“Not everything that is faced can be changed, but nothing can be changed until it is faced.”
—James Baldwin in No Name in the Street
The COVID-19 pandemic is a historic public health disaster that has occupied the attention of individuals and communities across the globe for over two years. The level of disruption caused by the spread of the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and its associated variants have been monumental as nearly all health, economic, and social institutions have been impacted. As we write these words, the number of deaths associated with COVID-19 approaches 1 million in the United States and the cumulative toll associated with this loss of life to surviving families, peers, and communities is incalculable. The burden of adverse outcomes related to COVID-19 has not been equally distributed in the United States, and long-standing inequalities have been laid bare by the destructive force of this infectious disease. African Americans have been more likely to be hospitalized for and die from COVID-related conditions than other groups in the country. Early explanations for these racial disparities focused on underlying health conditions such as obesity, diabetes, hypertension, and cardiovascular disease. It’s true that pulmonary, metabolic, and immune system diseases are associated with COVID-19 onset, progression, and death; however, the presence of these conditions does not fully explain the excess risk for SARS-CoV-2 infection among African Americans.
It has been nearly four decades since the release in 1985 of the Report of the Secretary’s Task Force on Black and Minority Health that sparked and fueled early research studies that have grown into the robust fields of minority health and health disparities research. Yet disparities in the burden of death and illness referenced in the report remain despite advances in medicine, science, and technology. Multiple factors contribute to racial health disparities, and patterns associated with COVID-19 among African Americans bring them into clear focus. This essay will highlight these factors, specify their contribution in a context of infectious disease transmission, and introduce collective opportunities to decrease future risks among African Americans and other marginalized populations in the United States.
Racist Structure Formation and Disease Risk among African Americans
Health conditions like COVID-19 are often presented in both scientific and non-scientific literature as personal phenomena related to individual-level factors such as genetics, biology, and behavior. Each of these factors contributes to risk, onset, and progression of disease; however, they often operate within and are influenced by the surrounding social environment. Social factors were largely absent from the medicine and clinical science literature until leading agencies like the World Health Organization (WHO) began to acknowledge non-medical factors that influence health outcomes in the early 2000s. According to the WHO, these factors, commonly referred to as “social determinants of health,” are “conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life.” Race is a major social factor influencing health and quality of life among African Americans. Race is a sociopolitical construct that has been used to establish, justify, and maintain a hierarchy in which African Americans are often unfairly disadvantaged in the effort to seek life, liberty, and the pursuit of happiness as enshrined in the Declaration of Independence. Racial hierarchy is a central component in the formation of the United States as chattel slavery rendered generations of African Americans as property for nearly 250 years. This brutal system of oppression, exploitation, marginalization, and suffering shaped the development of social, economic, political, scientific, and health-care institutions, and concretized racial inequities that contribute to elevated disease risk among African Americans.
The salience of social institutions and environments for health outcomes is not new. Scholars began to make these connections during the middle and late nineteenth century. Dr. James McCune Smith, an abolitionist and the first African American known to have a medical degree, was a leading voice among medical professionals who asserted that health was a function of intrinsic membership in groups formed by a race-structured society rather than innate constitution. This argument was among the first to link racial health disparities to an American caste system founded on racial inequality operating within and across local and societal institutions. Scientific support for this idea was provided by Dr. William Edward Burghardt DuBois when he published findings in 1899 from his comprehensive study of African Americans living in Philadelphia. The Philadelphia Negro presented evidence from analysis of qualitative and quantitative data that demonstrated that racial disparities in mortality could be explained by social factors (e. g., employment, sanitation, education) and not innate traits or tendencies. DuBois replicated this approach to study African Americans in Atlanta and results from this line of research identified and specified how discrimination, oppression, and white supremacy are related to excess risk for illness, disease, and death in African-American communities. The early work by Smith and DuBois established structural racism rather than race as a primary contributor to racial disparities in health outcomes. Drs. Theodore M. Brown and Elizabeth Fee invoked words from DuBois in a presentation at Eleventh Atlanta University Conference that made this position clear.
We might continue this argument almost indefinitely going to one conclusion, that the Negro death rate and sickness are largely matters of condition and not due to racial traits and tendencies . . . With the improved sanitary condition, improved education and better economic opportunities, the mortality of the race may and probably will steadily decrease until it becomes normal.
