Working at the Intersection of Race, Racism, and Public Health

COVID-19 has dramatically revealed the racism imbued in our country. It has not only laid bare wounds that never healed but also exposed those that festered unattended for generations. The human toll stemming from our collective ease with euphemistic phrases such as “systemic disinvestment” is devastating. This virus has used our Achillesʼ heel to bring our country to its knees.

COVID-19 is a public health emergency like no other. As of September 5, 9 months since this nightmare began, more than 177 000 souls have been lost in our country (CDC),¹ almost 24 000 (NYC DOHMH)² of them in New York City (NYC) alone. Fifty-six percent of New Yorkers who have died of confirmed or probable COVID-19 are Black and Latino, distressing data that mirror the national trend (NYC DOHMH).² Tragically, this number does not reflect the full burden of COVID-19 because it does not include the excess deaths that otherwise would not have happened. The true toll of this pandemic will take years to document.

The field of public health must play a central role in getting our country back on its feet. It is incumbent on us to do a rapid self-assessment of how the first wave of COVID-19 devastation is disproportionately ravaging our communities of color. We cannot let this moment pass without calling it what it is—a collective reckoning.

This “collective reckoning” will be meaningful only if justice and equity undergird public health practice. Even before COVID-19, many of us were working feverishly to operationalize racial equity agendas in our work in anticipation of the next public health emergency, one that we knew would devastate communities of color, especially those in our most underresourced neighborhoods. However, the scale of devastation caused by COVID-19 is a glaring reminder that we were just tinkering at the margins with our plans. To significantly mitigate the impact of racism on our communities' health, we need seismic shifts in resources—those that are seen by the broader public as only possible during “true” emergencies, which also, in and of itself, must change. We must build a constituency for public health outside of the field, and if we cannot do that now, we may never be able to do so. Antiracism practice, and operationalizing health equity, may be the way in which we can become—and stay—more visible to the community at large.

What We Must Do

First, we need to more forcefully advocate for complete racial demographics in the data we collect. While the principal responsibility lies with health care delivery systems and laboratories that collect this information, it is our civic responsibility to raise alarms about how incomplete data downplay the magnitude of race in outcomes, lest our silence be seen as complicity.

Second, it is a disservice to our communities when those of us with decision-making authority choose to not report the number of “probable” COVID-19 deaths. It is well known that access to testing across this country has been easiest for White Americans of means. Not counting those who have died of COVID-19 but were not confirmed as such because they could not access a test is double punishment because it deprives them, their loved ones, and their communities of the dignity of being counted and grieved for. It is a crucial part of the healing process we will all need to go through if we are to emerge a stronger country.

The third goes back to distribution of resources to where the data say they are most needed. However, data heat maps must be created and interpreted through a racial equity lens that takes into account historical injustices (ie, redlining) that have played a role in the accrual of health inequities within communities of color, as well as present-day exploitations (ie, denying nonunionized workers paid sick days) that influence the distribution of health outcomes.

The Intersection of Race and COVID-19

Early in our pandemic response, data showed Black and Brown New Yorkers dying at twice the rate as White New Yorkers. Beyond that, the data indicated that morbidity and mortality clustered in communities documented to have a high concentration of overcrowded housing and multigenerational households. It is important to emphasize that there is no biologic basis to race and therefore what we were seeing was not due to race as an independent risk factor but rather racism as a confounding factor. Black and Brown New Yorkers, as in the rest of the country, tend to be poorer than Whites and more likely to hold jobs where telecommuting is not an option. In addition, because of lower wages, they are forced to live in overcrowded housing and often in multigenerational households. This then is the trifecta of the high-risk profile that resulted in what we experienced in NYC and is playing out in many ways across the country.

Unfortunately, decisions on how to direct resources can have deadly consequences when they are driven by preconceived notions of who is most likely to experience complications and what actions should be taken without having a fuller race and power analysis about what this virus is unearthing. Such conclusions propagate the pervasive, racist myth that people of color are overly susceptible to disease due to substandard hygiene, faulty DNA, and hazardous lifestyle choices. This myth gains even more traction during times of national distress and has shaped the pandemic's narrative and emergency response in some parts of this country. I am saddened, but I am not surprised. Blaming people of color for their poor health is an age-old smoke screen used to prevent investing in environments wherein healthy choices would be the default. While historic oppression contextualizes the root causes of COVID-19 health disparities (along with other causes of death), public health cannot rest after tabulating data or acknowledging that disparities exist.

How NYC Reacted to Address COVID-19 Disparities

We broke with public health dogma in NYC and released data before it was fully complete because the stark inequities in how COVID-19 was playing out were so evident that it would have been malpractice not to do so. As a result, agency partners, health care providers, community leaders, and government officials immediately joined us in centering the most affected New Yorkers in their responses to the virus. Prioritizing action above convention, in this case, almost certainly saved lives.

There were then 3 strategic directions that were undertaken (Figure):

• We intensified resource support to the 27 communities that accounted for just over half the COVID-19 deaths and which had the highest concentration of clinical (diabetes and hypertension) and social (overcrowded and multigenerational households) risk factors, all of which were communities of color.
• We provided financial support to community-based organizations, seen as anchor institutions by their communities, to disseminate educational information through various means and provide social supports that would allow infected individuals to safely isolate or quarantine, including access to free food delivery and free hotel rooms.
• Finally, we identified all of the primary care providers in these communities—many of whom are themselves people of color—to ensure they had access to necessary PPE so they could reopen and provide essential care, especially for patients with chronic illnesses; that they were fully prepared to leverage reimbursement for telemedicine; and that we provided necessary support to call patients that they were unable to reach in order to assess patients' food and medication needs.

FIGURE: Three Strategic Directions

This was a powerful lesson in how racism in systems designed to ignore or perpetuate it necessitates more intentional intervention to undo it. Confronting public health inequities therefore demands that we confront public health's systemic rigidities and biases, as well as our own. Our challenge is to fight systemic racism with boldness, love, and a living commitment to the struggles for justice that the past months have made impossible to ignore, even for the most institutionally dogmatic.

Conclusion

America needs a COVID-19 equity action plan. States such as Louisiana, Massachusetts, Washington, and Virginia, along with cities such as Seattle, Minneapolis, and Washington, District of Columbia, have all joined in creating task forces or plans focused on equity, but those efforts will not be enough to prevent the mass devastation that faces the nation as some states rush to reopen. In the absence of leadership from the federal government, it is imperative that every jurisdiction creates public-facing equity action plans that center on its most marginalized residents. Community accountability is one tool to ensure we are doing the right thing in the right places at the right time for the people most in need.

As we move from the acute pandemic response to long-term recovery, racial equity must remain our most steadfast core value. Public health must remain committed to acknowledging, preventing, and mitigating racism and other intersecting spheres of oppression—particularly xenophobia and poverty—lest the next pandemic have the exact same results. The praxis of undoing racism in the face of a pandemic demands we act with speed and courage.