Prior to the onset of COVID-19, healthcare expenditures represented approximately seventeen percent of the US gross domestic product (GDP), and per capita healthcare spending in the United States was more than two times higher than many other industrialized countries. Despite these relatively exorbitant costs, Americans have a lower life expectancy and suffer from higher rates of chronic disease conditions than citizens of other high-income countries. When data are stratified by race, an even more compelling and troubling narrative emerges. Black Americans die earlier from heart disease and stroke than their white counterparts. For most cancer types, Blacks have the highest death rate and the shortest survival rate. They suffer kidney failure at a rate three times higher than whites. Health economists estimate that these types of disparities contribute to nearly ninety-three billion dollars in excess medical care costs and forty-two billion dollars in lost productivity annually.
On a more granular level, stark racial differences in health outcomes and healthcare utilization in the nation’s capital are a reflection of trends observed in other cities across the country. Although ninety-six percent of adults in the District of Columbia have health insurance, deaths due to diabetes are six times higher among Black residents than white ones. Disparities are strikingly delineated at the neighborhood level. The infant mortality rate in a predominately Black neighborhood is six times higher than an affluent white neighborhood approximately six miles away. Moreover, there is a sixteen-year difference in life expectancy between the two communities. Black residents with Medicare are two times more likely to have a preventable hospital stay than their white peers.
The healthcare system, alone, cannot be held culpable for health disparities. However, the Institute of Medicine’s landmark report, Unequal Treatment, provided overwhelming evidence that it bears a degree of responsibility. After controlling for socioeconomic variables, such as income, insurance status, and education, patients of color are more likely to have an unsatisfactory experience with their provider—particularly regarding communication barriers and differences in clinical treatment. Based on the Centers for Medicare & Medicaid Services (CMS) hospital quality rating, four and five star rated hospitals are most concentrated in high-income, predominately white communities.
These disparities stem from a legacy of racial injustice and socioeconomic inequities that have disproportionately burdened people of color. The issue becomes recognized and amplified as a public health matter in the wake of a pandemic such as COVID-19. Addressing systemic racism, operationalizing race as a social construct, and reconceptualizing healthcare to integrate social, economic, and environmental factors are opportunities to improve the delivery of care and more effectively respond to COVID-19 and future pandemics.
The Great Equalizer: Debunking the Myth
When the first case of 2019-nCoV (COVID-19) was documented in the United States on January 20, 2020, it was portrayed as “the great equalizer,” suggesting that susceptibility to infection transcends status on the social hierarchy continuum. Significant advancements in knowledge around transmission methods, treatment protocols, and mortality risks quickly challenged this notion. Initially, age and the presence of co-morbidities such as cancer, obesity, chronic obstructive pulmonary disease, heart disease, and diabetes were cited as risk factors for severe COVID-19 manifestations. However, as more states began to publicly report infections, hospitalizations, and mortality rates by race and ethnicity, it became increasingly clear that the virus was disproportionately burdening Blacks, Hispanics, and Indigenous people. For example, in the District of Columbia, Blacks represent forty-four percent of the population but make up three out of four persons who die from the virus. And nationally, when compared with whites, hospitalization rates are more than 5 times higher for American Indian/Alaska Natives, almost 5 times higher for Blacks, and more than 4.5 times higher for Hispanics.
These trends, coupled with ongoing police brutality and the contemporaneous senseless killings of George Floyd, Breonna Taylor, Ahmaud Arbery and others, sparked a national conversation on race and inequality in Black America.
Systemic Racism: The Root Cause of Poor Health in Communities of Color
Built on 336 years of slavery and legal segregation, the United States has profited at the expense of Black and brown bodies—perceived as genetically inferior and biologically different for centuries. And for more than twenty generations, whites have inherited assets that explain why the typical white family has eight times the wealth of the typical Black family. In the wake of a pandemic like COVID-19, accumulated wealth is a privilege that supports adherence to physical isolation guidelines. However, people of color are more likely to encounter day-to-day experiences that increase risk of exposure—including hourly-wage “essential” employment in high-risk settings, high density, multi-generational housing conditions, and dependence on public transportation modalities. These socioeconomic conditions and structural inequities compromise health and are contemporary manifestations of systemic racism.
