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COVID-19 Remains the Great Unequalizer

The pandemic's toll on Black people was going to be America's wake-up call on racism in health care. What happened?

A man receives a coronavirus vaccination at Community of Hope health clinic in Washington, D.C., in February 2021. Vaccination rates in Ward 7 and 8, where a majority of the people are African American, were the lowest in the city. (Jahi Chikwendiu/The Washington Post via Getty Images)

Soon after the coronavirus arrived in the United States, the racial inequities of its devastating toll became apparent: Black people were dying at twice the rate of whites.

The data shocked some Americans. Others panicked. The role that race and ethnicity play in Americans’ health outcomes became headline news as the numbers were broadcast across the country.

But as we enter the third year of the coronavirus pandemic, little has changed. Disparities in severe COVID-19 complications linger. Black Americans’ chances of dying from the virus are still double that of white people, and they are nearly three times as likely to be hospitalized, according to February data from the Centers for Disease Control and Prevention.

Not only that. Public concern about the disproportionate toll of the virus has diminished. Race and ethnicity data that is publicly reported has dwindled, making it difficult for researchers to identify and address disparities. And of the few efforts that have been made to target COVID’s racial inequities, some have received swift and forceful backlash.

On the positive side, racial gaps in vaccinations have narrowed, as more Black folks have rolled up their sleeves for a shot. But among those who are vaccinated, the limited data still shows striking inequities in outcomes.

“Even that tool is not enough to address the negative impacts of structural racism,” said Oni Blackstock, founder and executive director of Health Justice, a consultancy that focuses on reducing health inequities.

Black Americans have recorded more than 4.7 million COVID-19 infections and over 88,000 deaths nationwide since the beginning of the pandemic. Those numbers are likely an underestimate given race and ethnicity is missing for a significant portion of COVID data. 

Public health experts hoped the documented disparities would push American health systems to address the inequities baked into the institutions.

“When health equity came to light in the pandemic, I was excited but I was also biting my tongue,” said Dr. Panagis Galiatsatos, a critical care specialist and assistant professor at Johns Hopkins Medicine. Nearly two years later, he’s frustrated by the lack of action in curbing the vast racial differences in COVID outcomes. 

Health equity experts “ don’t get a permanent seat at the table,” he said. “We need true movement.”

While the problems have been identified, movement has been minimal. 

Soon after entering office, President Joe Biden created the COVID-19 Health Equity Task Force, which found that half of nationally reported data on COVID cases and deaths still do not identify the person’s race. Federally run vaccination sites popped up in vulnerable communities, but the number of doses administered was a small fraction of the total supply.

In Florida, Governor Ron DeSantis vowed early on to work with churches to ensure Black communities were supported in fighting the effects of COVID-19. But in a ​​recent letter, a group of Black pastors said the state is “failing to reach Florida’s communities of color and its most vulnerable.”

People wait in line to be pre-screened for the coronavirus outside of the Brooklyn Hospital Center in March 2020 in New York. Early COVID-19 data showed African Americans were bearing the brunt of the virus’ impact. (Photo by Angela Weiss/AFP via Getty Images)

‘A Great Equalizer’

The severity of COVID-19 racial disparities mirrors inequities that have been persistent in American medicine for decades. 

Data suggests that in addition to age, certain chronic conditions — such as hypertension, heart disease, diabetes and cancer — make patients more vulnerable to severe complications from infection. Black Americans are often at higher risk for those illnesses than white Americans because of factors like unequal access to nutritious food and quality health care. 

The stress of exposure to racism, which has a weathering effect on the body, compounds the disparities.

“An airborne virus in some ways is a great equalizer,” said Galiatsatos, noting the ease of transmissibility. But, he added, “community dictates your health more than anything else.”

Experts who have studied such disparities hoped the spotlight that COVID cast on structural racism in the American health system would inspire new approaches to tackling health disparities — tactics that take the whole patient into consideration and that recognize the impacts of stress and racism on the body.

“Just treating one patient’s blood pressure was not going to stop a community from getting completely sidelined by the pandemic,” said Dr. Utibe R. Essien, an assistant professor of medicine at the University of Pittsburgh. “How are we using the disparities in the pandemic to help create a more equitable health system?”

As vaccines began to roll out in December 2020, structural barriers such as inability to take time off from work and skepticism of the government-backed health institutions promoting injections – a fear rooted in the country’s long-standing history of medical racism – created another racial gap. Over time, the gap between vaccinated Black and white Americans has decreased, CDC data shows, a trend likely driven by grassroots efforts to dispel misinformation and get vaccines into vulnerable neighborhoods.

