COVID-19: Structural Racism and Health Inequity

Health disparities are personal to me because I have witnessed and experienced their injustices. Early on in life I had some encounters with racism in healthcare that lit a fire inside me before I even knew what health equity was. As a young African American man growing up in Perry County, Alabama, I remember being segregated from white patients in the waiting rooms of doctor offices. I remember one local physician who put sutures in a Black child, but when he found out the mother couldn’t pay, he removed them and she had to take her child to a veterinarian instead.

I had seen enough to motivate me to go into medicine to push for better, more equitable healthcare, and so I became a doctor, despite the odds. As an undergraduate biology major at The University of Alabama Tuscaloosa I protested a test question that was posed in the following way: “What reproduces the fastest? A. rabbits, B. rodents, C. negroes, D. plankton.” My objection resulted in federal mediation and a Washington Post article that was not well received by the University. When I subsequently applied for medical school at The University of Alabama at Birmingham (UAB), one interviewer told me that because of my actions at Tuscaloosa, he would not let me into medical school even if I attended the University for another four-year degree and made all A’s.

Some might point out that experiences like mine are relegated to the history books. But COVID-19 has arrived and painfully and tragically exposed to the world that a long history of racial disparity has taught us very little. Racism lives on and African Americans are dying from it. Regrettably, it comes as no surprise that Black people are infected with the novel coronavirus at a higher rate and dying from COVID-19 in disproportionate numbers. A report through June 10, shows that if all Americans had died at the same rate as White Americans, White Americans, at least 14,400 Black Americans, 1,200 Latino Americans and 200 Indigenous Americans would still be alive.

The reasons for the enormous death gap for Blacks are simple yet complex. Because typical social and working conditions in Black, urban communities make it difficult to be physically distant, Black people may be more prone to catching the coronavirus. Additionally, some Black people did not believe that social distancing was a necessity early on, partly due to false, racialized, disease narratives of Black immunity. To complicate matters more, early testing was in short supply and reserved for people who had recently traveled or were in contact with those who had traveled or already tested positive—which presented a structural barrier to testing our most vulnerable populations. Black communities across the country are now in the crosshairs of inequity, bias, racism, and increased rationing of care. Comorbid conditions, nonmedical determinants of health, and high allostatic load all further contribute to the high risk of infection and death for Black people from COVID-19.

While the mainstream media conversation about Black people and COVID-19 would have us focus on the impact of chronic diseases as the most significant contributor to the enormous inequity being experienced by Black people, we cannot and must not be distracted from the other stuff that is killing us and being exacerbated by the pandemic. We see increased unemployment, more police brutality, worsening hunger, housing evictions, and heightened minority stress. It is true that coronavirus patients who have a chronic condition like high blood pressure, obesity, or diabetes are more likely to develop COVID-19 and have a harder time recovering from it. But chronic diseases are the downstream expressions of upstream causes—primarily institutional and structural racism. This is the true conversation we need to have about COVID-19.

Historical injustices are not new. Over one hundred and twenty years ago W.E.B. DuBois wrote a scientific report that looked at the quality of care for Black people in Philadelphia called Philadelphia Negro. DuBois describes “a peculiar indifference” to the health, healthcare, and health outcomes of African Americans in Philadelphia. We see this indifference to the suffering of African Americans being played out in the pandemic and the streets today as a stark reminder that the peculiar indifference has persisted. Some providers are dismissing Black patients’ symptoms, while some Black people are reporting being turned away from healthcare facilities altogether. Some Black people may even delay seeking medical treatment for COVID-19 because of historically rooted mistrust of the healthcare system, including care that is laced with implicit bias. By the time some Black people are admitted to the hospital, if they make it there, they may be worse off than other patients.

It is the rule, rather than the exception, that African Americans bear the brunt of health and healthcare disparities. In the midst of this pandemic it is more urgent than ever that we act collectively, mutually, and intentionally to declare that if health inequity is to be eliminated, structural and institutional racism must be called out, addressed, and eliminated at long last. We must begin to build a system that is responsive to non-white and other marginalized patient populations. Leaders who care need to root out biased decision-making and communicate to care teams and policymakers about the need to serve the most vulnerable. We have to begin to hardwire this inside healthcare organizations.

For many years I have called for one major action step. We need a national patient safety goal that states that disparity and inequity must be eliminated. This must include collecting accurate race, ethnicity, and language (REAL) data and sexual orientation and gender identity (SOGI) data. This data must be analyzed and acted upon to ensure that resources are provided where they are most needed. In addition, we must go beyond cultural competency training and implement education and training for reducing implicit bias and fostering cultural humility in healthcare. We must lead with love and value all people. This is personal. This is heart work.

Below you will find articles about the topics discussed that we hope you will share to help raise awareness and spark discussions about these issues. We have also included links to a COVID-19 racial data report and a racial data tool on the pandemic, where you can see how your state is faring daily.

Best,
Ron Wyatt, MD, MHA