Epidemiologist Sharrelle Barber discusses the racial inequalities that exist for COVID-19 and many other health conditions.
Throughout the COVID-19 pandemic, whether cases are flaring up, slowing to a simmer, or back on the rise in areas across the United States, the data makes one fact apparent: The viral disease has disproportionally sickened and killed marginalized communities. A New York Times analysis of data from almost 1,000 counties that reported racial breakdowns of COVID-19 cases and fatalities revealed that, compared to white Americans, African Americans and Hispanics were three times more likely to experience and two times more likely to die from the illness. The Navajo Nation has, per capita, more confirmed cases and deaths than any of the 50 states.
Many factors, like access to healthcare and testing, household size, or essential worker status, likely contribute to the pandemic’s outsized toll on communities of color, but experts see a common root: the far-reaching effects of systemic racism.
That racism would have such an insidious effect on health isn’t a revelation to social epidemiologists. For decades, public health experts have discussed “weathering,” or the toll that repeated stressors experienced by people of color take on their health. Studies have demonstrated the link between such chronic stress and high blood pressure, the increased maternal mortality rate among black and indigenous women, and the elevated prevalence of diabetes in black, Latino and especially Native American populations. The pandemic has laid bare these inequities. At the same time, outcry over systemic racism and police brutality against African Americans has roiled the nation, and the phrase, “Racism is a public health issue” has become an internet refrain.
What exactly is the nebulous concept of “public health”? According to Sharrelle Barber, a Drexel University assistant professor of epidemiology, the concept goes beyond the healthcare setting to take a more holistic look at health in different populations. “The charge of public health,” Barber told Smithsonian, “is really to prevent disease, prevent death, and you prevent those things by having a proper diagnosis of why certain groups might have higher rates of mortality, higher rates of morbidity, et cetera.”
Below is a lightly edited transcript of Smithsonian’s conversation with Barber, who studies how anti-black racism impacts health, about the many ways in which racism is a public health crisis:
When people say, “Racism is a public health problem,” what, in broad strokes, do they mean?
We’ve been observing racial inequities in health for decades in this country. W.E.B. DuBois, who was a sociologist, in The Philadelphia Negro showed mortality rates by race and where people lived in the city of Philadelphia at the turn of the 20th century and found striking inequalities based on race. Fast forward to 1985, 35 years ago, and we have the [Department of Health and Human Services-sponsored] Heckler Report, one of the most comprehensive studies the country had undertaken, which again found striking inequalities across a wide range of health outcomes: infant mortality, cancer, stroke, et cetera.
There are various explanations for why these racial inequalities exist, and a lot of those have erroneously focused on either biology or genetics or behavioral aspects, but it’s important to examine the root causes of those inequities, which is structural racism…Racism is a public health problem, meaning racism is at the root of the inequities in health that we see, particularly for blacks in this country. So whether it’s housing, criminal justice, education, wealth, economic opportunities, healthcare, all of these interlocking systems of racism really are the main fundamental drivers of the racial inequities that we see among black Americans.
What are some specific factors or policies that have set the foundations for these health inequities?
Any conversation about racial inequities has to start with a conversation about slavery. We have to go back 400-plus years and really recognize the ways in which the enslavement of African people and people of African descent is the initial insult that set up the system of racism within this country. One of the major drivers that I actually study is the link between racial residential segregation, particularly in our large urban areas, and health inequities. Racial residential segregation is rooted in racist policies that date back at least to the 1930s. Practices such as redlining, which devalued black communities and led to the disinvestment in black communities, were then propped up by practices and policies at the local, the state and federal level, for example, things like restrictive covenants, where blacks were not allowed to move into certain communities; racial terror, where blacks were literally intimidated and run out of white communities when they tried to or attempted to move into better communities; and so many other policies. Even when you get the 1968 Fair Housing Act, the system finds a way to reinvent itself to still perpetuate and maintain racism.
