Pandemic Preparedness is Impossible Without Racial Justice

Joia S. Mukherjee

Pandemic Preparedness is Impossible Without Racial Justice.jpg

Abstract

The Global Health Security Index (GHSI)1-3, published in 2019, ranked the US first among nations in its pandemic preparedness.4,5 This paper uses the GHSI framework to explore the impact of racism on pandemic preparedness in the US.

Introduction

Health is a product of biology and historical, political, and social forces—collectively known as the social determinants of health (SDOH).5,6 Racism is among the most potent SDOH in the US and must be considered in assessing pandemic preparedness and response.

In 2019, the US was ranked first by the GHSI, yet has failed to respond to COVID-19.7-10 This failure is more pronounced among Black Americans who suffer two to three times the mortality rate of white Americans11-14 and bear a disproportionate burden in the economic crisis.15,16 This paper will examine the impact of racism in the US in the six areas of the GHSI: prevention, detection, rapid response, health system, compliance with norms, and risk environment (shown in Figure 1 below).

Figure 1: Six areas analyzed by the Global Health Security Index (GHSI)

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Impact of Racism on Preparedness

Prevention for COVID-19 requires mitigation of risk including staying at home. Countries around the world recognized the need to financially support their citizens to stay at home.17,18 Yet in the US, because workers received only six hundred dollars between March and December of 2020, the poorest felt obligated to work despite the risks. Black, Indigenous and Latinx people occupy more than fifty percent “essential” jobs in food, agriculture, transportation and often work for minimum wage or less and without sick leave or benefits.19

The GHSI’s second category of detection was impaired by the glacial roll-out of testing in the US20, worse in communities of color when measured by geographic accessibility and positivity rate of those tested.21 The disproportionately high rate of positive cases among BIPOC suggests a delay in diagnosis22,23, which impacts the GHSI’s rapidity of the response category.24,25 Fourth in the GHSI is the health system itself. Rife with racial inequality at baseline, healthcare access in communities of color declined during COVID-19 as safety net hospitals closed or were privatized due to falling revenue.26

During the pandemic, former-President Trump’s racist rhetoric defied international norms and increased risk: blaming of China27 (describing the virus as the “Kung Flu”) resulted in attacks against Asian Americans.28 Denial of aid to “blue states” was commensurate to a denial of aid to large communities of color. 29

To assess the association between Trump support, racist policies, and COVID-19 infection, publicly available data were used to identify the ten states with the highest COVID cases per 1,000 (average of 7,717) and the ten states with the lowest COVID-19 cases per 1,000 (average of 2,161).30 These two groups were then assessed based on the proportion of individuals who voted for Trump vs. Biden, issuance of a state-wide mask order, and pre-existing racial inequity in health insurance coverage.31,32

Table 1 below shows that among the ten states with the highest COVID-19 cases (top quintile), eight of ten cast a plurality of votes for Donald Trump compared with only one of ten in the lowest quintile of cases. Only five of ten states in the top quintile of cases had state-wide mask mandates as compared with nine of ten lowest quintile. In the top quintile of COVID-19 states, the percent of uninsured Black and Hispanic people was 8 and 11 percent, respectively, higher than white uninsured people. In the lowest quintile, this difference in insurance rates was 3 percent for Black 3 and 9 percent for Hispanic people as compared with the white population. These data suggest that political decisions in 2020 as well as political choices prior to the pandemic impacted COVID-19 rates.

Table 1: Comparison of the top vs bottom quintile of cumulative COVID cases by state, comparing selected social and political determinants

COVID cases per 100,000 population as of 12/4/2020 Political Determinants Social Determinants
State Total Last 7 days Percent of Votes for Trump First state-wide mask 2018 Rate below poverty line 2019 Uninsured Rate (White American) 2019  Uninsured Rate (Black American) 2019 Uninsured Rate (Hispanic American) 2019 Low-Income Uninsured Rate
North Dakota 10901 81 65% none 10.70% 4.91% 24.70% 13.08% 10.43%
South Dakota 9765 101 62% none 13.10% 6.61% 19.12% 24.27% 16.26%
Rhode Island 8329 111 39% 4/20/2020 12.90% 2.57% 9.24% 9.47% 6.15%
Iowa 7725 72 53% none 11.20% 3.92% 11.27% 13.91% 7.62%
Wisconsin 7476 81 49% 8/1/2020 11.00% 4.18% 8.39% 19.26% 8.90%
Nebraska 7140 98 59% none 11.00% 5.64% 16.86% 21.04% 14.65%
Utah 6863 94 58% none 9.00% 6.70% 18.71% 23.38% 17.14%
Idaho 6458 82 64% none 11.80% 9.15% 10.04% 20.53% 15.54%
Montana 6383 84 57% 7/15/2020 13.00% 6.87% 8.37% 7.72% 10.42%
Minnesota 6133 105 45% 7/25/2020 9.60% 3.54% 9.38% 16.65% 8.30%
Average of top quintile for COVID cases 7717 91 56% 12% 6% 14% 17% 12%
California 3385 46 34% 6/18/2020 12.80% 4.05% 5.67% 12.66% 10.75%
Pennsylvania 3166 67 49% 4/17/2020 12.20% 4.92% 6.90% 12.47% 8.19%
Virginia 2936 32 44% 5/29/2020 10.70% 5.33% 8.37% 24.70% 12.72%
West Virginia 2853 61 69% 7/7/2020 17.80% 6.58% 7.41% 12.70% 7.94%
Washington 2509 29 39% 6/26/2020 10.30% 4.48% 8.29% 18.24% 10.56%
Oregon 1984 37 40% 7/1/2020 12.60% 5.61% 7.81% 16.55% 9.69%
New Hampshire 1756 44 46% none 7.60% 5.66% 11.60% 15.38% 10.20%
Hawaii 1292 6 34% 4/20/2020 8.80% 4.51% 1.66% 4.68% 5.71%
Maine 964 20 44% 5/1/2020 11.60% 7.80% 8.36% 9.28% 10.83%
Vermont 762 20 31% 8/1/2020 11.00% 4.16% 17.07% 11.26% 5.78%
Average of 5th quintile for COVID cases 2161 36 43% 12% 5% 8% 14% 9%

Conclusion

Despite the high ranking on indices related to pandemic preparedness, the US COVID-19 response has failed. Profound racial disparities in the United States assure disproportionate morality among BIPOC. To improve health and pandemic preparedness we must undo racist policies and focus on repairing the harm done in communities of color.

About the Author

Picture1.jpg

Dr. Joia S. Mukherjee, MD, MPH, is an Associate Professor in the Division of Global Health Equity at the Brigham and Women’s Hospital and the Department of Global Health and Social Medicine at Harvard Medical School. For more than twenty years Dr. Mukherjee has been the Chief Medical Officer of the US based medical organization, Partners In Health. Dr. Mukherjee can be reached at jmukherjee@pih.org.

References

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Determinants of HealthHHPRrace, racial justice, GHSI index, Public health, covid-19, coronavirus, pandemic, pandemic preparedness, health inequity, health reform, global health, United StatesComment