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)

Picture1.jpg

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

  1. Ravi SJ, Meyer D, Cameron E, Nalabandian M, Pervaiz B, Nusso JB. Establishing a theoretical foundation for measuring global health security: a scoping review. (Internet).BMC Public Health,2019. (Cited Nov. 30, 2020) 19:954. (Available from: https://doi.org/10.1186/s12889-019-7216-0
  2. NTI and Johns Hopkins University Centre for Health Security. Global Health Security Index. (Internet) 2019. (Cited November 30, 2020) Available from: https://www.ghsindex.org/
  3. World Health Organization. Joint external evaluation tool: International Health Regulations. Geneva. ISBN 978-92-4-155022-2 (Internet) 2018, second edition. (Cited November 30, 2020) Available from: https://extranet.who.int/sph/sites/default/files/document-library/document/9789241550222-eng.pdf
  4. Haider N, Yavlinsky A, Chang YM et al. The Global Health Security index and Joint External Evaluation score for health preparedness are not correlated with countries' COVID-19 detection response time and mortality outcome.(Internet) Epidemiol Infect. 2020 (Cited 11, 30, 2020) Sep 7;148:e210. Available at: https://doi.org/101017/S0950268820002046
  5. Marmot MG, Shipley MJ, Rose G. Inequalities in death--specific explanations of a general pattern? (Internet) Lancet. 1984 May 5 (Cited November 30, 2020)1(8384):1003-6. Available at: https://doi.org/10.1016/s0140-6736(84)92337-7
  6. Murray CJL, Kulkarni SC, Michaud C, Tomijima N, Bulzacchelli MT, et al. Eight Americas: Investigating Mortality Disparities across Races, Counties, and Race-Counties in the United States. (Internet) PLOS Medicine 2006 (Cited November 30, 2020) 3(9): e260. Available at: https://doi.org/10.1371/journal.pmed.0030260
  7. Serchen J, Doherty R, Atiq O, Hilden D. A Comprehensive Policy Framework to Understand and Address Disparities and Discrimination in Health and Health Care: A Policy Paper From the American College of Physicians. (Internet) Ann Intern Med. 2021 Jan 12. (Cited January 16, 2021). Available at: https://doi.org/10.7326/M20-7219
  8. Himmelstein DU, Woolhandler S. America’s Health Care System on the Eve of COVID-19. (Internet) Int J Health Serv. 2020 Oct (Cited January 16, 2021) 50(4): 408–414. Available at: doi: 10.1177/0020731420937631
  9. Ehrenreich, B, Ehrenreich, J. The American Health Empire: Power, Profits and Politics. A Health-PAC Book. New York: Vintage Books; 1970:pp. 29–39.
  10. Christopher AS, Himmelstein DU, Woolhandler S, McCormick D. The Effects of Household Medical Expenditures on Income Inequality in the United States. (Internet) Am J Public Health. 2018 Mar (Cited January 16, 2021)108(3):351-354. Available at: doi: 10.2105/AJPH.2017.304213
  11. American Public Media Research Lab. The Color of COVID: COVID-19 Deaths by Race and Ethnicity in the US (Internet) 2020. (Cited January 16, 2021) Available at: https://www.apmresearchlab.org/covid/deaths-by-race
  12. Chang MH, Moonesinghe R, Truman BI. COVID-19 Hospitalization by Race and Ethnicity: Association with Chronic Conditions Among Medicare Beneficiaries, January 1-September 30, 2020. (Internet) J Racial Ethn Health Disparities. 2021 Jan (Cited January 16, 2021) 8:1–10. Available at: https://link.springer.com/journal/40615#
  13. Dalsania AK, Fastiggi MJ, Kahlam A, Shah R, Patel K, Shiau S, Rokicki S, DallaPiazza M. The Relationship Between Social Determinants of Health and Racial Disparities in COVID-19 Mortality. (Internet) J Racial Ethn Health Disparities. 2021 Jan (Cited January 16, 2021) 5:1–8. Available at: https://doi.org/10.1007/s40615-020-00952-y
  14. Gaffney AW, Himmelstein DU, McCormick D, Woolhandler S. Health and Social Precarity Among Americans Receiving Unemployment Benefits During the COVID-19 Outbreak. (Internet) J Gen Intern Med. 2020 Nov (Cited January 16, 2021) ;35(11):3416-3419. Available at: https://dx.doi.org/10.1007%2Fs11606-020-06207-0
  15. Mein SA. COVID-19 and Health Disparities: the Reality of "the Great Equalizer". (Internet) Journal of General Internal Medicine, 2020. (Cited January 16, 2021) 35(8), 2439–2440. Available at: https://doi.org/10.1007/s11606-020-05880-5
  16. Krieger N, Waterman PD, Chen JT. COVID-19 and Overall Mortality Inequities in the Surge in Death Rates by Zip Code Characteristics: Massachusetts, January 1 to May 19, 2020. (Internet) Am J Public Health. 2020 Dec (Cited January 16, 2021);110(12):1850-1852. Available at: doi: 10.2105/AJPH.2020.305913.
