Junia Howell, Ph.D. is an urban sociologist at the University of Pittsburgh whose work investigates how policies perpetuate racial and socioeconomic inequality.
Recent data from the Centers for Disease Control and Prevention on Covid-19 exposed stark inequalities: Rates of mortality and severe illness are far higher among Americans of color. Politicians, journalists and scholars have been attempting to explain these racial differences by pulling from a wide range of past studies and assumptions. Many of these early suggestions emphasize how Covid-19 is illuminating pre-existing inequality.
Yet, early reporting and existing studies suggest Covid-19 is not simply exposing past inequality. It is also creating it. Like previous crises, such as natural disasters, war, and economic recessions, our response to Covid-19 is exacerbating racial disparities. However, this is not inevitable. Addressing unequal distributions of Covid-19 testing, racial biases in health care, and policy responses to racial segregation now could mitigate how unjust this crisis turns out to be.
Comparing across regions in the U.S. and between countries, it has become abundantly clear that early detection and effective contact tracing are critical for both containing Covid-19 and curtailing its most severe symptoms. This requires widespread, accessible testing — something the United States has yet to implement anywhere. Yet, testing has been even more scarce in communities of color.
Early reporting by NPR has shown that Black Americans have been less likely to receive a Covid-19 test than White Americans even when showing the same symptoms. This has contributed to misdiagnosis and in some cases inaccurate medical advice. These patterns mirror previous research that has repeatedly shown doctors mis- and under-diagnosed Black people’s health conditions leading to further health complications and shorter life expectancy — an occurrence particularly pronounced for Black women whose knowledge about their own bodies is often dismissed, disregarded and misunderstood.
For Covid-19, the lack of testing and misdiagnoses has likely resulted in the virus spreading more rapidly across Black communities, and in individual cases escalating without the proper precautions and treatment. To fully empirically estimate the effect this lack of testing is having on the observed racial inequality, we need more data across all racial groups on who is getting access to proper testing and whether hospitalized Covid-19 patients are receiving improper advice or health care because of initial misdiagnoses. Not to mention, we also need more data from the tests themselves to see who is testing positive and how the virus is affecting various populations.
Beyond testing, initial studies on Covid-19 suggest severe symptoms and mortality are more likely when patients have underlying conditions such as hypertension, obesity, diabetes, asthma or cardiovascular disease. Black and Native Americans are more likely than their White counterparts to have these underlying and chronic conditions because of racial biases in health care, housing markets, employment sectors, educational institutions and the criminal justice system. Government officials and journalists have insinuated that Covid-19 hospitalizations and mortality inequities are a product of the racial gaps in these pre-existing conditions.
Although this is certainly part of the story, it is likely not all of it. The aforementioned lack of Covid-19 testing, lack of access to health care and the quality of health care received could be intensifying the effect underlying conditions have on patients of color with Covid-19. In other words, a White resident with underlying health conditions, who has access to early testing and whose doctors trust their account of their symptoms is more likely to avoid the most severe Covid-19 symptoms compared to a Black or Native American with identical underlying conditions and Covid-19 symptoms.
To fully unpack these various factors we need more data broken down by race about cases, treatments and outcomes. Yet, even without this data, it is clear it is not just pre-existing conditions driving the racial inequality. It is also access to and experiences within the health-care system that are creating the racial inequality.
In addition to underlying conditions, initial analyses by some scholars have explained this inequality as a product of existing occupational and residential segregation: Historical and contemporary labor policies and practices have concentrated workers of color into often below-living-wage employment sectors — many of the same sectors that are disproportionately experiencing heightened exposure to Covid-19 and offer inconsistent or limited sick leave policies. Yet, it goes beyond just class, as middle-class Black workers are disproportionately concentrated in government jobs like mail carriers or bus drivers compared to their White counterparts who are disproportionately employed by private companies.
Likewise, contemporary and historical (im)migration and housing policies have concentrated residents into certain neighborhoods, cities, counties and even regions of the country. This means, even in this time of social distancing, Americans are more likely to interact with people of their same race as they make essential trips to the local grocery store or receive packages on their front porch. Since Covid-19 is highly contagious, living in a community with more cases (for all the aforementioned reasons) means this contagion is likely to spread more quickly within racial groups, as we are witnessing in New York City’s Jackson Heights neighborhood and Louisiana’s Black communities. Just as so-called “Black-on-Black violence” is more a function of racial segregation and proximity than something cultural or biological as is often alleged, so might be Black-on-Black Covid-19 contraction.
Fully illuminating the role occupational and residential segregation are playing in the observed Covid-19 inequities will require significantly more data. Yet, even without this full picture, it is likely occupational and residential segregation combined with racialized practices within workplaces and across regions that are exacerbating the inequities.
Clearly, we need much more information before we can definitively say which mechanisms are contributing to the racial inequality in Covid-19 infections, hospitalizations and deaths. However, using history as a guide and what we know from early reporting, it is clear racial inequities are being created in how we are choosing to respond to this crisis.
To curtail this inequity, we need transparency about who has access to testing, test results, hospitalizations and mortality rates. We also need more data on how employees, residents and patients are interpreting their possible risk and access to healthcare. And we need to use this data to better understand who is getting sick, and why.
Beyond data, we need action steps that explicitly centralize the need for equity in our multifaceted response to this crisis. The federal government must make tests more widely available in communities of color. Health-care workers need to challenge their own racialized biases and ensure patients’ own assessments of their health are being heard. Corporate employers need to think critically about how their policies might directly and indirectly contribute to racial inequality. Federal and local governments need to consider how they can creatively decrease racial inequality through new ways of implementing immediate and long-term responses.
We cannot wait until the crisis is over to examine or address the structural inequalities Covid-19 is exposing. If we do, then these inequalities will only worsen. Prioritizing equity in our responses now is the only way we can begin to create a more equitable tomorrow.