Dear Joe, Let’s Talk About Structural Racism and Health Equity
An Thien (Andy) Tran, Staff Attorney, Public Law Center. I want to thank Emily M. Gerard, University of Virginia School of Law ’23, for her outstanding contributions to this piece, especially for her focused commentary and compelling introduction. I also appreciate comments provided by Reanna Tong and Leigh E. Ferrin. As is customary, the views in this paper should not necessarily be attributed to anyone whose contributions or comments I have acknowledged.
The eyes of the world are on the United States as we have just witnessed Trump supporters breach our Capitol building in an attempt to prevent you from taking office. White supremacy went unchecked, and tensions between parties and factions within the United States are extremely high.
In light of this violence, you may be compelled to focus on “reaching across the aisle” to seek common ground with our political opponents. While that is a dignified intent, there is also a pandemic going on that demands we deal with critical systemic issues now. These things cannot wait.
If left unaddressed, critical inequalities, such as the structural racism that is deeply rooted in the American healthcare system and the disparity of unequal access to healthcare will fester and further fracture American society. The pandemic has been catastrophic, especially for communities of color.
Joe, people need your help now.
COVID-19 IMPACT ON COMMUNITIES OF COLOR
“When America catches a cold, African Americans catch pneumonia.” Whether we interpret this declaration quite literally or metaphorically, there is truth here. In 2020, the world awoke to high-profile, racially motivated killings and a ground swell of race conversations. Community calls for justice erupted from a legacy of structural racism in this country.
The American Heart Association describes structural racism in healthcare as concentrating power and access to care among privileged groups and devaluing populations whose health needs to be equitably improved. Regrettably, complex health disparities, namely disparate access to quality healthcare, in communities of color have exacerbated from a combination of unique problems posed by Covid-19 and structural racism.
The reasons why minorities suffer from poorer health conditions from Covid-19 are undeniably complex. Structural racism and other social factors, including poverty, elevate the risk of Covid-19 diagnoses and hospitalizations in ethnic minority communities, such as Black and Latinx populations. For instance, segregation (e.g., residential segregation, school segregation, and workplace segregation) simultaneously isolates racial groups and concentrates exposures to Covid-19 and resources.
The disproportionate impact of Covid-19 was thus triggered by broader social needs that must be addressed to deliver healthcare and diversify the healthcare workforce in order to ensure access to high-quality and preventative care.
A man walks down a street in Washington, DC, July 18, 2020. Photo by Ted Eytan is licensed under CC BY-SA 2.0.
Let’s break down the numbers. According to the Centers for Disease Control and Prevention (CDC), Black and Latinx people are four times more likely to be hospitalized due to Covid-19 than their white counterparts. Younger Latinx and indigenous people are at higher risk than other ethnic groups. In California, the Latinx communities make up about 42% of the population between ages 35 and 49, but they represent 77% of the deaths for that age group. The California Latinx population is dying in disproportionate numbers due to Covid-19.
Why is this?
Black and Latinx Americans are overrepresented in low-wage jobs in the United States, such as healthcare and service industries. Their jobs are essential, requiring them to work outside of the home, where many rely on public transit. Working from home is neither an option nor a privilege, because they are on the frontlines. They hold a disproportionate share of jobs that interact directly with the public, according to the Center for Economic and Policy Research. Further, these jobs pay less, are often based on hourly wages, and often do not have employer-sponsored health insurance. These are critical risk factors for exposure and a lack of access to care.
Historically, communicable diseases hit both Latinx and Black communities very hard. Covid-19 is no exception. And today, many also have unequal access to quality health infrastructures and medical care. It’s not a matter of genetics. Public health experts opine that such trends are due to their general health profiles and unequal access to care. Many from disadvantaged backgrounds, compared to their more affluent and educated peers, struggle with more ancestral health problems and comorbidities. For example, Latinx communities and Native Americans suffer from higher rates of obesity and diabetes than those in white communities.