Within segregated communities, you have so many adverse exposures, like poor quality housing or lack of access to affordable, healthy foods, lack of access to quality healthcare, and the list goes on. The chronic stressors within these communities are compounded in segregated communities, which then can lead to a wide array of health outcomes that are detrimental. So for example, in the city of Philadelphia, there’s been work that has shown upwards of a 15-year life expectancy difference between racially and economically segregated communities, black communities and wealthier white communities.
I imagine that sometimes you might get pushback from people who ask about whether you can separate the effects of socioeconomic status and race in these differences in health outcomes.
Yeah, that’s a false dichotomy in some ways. Racism does lead to, in many aspects, lower income, education, wealth. So they’re inextricably linked. However, racism as a system goes beyond socioeconomic status. If we look at what we see in terms of racial inequities in maternal mortality for black women, they are three times times more likely to die compared to white women. This disparity or this inequity is actually seen for black women who have a college degree or more. The disparity is wide, even when you control for socioeconomic status.
Let’s talk about the COVID-19 pandemic. How does racism shape the current health crisis?
The COVID-19 pandemic has literally just exposed what me and so many of my colleagues have known for decades, but it just puts it in such sharp focus. When you see the disproportionate impact COVID-19 is having, particularly for blacks, but also we’re seeing emerging data on Indigenous folks, it is just laying bare the ways racism is operating in this moment to produce those inequities.
Essential workers who had to continue to work during periods of stay at home orders across the country were disproportionately black and Latino. These are also often low wage workers. They weren’t given personal protective equipment, paid sick leave, hazard pay, and really had to choose between being exposed and protecting themselves and having an income during this period. So that’s one way racism operates.
Then we know that those individuals aren’t isolated, that they return to homes that often are crowded because of the lack of affordable housing. Again, another system of racism that compounds the effect. Then you think about places like Flint, Michigan, or places that don’t have access to clean water. When we were telling people, “Wash your hands, social distance,” all of those things, there were people who literally could not adhere to those basic public health prevention measures and still can’t.
People with long-term Covid-19 complications are meanwhile struggling to get care.
In late March, when Covid-19 was first surging, Jake Suett, a doctor of anesthesiology and intensive care medicine with the National Health Service in Norfolk, England, had seen plenty of patients with the disease — and intubated a few of them.
Then one day, he started to feel unwell, tired, with a sore throat. He pushed through it, continuing to work for five days until he developed a dry cough and fever. “Eventually, I got to the point where I was gasping for air literally doing nothing, lying on my bed.”
At the hospital, his chest X-rays and oxygen levels were normal — except he was gasping for air. After he was sent home, he continued to experience trouble breathing and developed severe cardiac-type chest pain.
Because of a shortage of Covid-19 tests, Suett wasn’t immediately tested; when he was able to get a test, 24 days after he got sick, it came back negative. PCR tests, which are most commonly used, can only detect acute infections, and because of testing shortages, not everyone has been able to get a test when they need one.
It’s now been 14 weeks since Suett’s presumed infection and he still has symptoms, including trouble concentrating, known as brain fog. (One recent study in Spain found that a majority of 841 hospitalized Covid-19 patients had neurological symptoms, including headaches and seizures.) “I don’t know what my future holds anymore,” Suett says.
Some doctors have dismissed some of his ongoing symptoms. One doctor suggested his intense breathing difficulties might be related to anxiety. “I found that really surprising,” Suett says. “As a doctor, I wanted to tell people, ‘Maybe we’re missing something here.’” He’s concerned not just for himself, but that many Covid-19 survivors with long-term symptoms aren’t being acknowledged or treated.
Suett says that even if the proportion of people who don’t eventually fully recover is small, there’s still a significant population who will need long-term care — and they’re having trouble getting it. “It’s a huge, unreported problem, and it’s crazy no one is shouting this from rooftops.”
In the US, a number of specialized centers are popping up at hospitals to help treat — and study — ongoing Covid-19 symptoms. The most successful draw on existing post-ICU protocols and a wide range of experts, from pulmonologists to psychiatrists. Yet even as care improves, patients are also running into familiar challenges in finding treatment: accessing and being able to pay for it.
What’s causing these long-term symptoms?
