How racism undermines the COVID-19 response and recovery

The impact of racism is front and center of policy discussions about the devastating toll of the COVID-19 pandemic on communities of color. Early in the outbreak it became clear that African Americans, Hispanics and Native Americans had a higher incidence of this disease, higher hospitalization rates and a higher percentage of premature deaths, compared to non-Hispanic Whites. Historical racism plays a significant role as a root cause of this clinical phenomenon. The disparate impact of COVID-19 has alarmed many from the start, and the concern has escalated as people of all races have participated in mass protests against police brutality.

To understand how racism is at play in the midst of the COVID-19 pandemic and why so many people have been spurred to gather publicly and protest despite potentially increasing their risk of infection, it’s important to understand the three forms of racism: structural racism, personally mediated racism and internalized racism.

• Structural racism is the differential access of opportunities, goods and services by race. Examples include housing segregation, unequal schools, and redlining, in which one group gets a worse financial deal or less access to credit than another group based on race.

• Personally mediated racism happens when discrimination and prejudice are promoted based on one’s assumptions about the motives, intent and capabilities of another person or group. This is the classic way people generally see racism.

• Internalized racism occurs when the stigmatized group, tragically, accepts stigmatized perspectives about their own abilities and worth.

All these forms of racism have contributed to the fact that communities of color have been hit harder by COVID-19. Factors underlying these disturbing disparities include:

• Greater occupational exposure. People of color are more likely to work in jobs that place them at higher risk for infection, such as meatpacking plants and the service industry.

• Higher susceptibility because of the higher prevalence of chronic illnesses that increase the risk of severe disease and death should one get infected.

• A high correlation to social determinants of health known to promote illness and driven by racism in all its forms. These social determinants include economic instability, and lack of access to affordable, high-quality health care, and fresh, healthy food.

We cannot deny the existence of racism, but we can acknowledge its absurdity because race is a social construct based on physical characteristics and has little biological basis, considering 99.9% of everyone’s genetic material is the same.

Racism, the false belief in the superiority of one group of people over another based on race, is not only an ugly word; it unfairly disadvantages some people and communities while unfairly advantaging others. It also hurts the whole of society by wasting the human resources of the discriminated group. Imagine not having the next Dr. Charles Drew, who pioneered techniques for blood preservation, or the next Katherine Johnson, whose mathematics helped launch America into space. All of society benefits from the full engagement of its people and profits from their contributions.

All forms of racism have manifested themselves during the COVID-19 response. For example, testing policies were initially driven by the scarcity of tests and a belief that you got infected primarily by symptomatic people. This led to symptom-based priority for testing. If you did not have a relationship with a physician, you often had difficulty getting tested unless you were very ill.

We now know at least 25% of infected people can spread the virus asymptomatically. Because of this, many traditional barriers to care for people of color disproportionately increased their risk of spreading the virus. Significant transmission occurs within households so failure to diagnosis early led to more viral spread among families and friends in all communities; but its health impact has been greater in communities of color. On top of that, the initial placement of testing facilities, especially drive-through testing, was inconvenient at best, and often out of reach for people who lack access to a car, rely on public transportation or could not go for testing during the hours available. This was a particular barrier for people who lack paid sick leave or work shifts when testing centers were open.

While these early responses to COVID-19 were not intentionally biased, they resulted in a disparate impact on minority communities, and, in effect, are an example of how structural racism works. Some of these problems with access to testing are being rectified. However, in many cases, historical policies and procedures that were intentionally instituted to discriminate continue to harm people of color and leave them more vulnerable to the worst consequences of COVID-19.

Redlining, for example, was designed to promote neighborhood segregation, which disadvantages communities of color to this day. Similarly, education policies and financing mechanisms created separate and unequal schools — vastly under-resourced ones for minority students. The pandemic compounds these harms. The technology gap has made it extremely challenging for lower-income students to study remotely. The poor state of school facilities in lower-income communities makes it more difficult for students to return to school safely. The underinvestment in many societal institutions, based on place, race or income, has undermined the COVID-19 response and recovery.

Masking to prevent transmission of the virus is an essential activity, but it has become not only a political statement in some communities, but also a focus for racist acts. In Illinois, guards reportedly forced two African American men to leave a store because they were wearing masks and deemed a security threat. This is an example of personally mediated racism: masked individuals are profiled and presumed to be suspicious or dangerous because of their race. The term “Masking While Black” was coined because of incidents like this.

Finally, widespread disinformation and misinformation have influenced behavior in minority communities in ways that increase risk. Social media posts that gave African Americans the misinformation that they were immune to the virus may have encouraged people to ignore initial public health messages. Widespread disinformation on flyers targeting African Americans in New Orleans encouraged people not to get tested, according to Dr. Tom LaVeist, dean of the School of Public Health and Tropical Medicine at Tulane University. These flyers carried false claims about how the disease was spread and stoked fears about potential vaccine use.

Anti-vaccine activists often cite prior research misconduct on communities of color, such as the Tuskegee Study, to discourage minorities from getting vaccinated. This will be particularly challenging when we work to get communities of color to accept a SARS-2 vaccine. These are examples of manipulating people’s internalized beliefs, based on stigma, to cause them to act in ways that can hurt their own health.

There was great concern that the nationwide mass protests after the murder of George Floyd at the hands of Minneapolis police would result in disease spikes. Increased exposure during the protests was complicated by police actions such as the use of tear gas and pepper spray and corralling and detaining protesters in large groups.

Mass gatherings in the face of a severe pandemic create a perceived paradox. Why would people, including many in the health field, choose to increase their risk of infection and get sick with COVID-19 in order to participate in mass protest? What tradeoff are they are making? I believe it’s the tradeoff between the potential health risks from COVID-19 with the real risk of police brutality. For many, the urgency of ending police violence, racial profiling and verbal harassment driven by racism overshadows the risk of getting COVID-19.

It remains to be seen whether the protests lead to disease spikes. Nationally, we are seeing substantial increases in COVID infections and hospitalizations as the nation reopens. It will be difficult to determine how much of the rise is attributed to reopening and how much to the protests. However, it is clear that COVID-19 has had a disparate, devastating impact on communities of color and that racism in all of its forms plays a substantial role. Racism is corrosive to our whole society and we must fully understand its part in the pandemic so we can move forward as a nation.

Georges C. Benjamin, M.D., is the executive director of the American Public Health Association.