Examining the Relationship Between Institutionalized Racism and COVID-19

In 2020, protests erupted around police brutality and other forms of institutional and systematic racism within the justice system. These same forms of structural racism exist in the medical and healthcare industries, and explain fundamentally, why we have large, ongoing, racial health disparities in all health outcomes including COVID-19 (Harris et al. 2006; House 2002; Matthew 2015; Washington 2006). COVID-19 is an acute (short-term), infectious illness that has become an epidemic in the United States. COVID-19 spreads through the air; therefore, it ought to affect people equally. Unfortunately, we are already seeing substantial racial inequality in COVID-19 infections. African Americans are experiencing three times the rate of COVID infection and nearly six times the death rate of White majority counties (Garg et al. 2020; Scott 2020; Webb et al. 2020; Yancy 2020).

In this essay, we examine Black–White racial health disparities and their social determinants. We argue that racism, whether called systematic, structural, or institutionalized (for the sake of this essay these terms are interchangeable), is the primary cause of both explicit and implicit race-based discrimination. Furthermore, we will present and refute biological, behavioral, and social class explanations for racial health disparities. Next, we use the institutionalized racism framework to examine COVID-19. We finish with a set of proposals designed to interrupt the association of racism with health outcomes.

There is a large body of research on racial disparities in chronic health conditions. Chronic conditions, such as heart disease, diabetes, and hypertension are life-long illnesses and syndromes managed through medical treatments. Today, they are the top causes of death (Rana et al. 2020). African Americans have more chronic conditions such as hypertension, diabetes, cardiovascular disease, and lung disease than Whites, increasing their risk of death from COVID-19 (Garg et al. 2020).

What causes African Americans to have more chronic conditions and be more likely to contract infectious diseases such as COVID-19? Dressler et al. (2005) find that most research looks to five types of explanations for racial health disparities, genetic, behavioral, socio-economic, structural-constructivist, and psychosocial stress. We can dismiss the genetic explanation because race is socially constructed as W. E. B. Dubois demonstrated back in 1906. He found that from 1725 to 1853, while Whites lived longer than Black folks, life expectancy improved similarly for both populations, and that differences in mortality rates among Black folks living in different cities were due to environmental differences. Therefore, genetic inferiority could not explain Black peoples life’ span (DuBois 2003).

The research is clear that healthy behaviors are important for a long healthy life, but they do not explain racial health disparities. The extant literature examining the associations between health risk behaviors and racial health disparities find that only a small portion of those disparities is explained (Dressler et al. 2005; Harris et al. 2006). For example, Halfors et al. (2007) find that health behaviors do not explain racial disparities in HIV infection risk among adolescents. Black girls are the least likely to engage in any risky health behaviors (early sex, drug use etc.), yet are the most likely to contract HIV.

The third explanation Dressler et al. (2005) observed is socio-economic status (SES). Link and Phelan (1995) were particularly influential in developing Fundamental Cause Theory (FCT) to explain SES related health disparities. FCT argues that there are flexible resources tied to higher levels of SES, such as material and social capital: knowledge (of the complex demands of health in society), money, power, and prestige (Braveman 2006; Bourdieu 1986; Weber 1964), and beneficial social connections (Bartkus and Davis 2010; Bourdieu 1986). Thus, even in the face of a direct intervention to reduce a specific disease disparity, it will fail as SES ultimately affects our exposures and experiences regardless of changes in disease over time (House 1992; Lieberson 1985; Link and Phelan 1995).

FCT has been criticized for not addressing the interconnected nature of race and SES (Feagin and Bennefield 2014:8), despite Massey and Denton's (1993) argument that residential segregation is the key (fundamental) reason for racial inequalities. Early work examining the effect of racial residential segregation on health disparities produced mixed results, driving the need for further inquiry (Collins and Williams 1999; LaViest 1989, 1993; Polednak 1993, 1996; Williams and Collins 2001). Recent research has found that institutional racism produces race-based disparities in social, economic, and health-related conditions (Bailey et al. 2017; Castle et al. 2019; Feagin and Bennefield 2014; Greer et al. 2014; Link and Phelan 2015; Peek et al. 2010). Social stress, discrimination, nutrition, housing, transportation, crime, and environmental conditions are all influenced by race—with Black Americans being disproportionately disadvantaged in each category (Link and Phelan 2015).

This leads to the fourth explanation, structural-constructivism, which directly addresses how racism creates health disparities (Dressler et al. 2005). Critical race scholars provide important understandings of institutional/systemic racism (Ture 1967). Institutional racism is a term coined in 1967 by Stokely Carmichael, a civil rights activist who would later become Kwame Ture, in order to develop a framework for understanding more covert forms of racism embedded in the legal, economic, and social practices of America. As Feagin (2006:2) noted, systematic racism is, “far more than a matter of racial prejudice and individual bigotry. It is a material, social, and ideological reality that is well-embedded in major U.S. institutions.”