Scientists are still learning about the many ways the virus that causes Covid-19 impacts the body — both during initial infection and as symptoms persist.
One of the researchers studying them is Michael Peluso, a clinical fellow in infectious diseases at the University of California San Francisco, who is currently enrolling Covid-19 patients in San Francisco in a two-year study to study the disease’s long-term effects. The goal is to better understand what symptoms people are developing, how long they last, and eventually, the mechanisms that cause them. This could help scientists answer questions like how antibodies and immune cells called T-cells respond to the virus, and how different individuals might have different immune responses, leading to longer or shorter recovery times.
At the beginning of the Covid-19 pandemic, “the assumption was that people would get better, and then it was over,” Peluso says. “But we know from lots of other viral infections that there is almost always a subset of people who experience longer-term consequences.” He explains these can be due to damage to the body during the initial illness, the result of lingering viral infection, or because of complex immunological responses that occur after the initial disease.
“People sick enough to be hospitalized are likely to experience prolonged recovery, but with Covid-19, we’re seeing tremendous variability,” he says. It’s not necessarily just the sickest patients who experience long-term symptoms, but often people who weren’t even initially hospitalized.
That’s why long-term studies of large numbers of Covid-19 patients are so important, Peluso says. Once researchers can find what might be causing long-term symptoms, they can start targeting treatments to help people feel better. “I hope that a few months from now, we’ll have a sense if there is a biological target for managing some of these long-term symptoms.”
Lekshmi Santhosh, a physician lead and founder of the new post-Covid OPTIMAL Clinic at UCSF, says many of her patients are reporting the same kinds of problems. “The majority of patients have either persistent shortness of breath and/or fatigue for weeks to months,” she says.
Additionally, Timothy Henrich, a virologist and viral immunologist at UCSF who is also a principal investigator in the study, says that getting better at managing the initial illness may also help. “More effective acute treatments may also help reduce severity and duration of post-infectious symptoms.”
In the meantime, doctors can already help patients by treating some of their lingering symptoms. But the first step, Peluso explains, is not dismissing them. “It is important that patients know — and that doctors send the message — that they can help manage these symptoms, even if they are incompletely understood,” he says. “It sounds like many people may not be being told that.”
Long-term symptoms, long-term consequences
Even though we have a lot to learn about the specific damage Covid-19 can cause, doctors already know quite a bit about recovery from other viruses: namely, how complex and challenging a task long-term recovery from any serious infection can be for many patients.
Generally, it’s common for patients who have been hospitalized, intubated, or ventilated — as is common with severe Covid-19 — to have a long recovery. Being bed-bound can cause muscle weakness, known as deconditioning, which can result in prolonged shortness of breath. After a severe illness, many people also experience anxiety, depression, and PTSD.
A stay in the ICU not uncommonly leads to delirium, a serious mental disorder sometimes resulting in confused thinking, hallucinations, and reduced awareness of surroundings. But Covid-19 has created a “delirium factory,” says Santhosh at UCSF. This is because the illness has meant long hospital stays, interactions only with staff in full PPE, and the absence of family or other visitors.
Theodore Iwashyna, an ICU physician-scientist at the University of Michigan and VA Ann Arbor, is involved with the CAIRO Network, a group of 40 post-intensive care clinics on four continents. In general, after patients are discharged from ICUs, he says, “about half of people have some substantial new disability, and half will never get back to work. Maybe a third of people will have some degree of cognitive impairment. And a third have emotional problems.” And it’s common for them to have difficulty getting care for their ongoing symptoms after being discharged.
In working with Covid-19 patients, says Santhosh, she tells patients, “We believe you … and we are going to work on the mind and body together.”
Yet it’s currently impossible to predict who will have long-lasting symptoms from Covid-19. “People who are older and frailer with more comorbidities are more likely to have longer physical recovery. However, I’ve seen a lot of young people be really, really sick,” Santhosh says. “They will have a long tail of recovery too.”
Who can access care?
