Peeling back this pandemic’s layers of inequality

Here’s data straight from state websites as of Tuesday: In South Carolina, black Americans account for 56% of deaths, though the state’s entire population is just 27% black. While black Americans represent 15% of Illinois‘ population, they account for 42% of deaths there. In Louisiana, 59% of people who’ve died from the disease are black, a group that makes up only one-third of the state’s population.

The Navajo Nation — the country’s largest Native American reservation, which stretches across portions of Arizona, Utah, and New Mexico — has seen an alarming spike in casualties. In New York City, Latinos as of earlier this month account for 34% of deaths, a number that’s greater than their 29% share of the city’s population.

Far from being the “great equalizer,” the global pandemic, as with past catastrophes, is manifesting on layers of persistent disparities — in employment, in housing, in access to high-quality doctors. These facts strongly shape how communities experience the crisis.

To break down the underlying issues that seem to intensify the virus’ impact, I recently spoke with Tricia Neuman, senior vice president of the Henry J. Kaiser Family Foundation and executive director of its program on Medicare policy.

Our following conversation has been lightly edited for length and clarity.

Drawing on guidelines from the US Centers for Disease Control and Prevention, you recently co-authored an analysis identifying people who may be at risk of serious illness from Covid-19. What were your key findings?

The main takeaway is that many adults are at risk of serious illness if they become infected. We found that some 92 million (of 246 million) people ages 18 and older are at risk of serious illness if they become infected. That includes everyone 65 and older — but also many people who are under 65 who might think that they’re not at serious risk when in fact they are.

We also took a closer look at what’s going on at the state level and made some interesting observations. We found that there’s a relatively high proportion of younger adults in several Southern states who are at increased risk of illness if they become infected.

That last data point — in states across the South, more than a quarter of adults under 65 are at higher risk of serious virus-related illness — stood out to me as I was reading the analysis. It challenges the dominant assumptions about the virus regarding age and vulnerability. Why does the pandemic pose such a distinct threat to the region?

I think that it may be useful to focus on the under-65 population because then you’re picking up specific characteristics other than their older age that put them at risk. The numbers jumped out at us because 21% of all adults under 65 are at risk of illness due to conditions including heart disease, lung disease, diabetes, and asthma.

But in several states, the numbers are significantly higher. And these include states such as Alabama, Arkansas, Kentucky, Louisiana, Mississippi and Tennessee. These are Southern states with relatively large shares of black Americans, people who are low income, people of color who are disproportionately affected by health conditions and diseases.

In some ways, then, it was no surprise that we found that people in the South are at higher risk. But it was also discouraging to see that people of color make up such large shares of these populations.

So put differently, the pandemic is laid over a foundation of inequality.

Right, the virus is layering over an infrastructure where people of color have been living with so many disparities that affect their ability to deal with an economic crisis and a public-health crisis.

For example, because this is also a disproportionately low-income population, you find many people working in professions where they really have no opportunity to work from home. Many are essential health care workers who go to work not only because they have jobs that require them to do so, but because they very much need the income.

When they go to work, they put themselves at risk — and they may inadvertently put their families at risk, too. That’s because people of color, for a variety of reasons, are more likely to live in multi-generational households. Think of people who work as home health aides, caring for other people. There could be people living in the homes they visit who are asymptomatic carriers of the virus. These aides themselves may become asymptomatic carriers and return to their homes, where, through no fault of their own, they spread the virus to other people.

In the cities and states reporting data on race, we’re seeing evidence that Covid-19 is hitting black Americans especially hard.

You also could look at how this is overlaid with state policies on Medicaid expansion — with the fact that large shares of people at higher risk live in states where they don’t have the benefit of Medicaid expansion. (Most of these states are in the South.) This raises questions about the care they receive, and whether and how that care will be paid for moving forward.

Many people — from lawmakers to doctors — are calling for more granular data on race to be collected and released. Why is this important?

It’s vital for understanding what impact the disease is having on people of varying characteristics. Moreover, once it’s known that it’s affecting people of color differently, having more comprehensive data is useful for deciding what strategies to put in place to protect people who aren’t already infected and to take care of those who are. Without this information, it’s like shooting in the dark. It’s difficult to know what the country’s really dealing with on many different levels.

One area where this has become pretty evident — I don’t know if it disproportionately affects people of color — is nursing homes. We’ve been reading about how quickly the virus can move through nursing homes and how that can lead to a sort of surge in hospitalizations and deaths within a given facility. It’d be great to know if these are facilities that treat large shares of black patients versus white patients and others. But we just don’t know.

I’ve been thinking about how necessary it is to be careful with this early data. As trends continue to emerge, the information could be denuded of context and used to stigmatize or withhold help from black Americans; it could influence empathy and policy in harmful ways. Is this something you’ve thought about as the current crisis unfolds?

Absolutely. This is a national public-health emergency, and it isn’t helpful at all to start assigning blame to people who may be predisposed to having certain health conditions. Rather, we need to think systemically about why people have these conditions in the first place.

It’s also important to be sensitive to privacy issues with respect to individuals. While individuals may need this information, and while it may be helpful for family members to understand what to do if someone in their unit tests positive for Covid-19, that’s not to say that that information should be made public — because the public doesn’t need to know information of that kind, and people have a right to privacy and confidentiality.

It may be a different question as to whether people in a certain hospital or nursing home or other type of facility have tested positive, because then other patients and other staff are affected. But not at the individual level, where people really do have a right to privacy.

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