For at least the last 6 months, and what seems like much longer, the United States has been in a period of great upheaval unseen for decades. Thanks in part to a novel coronavirus that quickly spread globally, along with social and racial tensions reaching a boiling point after nationwide economic uncertainty and the deaths of George Floyd and Breonna Taylor at the hands of law enforcement. In the year of a presidential election, leaders both elected and running are looking for solutions. Medicine has also been scrambling for answers as hospitals deal with ever growing censuses and dwindling resources, which have placed a strain on budgets, employees, and communities. Through these difficult times, there appears to be a resolve to investigate how we arrived here, where do we want to go, and what will take us there. As industries look to foster more inclusive and diverse environments, health care also looks to lead this philosophical shift toward a more equitable system. In the meantime, minorities, particularly African Americans, are dying at alarming rates.
Dr. James T. Williams
With state government shutdowns, school closures, and a transition to work from home, Americans have been increasingly cognizant of issues that are more likely to be drowned out by the routine of previously “normal” life. As the staggering coronavirus infection numbers and deaths began to be published, undeniable trends were laid bare for the country to see. While the pandemic has been a deadly scare for the entire nation, the risk of serious complications or death for others was undeniable or even likely. For many Americans of underrepresented groups, but for Black people in general, 2020 has been another checkpoint in a long straight path, as centuries of systemic injustices and racist policies enacted through legislation, health policy have left these communities far behind and incredibly unprepared for this latest challenge.
For millions of Black Americans, although there is never acceptance of it, living with inequality has become a way of life. Much is known about the eventually desegregated lunch counters and public transportation but health care also facilitated disparities that have manifested themselves in the disparate outcomes we see today. Although Brown v Board of Education eliminated the legal precedent of segregated public spaces, enforcement was not immediately unanimous. In the paper The Politics of Racial Disparities, author David Smith describes the segregation in the state hospital in the state capital of Mississippi. Accounts detailed the dismay of white patients who traveled in the same elevators as Black patients, separate floors new and expectant Black mothers were admitted to, and even policies that discouraged Black and White children from utilizing play areas at the same time. All of these policies and the resistance to change were occurring in the 1960s as the larger national appetite toward overt discrimination began to sour. Although the deep south has historically held the reputation of outdated values, this was not solely a regional problem.
Nationwide, African Americans, as well as other minorities, are very aware of the health pitfalls that await them once leaving the hospital as newborns. According to CDC data, they are more likely than White non-Hispanic White adults to be diagnosed with diabetes and hypertension. Eighty percent of African American women are overweight or obese compared with 65% of non-Hispanic White women. These comorbidities have been especially telling this year as they account for a large proportion of comorbid conditions listed on deceased COVID-19 patients’ death certificates.
Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, and member of the White House coronavirus task force, is particularly concerned about these trends. He stated in a recent interview that the virus is, “shedding another bright light on a systemic problem that has been with us for a very long period of time.” While he does not explicitly state what the systemic problem is, you could assume it relates to racial injustice. He also goes on to say, “…social determinants of health put people of color in a position-because of employment, socioeconomic status, availability of jobs-that makes it more likely for them to be in contact with an infected person and not be able to separate themselves.”
When these statistics are quoted, discussions of personal responsibility are often discussed; however, these arguments do not stand up against the long documented, intentional exclusion of minorities, in particular Black people, from the health systems and economic opportunities the country has to offer. Lacking any significant economic power, these communities have no buffer against a pandemic, no option but to show up for work. Additionally, these jobs cannot be done in the comfort of one’s living room. Large cities, such as New York City, served as a harbinger to what could happen when masks and social distancing was ignored, as well as a tendency to blame overcrowding. More investigation unearths that the true culprit in major metropolitan areas is not the size but its effects on resident social habits. Dr. Mary Bassett explains in The New York Times, “The answer is simple: the high cost of housing.” Multigenerational households are more prevalent among minority communities, explaining the rapid spread through these epicenters.
The historical legacy of redlining and other laws that were exclusionary and hostile to racial equality have made systems much more difficult to change, even when the parties involved are willing to take a more active role in change. The question is will it be enough to have merely stopped these practices or will a more active role in reversal of policies and their intended effects be needed?
Medicine is grappling with its role in the larger context of how to provide better access and better care. The Affordable Care Act, signed into law by President Barack Obama in 2010, aimed to begin that journey. When the mandate for individual states to opt in was struck down in 2012, state legislators were able to decide whether to opt into a Medicaid agreement with the government, providing basic care to all citizens of their state. Twelve states currently have not opted into the Medicaid expansion, leaving a significant portion of their residents uninsured. Of those states, a majority have minority populations represented at levels greater than the national average.
Medicine should use this opportunity to position itself as an ally in the fight for equality. The American dream story has always been structured around innovation and discovery. The medical field shares in this delight when coincidence, discovery, and problem solving intersect. This country prides itself on its abilities to problem solve and has sold this branding to the rest of the world. America loves winning, our current President repeatedly says so. What greater win would equal care and elimination of racial disparities in chronic diseases. As our health leaders assemble solutions for a multifactorial problem, the public must become more engaged to assist in creating solutions, maintain dedication and focus on the goals, and continue to hold leaders and elected officials accountable.
Increased diversity in health-care spaces both on the ground and in leadership will help ensure less represented voices are heard. We must invest in our education system to broaden the representation of minority physicians who often do not represent their population’s share. Changes must also go beyond direct patient care and population health measures but must also address the social determinants of health, such as a livable wage, fair and affordable housing, and wealth inequality.
With federal support for biomedical research becoming more difficult, the path for the next big innovation becomes increasingly expensive and never guaranteed. We hope to create a safe and effective COVID-19 vaccine. The elimination of race as an indirect determinant of health is a worthwhile goal that, if achieved, would be near the top of the list of this country’s achievements. With 1.2 trillion spent on health care in 2019 (Brookings institute), we cannot afford not to.
Dr. Williams is Affiliate Professor, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Mississippi; and the G.V. (Sonny) Montgomery VA Medical Center, Jackson, Mississippi.