This is a paper from my sociology course that touched on ethical reasoning and grappled with power, privilege, and inequality in a national and global context. In this particular paper, we were tasked with choosing a topic that dealt with power, privilege, and inequality in a domestic perspective. I chose to examine the disproportionate impact of COVID-19 on communities of color, including the root causes and social determinants of health that cause discrepancies in the quality of medical care in different areas. I enjoyed and was proud of this paper because it was a subject I didn’t know much about when I began, but became very engaged with it as I conducted research and ended up learning a great deal.
March 2, 2021
A Hard Pill to Swallow: Lessons Learned from COVID-19 and How to Move Forward with Anti-Racism in Public Health
“I can’t breathe.” George Floyd’s words, that echoed around the nation amidst calls for an end to police violence, scrawled on signs, buildings, and banners, are a sobering reflection of the systemic racism that is still rampant in America. These inequities go beyond just policing and protesting in the streets, and have become increasingly evident in the wake of a global pandemic and our national response. Many are struggling to beat the virus, being put on ventilators, isolated from their families and passing away in solitude, with a large portion of those who have succumbed to the virus in the United States being people of color. The disproportionate impact of COVID-19 and the failures of the healthcare system are reflective of a culmination of centuries of widespread, systemic oppression of Black people in the US. More often than not, scientific fields have negated or inadequately attributed how racism itself is a social determinant of health and negatively impacts other crucial factors such as socioeconomic status, geographical location, food, education, and healthcare, all of which are contributors to the impact of COVID-19 and racial disparities in health, issues that “neither the scientific community nor the public-health world is confronting…directly” (Gladden-Young, 2020). The research presented will attempt to explore how social determinants of health as well as disparities regarding race and healthcare access have contributed to disproportionate COVID-19 mortality rates among communities of color and use Critical Race Theory to examine how a lack of racial consciousness and a culture of prejudice have led to inequalities in the healthcare system that are currently playing out in the midst of a global pandemic. It is clear from the evidence presented that health is not an isolated factor nor is COVID-19 mortality a matter of chance, but rather a systemic issue that has contributed to greater rates of underlying conditions, lower access to quality healthcare, and an unequal allocation of resources that negatively affect minority populations and people of color.
A shocking disproportion of Black and African-American individuals are contracting and dying from COVID-19 in comparison with their White counterparts, statistics that further reinforce the racial disparities in healthcare facing the country. People who are African American or Black are contracting the virus at much higher rates, and are more likely to die of the disease (Yancy, 2020, p. 1891). In the United States, at least 25, 565 Black lives have been lost. They make up only 13% of the population but 23% of deaths as of the end of 2020, and are dying at a rate of 65.8 per 100,000, compared ot White people who are dying at a rate of 28.5 per 100,000 (APM Research Lab Staff, 2020; COVID Racial Data Tracker, 2020). White Americans see mortality rates over twice as low as other groups including Indigenous Americans, with 2.2 times higher mortality rates, and Black people, with 2.1 times higher mortality rates (APM Research Lab Staff, 2020). A survey conducted indicates that in 132 predominantly Black counties in the US, the infection rate is 137.5 per 100,000, or three times higher than in predominantly White counties, while the death rate is 6.3 per 100,000, or six times higher than in predominantly White counties. In fact, in Chicago, Black individuals make up 50% of the COVID-19 cases and around 70% of deaths, though they comprise only 30% of the city’s population (Yancy, 2020, p. 1891). It is evident from these data that Black people and communities are heavily and disproportionately affected by the pandemic and do not have the adequate services to mitigate this impact. The strategies used to combat this virus are clearly overlooking marginalized and underserved groups, a fault demonstrated by the disparities in mortality rates among Black and White populations.
