US Surgeon General Jerome Adams gave America a dire warning on Monday: The country was about to enter its worst week yet of the coronavirus pandemic, “our Pearl Harbor moment, our 9/11 moment.” While Adams cautioned that the calamities wouldn’t be localized but would be “happening all over the country,” it’s becoming increasingly clear that based on new data, Covid-19 will have a starker impact on one group in particular: black people.
Over the past few days, several states and cities across the country have begun releasing Covid-19 outcomes by race. The preliminary numbers reveal that black people are facing higher risks when it comes to the disease caused by the novel coronavirus.
As of Tuesday, black people made up 33 percent of cases in Michigan and 40 percent of deaths, despite being just 14 percent of the state’s population. In Milwaukee County, Wisconsin, where blacks represent 26 percent of the population, they made up almost half of the county’s 945 cases and 81 percent of its 27 deaths, according to a ProPublica report. In Illinois, black people made up 42 percent of fatalities but make up only 14.6 percent of the state’s population. In Chicago, the data is even graver: Black people represented 68 percent of the city’s fatalities and more than 50 percent of cases but only make up 30 percent of the city’s total population.
In the South, the numbers are also grim. In Louisiana, black people accounted for more than 70 percent of deaths in a state population that is about 33 percent black. About 33 percent of the state’s 512 deaths as of Tuesday morning have occurred in Orleans Parish, where black people make up more than 60 percent of the population and where 29 percent of people live in poverty, according to 2018 census data. Louisiana’s first teen death — also one of the first teen deaths in the nation — was that of 17-year-old New Orleans resident Jaquan Anderson, an aspiring NFL player, according to local reports.
But while some states have released data broken down by race, others have not, including New York, deemed the country’s epicenter of coronavirus cases. Nationally, there aren’t stats either.
Health professionals and elected officials, like Congress members Elizabeth Warren and Ayanna Pressley, have called on institutions like the country’s Department of Health and Human Services (HHS) and the Centers for Disease Control and Prevention (CDC) to track Covid-19 testing and outcomes by race. The national Lawyers’ Committee for Civil Rights Under Law, bolstered by 400 doctors from across the country, also demanded on Monday that the federal administration and local governments address racial disparities in Covid-19 treatment and testing, starting with the release of comprehensive information that includes race and ethnicity.
Still, the emergence of just a smidgen of the Covid-19 data on race already tells a grim story that shouldn’t shock anyone who knows a little about the systemic oppression of black people in America. Hundreds of years of slavery, racism, and discrimination have compounded to deliver poor health and economic outcomes for blacks — heart disease, diabetes, and poverty, for starters — that are only being magnified under the unforgiving lens of the coronavirus pandemic. And negligible efforts to redress black communities are being agitated like a bee’s nest prodded with a stick.
This has left some health care professionals and academics wondering if the coronavirus pandemic will ultimately become a black pandemic. Once wealthy and middle-class white people overcome the early throes of the virus, will America still care when it’s only ravaging black communities? Can racial demographic information in testing eventually become a tool to further marginalize the most vulnerable?
“Nowhere else would we say let’s skip a major variable or factor in analyzing a national or worldwide epidemic,” Brookings Institution fellow Andre M. Perry tells Vox. “The reticence to report racial data is a reflection of how black and brown people are marginalized.”
How health disparities make black Americans more vulnerable to coronavirus
Well before the novel coronavirus arrived at America’s shores, black people across the country, regardless of socioeconomic status, have lived with chronic illnesses — long-term health conditions like diabetes and hypertension — at high rates. According to the US Department of Health and Human Services’ Office of Minority Health, the death rate for black people is generally higher than that of whites for “heart disease, stroke, cancer, asthma, influenza and pneumonia, diabetes, HIV/AIDS, and homicide.”
When combined with Covid-19 in the body, people already suffering from chronic illnesses or from comorbidity suffer the worst health outcomes. The underlying conditions increase a patient’s chance of hospitalization and even death. Some health professionals also stress that we pay attention to black people with less prevalent chronic conditions, like lupus and Crohn’s disease, or those with renal failure who can’t stay home because they must go outside for treatments like dialysis, as they may be more vulnerable to coronavirus, too.
In Detroit, where black people make up 80 percent of the city’s population, chronic illnesses have already created a lethal storm. Detroit represents 7 percent of Michigan’s population but 26 percent of the state’s infections and 25 percent of its deaths.
“What we are seeing is that because of the way [Covid-19] attacks the body, in terms of what it does in the lungs and how it interacts with the part of the body that controls the blood system, people with hypertension are more susceptible to the illness itself,” Philip Levy, a professor of emergency medicine and assistant vice president at Wayne State University where he focuses on health disparities in Detroit, tells Vox.
