7

The Battle of the Pandemics: Racism Exposed by COVID-19

With COVID-19 both an immediate threat and a window into more long-standing health disparities, this session was designed to explore the social determinants of health across key domains, according to planning committee co-chair Lynne M. Holden, M.D. (Albert Einstein College of Medicine; Mentoring in Medicine). These domains encompassed neighborhood and physical environment, discussed by Christopher Blaszczak-Boxe, Ph.D. (Pennsylvania State University); health and health care, Randall C. Morgan, M.D., M.B.A. (W. Montague Cobb/NMA Health Institute); income and wealth, Cora Bagley Marrett, Ph.D. (University of Wisconsin–Madison); and education, Dr. Holden. Camara P. Jones, M.D., M.P.H., Ph.D. (University of California, San Francisco), concluded the formal part of the session by discussing the impact of racism denial on health.

NEIGHBORHOOD AND PHYSICAL ENVIRONMENT

Dr. Blaszcak-Boxe spoke about the disparate effects of COVID-19 through the lens of the physical environment and historic roots of inequality. He explained that he used redlining, which became prevalent through the policies and practices of the Home Owners’ Loan Corporation in the 1930s, as a benchmark. As he has found in his research, redlining provided the platform to enhance the disparities that have been evidenced qualitatively and quantitatively during the COVID-19 pandemic. Using an area of Brooklyn as an example, Dr. Blaszcak-Boxe shared a 1940s-era color-coded map that “graded” A through D. The lower grades (identified on the map as “definitely declining” and “hazardous”) were communities that were predominantly Black and Brown. The map’s “clarifying remarks” associated with each grade included descriptors such as “very undesirable neighborhood of mixed races.” The maps were created for areas throughout the United States (see Figure 7-1). Although no longer on an official map, these characterizations permeate today, he commented.

Starting with this benchmark through which the real estate market was used to marginalize communities, Dr. Blaszczak-Boxe pointed out the connections between where people live, their environment, and health. Of the 7 million people globally who die per year of air pollution-related causes, most live in marginalized communities. Specific to COVID-19, many studies have quantified the racial disparities of the pandemic. For example, in 2020, the Centers for Disease Control and Prevention (CDC) found that Blacks were being disproportionality hospitalized.¹ A study by the Kaiser Family Foundation similarly found a higher per capita impact of hospitalizations and death among Black and Latinx people (Rubin-Miller et al., 2020), while a Harvard study reinforced these findings (Wasfy et al., 2021). A multitude of reasons account for this disparity, including air exposure, less access to testing, a higher likelihood of high-density living and working, preexisting conditions, and other factors, on top of racial bias in health care. CDC and global data from January 2020 through April 2021 amplify and reinforce this finding (Mude et al., 2021), he added.

Dr. Blaszczak-Boxe described ways to understand and tackle these disparities. For example, he has used GIS data to quantifiably identify communities in New York and Pennsylvania at greatest risk. Once they are identified, Internet of Things open source data can be used to measure indoor and outdoor air quality, among other issues. “We all have crossroads in terms of the contributing factors of public health,” he commented. He noted his goal is to combine environmental assessment and monitoring with communicating with the public about what he finds.

Given the underrepresentation of Black and Latinx men and women in the science and engineering workforce, he urged more partnering with the community to change the culture from the grassroots upward. As one example, he conducted a project in Brooklyn called the NASA GEO Tech Academy, which involved students and families in understanding community-based spatial effects while also learning about these new technologies. Reflecting on Dr. Emdin’s comments (see Chapter 6), he called for hands-on learning, proactively interacting with communities, and explicitly acknowledging that every accomplishment starts with the decision to try.

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¹ CDC has continued to report on disparities in COVID-19–associated hospitalizations. See https://www.cdc.gov/coronavirus/2019-ncov/community/health-equity/racial-ethnic-disparities/disparities-hospitalization.html.

HEALTH AND HEALTH CARE

Dr. Morgan focused on discoveries over the past 18 months and implications as a result. He noted that decades ago, medical leader Dr. W. Montague Cobb spent his career demonstrating that racism, segregation, and poverty damage not just the Black community but also society as a whole. Dr. Morgan stressed that the principles of social justice are an essential part of health promotion. These four principles, as they relate to health, are as follows:

• Equity, to ensure fair distribution of available resources across society
• Access, to ensure all people have access to goods and services regardless of age, gender, ethnicity, or other characteristics
• Participation, to enable people to participate in decisions that affect their lives
• Rights, to protect individual liberties to information about circumstances and decisions affecting them and to appeal decisions that people feel are unfair

Dr. Morgan noted that the CDC acknowledged that the pandemic has exposed systemic racism, for example, in a statement by Rochelle Walensky, M.D., soon after her appointment as CDC director (Walensky, 2021). He also pointed participants to the consortium Movement Is Life,² which has shown how systemic racism cements the health disparity divide, especially in urban communities. “The fact is that all health disparities are affected by systemic racism,” Dr. Morgan said. Redlined zip codes have fewer trees and green spaces, more pollution, fewer healthy food sources, less home ownership, less funding per student, fewer medical facilities, fewer leisure facilities, and fewer physicians and medical facilities. COVID-19 has exacerbated the social determinants of health; at the same time, these determinants play a role in who has been most affected by COVID-19.

