Will Covid-19 Be a Turning Point in the Fight Against Racial Disparities in Health Care?

Will Covid-19 Be a Turning Point in the Fight Against Racial Disparities in Health Care?

Will Covid-19 Be a Turning Point in the Fight Against Racial Disparities in Health Care?

Public health experts hope that the vast scale of the crisis will prompt meaningful political action to counter health inequities, which have been persistent in America for well over a century.


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Jason Hargrove was driving a bus through the West Side of Detroit when one of his passengers began to cough, failing to cover her mouth. It was March 21, and Covid-19 was spreading through cities across the United States. Hargrove was rattled. “Hey, look,” he said in a Facebook Live video taken on his lunch break, which quickly racked up tens of thousands of views. “This coronavirus shit is for real, and we [are] out here as public workers doing our jobs, trying to make an honest living to take care of our families…. That shit was uncalled for. I feel violated.”

A few days later, he developed a fever and told his wife, Desha Johnson-Hargrove, he felt “kind of off.” Soon after, he was sick enough that she took him to a hospital. He was sent home with orders to self-quarantine. He kept getting sicker. When his fingertips turned blue, she took him back to the hospital. The staffers sent him home again. “They said that there was no reason to do anything,” she later told a journalist. By March 29, he was struggling to breathe, and she took him to the hospital a third time. She never saw him alive again. It was only when she called to check on him that she learned her husband was dead.

Hargrove’s death underscored the hazards that blue-collar essential workers face from the virus. In Detroit and across America, those workers are disproportionately people of color. Elder Leslie Mathews, a Detroit resident and an organizer with Michigan United, remembers seeing a checkered effect as people began to self-isolate in March. “White people working in these upscale type of [jobs], they begin to disappear. And the black and brown people are the frontline workers.” Rumors had spread that black people couldn’t contract the virus, and when better information came out, “it was literally too late. It hit like an atomic bomb. It just came out of nowhere. And then next thing you know, hundreds of people are sick.”

Forty percent of the people who have died from Covid-19 in Michigan so far were black, though they make up only 14 percent of the state’s population. Nationally, one analysis found that black Americans have died from the virus at 2.4 times the rate of white Americans, and Hispanic and Native Americans have been infected at elevated rates in a number of states. Mathews has lost friends and relatives to Covid-19, including her ex-husband, who died after being discharged from a hospital. “He seems like he’s doing well, and he’s dead within a week,” she said. “And then the next week his mother died. I’m looking at my Facebook, and every time you scroll, ‘Rest in peace. Rest in peace. Rest in peace.’” She estimated that at least 10 of her high school friends have died in recent weeks. “I’m used to being a person who can help people, guide people through the loss of their loved ones and mourn. This Covid-19 literally has snatched all of that away.”

As the pandemic spread, states and the federal government were slow to release demographic data showing who was getting sick and who was dying. Once the racial disparities became indisputable, public officials across the political spectrum declared the statistics unacceptable. “They’re very nasty numbers. Terrible numbers,” President Trump said at an April 7 press conference. But what are they willing to do to change them?

Many public health experts are hopeful that the vast scale of the crisis will prompt meaningful political action to counter health inequities, which have been persistent and well documented in America for well over a century. Dr. Clyde W. Yancy of Northwestern University’s Feinberg School of Medicine recently described this as “a moment of ethical reckoning.” “There is a sense that this is getting more media attention than other disparities, and I’m hoping that when all is said and done, there is special attention and funding and resources paid to these issues,” said Dr. Uché Blackstock, an emergency physician in New York and the founder and CEO of the consulting practice Advancing Health Equity.

But as states begin reopening businesses and relaxing social distancing guidelines, there is still nothing resembling a coordinated effort to address the pandemic, much less its disparate impact. “I think that people have become very numb to black communities suffering,” Blackstock said in late April. “What can we do right now, structurally, to mitigate the effect of this dangerous virus? I haven’t heard that. I haven’t heard a solutions piece.”

Recognizing the urgency of the moment, civil rights groups and organizers like Mathews are working to get immediate relief to vulnerable communities while pressing elected officials to center racial equity in their policy responses to the pandemic. “People are angry,” said Mathews, who has been leading virtual town halls with Detroit residents. “I believe that there is a great awakening now.”