Critical Race Theory (CRT) is an interdisciplinary method of study and research that combines legal studies and social justice among other fields to emphasize the praxis between research and practice. It can be used to challenge racial hierarchies, and is deemed to be instrumental in assessing the impact of COVID-19 on Black communities and groups who are disproportionately affected by the virus, which will ultimately allow researchers to determine how race, as well as underlying conditions, and social determinants of health are impacting mortality rates and outcomes (Ford & Airhihenbuwa, 2010; Ford & Airhihenbuwa, 2018, p. 224). Social determinants of health are factors that perpetuate racial disparities and inequalities in the healthcare system and are further amplified by the current pandemic and unstable situations seen across the country. SDOH are defined as “the social conditions into which people are born and that affect their daily lives and overall well-being,” reflecting that health is not simply based on what one eats or how much they exercise but on underlying factors beyond their control (Teitelbaum & Wilensky, 2020, p. 139). They can explain a higher vulnerability of certain communities of color to health concerns that go beyond the healthcare system and include other factors such as education, employment, housing, and the justice system. This coincides with the CRT practices of interdisciplinary study and the consideration of racism in all areas of life to determine its impact, as well as the notion that racism is integrated into society (Blumenthal et. al, 2020; Ford & Airhihenbuwa, 2010). The purpose of incorporating CRT into health research is to acknowledge the widespread presence of racism in all of our institutions and to center research in the margins, or shift conversations from the majority perspective to the view of minority groups (Ford & Airhihenbuwa, 2010). CRT is meant to challenge the belief that race consciousness is a form of racism and that colorblindness represents a lack of racism, because in truth, colorblindness assumes that nonracial ideas can be explanatory of racial issues while consciousness is necessary to understand racialized constructs (Ford & Airhihenbuwa, 2010). Racism was not normally deemed a determinant of health, a statement made under an assumption of colorblindness, when, if approached with a critical and racially conscious lens, it is evident that racial disparities are caused by inequities and social determinants of health which include systemic issues that individuals cannot impact with their behavior and health choices (Teitelbaum & Wilensky, 2020, p. 139). This work reflects a larger national failure of our health system to adequately address the issues of people of color, including a lack of insurance, less access to care, higher rates of chronic illness, and fewer resources to mitigate underlying conditions, leading to a higher vulnerability to the virus that has been explained away by poor health choices rather than systemic racism that has had the greatest impact on these issues (Blumenthal et. al, 2020). The virus has uncovered and highlighted structural racism across our society as uneven racial patterns surrounding who has safer jobs, paid sick days, sparsely populated neighborhoods, private transportation, affordable and high quality healthcare, and access to healthy foods all reflect racial health disparities that have resulted in higher mortality rates among minority populations (APM Research Lab Staff, 2020).
In conjunction with public health experts, Critical Race theorists have created the Public Health Critical Race Praxis that offers frameworks and methods to determine and analyze the impact of racism on SDOHs, dismantle racism and pave the road to racial health equity in the US (Ford & Airhihenbuwa, 2010). The PHCRP reflects the crucial role CRT can play in all fields as it is currently being used in the medical field to begin to achieve equitable access and distribution of resources in healthcare. PHCRP rejects an essentialist understanding of identity and health and prevents social standing and economic status from capturing the entirety of a person’s health by identifying how other factors may play into wellbeing (Bridges et. al, 2020, p. 180). Public health generally overemphasizes individual and interpersonal factors and their role in creating health disparities, otherwise known as a community-deficits intervention approach, whereas PHCRP acknowledges how structural factors come into play and advocates for a community strength and resilience based intervention (Ford & Airhihenbuwa, 2018, p. 228; 2010). Non medical issues including housing and food insecurity, higher risk jobs, and other factors that are often overlooked but that are generally impacted by the effects of systemic racism, such as redlining, can be contributors to a poorer health status (Blumenthal et. al, 2020). In the present day, the health disparities among people of color have become even more apparent as seen by drastically different COVID-19 mortality rates among White communities and people of color. CRT and PHCRP can address these gaps in awareness and research. The public health sector ignored “the unequal conditions that render[ed] some populations more susceptible to the virus than others and that render mainstream interventions less accessible to them” (Ford, 2020, p. 184); however, they can use CRT and PHCRP to “acknowledge and address the fundamental role of racism and other social inequalities in shaping the spread of the virus and the capacity of…communities of color to overcome it” (Ford, 2020, p. 184). Resource allocation that doesn’t account for race, structural racism, and healthcare disparities “assign worth to different groups” in a similar way to housing segregation (Chomilo et. al, 2020). As resources are distributed in response to COVID-19 based on certain data points, such as amount of underlying conditions, health of existing populations, etc. they are failing to heed how race impacts these factors and further perpetuating inequities in healthcare and access. In New York City, for example, a Harlem zip code (10030) has a life expectancy of 72.7, while less than five miles away in the Upper East Side of Manhattan (10075), they have a life expectancy of 89 years. Prioritizing life expectancy when deciding where to expend resources and services to combat the virus without regarding the underlying structural racism will continue to perpetuate and reinforce disproportionate mortality rates by race (Chomilo et. al, 2020). Public health as a field has historically failed to understand the intersection of race, socio-economic factors and health disparities by not recognizing the contribution of racism to poor health and economic barriers to access (Ford, 2020, p. 184). Mitigating the impact of structural racism on health outcomes begins with quality research that acknowledges and investigates the influence of such racism on healthcare, access, and social determinants of health, all of which requires a critical race approach with a PHCRP focus to truly understand the intersectionality of these issues and move away from the antiquated and individualistic assumptions of health determinants.