Racism was explicitly embedded into healthcare law from the early 19th through early 20th centuries (Matthew 2015). Healthcare law was the specific mechanism used to deny Blacks access to the same health care available to Whites. For example, in the early 1800s, separate and segregated health facilities were built and then sanctioned by the Supreme Court in the 1896 Plessy v. Ferguson ruling. This opened the door nationwide for state and local segregation ordinances in both public and private health care facilities for almost a century (Matthew 2015). The healthcare received by Black people continued to be inferior to that of Whites well into the 20th century.

The 1946 Hill-Burton Act was a massive hospital construction bill to modernize and increase the number of hospitals around the nation. This act codified the separate but equal doctrine for hospitals in its ironic nondiscrimination policy. The nondiscrimination policy allowed exceptions for areas where separate hospital facilities existed for separate populations. Under this act, for example, in 1955, a federal court allowed an Arkansas hospital to deny access to a young Black man even though beds were open on the White side (Matthew 2015). Many lawsuits challenging separate but equal accommodations for patients of color or for physician privilege access failed in this period. It wasn't until the 1979 Cook v. Ochsner lawsuit that the separate but equal exclusion clause was challenged and revised for Medicaid patients (Matthew 2015).

Racism is also embedded in the healthcare system itself. White racial framing in health care education, research, policy, and practice has been a central explanation for the persistence of institutional racism (Burgess 2011; Burgess et al. 2019; Burgos et al. 2017; Castle et al. 2019; Williams and Wilson 2016). Feagin and Bennefield (2014:8) note that Whites, particularly White men, make up the majority of “decisionmaker” positions, such as “public health researchers and policy makers, medical educators and officials, hospital administrators, and insurance and pharmaceutical executives, as well as medical personal.” For example, the Association of American Medical Colleges Report (2019) notes that White physicians and healthcare educators make up roughly 60 percent of their respective medical fields; further, Whites make up almost three quarters of the delegates at the American Medical Association—whilst also encompassing 70 percent of the board of trustees.

With the 1960's civil rights movement, some forms of explicit institutional racism began to change. Matthew (2015) argues that the 1963 Simpkins v. Moses H. Cone Memorial Hospital marked this change in the law. The appeals court in this case found the Hill-Burton Act to be unconstitutional. Title VI of the Civil Rights Act was used to successfully challenge explicit racial discrimination by demonstrating disparate impacts for almost 30 years. Note that Healthcare facilities were not required to make changes unless they were challenged legally.

Hospitals today remain racially segregated, especially in Midwest and northeastern metropolitan areas. In addition, we now have medical deserts. Medical deserts, a term born from an analogous concept of “food deserts,” can be described as areas lacking sufficient access to vital medical resources (Carr et al. 2017). Originally used to describe rural regions, they also apply in urban/suburban areas where trauma services have either never materialized or disappeared leaving trauma deserts in racially segregated areas illuminating racial disparities in access to care, in treatment, and in outcomes from the healthcare system (Tung et al. 2019). Moreover, since 1975 over 1,000 hospitals, many in rural areas and Black majority census tracts, have closed (Scott 2020). Rural folks, Black city dwellers, and Indigenous peoples residing in reservations (IHS) experience the most prominent inequities in health, in part due to the effects of medical deserts and distribution of resources (Carr et al. 2017, Tung et al. 2019; Sequist et al. 2011). In fact, one study demonstrated that in Los Angeles, Chicago, and New York City respectively, 89, 73, and 14 percent of Black majority census tracts exist in these trauma deserts (Tung et al. 2019).

Access to healthcare via insurance, is also influenced by institutional racism. Occupational segregation has led to Black people and Hispanic people being employed in occupations with higher turnover rates, and thus, are more likely to lose their employer provided insurance if their employers even offered it (Fairlie and London 2008). There are also access issues related to public forms of insurance. For example, the passage of the Affordable Care Act under the Obama administration sought to increase healthcare access, in part, by expanding state funding for Medicaid, which would disproportionately improve the lives of marginalized groups. Unfortunately, many states with large minority, rural, uninsured, and low-income populations chose not to access these benefits. This has led to an insurance coverage-gap between Whites, Black folks, and Hispanic folks (Kaiser Family Foundation 2020; Scott 2020). Around 30 million people remain uninsured in America. Specifically, from 2010–2018 Black folks have remained 1.5 times more likely to be uninsured than Whites, and Hispanic folks over 2.5 times more likely (Kaiser Family Foundation 2020).

In sum, institutional racism is explicitly embedded in every aspect of the healthcare system. Racism is also implicitly embedded in healthcare as discussed in the psycho-social stress framework (Dressler et al. 2005) our final explanation of racial health disparities. Implicit bias is also known as unintentional racism. Implicit biases are defined as unconscious thoughts and feelings that are either negative or positive (Hall et al. 2015). Therefore, unlike institutionalized racism, these are microlevel racialized interactions.