Further, language barriers prevent older individuals who are often limited- or non-English speaking from understanding best practices to stay safe during the pandemic, significantly contributing to reduced linguistic and culturally responsive access to healthcare and resources (e.g., testing, personal protective equipment, education, and support to enforce social distancing practices). Additionally, many also reside in multigenerational homes, further exposing them to the risk of infection.
Because of these vulnerabilities and a higher likelihood of increased exposure and infection, groups that are disproportionately impacted experience a stigma, even when racial and ethnic minorities are already targets of negative stereotypes. While socioeconomic and underlying health conditions are major contributors to the high rate of hospitalizations among people from racial and ethnic minority groups, misinformation, a history of deep-rooted mistrust in the healthcare system and government institutions, and tensions surrounding discrimination in the United States stand in the way of high-risk populations from getting vaccinated. Yet Black and Latinx communities need the vaccines most urgently.
In 2020, many would contend that we failed to invest in the social infrastructure and services that protect the most vulnerable against a global pandemic. These disparities did not just surface due to Covid-19. The truth is, they’ve been around for a very long time. But they are avoidable, and the government must act to address the underlying structures behind ethnic and health disparities and access to treatment both right now and after the vaccines are more widely available.
To understand where we need to go from here, we must first examine the ways in which the Trump administration failed in their response to Covid-19 and explore how these decisions disproportionately impacted people of color.
TRUMP ADMINISTRATION CHALLENGES AND ERRORS
The global outbreak of Covid-19 upended multiple aspects of our lives, urging both national and international governmental response at extraordinary speeds. According to the Global Health Security Index on pandemic responses, the United States ranked 175th out of 195 countries on healthcare access for all citizens, largely due to the federal government’s failure to address illnesses of health workers, for instance.
Hospital beds line the floor of the Los Angeles Convention Center as a part of the COVID-19 pandemic response. Photo by US Air National Guard is licensed under CC-BY-2.0.
Contradictory Public Messaging & Blame Shifting.
At the outset of the pandemic, President Trump vehemently contradicted top U.S. public health officials and defended the faulty assertion that the risk of Covid-19 infection was low, downplaying the rising cases and assigned blame to the media for histrionics of the coronavirus’ threat to public health.
The President also misrepresented the effectiveness of masks and discouraged simple precautionary measures, such as social distancing, because he saw these as impediments to normal social and economic life.
Even after the Trump administration began to formally acknowledge that certain practices like social distancing and mask wearing were important, the President and Vice President publicly demonstrated non-compliance and scorn on multiple occasions. This sent mixed messages to all Americans, especially to those who supported the administration.
As the crisis worsened and videos of refrigerated trucks fraught with bodies in NYC began to circulate, the Trump administration failed to acknowledge the full scope of the pandemic and take responsibility. Instead, the administration tasked state governors with responding to the wrath of Covid-19. In essence, the onus fell on states to employ their resources, or lack thereof, to flatten the curve and even forced states into bidding wars with one another, driving up the already skyrocketing price of personal protective equipment for frontline workers. The Trump administration also expended considerable time attempting to disband the White House’s coronavirus task force and shift those responsibilities to individual departments and agencies. President Trump never issued a national stay at home order, even as the coronavirus continues to burn through our healthcare system.
American flags representing the 200,000 dead from COVID-19 planted at the base of the Washington Monument on September 23, 2020. Photo by Ted Eytan is licensed under CC BY-SA 2.0
Failing to take responsibility, President Trump blamed his predecessors for their lack of preparedness and response guidance necessary to subdue a national and global pandemic, despite the fact that the Trump administration continually ignored past administrative guidance on handling a pandemic and failed to allocate funds for core public health programs.
Throughout the pandemic, people simply did not know who or what to believe. As a result, public trust in the government and the words of public health officials disintegrated.
Unmoving Focus on the Economy.