Dr. Morgan also discussed the COVID-19 Community Vulnerability Index (CCVI), created by the nonprofit Surgo Ventures as a tool to assess which U.S. communities may be less resilient to the impacts of COVID-19. It looks at 7 key themes and 29 variables that can be calculated per census

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² See https://www.movementislifecaucus.com.

tract, then aggregated to the state and county level.³ Interventions can be focused on the most vulnerable areas. As an example, the CCVI was used to identify an area in Georgia with low rates of vaccination and high rates of hesitancy where trusted voices can help in a vaccine intervention.

Early confirmation of the significant impact of COVID-19 on the Black population was reported by Roundtable member Clyde W. Yancy, M.D., Ph.D. (Yancy, 2020). Discussing the multiple pandemics of COVID-19 and racism-related violence, Dr. Morgan noted that the approximately 1,210 fatal police shootings, while unacceptable, are those that make the headlines, but “they are the tip of the iceberg.” Blacks are 13 percent of the U.S. population but constituted at least 23 percent of COVID-19 deaths in December 2021. Unfortunately, much of the racial and ethnic data have not been reported or are reported sporadically, so the exact numbers are not known, Dr. Morgan noted. Misinformation and confused messages add to the challenges, Dr. Morgan continued:

Broader public health challenges include lack of access to health care, which the pandemic has exacerbated, Dr. Morgan stated. Comorbidities have been made more evident and complicated. There has been deferral of routine health maintenance. Health policies with a negative effect on people of color are far more common than once thought, and there is a differential effect of uninformed and unproven health policy. In response,

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³ See https://precisionforcovid.org/ccvi.

a National Academy of Medicine study proposed a post-COVID recovery plan encompassing lessons learned and compelling needs (NASEM, 2021).

“It is up to our organizations and academic centers to work hand in hand with public health specialists to make a difference,” Dr. Morgan said. He described several efforts carried out in a partnership among the Cobb Institute, National Medical Association, National Black Nurses Association, and the four historically Black medical schools, including the COVID-19 Prevention Network and town hall meetings. The Cobb Institute strategy has been to increase communication with community members and partners; serve as a trusted convenor to create a plan for patient safety and trust; urge all in the Black community to seek information from trusted voices and sources, process the information, and move forward; and emphasize the real potential for unchecked COVID-19 to ruin lives and well-being. “Through attention to social justice, when all the barriers are removed, there are opportunities for everyone to participate,” Dr. Morgan concluded.

INCOME AND WEALTH

As indicated throughout the workshop, said Dr. Marrett, the consequences of racial disparities on minority populations are not unique to COVID-19. Research on education, neighborhoods, and economic gaps show racial differences, she stressed, with great discrepancy in both wealth and income. She noted:

Using U.S. Census and other data, Dr. Marrett reported persistent income gaps over generations. Young Blacks growing up in relatively affluent families are not likely to sustain the kind of economic resources that they experienced growing up; people are falling out or moving from the top levels of incomes over their lifetimes below what their parents experienced. Why are these differences persisting, especially for Native American and Black

youth, she questioned. Controlling for differences in family composition cannot account for the income differences, she explained. Neighborhoods can make a difference, yet these effects are not always attributed to income differences. Some research suggests the difference has to do with racial bias or attitudes and with predispositions in the larger population associated with continued disparities. However, Dr. Marrett urged research that goes beyond attitudes to larger systemic forces. She urged the Roundtable to examine which of these conditions might be important to explain economic disparities across generations.

Returning to the issue of neighborhoods, Dr. Marrett said Census data show that areas with lower poverty rates and higher educational attainment are associated with better future incomes for both Blacks and whites. Insights are needed to be able to adjust and affect discrepancies, and she called on the Roundtable “to help sort through and try to define more sharply what is going on. Simply seeing conditions are occurring will not tell us about interactions and consequences. People living in the same situation are not necessarily living the same kinds of experiences. Making those kinds of distinctions are important.” She added that stakeholders can help define what is going on.

She concluded that outcomes to address COVID-19 will not solve disparities related to income. A strategy of antiracism is needed to provide opportunity and advances for all.

EDUCATION

Dr. Holden introduced the negative effects of COVID-19 on educational pathways with three examples. First, because of how the pandemic affected education, studies show Black students are on average 3 to 5 months behind compared with white students, who are 1 to 3 months behind. Second, Blacks made up 14 percent of graduating seniors in U.S. public high schools in spring of 2020 but only 8.3 percent of students who took an advanced placement exam. Third, college enrollment declined 3.9 percent from 2019 to 2020, but declined 11.4 percent in high-poverty high schools (ED, 2021).