Amid discussions about returning to life as “normal,” much of the decision about opening schools and scrapping mask mandates hasn’t accounted for the needs of people with different resources, said Blackstock, a primary care and HIV physician. Those with the privilege of working from home, sufficient child care and adequate health insurance are being prioritized, she said. 

“It’s not really including an equity lens or considering more vulnerable communities,” she said.

The pandemic and the racial justice protests of 2020 shifted American attitudes toward the institutional racism within the health care system — but only momentarily. 

A study by RAND, a nonprofit research institution, showed that public acknowledgement of the role systemic inequities play in health outcomes increased around December 2020, said Anita Chandra, a senior policy analyst at RAND. But over time, that acknowledgement began to fade.

About two-thirds of respondents agreed that people of color were disproportionately burdened by the health and financial impacts of the virus. By September 2021, that proportion decreased to about one-half.

Respondents were also more likely to recognize social and economic inequities than racial ones.

“The policy windows for social change are pretty narrow,” Chandra said. “We’ve got more of an uphill climb than people think.”

A woman adjusts her mask as people gathered to watch the arrival of a U.S. Navy hospital ship at the Port of Los Angeles in March 2020. The ship came to help hospitals amid the growing coronavirus crisis (Photo by Robyn Beck/AFP via Getty Images)

New equity policies are rolled back

As the highly contagious omicron variant surged, public health officials recommended doctors consider a patient’s race and ethnicity, in addition to their underlying conditions,  when allocating the life-saving treatments, such as monoclonal antibodies and oral antiviral drugs.

The move, experts say, is a nudge towards ensuring patients had equal access to the therapies. An analysis by the CDC published in January showed that Black people who tested positive for the virus were less likely than white people to receive monoclonal antibody treatment.

In December, the state of New York published guidelines for administering the treatments, noting that COVID-19 patients should be eligible if they “have a medical condition or other factors that increase their risk for severe illness.” It adds that “Nonwhite race or Hispanic/Latino ethnicity should be considered a risk factor, as long-standing systemic health and social inequities have contributed to an increased risk of severe illness and death from COVID-19.”

The U.S. Food and Drug Administration made a similar recommendation. 

But some conservative lawmakers oppose such a protocol, saying it discriminates against white patients – though there is no evidence treatment for white people has been delayed or denied. New York State faces a federal lawsuit filed by America First Legal, a conservative law organization, which says the recommendation is “racist and unconstitutional.” 

Amid the backlash, Minnesota and Utah have since dropped their policies. 

Race is not the only factor that the guidelines recommend providers take into account. Others include age, severity of symptoms and ability to start treatment within five days of the first symptoms.

Because Black patients have a higher likelihood of being exposed to COVID-19, said Dr. Essien of the University of Pittsburgh, “we need to really increase their exposure to treatments as well.”

A woman is tested for covid-19 at a drive-thru testing site at Camping World Stadium in Orlando, Florida in July 2020. Photo by Paul Hennessy/NurPhoto via Getty Images)

Holes in the data

Those studying covid-19’s racial disparities say having standardized data collection across states –  particularly for vaccinations – is crucial to accurately measuring the impact of the pandemic and ensuring equitable distribution of vaccines. 

For a third of covid-19 cases, the race and ethnicity of the patients is unknown, according to the CDC, suggesting estimates may be inaccurate. 

“That has really been a barrier to getting a comprehensive full picture of how the pandemic is affecting different communities,” said Blackstock of Health Justice.

The amount of publicly available data varies across states and jurisdictions, so does its level of completeness. For vaccinations, the race data comes from patient questionnaires. But how states collect and report the data varies, and people can opt not to indicate their race on the form.

As of the beginning of January, only nine states reported vaccination data by race and ethnicity for children. Even then, how the data is reported varies by state, making it hard to compare. 

King County in Seattle has become a model for vaccination data collection, comprehensively reporting and publishing its numbers by demographics. The weekly updated report makes it easy for public health officials to identify gaps and expand vaccination efforts in communities where vaccine uptake is lagging. 

Factors like ability to take paid time off of work to rest after getting a shot remain a barrier for some, even as widespread availability of vaccines has made getting vaccinated easier than ever before, said Dr. Essien. To combat some of the structural issues, community health centers have played an active role in increasing vaccination rates in Black communities, he said. 

“When you actually give people the resources, the tools, the information that they need to be able to get this life-saving therapy,” he said, “they are going to get it.”