Perhaps the starkest reality of this pandemic is the extent of the racial health disparities it has exposed. As of early August, the number of Black lives lost to COVID-19 surpassed 30,000. Generally, African Americans are dying at a rate two times higher than their share of the U.S. population. Among the Navajo Nation and Hopi Reservation, COVID-19 per capita case rates are upwards of 2,500 per 100,000 people—one of the highest in the United States. In some states, Hispanics are 20 times as likely as other population groups to have COVID-19. The hardships do not end with poorer health outcomes. Communities of color are also bearing the brunt of the economic downturn, experiencing record numbers of joblessness, eviction threats and foreclosure, loss of employer-sponsored health insurance coverage, and a host of other obstacles.
In this country, vast racial inequalities are nothing new. They are the result of centuries of structural racism—unequal treatment by American institutions—and dominant white power structures—toward people of color. COVID-19 has simply magnified racial inequalities. Big structural change is drastically needed in order to overcome these inequalities, so that the country is better prepared for future public health emergencies.
Racial Health Disparities
Racial health disparities can be seen across a number of conditions. African Americans are more likely to develop heart disease, diabetes, and certain cancers. They also have shorter life expectancy when compared to white Americans. Similar trends in life expectancy can also be seen when comparing Native Americans and white Americans. Infrastructure issues including uneven access to clean, running water and close living quarters make it difficult for those living on American Indian reservations to adhere to proper hand washing and physical distancing guidance from public health experts. Language barriers and culturally incongruent health-care practices, which happen when the health-care approach fails to incorporate patient values, beliefs, lifestyle, and cultural traditions, can cause Hispanics to delay needed health care, leading to poorer health outcomes. These populations are also more likely to lack health insurance coverage and experience additional barriers to health-care access. Majority-minority neighborhoods have historically been concentrated around lower-quality health facilities and providers. Studies have also consistently shown that bias, racism, and discrimination within the health-care system also contributes to lower-quality care, differences in treatment practices along racial/ethnic lines, and harmful health-care experiences for people of color. The pandemic has only made these conditions worse.
COVID-19 is a relatively new phenomenon and there is still much to learn about the virus. This includes a more full, robust picture of the impact on specific communities. Efforts have been made to ensure better research and data collection on demographics, including recently passed legislation in Congress, but the slow response by the federal government has been tragic. The national demographic data currently being reported by the Centers for Disease Control and Prevention are incomplete. The agency has also failed to adequately comply with the mandate from Congress to not only report demographic data, but to also develop comprehensive plans to address COVID-19 among vulnerable populations, including communities of color. Without reliable data, including that related to cases, deaths, intensive care admissions, and equitable access to testing and treatment, it is impossible to adequately address the needs of people of color who are at greater risk of dying from COVID-19. Anecdotally, it has also been reported that African Americans and Hispanics have been turned away from testing—only to eventually return to health facilities with serious, life-threatening conditions due to COVID-19. Some have died after being turned away from care several times. Further study is therefore immediately necessary to assess the role of bias, discrimination, and racism in the denial of testing and treatment for COVID-19.
Racism and the Connection to Health Outcomes
It is imperative that we move toward achieving a truly universal, comprehensive, and equitable health-care system in the United States. Without this, we will continue to see vast racial disparities across a number of health conditions, including infectious diseases such as COVID-19. Not only must access to insurance coverage and comprehensive health-care services be expanded, but we must also ensure that care is of the highest quality for all people, and that we address bias, discrimination, racism, and other systemic barriers that keep marginalized communities from attaining the timely, compassionate care they need and deserve. This requires us to acknowledge the historical foundations of racism against African Americans, indigenous people, and those of Latin descent in this country, while also recognizing that the impacts of that racism can still be seen today.
Longstanding evidence has shown that the cumulative effects of experiencing racism in and of itself actually makes people of color sick. In particular, it causes African Americans to die prematurely and develop chronic illnesses and mental health challenges more than other population groups. A study published in the journal Psychoneuroendocrinology found that racist experiences appear to cause an increase of inflammation in African Americans. This increase in inflammation makes it harder to fend off disease and increases the risk of becoming chronically ill. The body’s response to stress, trauma, and adversity compromises the immune system. Experiences of poverty, lack of neighborhood safety, housing insecurity, risk of deportation, and increased likelihood of incarceration or ICE detention are just a few of the trauma-inducing occurrences that are uniquely heightened for racially marginalized groups in this country.
This lived experience of people of color, as well as their poorer health outcomes, can be used to explain the distribution of COVID-19 cases and deaths. It should not be lost on us that people with comorbidities such as diabetes, heart disease, and asthma are more likely to become seriously ill (or even die) from COVID-19. These are also health conditions that African Americans, Hispanics, and Native Americans are more likely to be living with. It is no coincidence that, in the geographic locations hardest hit by COVID-19, also referred to as “hotspots,” people of color make up large concentrations of the population. Of the 20 counties with the highest COVID-19 death rates, seven are majority African American. One (Hudson, New Jersey) is majority Hispanic or Latino, and another (McKinley, New Mexico) is majority American Indian and Alaska Native.