Systemic racism goes beyond overt acts of racism. Instead, it is insidiously baked into the DNA of the systems and institutions that govern society, including education, criminal justice, and healthcare. Racial disparities in health are the cumulative effect of race-based laws, policies, and practices that perpetuate an unlevel playing field in access to opportunity for people of color. The repercussions have a profound effect on both individual and population health.
In The Health and Physique of the Negro American (1906), visionary sociologist W.E.B. Du Bois posited that “with improved sanitary conditions, improved education, and better economic opportunities, the mortality of the [Black] race will steadily decrease until it becomes normal.” His argument was subsequently corroborated by extensive public health research recognizing these “social determinants of health” as the most significant drivers of health status. Although those revelations have aged, they are still applicable today and warrant a societal shift in how healthcare is perceived and delivered. Evolution from a medically-centric model of care to a system of care that integrates social, economic, and environmental factors in patient care protocols can improve quality of care and help close the chasm of health disparities. However, success requires policymakers, practitioners, and executives to unlearn the ways in which race has been psychologically internalized and professionally operationalized.
Reconceptualizing Race
Race is a social construct, originally conceived to suppress the advancement of people of color. While the Human Genome Project confirmed that race cannot be found in the gene pool, the legacy of race has created an overwhelming tendency to default to “race” and racialized medical fallacies as explanatory factors for poor health and variations in how patients of different races are clinically treated, respectively. However, race is a confounding variable. The socioeconomic conditions that are culpable for high rates of morbidity in Blacks are the same conditions that have yielded high rates of COVID-19 hospitalizations and associated mortality in Blacks. These conditions include disparities in housing, employment, education, insurance status, and access to timely, high-quality medical care. Moreover, a robust body of peer-reviewed literature acknowledges the physical and mental effects of discrimination and chronic exposure to microaggressions and expressions of implicit bias. Collectively, these manifestations of systemic racism make communities of color especially vulnerable and their ability to rebound from the economic impact of a virus like COVID-19 is distinctly arduous.
Moving Forward: Reconceptualizing Healthcare
Shortly after George Floyd was killed, a surge of healthcare organizations released position statements standing in solidarity and explicitly condemning all forms of racism. As these institutions translate their philosophical statements into action items, a broader interpretation of healthcare is warranted. Leaders who have working knowledge of how racial inequality manifests itself in their institutions and the broader ecosystem are key to transformational change. Recognition of how those injustices impact the short- and long-term health of the populations they serve is paramount.
Rectifying the issue requires an unconventional framing of healthcare—one that extends beyond the walls of the healthcare provider. Formally integrating social, environmental, and behavioral measures in the electronic health record (EHR) offers a more informed perspective of the actual barriers faced by patients. Modernizing the public health infrastructure for tri-directional exchange of real-time population health data between health systems, community-based organizations, and local departments of health will be prudent for a more effective response to COVID-19 mitigation strategies, vaccine distribution efforts, and management of future pandemics. Diversifying leadership, normalizing cultural humility, shifting power, partnering with respected community leaders, as well as community-based organizations with a racial justice mission, are all prerequisites for building trust, fostering meaningful engagement, and advancing restorative justice imperatives. Operating as a healthcare anchor institution that invests in the future of historically marginalized communities of color brings promise for transformational outcomes. Incorporating racial equity impact assessments in strategic planning will ensure racial groups are not disproportionately impacted by short- and long-term plans.
Undoing the Damage
There is a saying in the Black community: “When white folks catch a cold, Black folks get pneumonia.” COVID-19 is a prime example of this, by creating health issues and an economic setback, which will have long-lasting effects on communities of color. Resolving the problem requires a continuous cross-sector, interdisciplinary critical audit of 400 years of racialized policies and practices. By applying a racial equity lens in examining healthcare and the broader ecosystem, traces of systemic racism can be unearthed and dismantled. This approach will result in new policies, practices, and more equitable distribution of resources that will improve socioeconomic conditions, and ultimately, the health of people of color—taking the nation one step closer to realizing life, liberty, and the pursuit of happiness—for all Americans.
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Christopher J. King, PhD, FACHE is an associate professor, health systems researcher, and population health strategist who specializes in applying racial equity concepts in health systems operations and governance. He is a Fellow of the American College of Healthcare Executives and Chair of the Georgetown University Department of Health Systems Administration.
Deliya B. Wesley, PhD, MPH is the Scientific Director for Health Equity Research in the Healthcare Delivery Research Network at MedStar Health Research Institute. She is also an assistant professor at the Georgetown University School of Medicine.
