The Pandemic's Unequal Toll
As the data from the COVID-19 pandemic begin to accumulate, a familiar and disturbing trend has emerged: the disproportionate toll on poorer Americans and communities of color. According to figures from the Centers for Disease Control, black Americans make up 13 percent of the country’s population but one-third of confirmed COVID cases; Latinos are 18 percent of the population but nearly one-fourth of cases. These groups are dying in larger numbers too: In cities like Milwaukee, Chicago, New Orleans, and New York, the mortality rates for black and Latino Americans are two, three, or even four times higher than they are for whites.
These inequities were the subject of an online discussion Tuesday afternoon, hosted by the Radcliffe Institute, between Khalil Gibran Muhammad, Murray professor at Radcliffe and professor of history, race, and public policy at the Kennedy School; and Mary T. Bassett, director of the Harvard FXB Center for Health and a professor in the Harvard T.H. Chan School of Public Health.
The pair began with history. “There’s a reason that none of us are shocked that COVID-19 is taking a threefold higher toll in some cities on blacks than on whites,” said Bassett, who served as commissioner of New York City’s health department from 2014 to 2018. Heath disparities along racial lines date to the colonial period—“and not due to unusual diseases,” she added. “People often think the excess mortality among blacks is due to violence or H.I.V., but no. It’s the leading causes of death—cardiovascular disease and cancer—hitting people at younger ages and taking a higher toll.”
She also noted the ways that the field of public health has often been blind to inequalities, and in some ways has actually facilitated them. “Beginning in the middle of the twentieth century, the public-health field really hitched its wagon to clinical medicine,” she explained. “The pathway to health was to have a doctor.” Previously, public health had focused more on the conditions of life and work: housing, sanitation, a living wage, urban design. As health became more individualized, it was increasingly tied to the notion of personal responsibility, to the idea that one’s health was a consequence of individual lifestyle decisions.
“That really shifted the focus away from thinking about what some people now call the social determinants of health,” Bassett said. “I think we are beginning to see the pendulum swing back, but for probably 50 years, public health was heavily focused on individual behavior rather than the context in which people can have healthy lives.…I think it helped lead us to the vulnerabilities that we are seeing unfold before our very eyes, where the United States, the wealthiest country in the world, the country that spends more money on healthcare than any other country, is now the epicenter of the COVID-19 pandemic.”
Poverty necessarily figures into this equation. Bassett shared a slide showing the overlap in New York City between neighborhoods with high numbers of coronavirus cases and neighborhoods with large populations of service workers and rent-burdened households. Those communities are also often home to the employees deemed essential during the pandemic—grocery store clerks, delivery drivers, public bus and train operators. And often those people are black or Latino. “These are individuals who have to go to work in order to get paid and take public transport that may be crowded. They go home to crowded houses that may be multi-generational,” Bassett said. “That’s the part of the story that isn’t being discussed—the role of essential workers and the way in which people of color, if they have jobs in the workforce right now, it is low paid and precarious. And the risks of exposure that carries.”
She and Muhammad also discussed what Bassett called the “policing of the public-health response.” She noted troubling reports of black men in masks being escorted out of stores and a black physician in Miami who was handcuffed by police while ministering to homeless neighbors. Often, “a behavioral explanation”—rather than a societal or structural one—"is given for why people have more exposure to COVID-19,” Bassett said, “and it is also now transitioning to something else that we have a long legacy of in this country: the criminalization of blackness and the criminalization of poverty.” Regarding the near-arrest of the Miami doctor, Armen Henderson, Muhammad (whose book The Condemnation of Blackness traces the link between race and crime) added, “There couldn’t be a more revealing intersection of public health and policing.”
A third related element in that intersection: disinvestment in poor neighborhoods and in the public sector. Muhammad pointed to a recent New York Times report on the University Hospital of Brooklyn, located in one of the borough’s hardest-hit communities. “A massive public-health facility that has been subject to decades of disinvestment,” he said. “It’s literally falling apart and has the greatest need for public-health workers to have PPE [personal protective equipment] and medical equipment. And in Manhattan, at Mount Sinai [a private hospital], serving one of the wealthiest populations in the world, they hired private jets to pick up N95 respirators.”
“They borrowed them from Warren Buffett,” Bassett interjected.
“Yeah,” Muhammad said. “So we’re having more policing of the communities facing the greatest disadvantage, being asked to give the greatest sacrifice as essential workers, and when they show up in the hospital, they go to the worst possible hospitals.”
The discussion carried on from there, concluding with a Q&A in which viewers submitted questions asking about health disparities for indigenous communities and rising anti-Asian sentiment and the dire outbreak situation for incarcerated people. One viewer wanted to know what readily achievable first steps the country could take toward remedying health disparities. “Well,” Bassett said, “the protection of essential workers is pretty straightforward”—masks and other protective gear, alternate places to stay for those worried about carrying the virus home, paid sick leave, and hazard pay. She also cited the need to reduce incarcerated populations by releasing prisoners who do not pose a threat to public safety. “These are all things that could be happening now,” she said, “rather than hammering on the idea that people are already so sick that we can’t do anything for them but to look after them when they come down with COVID.”