The words and work of Smith, DuBois, and others were largely ignored for nearly a century. Few studies focused on African-American health, and the bulk of such work was founded on the premise that poor health outcomes among this population was a function of biological, intellectual, and moral inferiority. These racist notions were used to justify the second-class citizenship of African Americans that restricted access to public health systems and health-care providers. Racist policies and practices were eventually replaced with civil rights legislation after long-standing social movements established the full citizenship of African Americans. But the damage from generations of oppression and marginalization was considerable and continues to perpetuate racial disparities in risk for illness, disease, and death.
Structural Inequality and Excess Risk for COVID-19
African Americans experience unfavorable social and economic circumstances emerging from structural racism, discrimination, and other forms of unfair treatment like no other group in U.S. history. The social landscape for many African Americans continues to be characterized by restricted employment opportunities, substandard educational resources, inadequate housing, family disruption, general disorder, pollution, and danger. Airborne infectious diseases like COVID-19 are highly transmissible among residents in marginalized communities because exposure is influenced by factors such as occupation, transportation, and housing density. African Americans make up a significant segment of individuals living in densely populated areas and households where their neighbors or family members are employed in “essential” occupations (i.e., food/agriculture, transportation, manufacturing, facilities) that involve close contact with people in environments with poor ventilation. Frontline positions in these occupations tend to have demanding schedules with little flexibility to adhere to handwashing and physical distance protocols, and virtually no authority to enforce mask wearing among clients, customers, and coworkers. The effort to stay employed and care for themselves and their loved ones increased exposure to SARS-CoV-2 and contributed to the disproportionate rate of COVID-19 infection, disease, hospitalization, and death among African Americans and other financially challenged populations.
Structural inequality is also associated with disproportionate COVID-19 susceptibility among African Americans because instability in employment, transportation, housing, and insurance was exacerbated by the pandemic. The confluence of structural pressures significantly restricted the ability and capacity of individuals in marginalized communities to acquire necessities such as food. Deficiencies in micronutrients emerging from food insecurity can limit immune responsiveness, thereby increasing susceptibility to COVID-19. Patients with low vitamin D levels were found to be more than 1.7 times more likely to test positive for COVID-19 than persons with normal vitamin D levels. Vitamin D deficiency was already more common among African Americans prior to COVID-19 and undernourishment resulting from food insecurity further compounded risks for poor health outcomes. Serious consideration of COVID-19 among African Americans presents an opportunity to observe how structural factors can get under the skin to impact health.
Arrested Development and Prospects for African Americans
Over two years have passed since the first case of SARS-CoV-2 infection in the United States was documented, and exhausted citizens, health professionals, and policymakers have not come together to provide a clear plan for life with COVID-19. Currently, COVID-19 cases, hospitalizations, and deaths have declined steadily after the peak of the Omicron variant infection. Mitigation strategy discussions have declined, and COVID-19 case count reports are more difficult to find. COVID-19 testing and vaccines are a highly divisive topics, and political pressure has been mounting for policymakers to move on from COVID-19. It is notable that African Americans have been largely supportive of COVID mitigation strategies like masking. During the early stages of the pandemic, 82 percent of African Americans reported wearing masks in public spaces with other people. Stalemates in Congress have prevented the passage of bills to continue funding to subsidize vaccines, booster shots, treatments, tests, and high-quality masks. The White House released a statement on March 22 indicating that failure to continue funding for COVID-19 response efforts “will have severe consequences as we will not be equipped to deal with a future surge. Waiting to provide funding once we’re in a surge will be too late.” Several COVID-19 programs have been discontinued, including the Health Resources and Services Administration (HRSA) COVID-19 Uninsured Program that reimbursed health-care providers for expenses associated with providing COVID-19 testing and treatment services and vaccine administration to uninsured individuals. This HRSA program stopped accepting reimbursement claims for COVID-19 testing and treatment services on March 22, 2022 and vaccine administration on April 5, 2022. Payment for COVID-19 tests, vaccines, and services have been transferred to individuals, making millions of people without adequate health insurance less able to protect themselves from COVID-19 and get medical care if they need it.