Steps are needed to strengthen the understanding of racial phenomena to improve the inclusivity of research, which a PHCRP approach would emphasize. Public health research must go beyond the valued quantitative methods that are common in scientific approaches, and would benefit from a mixed methods approach that includes qualitative analysis and narratives to provide a story behind the numbers because “privileging quantitative methods in our understanding of biodiversity sustains the post enlightenment fantasy that the “hard sciences” alone can address our social issues” (Bridges et. al, 2020, p. 180). In terms of COVID-19 and a CRT approach, PHCRP would have advocated for racial data collection and analysis, both qualitative and quantitative, early on, a practice which only occurred after public demands from political officials such as Senator Elizabeth Warren and Representative Ayanna Pressley, and racial scholars such as Ibram X. Kendi. The lack of racial data collection contributes to a racially disproportionate impact of the virus as the effects of unequal resource allocation and disparities in access cannot be measured or adequately addressed if the motivating factors behind these disparities are not well documented. Some states still are not collecting race-related data, meaning that the racial inequities are potentially higher than recognized (Gladden-Young, 2020; Goodman, 2020). By failing to acknowledge racial disparities that contributed to the disproportionate impact of COVID-19 and collect racial data surrounding the virus, it is impossible to develop an effective mitigation response to the virus. Collecting this data and making an effort to focus on racial health disparities, as the application of CRT would encourage, is necessary to respond properly to the pandemic so that the vulnerable populations are protected and the nation as a whole becomes safer (Goodman, 2020). In fact, “reporting is the starting point for coming to terms with inequity in our health system” (Blumenthal et. al, 2020). PHCRP and its tactics also reveal further healthcare system inequities and the injustice displayed by early triage responses to intensive care patient surges, including proposals to withhold life-saving treatments from those with potentially fatal underlying conditions such as lung and heart diseases, diseases that disproportionately impact Black people due to structural racism and social determinants of health (Gladden-Young, 2020). The glaring inequalities become clear when one digs deeper into the public health system and its most recent responses to COVID-19 through a critical race lens as other factors and qualitative aspects highlight the disproportionate impact the virus has on communities of color that is amplified by the misallocation of resources and access to life-saving services, all of which can be attributed to structural racism within healthcare. Improving these health outcomes and minimizing the disparities present is impossible until medical professionals acknowledge that these fields of practice are based on racialized social, political, and economic methods of controls.
The medical field has been consistently plagued by racial biases and stereotypes that are not new in the era of COVID-19, although the virus and its response has brought many of these disparities to light. In fact, antiquated theories of race have strongly impacted medical education, including the idea of racial typologies and the assumption that visual distinctions and our social perceptions reflect tangible biological differences that explain different health outcomes among racial groups which perpetuates a theory of biological race in medicine (Bridges et. al, 2020, p. 179). These biological conceptions of race are accompanied by greater acceptance of racial disparities and attribution of other factors as determinants of health status to the extent that some doctors have even been known to cite racial bias in pain perception. These assumptions and stereotypes are reflective of a culture of prejudice embedded not only in medicine but in society as a whole, although they are reinforced through biased educational materials and practices. Culture of prejudice theorizes that prejudice is embedded in our culture and perpetuated by our institutions, such as schools and hospitals, and utilizes stereotypes as depictions of an entire group. It is further strengthened by attitudes, ideologies, policies, and social constructs that lead to the belief of inferior and superior groups, essentially an “us and them” view (Adeola, 2005, p. 62; Blackwell et. al, 2003, p. 67). In terms of a culture of prejudice within healthcare, studies have found that Black patients are less likely than White patients to receive adequate pain medications for fractures in the emergency room (54% vs. 74%, respectively) though they reported similar levels of pain, and physicians in general are more likely to underestimate the pain of Black patients (47% of the time) than non-Black patients (33.5% of the time) (Hoffman et. al, 2016, p. 4296). These failures are not necessarily the result of racist individuals acting upon their racism but of prejudices ingrained in society that are reflected in these institutions, including beliefs about differences that perpetuate race as a biological factor, such as the idea that Black people have thicker skin and that their blood coagulates more quickly, both of which, if true, would warrant lower doses of pain medication (Hoffman et. al, 2016, p. 4297). Viewing race as a natural occurrence prevents a deeper understanding of racial disparities as they relate to other factors, an issue that can be prevented through use of CRT and PHCRP as well as an understanding of the culture of prejudice.