In a review of fifteen studies, Hall et al. (2015), found that most health care providers appear to have positive implicit biases towards Whites and negative implicit biases towards Black folks. Matthew (2015) found that physicians’ implicit bias led to disparate treatment of patients by race at all stages of the clinical encounter. These implicit biases can affect how physicians treat black patients, but also can affect Black patients’ reactions to medical interactions. Both of which add to racial health disparities (Penner et al. 2014). These biases prevent White health professionals from understanding how pervasive racism is within major U.S. institutions, and in response maintains the inequity of the current system.

Experiencing constant negative implicit bias is stressful. Geronimus et al. (2006) calls the psycho-social stress explanation the weathering hypothesis and argues that health deteriorates earlier for Black folks leading to health disparities early in the life course that accumulate over time so that these disparities widen with age. This is due to the stress of living with racial stigma associated with social, economic, and political marginalization (Geronimus et al. 2006). In fact, in examining allostatic load, a multi-item biomarker proxy for the wear and tear of stress on the body (Chyu and Upchurch 2018; Geronimus et al. 2006; McEwen and Seeman 1999), they found allostatic load was higher among Black folks compared to Whites and that as people aged, that disparity grew larger. Harris et al. (2006) confirms this result; finding that racial health disparities do increase with age. Furthermore, socioeconomic status did not explain or even reduce the racial disparities in allostatic load suggesting FCT theory has the race-SES association backwards (Geronimus et al. 2006).

Unfortunately, implicit bias or unintended racism is not recognized by the courts. Legal support to end discrimination in healthcare ended in 2001 when the Supreme Court ruled (Alexander v. Sandoval) that disparate impact claims, even where there is a clear impact, are not valid if the discrimination is unintentional (Matthew 2015).

This is the racial relations in the United States as COVID-19 is spreading. Structural racism has created the conditions that make Black folks more susceptible to contracting COVID-19. Black folks and Whites are segregated residentially with Blacks, on average, living in more densely populated urban areas. With schools about to open for the fall, funding policies alongside segregation will result in Black neighborhood schools not being able to meet Centers for Disease Control and Prevention's guidelines for opening. Thus, COVID-19 spreader events are far more likely in segregated Black neighborhoods.

Blacks and Whites are also segregated in terms of occupations. Black Americans make up only 12 percent of the workforce, but make up a disproportionate percentage of so-called, essential jobs—such as 25 percent of food and courier delivery workers, 27 percent of postal workers, and 31 percent of transportation workers (U.S. Bureau of Labor Statistics 2019). In addition, Black folks, particularly Black women, are unevenly facing greater unemployment due to COVID-19 (Economic Policy Institute 2020). Black families are also subject to lower wages, and salaries and have significantly less savings to fall back on (Economic Policy Institute 2020). Thus, Black folks are less able to isolate during the pandemic and must put themselves at greater risk of contracting COVID-19.

COVID-19 as it stands illuminates and exacerbates racial disparities in healthcare. For example, Black Americans disproportionately face more medical/trauma deserts, less health insurance, inadequate access to and quality of healthcare, and greater underlying health conditions. Implicit bias also plays a role here. While we argue institutional racism has led to disparities in the COVID-19 related comorbidities, the media has implied value-judgments that those who die have underlying conditions, a sort of, “shame on you for not taking better care of yourselves” approach. This is a health behavior approach that has been shown to not explain racial health disparities. This blaming framework is a common reaction to epidemics, however, it allows others to (falsely) distance themselves from risk (Rosenberg 1989). While it is too early for there to be research on how this framework affects the implicit bias of medical staff, there is some anecdotal evidence. News story, after news story (Eligon and Burch 2020; Gupta 2020; Stafford et al. 2020; illuminate the realities that Black Americans experience while just trying to get treatment that very well may end up killing them. The narrative of the Relf family is only one of many. Reginald Relf, an African American engineer, was refused a COVID-19 test, turned away by the medical clinic yet told to quarantine, and died a week later. This story poignantly highlights the realities of existing structural racism and further gatekeeping from implicit bias affecting the medical system's treatment of (or lack thereof) Black people that can lead to death (Eligon and Burch 2020). So, while access to resources may be one part of the explanation, Implicit bias also contributes to the larger picture of racism for marginalized folks in this pandemic.

American society has long focused on the impact of racism in our economic and justice system with little to show for that effort. However, Americans are less aware that racism is pervasive in the medical field. Martin Luther King Jr. (1966) in a press conference prior to a Chicago speech called inequality in health, “the most shocking and the most inhuman because it often results in physical death.” To address the persistence of inequity in our healthcare system, we call on more health disparity researchers to center institutional racism in their research models. Similarly, legislators need to acknowledge the many subtle ways that racism permeates healthcare experiences for African Americans and suggest legal remedies to deter discrimination. Further, we have acknowledged in this essay that health disparities are deeply connected to economic injustice(s); thus, we must imagine alternatives or mitigations to our current capitalist system, such as expanding access to and improving the quality of education, housing, transportation, and healthy food options. Universal healthcare is a needed remedy to resolve discrimination in access to care.