African Americans make up a substantial segment of individuals who are uninsured or underinsured and lack of health insurance is often not a function of individual choice. Private insurance can be expensive, and employers in sectors where African Americans have jobs often do not provide health coverage. The Affordable Care Act reduced the number of African Americans without adequate health coverage during the early years; however, these gains have been largely erased over the past five years. This erosion can be attributed to policy changes reducing access to and enrollment in coverage. Frank J. Thompson, Kenneth K. Wong, and Barry G. Rabe in Trump, the Administrative Presidency, and Federalism outline how the Trump Administration sabotaged the Affordable Care Act after congress failed to repeal it. Reducing outreach and opportunities for insurance exchanges, elimination of the individual mandate, and termination of cost-sharing subsidies were part of the effort to undermine the effectiveness of the Affordable Care Act and hold back health-care insurance reform. The persistence of barriers to health insurance coupled with the elimination of subsidies for testing, vaccines, and COVID-19 services leave millions of African Americans vulnerable to the health and financial devastation often related to COVID-19 onset, progression, hospitalization, and death.
The Fierce Urgency of Social Justice and Health Equity
The WHO defined health in 1948 as the “the state of complete physical, mental, and social wellbeing and not merely an absence of disease or infirmity.” This same organization nearly 40 years later indicated that everyone should have access to a wholesome, healthy life. In the four decades since that pronouncement in 1985, the Centers for Disease Control and Prevention (CDC) has identified health equity as a goal in Healthy People 2020 and 2030. According to the CDC, health equity is “the attainment of the highest level of health for all people.” Racial disparities in COVID-19-related outcomes are stark reminders of poor health status and constrained life chances of African Americans and other historically marginalized populations. Serious pursuit of health equity requires that everyone’s life is valued equally with an emphasis on comprehensively addressing historical and current injustices, health and health-care disparities, and all structural inequalities. The current discourse associated with health equity operates primarily at the individual level with a focus on areas such as cultural competence, stereotype threat, and implicit biases. Each of these areas are important for individual interactions; however, they do little to alter challenging and stressful social environments that African Americans navigate. Changing the life course trajectories of historically marginalized populations necessitates structural level transformation.
The WHO has outlined three major principles of action to address structural inequality and systematic injustices that perpetuate racial health disparities. These include: 1) economic and occupational policy changes that enhance each individual’s living and working conditions to allow them to achieve their full health potential, 2) the development of social policies that guide fair and equitable distribution of federal, state, municipal, and community resources, and 3) the emergence of pedagogical and mass communication strategies that demonstrate to individuals, regardless of their educational level, how structural inequality and injustice harms individuals and communities in ways that threaten national interests and security. The COVID-19 pandemic has demonstrated how vulnerabilities of the marginalized can have implications for those in seats of power. The words of Dr. Martin Luther King, Jr. in The Trumpet of Conscience summarize the salience of equity, equality, and justice for the health of humanity.
It really boils down to this: that all life if interrelated. We are all caught in an inescapable network of mutuality, tied into a single garment of destiny. Whatever affects one destiny, affects all indirectly.
Societies that contribute to the health of its citizens are prosperous because healthy individuals contribute to their families and communities in multiple ways. Early efforts by the current federal administration at the start of the pandemic demonstrate how governments can operate in the best interest of those it serves. Short-term policies like the Coronavirus Aid, Relief, and Economic Security (CARES) Act and the Families First Coronavirus Response Act provided resources that allowed American citizens to have access to COVID-19 testing and vaccines regardless of ability to pay. Each of these policy interventions lowered barriers to important COVID-19 resources for millions of individuals and families; however, these federal acts operate through health-care insurance plans leaving behind African Americans and other low-income working families who do not have health insurance and exposed them to potential health threats and additional health-care costs associated with COVID-19.
The COVID-19 pandemic makes more stark just how much racism has implications for the life chances and lifespan of African Americans. The structural roots of racism run deep in the United States and the achievement of health equity is inextricably linked to the dismantling of the American racial caste system. The pursuit of a more perfect union where African Americans and other historically marginalized populations have the opportunity to achieve and maintain good health requires a collective effort to: 1) reorganize the structure of society to enhance each individual’s living and working conditions to allow them to achieve their full health potential; 2) re-align the distribution of power and wealth in a more fair and equitable manner, and 3) educate not only health-care professionals but the broader public on how inequities in the distribution of the economic, political, and social resources drive health disparities. In sum, health is a social justice issue and we must address it as such by rectifying historical and current injustices to allow every individual in the United States to live their best and healthiest lives.