When the virus first began to manifest in the city, Levy helped set up infrastructure to test health care workers and first responders. He has seen a lot of comorbidities in the firefighters and police officers he’s tested, and those who test positive for Covid-19 are especially vulnerable. “We have to get them out of the workforce,” he says.
Levy points out that it’s not just elderly people who are falling prey to comorbidity. “There’s a high degree of hypertension among younger individuals here, where they have elevated blood pressure on a higher basis,” he says. “Young people think they are invincible, but they might have hypertension at 30 and succumb to this infection.”
This is also backed up by data released in Louisiana on Monday. In the state, the leading underlying medical conditions in patients who tested positive for coronavirus are hypertension (66.4 percent), diabetes (43.52 percent), chronic kidney disease (25.1 percent), and obesity (24.7 percent).
“Louisiana is already being hit hard by [Covid-19] since there are a lot of comorbidities associated with negative outcomes for the virus,” Paula Seal, an associate professor at Louisiana State University School of Medicine’s infectious diseases division in New Orleans, tells Vox. On the clinical side, Seal works in the HIV outpatient clinic at the University Medical Center and does inpatient counsel for general infectious diseases patients. Seal has been present since her facility, one of New Orleans’ key safety net hospitals, began seeing Covid-19 patients in the second week of March.
The fact that New Orleans sees new HIV diagnoses often means that patients at the clinic already walk in with the hurdles of health inequity and racial disparity, Seal says. “HIV itself accelerates aging and presents a higher incidence of cardiovascular disease and kidney disease, and we are now seeing increased weight gain,” she says. “Many of these things identify as risk factors for [Covid-19 too].”
Seal points out that a reason why racial disparities in health care are more pronounced in the South is the fact that a number of governors, including former Louisiana governor Bobby Jindal, rejected Medicaid expansion under the Affordable Care Act. “It wasn’t until Jon Bel Edwards came in that Medicaid expansion was accepted. That helped a lot,” Seal says.
The 2016 expansion, which covers 10 percent of people in the state, has been proven to decrease annual mortality in Louisiana, cut uninsurance rates in half, and expand access to care. Louisiana is the only state in the Deep South to embrace the legislation. Still, Seal suggests that a lack of access to primary care for generations may have added to the Covid-19 risk factors the black community was already facing.
The reason for compounded health problems among black Americans: racism
“It’s almost like structural racism has made black people sick,” Uché Blackstock, an emergency medicine physician in Brooklyn and the founder and CEO of Advancing Health Equity, an organization that fights health care inequity, tells Vox.
Blackstock, who works in a gentrifying neighborhood in central Brooklyn, says she is used to seeing a mix of people at her clinic, but with Covid-19, it’s lately “been all black people” — essential workers who don’t have the luxury of leveraging wealth to escape to homes on Long Island, upstate New York, Connecticut, or Rhode Island. Environmental racism, including practices like toxic dumping, has worked in tandem with other kinds of oppression (racial restrictive housing covenants and anti-busing measures, to name two) to produce stress and contribute to high rates of chronic illness.
According to Blackstock, the pandemic is exposing a deep-rooted system of the haves and have-nots. It’s also displaying how black and brown people have a more tenuous existence in New York City since they lack job security, sick leave, and health insurance. They must ride public transportation to get to work on the front lines, many of them driving the buses themselves or cleaning the hospitals where they are directly at risk.
And those are the ones who still have jobs: The latest US unemployment figures show that black people were disproportionately impacted by job losses in March. The unemployment rate was highest for blacks at 6.7 percent and lowest for whites at 4 percent. Nationally, the unemployment rate was 4.4 percent as nearly 10 million Americans filed for unemployment compensation at the end of the month.
To fight the spread of the coronavirus, public health experts say that social distancing is one of the most effective measures people can take. But being able to socially or physically distance is a privilege. Black families often live in multigenerational homes, with the very young and the very old together under one roof. In 2016, 26 percent of black people lived in multigenerational homes, while 16 percent of whites did, according to Pew Research. Perry says residential segregation is making black people sick, and it started with housing discrimination and redlining, the unethical practice of refusing or limiting loans and services to people based on race, income, or neighborhood.
“Redlining determined that certain black areas weren’t worthy of housing, ensuring that black people didn’t have the ability to pass down wealth to their children. It determined where black people could live, what kind of jobs they had, and the colleges and elementary schools they would attend,” Perry says.
And over time, low-income black people became concentrated in the same areas, with vulnerabilities stacking atop one another. Black people’s movement has been restricted, making them more vulnerable to economic shocks. “When you’re poor, you use other people to make ends meet,” Perry says. “You share cars, you share energy, you live together. You’re not afforded the luxury of not being connected.”