At the new OPTIMAL Clinic at UCSF, doctors are seeing patients who were hospitalized for Covid-19 at the UCSF health system, as well as taking referrals of other patients with persistent pulmonary symptoms. For ongoing cough and chest tightness, the clinic is providing inhalers, as well as pulmonary rehabilitation, including gradual aerobic exercise with oxygen monitoring. They’re also connecting patients with mental health resources.
“Normalizing those symptoms, as well as plugging people into mental health care, is really critical,” says Santhosh, who is also the physician lead and founder of the clinic. “I want people to know this is real. It’s not ‘in their heads.’”
Neeta Thakur, a pulmonary specialist at Zuckerberg San Francisco General Hospital and Trauma Center who has been providing care for Covid-19 patients in the ICU, just opened a similar outpatient clinic for post-Covid care. Thakur has also arranged a multidisciplinary approach, including occupational and physical therapy, as well as expedited referrals to neurology colleagues for rehabilitation for the muscles and nerves that can often be compressed when patients are prone for long periods in the ICU. But she’s most concerned by the cognitive impairments she’s seeing, especially as she’s dealing with a lot of younger patients.
These California centers join new post-Covid-19 clinics in major cities across the country, including Mount Sinai in New York and National Jewish Health Hospital in Denver. As more and more hospitals begin to focus on post-Covid care, Iwashyna suggests patients try to seek treatment where they were hospitalized, if possible, because of the difficulty in transferring sufficient medical records.
Santosh recommends that patients with persistent symptoms call their closest hospital, or nearest academic medical center’s pulmonary division, and ask if they can participate in any clinical trials. Many of the new clinics are enrolling patients in studies to try to better understand the long-term consequences of the disease. Fortunately, treatment associated with research is often free, and sometimes also offers financial incentives to participants.
But otherwise, one of the biggest challenges in post-Covid-19 treatment is — like so much of American health care — being able to pay for it.
Outside of clinical trials, cost can be a barrier to treatment. It can be tricky to get insurance to cover long-term care, Iwashyna notes. After being discharged from an ICU, he says, “Recovery depends on [patients’] social support, and how broke they are afterward.” Many struggle to cover the costs of treatment. “Our patient population is all underinsured,” says Thakur, noting that her hospital works with patients to try to help cover costs.
Lasting health impacts can also affect a person’s ability to go back to work. In Iwashyna’s experience, many patients quickly run through their guaranteed 12 weeks of leave under the Family Medical and Leave Act, which isn’t required to be paid. Eve Leckie, a 39-year-old ICU nurse in New Hampshire, came down with Covid-19 on March 15. Since then, Leckie has experienced symptom relapses and still can’t even get a drink of water without help.
“I’m typing this to you from my bed, because I’m too short of breath today to get out,” they say. “This could disable me for the rest of my life, and I have no idea how much that would cost, or at what point I will lose my insurance, since it’s dependent on my employment, and I’m incapable of working.” Leckie was the sole wage earner for their five children, and was facing eviction when their partner “essentially rescued us,” allowing them to move in.
These long-term burdens are not being felt equally. At Thakur’s hospital in San Francisco, “The population [admitted] here is younger and Latinx, a disparity which reflects who gets exposed,” she says. She worries that during the pandemic, “social and structural determinants of health will just widen disparities across the board.” People of color have been disproportionately affected by the virus, in part because they are less likely to be able to work from home.
Black people are also more likely to be hospitalized if they get Covid-19, both because of higher rates of preexisting conditions — which are the result of structural inequality — and because of lack of access to health care.
“If you are more likely to be exposed because of your job, and likely to seek care later because of fear of cost, or needing to work, you’re more likely to have severe disease,” Thakur says. “As a result, you’re more likely to have long-term consequences. Depending on what that looks like, your ability to work and economic opportunities will be hindered. It’s a very striking example of how social determinants of health can really impact someone over their lifetime.”
If policies don’t support people with persistent symptoms in getting the care they need, ongoing Covid-19 challenges will deepen what’s already a clear crisis of inequality.
Iwashyna explains that a lot of extended treatment for Covid-19 patients is “going to be about interactions with health care systems that are not well-designed. The correctable problems often involve helping people navigate a horribly fragmented health care system.