We heard public declarations from the Trump administration to reopen the economy as quickly as possible despite an increasing death toll. Questions and concerns raised at White House briefings were redirected toward President Trump’s faux achievements in tax reductions, regulatory cutbacks, job creation, and military spending. Consequently, “Operation Warp Speed” under the Trump administration overpromised and underdelivered, where the development and distribution of Covid-19 testing ran into numerous regulatory hurdles and supply chain complications. As highlighted earlier, this focus had a disproportionate impact on communities of color, because they comprised many of the so-called “essential workers” who were on the front lines. The Trump administration’s response to Covid-19 effectively siloed Black and Latinx communities and other communities of color into unsafe working conditions to fuel our faltering economy.
And that was for the “lucky” ones who were able to keep their jobs. The unemployment crisis that resulted from Covid-19 also disproportionately impacted Black and Latinx workers. When they lost their jobs, the administration did little to cushion the impact of that loss. Despite the fact that 22 million Americans lost their jobs due to the pandemic, the disbursement of unemployment benefits slogged due to unyielding disagreements about further rounds of economic stimulus.
Now, even with the Pfizer-BioNTech and Moderna vaccine cavalry on the way, a grave situation continues to confront our country, especially as new and deadlier genetic variants of Covid-19 loom on the horizon.
MOVING FORWARD
It’s clear that our fundamental concepts about race and healthy equity must be rethought and reformed.
But first, we must address the immediate harmful impacts of Covid-19 that are disproportionately impacting communities of color.
Protest for Trans Rights, Humphrey Building, Washington, DC USA on July 13, 2020. Photo by Ted Eytan is licensed under CC BY-SA 2.0.
Follow through on your plans to expand stimulus payments and greater unemployment benefits and extend the expiration dates on emergency Covid-19 measures such as the CARES Act.
Follow through on your plans to fortify the Affordable Care Act through incremental expansions in government-subsidized coverage.
Follow through on your plans to add public options, like Medicare, for purchases on health insurance exchanges, increase premium tax credits for families to afford more general health plans, stop surprise billing, allow negotiation of Medicare drug prices, and limit drug prices.
Impose bilingual contact tracing and culturally sensitive outreach in order to help prevent the spread of Covid-19 in limited- and non-English speaking communities.
To dispel stigma, you must mount an aggressive campaign to inform the public that the higher rates of infection and death are not an accurate reflection of an inherent characteristic of a person. The elevated rates are, in large part, from living circumstances and unequal political and social structure for certain groups of people. Our policies and institutions create inequities in accessing resources, making it challenging for people to seek health care and make healthier choices.
Foster the regrowth of trust in American political leadership. Leaders must provide fact-based, consistent messaging to the public, not false reassurances, particularly to communities of color, where people are predisposed to fear and distrust of government at all levels. For these reasons, it is critical that you follow through on your plans to provide daily public White House reports on the number of tests conducted, expand surveillance programs by the CDC, and instruct federal agencies on how to expand national hospital capacity and telehealth capabilities.
You must empower and encourage minority physicians to help their patients locate resources that enable those patients to acquire quality healthcare, find food and housing, apply for unemployment, and seek other assistance. The pandemic illustrates that we must account for not only medical issues but also social ones.
It is also essential to acknowledge that the pandemic has only exacerbated pre-existing issues in American healthcare. While we are asking a lot of you, Mr. President-elect, it is imperative that we all learn from our past mistakes.
Together, we should start by reflecting on how our own subjectivity, power, and privilege shape our engagement in public health advocacy as well as where we fit into the structural-racism narrative. We should engage with our local community organizations to address the complicated intersection between the social determinants of health and justice through co-defining issues and co-developing innovative measures for change.
This is the time for collective responsibility. We are called upon to deepen our empathy for communities of color that have historically been pushed to the margins due to structural racism and continue the work on inclusion and equity. The best place to begin creating an equitable future is where we are right now. Although this work is exhausting, laden with heartache and frustration, tectonic social change to address racial justice and health equity requires patience, pathos, and perseverance.
Let’s get to work.
Cover Photo: Biden DNC Nomination: "Joe Biden Accepts the Nomination for the Democratic Party's Ticket for President of the United States - Wilmington, DE - August 20, 2020" by Biden For President. Licensed under CC BY-NC-SA 2.0.