This dependency feeds the cycle of poverty. Without any intervention, families remain trapped, vulnerable to factors like low food access or low-quality education in segregated neighborhoods that beget their susceptibility to infectious disease. In 2018, the poverty rate for black Americans was 22 percent, according to a 2018 analysis by the Kaiser Family Foundation. By comparison, it was 9 percent for white Americans.
Abandoned populations are the most vulnerable in the pandemic
Black people are also often overrepresented in abandoned populations like the homeless and incarcerated. Because these groups are an afterthought in American society, they’re especially vulnerable. Covid-19 will easily compromise them, public health officials warn, which is why advocates are calling for specific protection measures now.
In Detroit, where the homeless population is majority black, Levy is working with the city to test members of the homeless for Covid-19, an effort that could save thousands of lives.
“There are 2,100 chronically homeless people in Detroit, and we must make sure they don’t get duly afflicted with coronavirus as a virtue of residing in shelters together,” Levy says. The city is reopening temporary shelters and setting up 500 more beds across the facilities that will allow for social distancing.
Black people are also disproportionately represented in the country’s prison system; police targeting leads black people to be incarcerated at more than five times the rate of whites. Add the conditions of confinement — lack of access to basic necessities like clean water, soap, and ventilation — to already existing health conditions, and it’s no surprise that incarcerated people are more susceptible to sickness. In New York City’s Department of Corrections facilities, 286 inmates have tested positive for Covid-19, and on Sunday, New York City’s first inmate died at Rikers Island prison, according to BuzzFeed News. He was awaiting a hearing on a parole violation.
According to Brendan Saloner, a health policy researcher at Johns Hopkins, the result of a widespread outbreak in jails and prisons has catastrophic consequences. “The nature of outbreaks in prison is that once they set off, it’s hard to contain,” he tells Vox. “The pandemic is only magnifying structural inequality, and we won’t ever understand the true magnitude of what’s happening if we don’t include incarcerated populations.”
Some states, like California and even New York, have begun releasing people incarcerated for nonviolent crimes to reduce spread in the pandemic. However, advocates say more could be done, such as releasing those who are more vulnerable to the virus, including people who committed violent crimes but are no longer a threat because they are sick and old. Ultimately, advocates say, bold reforms at both the state and federal levels need to be taken, and taken quickly, if correctional facilities want to slow the escalating number of cases not only among the incarcerated but among those who work in prisons and jails, too.
What comes next will probably further disenfranchise the black community
With a lack of data comes a solid lack of certainty. Many health and civic leaders agree that a disaggregation of race and other demographic information would help health care professionals better treat patients as the country ventures through what is said to be its worst week yet in the pandemic.
“We are in unprecedented times right now so we need the data released immediately,” says Blackstock. “We know it will confirm what we are predicting. We need the information to determine exactly how to respond to the demands of surges of sick people.”
There’s worry that we will get the details when it’s far too late. Or worse, even when we get the information we need, it might serve as a ticket for the rest of the country to move on.
In Memphis, Tennessee, community activist and pastor Earle Fisher is certain that the city will be ground zero for understanding how poverty leads to outsized health disparity, particularly in the face of a pandemic. But Memphis and Shelby County leadership have not displayed an interest in releasing detailed information on Covid-19 testing or in ramping up testing for residents at large, according to Fisher. “We’re leaving out a vulnerable community and subjecting them to even more deaths,” he says.
Past pandemics like the 1918 influenza outbreak and subsequent H1N1 seasons show that black people have a higher risk of dying when they contract widespread disease. In 1918, for example, even though blacks had lower morbidity and mortality overall, they still had higher fatality rates. And though black people had lower rates of influenza, whites still advanced racist theories about blacks being infectious disease threats. Then there is HIV, which has also disproportionately affected black Americans in recent years, a statistic that is rarely talked about.
Fisher recited an age-old saying in the black community: “If white America has a cold, black America has the flu. If white America has Covid-19, what do we have?” The question stumps other leaders, too.
Blackstock and Perry see some validity in asking, if white America recovers and moves on, will the country care about a pandemic that continues to terrorize black communities? Will the president or the CDC continue to hold press conferences once white people are mostly in the clear?
“Black people have been suffering from a number of epidemics and no one batted an eye,” Perry says. “The status of the country has always been measured by the status of white people.”
While Blackstock said it’s still too early to make any definitive predictions, she says “those who do care have to be as vocal as possible — we have families and generations of people who call these communities home.”
The burden is once again on black people to demand information and related actions that will save their lives.