“We can fix that, but we’re not going to fix that tomorrow. These patients need help now.”
The debate over whether and how much to re-open schools in the fall has put teachers in the precarious position of choosing between their own safety and the pressures from some parents and local officials.
Why it matters: Teachers are the core of K-12 education. The people we depend on to educate our society’s children may end up bearing the brunt of both the risk and the workload.
What’s happening: With coronavirus cases spiking in many parts of the U.S., districts are weighing the feasibility of keeping classes all virtual, as Los Angeles and San Diego are doing, or conducting a rotation of in-person and remote lessons.
While all back-to-school options have pros and cons, there are specific worries for teachers.
1. Exposure: Despite a child’s overall low health risk if they contract COVID-19, scientists still do not conclusively know if schools could become hotspots for more vulnerable populations.
- Schools are on a time and money crunch for better ventilation, more disinfectant and masks and proper social distancing techniques. If a cluster of cases do occur, teachers and parents are short on answers about how to isolate students and contact trace.
- Districts were already facing staffing shortages before the pandemic. And nearly 1.5 million teachers have a condition that puts them at increased risk of serious illness from coronavirus, per a Kaiser Family Foundation study. A separate KFF study out today found that 3.3 million adults age 65 or older live in a household with school-age children.
- A study in Germany found that infections in schools had not led to outbreaks in the community. But an analysis of a surge of cases in Israel found that nearly half the reported cases in June were traced back to illness in schools.
“We as teachers prepare for active shooters, tornadoes, fires and I’m fully prepared to take a bullet or shield a child from falling debris during a tornado. But if I somehow get it and I’m asymptomatic and I get a student sick and something happens to them or one of their family members, that’s a guilt I would carry with me forever.”
— Michelle Albright, a second grade teacher from northwest Indiana
2. Difficulty of a hybrid approach: Many school districts like New York City are opting to split school between in-person and online to minimize exposure. That’s an effective but more burdensome approach for teachers, top teachers union chief Randi Weingarten told Axios’ Dan Primack Monday.
- In-person contact with a teacher can make a big difference for students struggling with a concept or who need one-on-one time.
- But many teachers will have to prepare virtual and in-person lessons and ensure the same learning outcomes for students in both settings — a tall order.
3. Child care availability: Teachers with children of their own are concerned about how to care for them when they are teaching.
- States could choose to provide child care services for educators as essential employees, but it’s unclear what non-school child care options will be available in areas with high infection rates or where day care centers have struggled to stay in business.
4. Concerns of other school staff: Bus drivers, custodians, classroom aides, administrative staff, cafeteria workers, school nurses and substitute teachers may come in contact with more children throughout the day because they are less likely than teachers to be confined to a single classroom.
What to watch: School districts ought to be finding other roles for teachers who are not comfortable returning to the classroom, such as reassigning them to virtual-only roles or providing one-on-one online tutoring sessions with students, said John Bailey, visiting fellow at the American Enterprise Institute and former domestic policy adviser during the George W. Bush administration.
- But there’s not much time to sort that out on top of getting teachers the professional development they need for effective remote learning.
- “What I worry about is that we squandered the few months we had to make sure we can think through these challenges,” Bailey said. “This was one of the most obvious challenges facing schools with reopening and we should have been thinking about that for the last several months. Instead it’s creeping up on districts.”
The bottom line: Due to the unprecedented nature of this pandemic, teachers are worried about the uncertainties and, in some cases, lack of clear planning should conditions worsen. That may drive some to quit teaching altogether.
- “You’ve got 25% of teachers who may be in either a high-risk situation because of pre-existing conditions or because of age, and a lot of them, if they can, they may just check out and say ‘nobody’s taking care of me. I can’t go back,'” Weingarten said.
More young people are being infected with the coronavirus, and even though they’re less likely to die from it, experts warn the virus’ spread among young adults may further fuel outbreaks across the United States.
Why it matters: Some people in their 20s and 30s face serious health complications from COVID-19, and a surge in cases among young people gives the virus a bigger foothold, increasing the risk of infection for more vulnerable people.