While Covid-19 is novel, its impact at the community level was predictable: Whether from infection, chronic disease, or natural disasters, people of color and the poor tend to suffer disproportionately. The idea of Covid-19 as “the great equalizer” was not only an inaccurate assumption but also a damaging one. Taking a colorblind approach to the virus meant that public officials missed early opportunities to blunt its lopsided impact.

The most obvious missed opportunity was in not making testing widely available, especially in vulnerable communities. Initially, testing was limited to people who had traveled to countries where the virus was prevalent, including China and Iran, or who had been in close contact with someone who’d tested positive. “It was very clear to me from the outset that that excluded certain patients, and those were mostly black patients in the neighborhoods that I work in,” said Blackstock, who practices in central Brooklyn.

Most states are not reporting demographic data for testing, but in Illinois, which does, black residents received fewer than 10 percent of Covid-19 tests as of May 22, though they accounted for 30 percent of deaths and 17 percent of confirmed cases. In Philadelphia, an analysis by Drexel University epidemiologist Usama Bilal found that people living in higher-income zip codes were tested at almost six times the rate that residents of poorer areas were. Ala Stanford, a pediatric surgeon, grew so frustrated by the limited diagnostics in the city that she and other volunteers formed the Black Doctors Covid-19 Consortium, which has offered free testing in church parking lots and people’s homes.

Under pressure, some state and city officials, including in New York City and Florida’s Broward County, added testing sites in predominantly black neighborhoods. In Detroit, officials opened a drive-through site on state fairgrounds. But more than a third of Detroit residents don’t have a car, presenting another hurdle, which the city tried to navigate by signing up taxi companies to give $2 rides to the site.

In addition to testing and demographic data, a priority for many grassroots groups has been reducing the number of people in jails, prisons, and immigration detention centers, where access to soap, other cleaning supplies, and health care is limited. According to the ACLU, African Americans make up more than half the prison population in several states with big racial gaps in their rates of Covid-related infections, including Michigan, Illinois, and Louisiana. Again, the response has been scattershot: While many local governments have reduced the number of people in jail by 25 percent or more, according to the Prison Policy Initiative, state prisons have released “almost no one.” The organization’s Emily Widra and Peter Wagner write, “For the most part, states are not even taking the simplest and least controversial steps, like refusing admissions for technical violations of probation and parole rules, and to release those that are already in confinement for those same technical violations.” Meanwhile, more than 1,100 detainees in Immigration and Customs Enforcement custody have tested positive for Covid-19—almost half of those who have been tested.

Workplace protections are another area where political leaders could do more to mitigate the spread of the virus. “The idea that we don’t have guaranteed wages, [universal] hazard pay…[stronger] OSHA regulations to make sure that workers have safe conditions—none of that stuff is in place to protect those that are most susceptible to this virus and are the least able to access health care,” said Dr. Sharrelle Barber, a social epidemiologist at Drexel University and a coordinator of the Poor People’s Campaign’s newly formed Covid-19 Health Justice Advisory Committee. Nearly one-fourth of civilian workers in the United States have no paid sick days, and while the federal coronavirus response package passed in March provided two weeks of paid sick leave for some employees, companies with more than 500 people or fewer than 50 are exempt, a loophole that leaves out millions of workers. “Almost all around, we’ve left communities to fend for themselves,” Barber said. “It’s been just really frustrating, really infuriating, to watch the level of neglect we’re seeing.”

With no coordination or strategy happening at the federal level, various states and cities have set up task forces to study and propose responses to the asymmetrical impact of the pandemic. Chicago announced the formation of a Racial Equity Rapid Response Team in early April in partnership with West Side United, aiming to “bring a hyper local public health strategy to targeted communities.” Michigan and Louisiana have established statewide task forces. At the federal level, Senator Kamala Harris introduced a bill that would require the Department of Health and Human Services to create a racial and ethnic disparities task force.

It’s unclear whether these expert panels will have an impact. “The primary function of this task force cannot be to engage in a long, protracted process of deliberation and study, dwelling on how we got here,” New York City Public Advocate Jumaane Williams said in response to the formation of a city task force. “Ultimately, we need results, not a report.” Andre Perry, a fellow at the Brookings Institution, told me, “I get invited to racial equity task forces all the time, and while I love doing research, research is not needed in this area. Checks cut to black and brown people are what’s needed.”

