Feb 2021: The Pandemic, Health Inequities, and Reckoning with Racism
The pandemic has undoubtedly been on your mind. And you are probably aware that African-Americans and other minorities have been disproportionately affected. Do you know how and why and the role that racism has played?
The pandemic has laid bare already existing inequities. As Dr. David Ansell, director of community health equity at Rush University Medical Center wrote, “An epidemic shows in a short period of time what’s been going on for hundreds of years.”
The current toll of Covid-19 on people of color is bleak. Black, Latinx, and indigenous Americans are twice as likely to die as whites. In our area, if you leave out the deaths related to long-term care residences, three of four of those community-related deaths occurred in people of color.
These disparate statistics didn’t appear on a blank slate. Before Covid, the Black death rate was higher with a resultant lower life expectancy. According to Gus Weserek in the New York Times, even though the pandemic has been causing the biggest increase in white mortality since World War II, “if black people were immune to the coronavirus, their death rate in 2020 would still probably surpass white people’s.”
Why do health inequities exist for Blacks?
Risk factors for serious Covid-19 illness include frontline jobs, crowded housing (which makes quarantining difficult), air pollution, no access to health care, and underlying conditions.
Why are these factors more common for African-Americans?
Segregated housing has a long history and has been enforced by laws going back to 1911, as well as extralegal means such as intimidation and restrictive covenants. One of the less admirable parts of the New Deal was housing policies enforcing segregation that became entrenched, raising barriers to Black home ownership.
There have been many discussions of segregation policies here in Charlotte, but you may not be aware that segregation has many effects on health. It determines socioeconomic status, prevents accumulation of wealth (as the main route to building wealth is home ownership), reduces availability of good jobs and schools, increases exposure to environmental hazards, and reduces access to healthcare.
Throughout the Covid-19 pandemic, we have been reminded that people with underlying conditions are more likely to experience severe disease and death. These underlying conditions include many that are more common in Black people, such as chronic kidney disease, heart disease and diabetes.
Again, this raises the question of why these underlying conditions are more common in Blacks.
I want to make a critical point here: there is nothing wrong with Black bodies. Most of the causes have little to do with genetics, but with what happens to Black bodies throughout their lives.
Among the underlying reasons for underlying conditions are lack of health insurance and poor access to health care. Chronic conditions that are poorly controlled are greater risks than if they are well-controlled. To use diabetes as one example, when I was in practice, I saw many people with diabetes. If they were able to come for visits and could afford their medications, I could usually get them under good control. But diabetics who cannot access medical care are more likely to run high blood sugars and be at higher risk.
Other factors that contribute to underlying conditions are socioeconomic determinants, i.e., nonmedical factors that affect health. These include education, poverty and lack of wealth. Even people who have middle class incomes may lack wealth.The median Black household has about 1/8 the wealth of the median white household. Wealth is what allows families to seek medical care if they have an unexpected illness. And, if they do seek medical care for a critical illness, wealth is what enables them to avoid financial devastation.
And then there is racism itself, which affects the underlying factors not only indirectly through the factors already mentioned, but directly. Blacks often get lower quality medical care, with less attention to their pain and access to fewer indicated procedures. Not surprisingly, they are more likely to avoid needed care. In 2017, NPR reported that 22% of Blacks avoided seeking healthcare due to discrimination.
Racism also acts directly on the body. Chronic stress, including that due to racism, causes increased stress hormones and chronic inflammation. It contributes to diabetes, obesity, depression, and high blood pressure. Note that some of these are risks for severe Covid-19 disease.
There has been considerable discussion of the lack of trust of the Black community in the healthcare system, most recently regarding reluctance to get the Covid vaccine. Many people are aware of the Tuskegee syphilis study in which Black men with syphilis weren’t treated even when treatment was available. But experimentation and maltreatment of Blacks has been far more pervasive.
People often ask what we can do to make Black people trust the healthcare system. The better question would be what we can do to make the healthcare system more trustworthy.
Some people talk about the two pandemics of Covid-19 and racial violence. These aren’t two completely separate entities. Violence, incarceration and policing are related to the Covid-19 pandemic. A few facts: Black men are three times as likely to be killed by police as white men. At current rates, one in 1000 Black men will be killed by police. African-Americans are incarcerated at more than five times the rate of white, and incarcerated people are more than four times as likely to get Covid-19.
The effects of violence go beyond the victims to include bystanders and families. Youths who witness violence are more likely to have PTSD, substance abuse, depression, and poor health. Children whose parents are incarcerated are more likely to have depression, PTSD, anxiety, asthma, and migraines. People who live in surveilled neighborhoods, which are more likely to be Black, are more likely to have high blood pressure, and obesity.
Note that many of these effects are risk factors for severe disease from Covid-19.
That’s the bad news. The good news is that this knowledge can lead to action.
With regard to health care justice, we should pass Medicare for All legislation. While it would by no means eliminate racial inequities, it would go a long way by giving everyone access to equitable, high-quality health care, affordable to individuals because there would be no charges at the point of service and affordable to the country because of savings in administration and drugs. In the short run, we should expand Medicaid in NC, which would help hundreds of thousands of people.
To improve health and resolve inequities, we must go beyond that with a broader agenda that includes education, housing, a living wage, criminal justice reform and addressing all the social determinants that affect health.
To address racism, we must name it and recognize where it is acting, however subtly or insidiously. We must teach our real history, recognizing the role that racism and white privilege and white supremacy have played in our schools and universities, as well as in our medical and health professional schools. In our healthcare workforces, as well as other institutions, we must move from diversity to inclusion to desegregation so that the workforce looks more like our country. Members of the majority must engage in some “cultural humility,” realizing that they are not asking others to simply join an existing culture, but to open up our institutions to appreciate the best of all cultures.
And we should consider Truth and Reconciliation forums and looking at restorative justice efforts, all of which are being discussed in our community.
With the awareness of the disproportionate toll of the pandemic on Black Americans and other minorities, and in the wake of the George Floyd protests, the largest social protest movement in US history, we have a moment. We can’t squander this moment, but need to harness the attention and use it not to move back to pre-pandemic life but forward to a country that lives up to the promise of liberty and justice for all.