Lisa Cooper is a professor of medicine and Bloomberg Distinguished Professor of equity in health and health care at the Johns Hopkins University schools of Medicine, Nursing, and Public Health. The following op-ed was published in the 2020 State of Black America report from the National Urban League.
Many people were caught off guard as we witnessed rising inequities in the impact of COVID-19 on communities of color. Sadly, as a physician and public health researcher who has focused on addressing inequities in health for nearly three decades, these disparities came as no surprise to me. I direct the Johns Hopkins Center for Health Equity where my team and our healthcare and community partners collaborate to develop, test, and apply programs that alleviate health disparities and translate these programs into policy changes for community health benefits. For us, the pandemic was simply shining a magnifying glass on structural racism as a public health issue.
By February, the United States reported its first deaths from COVID-19, and it was not long before we began to see that African Americans, Latinos, and Native Americans were overrepresented among reported coronavirus infections and deaths. In New York City, for example, the predominantly ethnic minority neighborhoods of the Bronx had the most COVID-19 hospitalization and deaths, while the predominantly white borough of Manhattan had the lowest rates—despite being more densely populated. This pattern has been replicated across the country. On June 24, 2020, the American Public Media Research Lab reported that the COVID-19 mortality rate for Black Americans was about 2.3 times as high as the rate for whites and Asians, about twice as high as the Latino and Pacific Islander rate, and 1.5 times as high as the Indigenous rate. They also reported that Black Americans are dying above their population share in 29 out of 50 states and Washington, D.C.
Structural inequities are reflected in the policies and structures that allow a dominant group in society, in our case, white persons and those with high levels of income, to differentially allocate desirable opportunities and resources to groups regarded as inferior. In this country, the latter typically includes African Americans and other persons of color. Residential segregation, emerging from housing policies that originated in the early 1900s, is one important example of practices and policies that have shaped the health of African American and Native American populations. The impact of these racist policies endures in urban areas. To this day, neighborhoods that were "redlined" for Black residents and experienced the systematic elimination of key social and economic resources face a lack of access to healthy food, a strong education, gainful employment opportunities, safe physical and social environments, and high quality health care.
The psychological stress associated with these negative exposures,—as well as pervasive interpersonal experiences of discrimination in education, employment, housing, public safety, criminal justice, and even health care—produce negative effects on biological processes and lead to poor physical and mental health. In fact, social science and public health research has linked these structural inequities to higher rates of infant mortality among African American and Native American babies, higher rates of asthma and obesity among African American children, higher rates of complications and deaths among pregnant women, and earlier onset of multiple chronic conditions such as obesity, hypertension, heart disease, diabetes, and cancers among African American adults, leading to premature death and disability. These same factors are now contributing to an overrepresentation of African Americans among hospitalizations, complications, and deaths from COVID-19.
To address the effects of structural inequities during the pandemic in the short term, Josh Sharfstein, vice dean for public health practice at Johns Hopkins Bloomberg School of Public Health, and I have suggested that local and national leaders do the following:
- Track and monitor data on racial disparities in the impact of COVID-19;
- Provide better access to testing and medical care;
- Communicate in a trustworthy and respectful manner with communities of color;
- Encourage employers to provide protective equipment and improve working conditions for essential and frontline workers (the majority of whom are people of color); and
- Address the immediate risks these groups face with respect to stable housing, food security, digital access for education, and health care.
All of these strategies are needed to ensure that disadvantaged populations don't continue to bear the greatest burden of the pandemic.
However, in the long term, the U.S. needs to engage in a much more comprehensive response to the impact of structural racism on our culture, our institutions, and on all people, but especially on people of color. David Williams, professor of public health, African American studies, and sociology at Harvard University, and I have described three broad strategies to do this. First, we have suggested that "communities of opportunity" should be developed to minimize the adverse effects of structural racism. This would mean creating communities that provide early childhood development resources, put policies in place to reduce childhood poverty, provide work opportunities and income support for adults, and ensure healthy housing and neighborhood conditions. Second, we suggested that the health care system needs new emphases on ensuring access to high quality care for all, strengthening preventive and primary care approaches, addressing patients' social needs as part of health care delivery, and diversifying the health care work force to more closely reflect the demographic composition of the patient population. Third, we recommended new research to identify the best approaches to build political will and support to address social inequities in health. This could include initiatives to raise public awareness of the pervasiveness of health inequities and the connections between social factors and health; to build empathy and support for addressing inequities by telling the stories of people whose lives have been impacted (we have seen a great increase in this since the media has shone a bright light on the killings of Black people by police brutality and violence); and to enhance the capacity of individuals and communities to actively participate in efforts to address inequities at all levels.
The silver lining during these dark times is that this pandemic has revealed our shared vulnerability and our interconnectedness. Many people are beginning to see that when others don't have the opportunity to be healthy, it puts all of us at risk. I am hopeful because I see the pandemic producing a shift in thinking among many as they acknowledge the disparity between the lives of white people and people of color in this country.
As we have seen through the Black Lives Matter protests, many people are finally recognizing the inequities that are borne out of systemic racism, becoming motivated to speak and act for justice and change. We know now, more than ever, that everyone's voice is important to bring about the change that we seek. The crises of the COVID-19 pandemic and police violence and killings of African Americans are forcing us to confront the injustices and eliminate the inequities that prevent us from living up to our stated ideals of "liberty and justice for all."