Access to health-care services, including COVID-19 testing and treatment, is particularly challenging for people of color. As mentioned, African Americans, Hispanics, and American Indians/Alaska Natives are more likely to be uninsured. Even when people of color have health insurance, residential segregation makes it less likely that access to a quality health-care provider will be available in their neighborhood. And at other times, people of color with health insurance are turned away from the services they need—a product of racism and bias in the health-care system based on the long-held perception that Black people have “thicker skin” or stronger thresholds for pain than other populations. Rana Zoe Mungin, a young Brooklyn-based African American teacher, died due to complications stemming from COVID-19 after being turned away from treatment three times. Similar experiences contributed to the deaths of Reginald Relf, Gary Fowler, Deborah Gatewood, and other Black COVID-19 patients.
The Pandemic Recession and People of Color
People of color have also been hit disproportionately hard by the pandemic recession. Before the spread of COVID-19, African Americans were on average more likely to live in poverty when compared to white Americans. The racial wealth gap was expansive. Income inequality made it so African Americans with the same jobs and same levels of education as white Americans, struggled to support themselves and their families. COVID-19 has brought on historic unemployment rates—a key indicator of a crumbling U.S. economy in the age of the pandemic recession. While the national unemployment rate for white Americans stood at 10.1 percent as of June 2020, it was 15.4 percent for Black Americans. Less than half of Black working aged Americans currently have a job.
Loss of employment has also led to loss of income, loss of employer-sponsored health insurance, and economic hardship including the inability to pay rent or mortgage and meet other financial obligations for millions of people. Between February and May, 5.4 million workers lost employer-sponsored health insurance upon unemployment due to the pandemic recession—the largest health insurance losses in the country to date. In April of this year, one in three people did not pay rent. Despite moratoriums being passed at both the local and federal levels, renters are still being evicted from their homes, and many of these moratoriums have now expired. Millions of people have gotten behind and have had to seek rent or mortgage relief, or forgo paying housing expenses altogether. According to the Social Policy Institute at Washington University, risk of eviction is particularly high among the Hispanic population. Delays in utility payments and home repairs are highest among Black Americans and Hispanics. These populations also have accumulated drastically lower wealth when compared to white Americans and lack the emergency savings to be able to pay for unforeseen expenses.
Hispanics and African Americans also make up an overwhelming majority of front-line, essential workers. They are overrepresented in service industry jobs that typically lack paid leave including housekeeping, food service, health care, and others. Efforts to reopen the economy prematurely, without universal testing and adequate personal protective equipment (PPE), put front-line workers of color at grave risk for contracting COVID-19. According to the Kaiser Family Foundation, one in four adult workers is vulnerable to severe illness from COVID-19.
The pandemic recession has also thrust millions of people into food insecurity. It must be noted that food insecurity was a challenge in the United States before COVID-19. In 2018, 37.2 million people lacked consistent access to food. Low-income families and communities of color suffer disproportionately from hunger and malnutrition because of lack of proper food access. The neighborhoods in which they live tend to lack grocery stores with fresh, nutritious whole foods. Lack of access to healthy food compounds the likelihood of poor health outcomes including diabetes and heart disease, while also instigating the likelihood of contracting and dying from COVID-19. COVID-19 has magnified America’s food access problem—with miles-long breadlines on the news and on social media for all to see. At a foodbank in Texas, it was reported that 70 percent of its visitors had never been to a foodbank before.
Reimagining Progressive Change for Racial Equality
This moment has offered a clarion call for big structural change to address racial inequality in health care and financial security. COVID-19 is ravaging communities of color, staking claim to both their health and economic wellbeing. Historically rooted structural racism has implications for the racial inequalities seen today. In order to rise above them and better prepare for public health challenges in the future, we need to implement a universal health-care system that guarantees accessible, affordable, high-quality health care to all. We must invest in majority-minority neighborhoods so that they have all of the available resources to lead healthy lives, including highly trained, culturally sensitive health providers; state-of-the-art health-care facilities; and grocery stores fully stocked with affordable, nutritious foods. We must train and educate health providers on anti-racism and on when to recognize bias if it is interfering with the equitable provision of care. These are imperatives to ensure optimal health outcomes and protection of health-care coverage for all people. We must also ensure that all workers are protected, have access to paid leave, can afford stable housing, and are valued with adequate wages so that they can thrive and support their families.
COVID-19 has magnified centuries of inequality, but that does not have to continue to define this country. We must seize the moment and use it to shift the trajectory. We can create a better society where people of color are not needlessly succumbing to preventable illness. We can create an equal playing field where all workers are supported and paid what they are worth. We can dismantle the racism that pervades our institutions and structures. But none of this is possible without political will, and the courage to meet this moment’s challenges head on.