  17. Peek ME, Simons RA, Parker WF, Ansell DA, Rogers SO, Edmonds BT. COVID-19 Among African Americans: An Action Plan for Mitigating Disparities. (Internet) Am J Public Health. 2021 Feb (Cited January 16, 2021).111(2):286-292.
  18. Sarlin B, Ruhle S. As Corona Virus surges, countries spend more on aid. But not the US. (Internet) NBC News. Dec. 7, 2020 (Cited January 16, 2021) Available at : https://www.nbcnews.com/politics/politics-news/coronavirus-surges-countries-spend-more-economic-aid-not-u-s-n1250411
  19. Economic Policy Institute. Who are essential workers? (Internet) https://www.epi.org/blog/who-are-essential-workers-a-comprehensive-look-at-their-wages-demographics-and-unionization-rates/
  20. Stein R. Is Your State Doing Enough COVID Testing? National Public Radio. (Internet) December 22, 2020. (Cited January 16, 2021). Available at: https://www.npr.org/sections/health-shots/2020/12/22/948085513/vaccines-are-coming-but-the-u-s-still-needs-more-testing-to-stop-the-surge
  21. Lieberman-Cribbin W, Tuminello S, Flores RM, Taioli E. Disparities in COVID testing and positivity in New York City.(Internet) Am J Prev Med 2020 (Cited January 16, 2021) ;59(3):326−332. Available at: https://dx.doi.org/10.1016%2Fj.amepre.2020.06.005
  22. Ogedegbe G, Ravenell J, Adhikari S, Butler M, Cook T, Francois F, Iturrate E, Jean-Louis G, Jones SA, Onakomaiya D, Petrilli CM, Pulgarin C, Regan S, Reynolds H, Seixas A, Volpicelli FM, Horwitz LI. Assessment of Racial/Ethnic Disparities in Hospitalization and Mortality in Patients With COVID-19 in New York City. (Internet) JAMA Netw Open. 2020 Dec 1 (Cited January 16, 2021).3(12):e2026881. Available at: doi: 10.1001/jamanetworkopen.2020.26881.
  23. Pflugeisen BM, Mou J. Empiric evidence of ethnic disparities in coronavirus positivity in Washington State. (Internet) Ethn Health. 2021 Jan 11 (Cited January 16, 2021) 1-13. Available at: doi: 10.1080/13557858.2020.1863922.
  24. Sarmiento JM, Mukherjee D, Nosova K, Schievink WI, Alexander MJ, Patil CG, Nuno MA. Predictors of treatment delay in aneurysmal subarachnoid hemorrhage patients. (Internet) J Neurol Surg A Cent Eur Neurosurg. 2015 Jan (Cited January 16, 2021) 76(1):46-55.Available at: doi: 10.1055/s-0034-1372438.
  25. Smith EC, Ziogas A, Anton-Culver H. Delay in surgical treatment and survival after breast cancer diagnosis in young women by race/ethnicity. (Internet) JAMA Surg. 2013 Jun (Cited January 16, 2021);148(6):516-23. Available at: doi: 10.1001/jamasurg.2013.1680
  26. Bazzoli GJ, Lee W, Hsieh HM, Mobley LR. The effects of safety net hospital closures and conversions on patient travel distance to hospital services. (Internet) Health Serv Res. 2012 Feb (Cited January 16, 2021) 47(1 Pt 1):129-50. Available at: doi: 10.1111/j.1475-6773.2011.01318.x
  27. Jaworsky BN, Qiaoan R. The Politics of Blaming: the Narrative Battle between China and the US over COVID-19. J Chin Polit Sci. 2020 Sep 1:1-21. doi: 10.1007/s11366-020-09690-8. Epub ahead of print. PMID: 32904977; PMCID: PMC7462109.
  28. Choi M, Kao G. The Anxiety of Being Asian American: Hate Crimes and Negative Biases During the COVID-19 Pandemic. Am J Crim Justice. 2020 Jun 10:1-11. doi: 10.1007/s12103-020-09541-5. Epub ahead of print. PMID: 32837158; PMCID: PMC7286555..
  29. Hart PS, Chinn S, Soroka S. Politicization and Polarization in COVID-19 News Coverage. Sci Commun. 2020 Aug 25:1075547020950735. doi: 10.1177/1075547020950735. PMCID: PMC7447862.
  30. Johns Hopkins University. COVID Tracking Project. (Internet) (Cited December 4, 2020) Available at: https://coronavirus.jhu.edu/us-map
  31. Kaiser Family Foundation. Uninsured non-elderly Americans by state, race and ethnicity. (Internet)(Cited December 4, 2020) Available at: https://www.kff.org/uninsured/state-indicator/nonelderly-uninsured-rate-by-raceethnicity/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D
  32. US Census Bureau. Percent of people below poverty line by state, from 2018 American Community Survey. (Internet) (Cited December 4, 2020) Available at: https://en.wikipedia.org/wiki/List_of_U.S._states_and_territories_by_poverty_rate Accessed 12/4/2020.
Related Articles
Letter from the Editor: In Memory of Ryan Murdock '25
Letter from the Editor: In Memory of Ryan Murdock '25