Shallow conceptions of race result in a failure of the medical field to adequately assess and treat people of color, resulting in a deeply rooted mistrust of the public health field that played out during initial responses to the pandemic. Counties with lower educational levels were less efficient in social distancing, and researchers noted that those with less education perceive their risk of COVID-19 to be lower. Education is often accompanied by a greater trust in science, and lack of trust was linked with less compliance with preventative measures and guidelines (Abdalla et. al, 2021). Given that education is a social determinant of health and the education system is subject to institutional racism, with much higher obstacles to education, particularly higher education, for people of color and marginalized groups, the lack of urgency to social distance is understandable when examined using a critical race perspective and can partially explain higher mortality rates within these groups. Additionally, towns with larger proportions of non-White residents, when independent from other variables, reported higher delays in social distancing implementation as well. This distrust, a reflection of higher reported levels of medical and physician distrust among Black people than White people, manifested itself as resistance to predominantly White healthcare professionals prescribing guidelines to minority populations who have historically and continuously been victims of medical injustice (Abdalla et. al, 2021). Ibram X. Kendi noted that, when more Americans realized Black people were dying disproportionately in mid-April, their first reaction was to blame Black people and say that they were not taking the virus seriously and refusing to follow medical advice, again displaying the rampant and pervasive impact that the culture of prejudice has when snap judgements were made about the intelligence and cooperation of the Black community rather than an analysis of underlying structural racism that led to this point (Goodman, 2020). What many fail to recognize is that people of color hold a disproportionate number of front-line and essential jobs and the privilege of maintaining social distance, working home, and telecommuting is impossible, another reflection of structural racism and economic injustice contributing to social determinants of health and COVID-19 outcomes (Yancy, 2020, p. 1891). Another argument was raised, as elaborated on by Kendi, that Black people have greater underlying conditions and that can account for their higher mortality rates, while the reality is that access to medical care and high quality care are more predictive of Black infection and death rates, along with other social determinants of health such as environment and employment status, than underlying conditions truly are (Goodman, 2020). Regardless, each of these factors can be explained and analyzed in the context of systemic and structural racism present not only in the medical field but in the housing market, the economy, social institutions, and the education system. It is evident when examining the public health field and COVID-19 response and reaction in conjunction with CRT, PHCRP, and factoring in the culture of prejudice in the United States that there are other issues involved beyond poor health, biological differences, and economic status and that it is underlying systemic racism that is the largest contributing factor to the disparities in the effect of the virus on communities of color.
While racism is beginning to be examined and dismantled in society, there are still large gaps in certain institutions that could greatly benefit from a critical race approach to determine how race plays into practices and account for these different factors. The medical field most certainly does not adequately serve Black communities and individuals and the bias and prejudice within this field ultimately has a negative impact on these groups when this bias goes unrecognized and unquestioned. CRT and PHCRP both aim to uncover and examine how race intersects with other determinants of health and how this affects health outcomes, specifically regarding the mortality rate of COVID-19. The lack of recognition of the importance of race and the impact it has on health care and access to treatment is astounding and it is clearly time for the United States to open its eyes and incorporate critical race practices into all areas of study. These disparities are not new nor are they going to be easily remedied but it is time to begin approaching them from a new angle that includes all perspectives and accounts. Clyde Yancy, in an article for the Journal of American Medical Association, noted that “the US has needed a trigger to fully address health care disparities; COVID-19 may well be that bellwether event” (Yancy, 2020, p. 1892). Moving forward, it is crucial to keep this in mind as new research, studies, and approaches are considered and be sure to tackle all issues through a critical lens in order to begin the arduous process of dismantling the institutional racism rampant in America today.
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