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Despair and Disparity: The Uneven Burdens of COVID-19
The COVID-19 global pandemic is a nightmare unfolding before our eyes that could have devastating impacts that Black Americans could feel most acutely. With scarce testing, health care workers and ventilators, combined with a pattern of red state governors ignoring science and placing profits above people, there are signs that Black communities across the country are bearing the brunt of an inept federal response and unjust health care system unprepared to handle the surge of COVID-19 patients.
This, of course, doesn’t have to be the case, but government failure and systemic racism means far too many Black people, especially in the South, will lose their lives unless government leaders immediately course correct from the predictable and alarming outcomes ahead.
Preliminary data show high case counts among Black residents in emerging hotspots, including New Orleans, New York, Detroit, Milwaukee, Charlotte and Albany, Georgia. There are also reports from cities, including St. Louis and Nashville, that predominantly Black neighborhoods have been slow to receive testing sites and equipment compared to white, affluent areas.
COVID-19 is a perfect storm of systemic inequities operating together to worsen existing vulnerabilities. Widespread testing, for example, is still not happening, and tests are being rationed with only the sickest, often at death’s door, being provided diagnostic tests to determine if they have the virus. Health care workers are doing heroic work under unimaginable conditions, but stories like that of Rana Mungin — a 30-year-old Black woman and Brooklyn teacher who was turned down three times before receiving a COVID-19 test and was in a coma, clinging for her life — is a warning sign of a system under stress and poised to reproduce known racial inequities in health care services.
With little to no race or ethnicity data being reported on who has been tested and a well-documented history of racial bias shaping health care decisions, a group of doctors and researchers called on the Centers for Disease Control and Prevention and the World Health Organization to report these numbers for COVID-19 testing. Several Democratic leaders including Sen. Elizabeth Warren and Rep. Ayanna Pressley followed with a similar request to Health and Human Services Secretary Alex Azar. Biases are more likely to shape decisions under stressful situations, and with a system overwhelmed, such biases may enter the equation when health care workers have to make difficult decisions about who qualifies to be tested.
The same is true for determining who has access to other limited health care resources like ventilators. Recently, I awoke to a heartbreaking email from a public health colleague in a hard-hit state. He was seeking guidance on how to make equitable decisions on ventilators because current crisis standards of care, which are guidelines that state health departments use for these types of public health emergencies, will likely further disadvantage the already disadvantaged — including Black patients that have underlying health conditions that may worsen their prognosis for survival.
Physicians shouldn’t be placed in these positions in a nation that has the resources to coordinate a rapid and equitable response to the demands of this pandemic. Instead, the Trump administration has dragged its feet in using the Defense Production Act to ramp up production of badly needed ventilators and other medical supplies. All along the way, the president has failed as a leader by calling the COVID-19 threat a hoax, and criticizing requests for medical supplies and demanding praise in return for federal aid from Democratic governors in states hit hard by the virus.
Equity — not petty politics — should be the guiding principle in this emergency, and that means resources should be targeted to where they are needed most. Ventilators, for example, should be prioritized for distribution to known hotspots like New York City, New Orleans, Detroit and areas that will likely experience a surge in severe coronavirus cases because of chronic health inequities and under-resourced health care systems, common in the South.
Long before COVID-19, Black communities were experiencing deep health and economic inequities that are only intensified by a public health crisis of this magnitude. African Americans experience higher rates of diabetes, hypertension and respiratory illnesses associated with COVID-19 death not because Black people are inherently sicker, but because systemic racism has created the conditions for these health inequities to develop. Concentrated poverty, substandard housing, lack of health insurance, employment discrimination, poor water and air quality, and the day-to-day stress of living in a society that devalues our humanity all work together to chip away at our health.
Combine these health inequities with resistance among Republican governors to implement stay-at-home orders that public health experts have said are needed to slow the spread of the virus, and we have the conditions for COVID-19 to explode in the South, where close to 60 percent of all Black people in the U.S. live and where the majority of states in the region have not expanded Medicaid. Alabama’s GOP Gov. Kay Ivey, for example, in initially refusing to issue a stay-at-home order, stated that she didn’t want to “choke” business, and proudly proclaimed the state was unlike Democratic-led Louisiana, New York and California, which have stay-at-home orders in place. Florida, Georgia, Mississippi, South Carolina and Tennessee were also among holdout states that refused to promptly issue statewide shelter-in-place orders.
Inept government leadership in this pandemic is costing lives, and the slow and uncoordinated federal response is having domino effects across the country. Those impacts will be deeper and greater for Black and Brown workers, many of whom are already struggling to make ends meet, have no health care coverage, and have jobs where they are expected to work while everyone else is sheltering at home to flatten the curve and avoid being infected by the virus.
Moreover, Black Americans make up 40 percent of the homeless population, who are especially vulnerable to a pandemic where the public is being asked to stay home as a protective measure. In prisons and jails, where Black people are disproportionately among those incarcerated, these environments are ticking time bombs for an outbreak of COVID-19 due to the difficulty of maintaining social distance in close quarters, unsanitary conditions, and the number of people regularly moving in and out.
Leadership at all levels of government needs to rise to the level of this crisis and do so with a focus on health equity and racial justice. That means widespread universal testing with no age restrictions, free COVID-19 testing and treatment provided to anyone diagnosed, and targeted outreach to communities of color to allay fears of not having access to treatment or receiving an astronomical health bill after a hospital stay.
But there are other critical policy solutions that should be considered as part of an equitable COVID-19 response and recovery plan, including immediate action to release incarcerated people, permanent paid sick and family leave for all workers, Medicare for All, housing for the unsheltered and a federal jobs guarantee in the face of massive unemployment. Enacting these policies would begin to address the depths of racial inequities that are intersecting with the COVID-19 crisis and set the stage for a reset as the pandemic subsides.
We’re learning in this crisis that we desperately need better planning, leadership, a focus on our shared humanity and targeted strategies to reach, connect with and care for the populations and communities that will experience the most economic harm and loss of health and life. Racial health inequities are not a foreign concept in public health and it should concern all of us that the most basic step for addressing them — reporting racial data — has been largely ignored in local, state and federal reporting on COVID-19. Without an approach that actively addresses the many ways that systemic racism is already shaping outcomes in this pandemic, Black communities will be left without the resources to address the compounding impacts of COVID-19 as the rest of the country recovers and pushes forward.
With intentional policies and actions that prioritize racial equity now, government leaders and policymakers can avoid repeating mistakes of the past. They can reject calls to go back to “business as usual” and seize the moment to usher fundamental change that addresses the generations of neglect and political malpractice that created the pre-existing health, social and economic conditions that are being magnified in this tragedy.
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