Ryan was a remarkable member of our HUHPR community, known for his kindness, advocacy, and passion for important policy issues like environmentalism and human rights. 

Destigmatizing Physicians’ Mental Health: A Conversation with Dr. Carrie Cunningham on the Stigma Facing Physicians Struggling with their Mental Health
Mental Health
Destigmatizing Physicians’ Mental Health: A Conversation with Dr. Carrie Cunningham on the Stigma Facing Physicians Struggling with their Mental Health
Mental Health

For many physicians, there is a lack of accessibility to healthy coping mechanisms and opting to ask for help. How can policy through legislation and broader reorganization of societal standards help alleviate physicians’ mental health and burnout?

Mental Health
The Development and Future of Health IT: A Conversation with Dr. David Blumenthal
The Development and Future of Health IT: A Conversation with Dr. David Blumenthal

Health IT is expensive to acquire and implement in hospital structures. Health IT poses a major disruption to the daily workflow of clinicians and organizations. How can this transition be more efficient, and what role does IT have in the patient-provider workflow?

Interview with Dr. Meredith Rosenthal: C. Boyden Gray Professor of Health Economics and Policy
Interview with Dr. Meredith Rosenthal: C. Boyden Gray Professor of Health Economics and Policy

Dr. Meredith Rosenthal is the Director of Graduate Studies for the Harvard PhD Program in Health Policy and the Faculty Chair for Harvard’s Advanced Leadership Initiative. She received her Ph.D. in Health Policy on a Economics track from Harvard University. She primarily focuses her research on policies aimed at enhancing the affordability and quality of healthcare in the United States. Her work has played a significant role in shaping provider payment systems in both public and private spheres. Additionally, she has provided guidance to federal and state policymakers regarding healthcare payment policy development and implementation.

