Why Racism, Not Race, Is a Risk Factor for Dying of COVID-19

Editor’s Note (12/21/21): This article is being showcased in a special collection about equity in health care that was made possible by the support of Takeda. The article was published independently and without sponsorship.

COVID-19 has cut a jarring and unequal path across the U.S. The disease has disproportionately harmed and killed people of color. Compared with non-Hispanic white people, American Indian, Black and Latinx individuals, respectively, faced 3.5, 2.8 and 3.0 times the risk of being hospitalized for the infection and 2.4, 1.9 and 2.3 times the chance of dying, according to the Centers for Disease Control and Prevention.

The reason for these disparities is not biological but is the result of the deep-rooted and pervasive impacts of racism, says epidemiologist and family physician Camara Phyllis Jones. Racism, she explains, has led people of color to be more exposed and less protected from the virus and has burdened them with chronic diseases. For 14 years Jones worked at the CDC as a medical officer and director of research on health inequities. As president of the American Public Health Association in 2016, she led a campaign to explicitly name racism as a direct threat to public health. She is currently a Presidential Visiting Fellow at the Yale School of Medicine and is writing a book proposing strategies for a national campaign against racism.

As the country began to confront the unequal impact of COVID and the ongoing legacy of racial injustice it represents, Jones spoke with Scientific American contributing editor Claudia Wallis about the ways that discrimination has shaped the suffering produced by the pandemic.

Along with age, male gender and certain chronic conditions, race has turned out to be a risk factor for a severe outcome from COVID. Why is that?

Race doesn’t put you at higher risk. Racism puts you at higher risk. It does so through two mechanisms: People of color are more infected because we are more exposed and less protected. Then, once infected, we are more likely to die because we carry a greater burden of chronic diseases from living in disinvested communities with poor food options [and] poisoned air and because we have less access to health care.

Why do you say Black, brown and Indigenous people are more exposed?

We are more exposed because of the kinds of jobs that we have: the frontline jobs of home health aides, postal workers, warehouse workers, meat packers, hospital orderlies. And those frontline jobs—which, for a long time, have been invisibilized and undervalued in terms of the pay—are now categorized as essential work. The overrepresentation [of people of color] in these jobs doesn’t just so happen. (Nothing differential by race just so happens.) It is tied to residential and educational segregation in this country. If you have a poor neighborhood, then you’ll have poorly funded schools, which often results in poor education outcomes and another generation lost. When you have poor educational outcomes, you have limited employment opportunities.

We are also more exposed because we are overrepresented in prisons and jails—jails where people are often financial detainees because they can’t make bail. And brown people are more exposed in immigration detention centers. We are also more likely to be unhoused—with no access to water to wash our hands—or to live in smaller, more cramped quarters in more densely populated neighborhoods. You’re in a one–bedroom apartment with five people living there, and one is your grandmother, and you can’t safely isolate from family members who are frontline workers.

Why have people of color been less protected?

We have been less protected because in these frontline jobs—but also in the nursing homes and in the jails, prisons and homeless shelters—the personal protective equipment [PPE] was very, very slow in coming. Look at the meatpacking plants, for example. We are less protected because our roles and our lives are less valued—less valued in our job roles, less valued in our intellect and our humanity.

You’ve noted that once infected, people of color are more likely to have a poor outcome or die. Could you break down the reasons?

This has two buckets: First, we are more burdened with chronic diseases. Black people have 60 percent more diabetes and 40 percent more hypertension. That’s not because we are not interested in health but because of the context of our lives. We are living in unhealthier places without the food choices we need: no grocery stores, so-called food deserts and what some people describe as “fast-food swamps.” More polluted air, no place to exercise safely, toxic dump sites—all of these things go into communities that have been disempowered. That’s why we have more diseases, not because we don’t want to be healthy. We very much want to be healthy. It’s because of the burdens that racism has put on our bodies.

What is the second bucket that raises risks from COVID?

Health care. Even from the beginning, it was hard for Black folks to get tested because of where testing sites were initially located. They were in more affluent neighborhoods—or there was drive-through testing. What if you don’t have a car? And there was the need to have a physician’s order to get a test. We heard about people who were symptomatic and presented at emergency departments but were sent back home without getting a test. A lot of people died at home without ever having a confirmed diagnosis. So even though we know we are overrepresented, we may have been undercounted.

Once you get into the hospital, there’s a whole spectrum of scarce resources, so different states and hospital systems had what they called “crisis standards of care.” In Massachusetts, they were very careful to say you cannot use race or language or zip code to discriminate [on who gets a ventilator]. But you could use expected [long-term] survival. Then the question was: Do you have these preexisting conditions? This was going to systematically put Black and brown people at a lower priority or even disqualify them from access to these lifesaving therapies. [Editor’s Note: Massachusetts later changed its guidelines, but Jones viewed the revision as an incomplete fix.]

Making sure that vaccine campaigns reach communities of color is surely part of the solution, but what else can be done to better protect vulnerable minorities?

We need more PPE for all frontline workers; we need to value all those lives. We need to offer hazard pay and something like conscientious objector status for frontline workers who feel it is too dangerous to go back into the poultry or meatpacking plant. We know there are communities at higher risk, and we need to be doing more testing there. We need to broaden our gaze from a narrow focus on the individual (“vaccine hesitancy”) to acknowledge that structural barriers continue to impact access to the vaccines.

Several states do not report racial and ethnic data on COVID cases. Why is that a problem?

States should be reporting their data disaggregated by race, especially now we know Black and brown and Indigenous folks are at higher risk of being infected and then dying. It’s not just to document it, not just to alarm or to arm some people with a false sense of security. It’s because we need to provide resources according to need: health-care resources, testing resources and prevention types of resources.

Are you concerned about how the CDC’s relaxation of its face mask guidance will impact essential workers and communities of color?

Yes. We need to recognize that we are all in this together, that masks provide reciprocal protection with no downsides, and that asymptomatic spread continues to fuel this pandemic, so that a continued mask mandate for all without regard to immunization status should be maintained until there are no COVID infections, hospitalizations or deaths. It is such a simple, effective, and community-minded intervention that hurts no one and helps everyone.

Over the past year we have seen people take to streets to protest another kind of deadly racial inequity: police violence against people of color, especially against Black men and boys. As awareness spreads about the pervasive nature of racism in systems ranging from law enforcement to health care to housing, do you see an opportunity for meaningful change?

The outrage is encouraging because it has been expressed by folks from all parts of our population. The Black Lives Matter protests were potentially mixing bowls for the virus, but at least they are not frivolous mixing bowls like pool parties. Participants in such protests were thinking not just about their individual health and well-being but about the collective power they have now to possibly make things better for their children and grandchildren. This is both a treacherous time and a time of great promise.

Racism is a system of structuring opportunity and assigning value based on the social interpretation of how one looks (which is what we call “race”) that unfairly disadvantages some individuals and communities, unfairly advantages other individuals and communities, and saps the strength of the whole society through the waste of human resources. Perhaps this nation is awakening to the realization that racism does indeed hurt us all.