspective, studying inequalities is important, but ultimately what we want is to empower people who are experiencing inequalities with the tools and knowledge and agency to effect change in their communities. I think the AHEaD program is one concrete example of how Stanford is trying to empower a young generation of researchers to address these inequalities in their own communities.
My favorite memory from last year — I had an amazing mentee, Lanae, who grew up in Navajo Nation and continues to give back to her community there while studying at New Mexico State. We met weekly and would often write code together, and my favorite memory was the first time we did that. I had just shown her how to do a bit of data exploration and plotting and then asked her to try it on her own. This is all over Zoom obviously, but as soon as she hit the “Enter” button and her plot appeared, her face just completely lit up and she whispered, “This… is… magic.” It’s hard to imagine a more rewarding moment than preparing her for population health research and just seeing her eyes light up like she just gained a new superpower.