Dr. Holden noted the social determinants of health are known to influence health equity, and education is considered one of these factors. She presented a complementary model known as the social determinants of learning (Sanderson et al., 2021). In this framework to address learning disparities, student characteristics are at the center, with six social determi-

nants that influence success: physical health, psychosocial health, economic stability, self-motivation, social environment/community, and physical environment/community.

Dr. Holden shared student perspectives about the pandemic gleaned through the COVID-19 Community Education Empowerment Internship, a partnership between five New York medical schools and Mentoring in Medicine.⁴ The 1,200 students who are now in college or recently graduated were asked how the pandemic affected them. She related that the students talked about loss of opportunities and family members, their mental health, isolation, and other effects. The pandemic has affected their personal lives, and they have seen the impacts on their community and the world at large through a lack of travel, financial instability, family separation, and other setbacks. They shared increased anxiety and depression, and the difficulty in not being able to celebrate milestones.

Dr. Holden also noted that food insecurity has affected Blacks more than whites during the pandemic. Loss of family caregivers is also devastating. From April 1, 2020, through June 30, 2021, 140,000 U.S. children lost their primary caregivers. The rate was 4.5 times higher among ethnic minorities and highest among Black children in the Southeast (Hillis et al., 2021). Related to psychosocial health, Dr. Holden continued, in a survey of college students, 40.9 percent of respondents reported at least one adverse mental or behavioral health condition, and 10.7 percent had considered suicide in the past 30 days. The pandemic has had a “multifaceted effect on students and the need for support is clear,” she concluded.

RACISM DENIAL

Given the different sectors discussed during the session, Dr. Jones posited that society’s narrow focus on the individual is an important barrier to achieving health equity. It is a root cause of racism denial and pandemic response, she said, and identified it and other barriers that interfere with the ability to ensure optimal health conditions for all people: (1) the narrow focus on the individual limits a sense of interdependence and collective efficacy; (2) an ahistorical stance in the United States; (3) the myth of meritocracy; (4) the myth of zero-sum game; (5) a limited future orientation; (6) the myth of “American” exceptionalism; and (7) white supremacist ideology.

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⁴ For more information, see https://centerforhealthequity.cornell.edu/education/diversity-center-of-excellence/covid-19-community-education-empowerment-program/.

Dr. Jones pointed out how the focus on the individual has hampered the response to the COVID-19 pandemic, contributing to failures in testing, masking, school reopening, vaccine trial endpoints, vaccine optimism, vaccine rollout, and the death toll.

For example, related to testing at the beginning of the pandemic, a medical care approach that confirmed individual diagnoses was favored over a public health approach. This more collective approach would have estimated population prevalence using probability surveys that include asymptomatic persons. That matters, she explained, because the time delay in prevalence estimates affects treatment and prevention, while probability surveys can occur in real time.

The message about masking was for individuals to protect themselves versus a more collective message to protect others. Mask mandates are essential to protect the health of the public in the face of individual objections, she said. Similarly, school reopenings have been discussed with an individual focus on children rather than a community focus on children as vectors.

Vaccines trials had symptomatic disease as the primary endpoint, while a population focus would have had asymptomatic viral infection as an additional endpoint of interest, because asymptomatic spread is fueling the pandemic, Dr. Jones continued. Vaccines provided optimism, but she noted the focus was to decrease the vulnerability of individual hosts rather than a public health approach to decrease the number of available hosts. The rollout favored individuals with risk factors due to age or medical conditions, rather than structural risk for those with increased exposure. This had disproportionate implications for communities of color, she observed.

“The COVID-19 death toll has had private losses but also a loss to whole society,” Dr. Jones said. “We all need to recognize and mourn the monumental collective loss as a nation. We are all in this together.”

DISCUSSION

A participant asked how Dr. Jones’s observations about an individual versus collective focus come through in the other topics discussed. Dr. Morgan commented he has been amazed by some people’s sense of detachment about COVID-19. “Until it affects them very closely, even with the high numbers of death, it does not cause behavior change. That, to me, is significant; otherwise, the 33 percent hard anti-vax would start to change,” he posited. Dr. Holden said when students came together to decompress,

they shared a sense of collective relief realizing they are not alone. Dr. Jones commented on the troubling tendency of people “othering” other people because they do not feel personally vulnerable.

Regarding what may change or improve as a result of the pandemic, Dr. Blaszczak-Boxe said he hoped some form of mutual understanding of lived experiences might result in more explicit partnering with and across communities. Dr. Marrett said she hoped a larger sense of responsibility and cooperation will develop, with “shared concerns if we as a nation and world are to survive.” She urged looking for levers of change to bring people together to preclude selfishness. Dr. Morgan called for more adaptability in the postpandemic period and learn different ways to do things. Dr. Jones echoed the hope that people learn that “we are all in this together,” noting the need for wider global availability of vaccines to effectively combat COVID-19 and its variants as an example. She continued, “If anything is raging anywhere on earth, whether the virus, poverty, drought, or anything else, it is a threat to all. We are one Earth.” Dr. Holden expressed the hope that young people can see they are needed and offer their new perspectives to find new solutions.

REFERENCES