The drivers of racial health disparities are well documented. People of color are more likely than whites to live in segregated neighborhoods with more pollution, unsafe housing, and limited access to health care, nutritious foods, and economic opportunity. Those and other social and environmental factors can lead to poor health outcomes, including higher rates of chronic conditions like diabetes and hypertension, which have been associated with Covid-19 deaths. “A pandemic is in some ways about the pathogen but in so many more ways about the host and the environment,” said Dr. Abdul El-Sayed, a former executive director of the Detroit Health Department. “Detroit, as an environment, is a place that has been beating up on the host—predominantly black and low-income folks in the city—for a really, really long time.”

Compounding these environmental factors is bias within the medical system. Numerous studies show that black patients receive worse care than white patients. Although it’s difficult to say whether bias is a factor in individual cases, there are many stories of people like Hargrove who were turned away from hospitals multiple times, only to die later. (Hospitals have generally denied accusations of bias regarding Covid-19 patients, pointing instead to capacity issues that required them to admit only the severest cases.)

There’s evidence that systemic racism affects health in more subtle ways, too. In the 1990s, Arline Geronimus, a professor at the University of Michigan School of Public Health, coined the term “weathering” to describe the way that discrimination wears away at the body, leading to early onset of chronic disease and other poor health outcomes, even as people move up the economic ladder. “There’s this accelerated biological aging that’s caused by chronic exposure to stressors and high-effort coping with stressors [from] living in a structurally racist system,” she explained. She said this may be one of the reasons Covid-19 is hitting communities of color particularly hard. Historically, though, policy interventions to address racial disparities have focused on changing individual behaviors. Geronimus and others argue that what’s needed are structural changes aimed at rooting out discrimination and bias.

Recently, some local governments have started to acknowledge the link between discrimination and poor health. Last year Milwaukee became the one the first cities in the United States to declare racism a public health crisis. Milwaukee is one of the country’s most segregated metro areas: Wisconsin’s mortality rate for black infants is the highest among the states, and Milwaukee has one of the most-incarcerated zip codes in the country. The point of the resolution was to make racial equity a core element of all decision-making, and it may have contributed to the fact that Milwaukee was more transparent than other locales about data showing disproportionate deaths early in the pandemic.

Dr. Dierdre Cooper Owens, a historian of medicine at the University of Nebraska–Lincoln, has argued that the federal government should issue a similar declaration in response to Covid-19. She argues that racism meets the Centers for Disease Control and Prevention’s criteria for declaring a public health threat: It puts a significant burden on society, it disproportionately affects part of the population, current measures to address it are inadequate, and a coordinated, broad approach is necessary in response. “Most white Americans do not like to have conversations around racism,” Cooper Owens told me. “We have to be able to root it out at its source and just call a thing a thing.”

As cities and states develop their pandemic response and recovery plans, advocacy groups are trying to make sure that they don’t reinforce existing inequities. “When people are dying, we default to speed and efficiency, but efficiency and speed and doing what we used to do result in black and brown people getting left out,” said the Brooking Institution’s Perry. That’s what happened after Hurricane Katrina, according to Ashley Shelton, who previously worked on disaster recovery and now leads the Power Coalition, an alliance of more than 20 community groups in Louisiana. “A lot of people of color were disenfranchised” from federal aid after Katrina, she said, and so far, the federal response to the pandemic has followed a familiar pattern, with economic aid flowing to the customers of big banks and to larger businesses. In April the Power Coalition released a Roadmap for Recovery, with specific policy recommendations for racial and economic equity at the state and local levels. As a state commission determines how to spend $1.8 billion in federal relief, Shelton and her coalition will be following the money and advocating for their policy priorities. She’s facing a challenging political landscape in Louisiana. When we spoke, she was at the state capitol, where just a few days earlier, a bill to expand paid sick leave died in committee on a party-line vote.

Although much of the grassroots energy is at the state and local level, Shelton described the federal government as a necessary “engine” for recovery. Several other people emphasized this point, including Sharrelle Barber. “Marginalized folks, black folks, poor folks have always had to fight, even in the midst of a pandemic, to do what’s necessary,” she said, referring to the mutual aid networks and other groups that have taken matters into their own hands. But “there’s still so much need that needs to be addressed that can only be addressed by the power structures that actually created the inequity in the first place.”

When I asked Elder Mathews what her community in Detroit needed most, she put it simply: “I think what they needed was the truth—and a real plan.”

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