- “We may see a pattern of younger people being affected initially, but then, in a number of weeks from now, we’re going to see a more deadly pandemic spreading to elderly people,” says Alison Galvani, an epidemiologist at Yale University.
People can transmit the virus without knowing they have it, and younger people, in particular, could be unknowingly spreading the disease.
- A study in Italy, yet to be peer reviewed, found the probability of having symptoms increased with age and that among 20–39-year-olds only about 22% had a fever or respiratory symptoms (compared to about 35% of 60–79-year-olds).
- About half of the clusters in a study in Japan were traced back to people ages 20–39 at karaoke bars, offices and restaurants — and 41% of them did not have symptoms at the time.
- “Younger people are at lower risk for serious COVID outcomes but are disproportionately responsible for asymptomatic transmission,” says Galvani, who published a study earlier this week that found the majority of COVID-19 transmission is from silent carriers who are pre-symptomatic or asymptomatic.
- In the county of Los Angeles, nearly 50% of cases are now in people under 40 (compared to about 30% in April), per the LA Times.
- In Harris County, Texas, home to Houston, 43% of the 40,000 cases are in people ages 20–39, as of yesterday.
- In Florida, the median age of confirmed cases is hovering in the mid- to late-30s, compared to age 65 in March.
And the proportion of young people hospitalized for COVID-19 has also grown.
- 40% of hospitalizations for COVID-19 at the end of June were for people 18–49-years-old, compared to 26% at the end of March, according to the COVID-NET database of hospitalizations in 14 states that represent about 10% of the U.S. population.
Between the lines: Yes, young people are going to bars and parties — but also to work.
- 42% of people ages 18–39 said they had socialized without social distancing compared to 26% of people over 40, in a survey last month from the Democracy Fund + UCLA Nationscape.
- 64% of frontline workers (grocery store clerks, health care workers, delivery drivers and other essential workers) are under 50.
- There’s a need for better education so that young people choose to take steps to prevent infection, says Lauren Ancel Meyers, a mathematical epidemiologist at UT Austin.
- “But it also might come down to policies or regulations that get employers to ensure they are providing a safe workplace or resources to protect 20, 30 and other age groups that are working for them.”
Where it stands: Young people are still much less likely to be hospitalized or die from the virus than people older than 60.
- Yes, but: They can and do get very sick with the disease — from dangerous blood clots in their lungs to inflammation of the heart, lungs and even brain.
- And the long-term consequences are unknown.
- The risk is higher for young people of color: For example, the majority of coronavirus hospitalizations among Latino/Hispanic Americans are in people ages 18–49, my Axios colleague Caitlin Owens reported.
“The death rate among the young is not zero, and it is particularly not zero for people who have at least one co-morbid condition. This is not a completely benign disease of the young.”
— Joshua Schiffer, of the Fred Hutchinson Cancer Center
What to watch: “If hospitals are strained now dealing with younger cases, they are going to be all the more taxed when the age distribution of infections shifts to the elderly,” Galvani says.
- Already hospitals in some states are hitting their capacity of ICU beds, indicating more vulnerable people are being infected with the disease, and the death rate is climbing in hot spots.
Counties populated by larger numbers of people of color tend to have more coronavirus cases than those with higher shares of white people.
What we’re watching: As the outbreak worsens throughout the South and the West, caseloads are growing fastest in counties with large communities of color.
The big picture: The southern and southwestern parts of the U.S. — the new epicenters of the outbreak — have higher Black and Latino or Hispanic populations to begin with.
- People of color have seen disproportionate rates of infection, hospitalization and death throughout the pandemic.
Between the lines: These inequities stem from pre-existing racial disparities throughout society, and have been exacerbated by the U.S. coronavirus response.
- Black and Hispanic or Latino communities have had less access to diagnostic testing, and people of color are also more likely to be essential workers. That means the virus is able to enter and spread throughout a community without adequate detection, often with disastrous results.
The bottom line: Until we plug the huge holes in the American coronavirus response — like inadequate testing and contact tracing and a lack of protection for essential workers — people of color will continue to bear the brunt of the pandemic.