A Community-Based Policy Approach to Advance Maternal & Reproductive Health Research among Minoritized Birthing Populations in the United States
A Community-Based Policy Approach to Advance Maternal & Reproductive Health Research among Minoritized Birthing Populations in the United States

Black and Brown maternal health disparities are rooted in historical health policies limiting power and reproductive decision-making in the United States. From anti-Black racism in the field of obstetrics and gynecology and policies such as the Sheppard–Towner Act of 1921 in the American South, to xenophobia through the forced sterilization of non-English speaking mothers in the 20th and 21st centuries, there is a clear link between health policy and minoritized maternal health outcomes.

Exploring the Intersection of Neurosurgery and Immunotherapy: A Conversation with Dr. Bryan Choi
Exploring the Intersection of Neurosurgery and Immunotherapy: A Conversation with Dr. Bryan Choi

Dr. Bryan Choi, an attending neurosurgeon, specializes in surgical care for patients with benign and malignant brain tumors. He graduated summa cum laude from Harvard College and earned both MD and PhD degrees at Duke University School of Medicine, focusing on tumor immunology.

PTSD and Mental Health during the Coronavirus Pandemic: A Conversation with Dr. Karestan Koenen
PTSD and Mental Health during the Coronavirus Pandemic: A Conversation with Dr. Karestan Koenen

HHPR Associate Editor Kiran Ebrahimi interviewed Dr. Karestan Koenen, a psychologist and epidemiologist at the Harvard T.H. Chan School, whose research focuses on the physical and mental effects of trauma and PTSD. Dr. Koenen received her B.A. in Economics from Wellesley College, M.A. in developmental psychology from Columbia University, and Ph.D. in clinical psychology from Boston University. She is a strong advocate of better support for victims of sexual assault and PTSD. This interview has been edited for brevity and clarity.

A Policy Approach to Rewiring the Narrative on Mental Health & Education Outcomes for Boys & Young Men
A Policy Approach to Rewiring the Narrative on Mental Health & Education Outcomes for Boys & Young Men

Rigid adherence to traditional masculine norms typified by self-reliance and restrictive emotionality is associated with poor mental health and education outcomes for boys and young men. Existing approaches to encourage more flexible, positive expressions of masculinity have largely been focused on achieving individual behaviour change. Here we discuss the need for a policy lens on efforts to reduce the influence of restrictive gender role norms for boys and young men. Examples of current solutions span the sensitisation of mental health care for boys and men, alongside embedding of positive masculinity programming into educational policy. In all, applying a policy and systems lens when promoting positive masculinities does due justice to the structural nature of restrictive frameworks of masculine self-expression.

Social Determinants of Health and Child Development: An Interview with Dr. Henning Tiemeier
Social Determinants of Health and Child Development: An Interview with Dr. Henning Tiemeier

Associate Editor Allie Oh interviewed Henning Tiemeier, MA, MD, PhD, a Professor of Social and Behavioral Science and the Sumner and Esther Feldberg Chair of Maternal and Child Health at the Harvard T.H. Chan School of Public Health. Dr. Tiemeier received both his medical and sociological degree from the University of Bonn, Germany, and his PhD from the Erasmus University in Rotterdam, Netherlands. Since 2018, he has led the Maternal and Child Center of Excellence at Harvard Chan. As one of just 13 HRSA-funded Centers of Excellence in Maternal and Child Health in the United States, the center trains future leaders in the field. Dr. Tiemeier has worked broadly in pediatric epidemiology for more than 20 years with an emphasis on child developmental research. At Harvard his research focuses on high-risk children, such as preterm children and homeless families. 

Bridging Healthcare Gaps in Underserved Boston Communities: An Interview with Dr. Mollie Williams
Bridging Healthcare Gaps in Underserved Boston Communities: An Interview with Dr. Mollie Williams

HUHPR Senior Editor Beier Nelson interviewed Dr. Mollie Williams, Dr.P.H. Dr. Williams is the executive director of The Family Van, a mobile clinic that utilizes a community-oriented approach to provide free preventative care screenings to Boston’s underserved, neighborhoods. Dr. Williams is also a lecturer on Global Health and Social Medicine at Harvard Medical School.

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