Structural racism undergirds American society. To deny so is myopic to our history – this country was built on the backs of slave labor and on the lands of indigenous people. Public health is not without fault, as advances have occurred at the expense of Black, indigenous and people of color. From 1932 to 1972, the U.S. Public Health Service tracked almost 600 hundred low-income African-American men in Tuskegee, Alabama; about two-thirds of them had syphilis. The study was designed to monitor the progression of untreated syphilis, so the men were lied to and provided with sham treatments. They passed it on to family members, needlessly causing suffering and death. By 1947, penicillin was well recognized as effective treatment, but was nevertheless withheld. The Centers for Disease Control and Prevention (CDC) ended the study only after a “whistleblower” went to the media in the 1960s. As one scholar put it, the Tuskegee study “revealed more about the pathology of racism than it did about the pathology of syphilis.” This history has significantly impacted Black Americans’ confidence in public health and the health care system.
“Marginalized” or “vulnerable” refer to the processes and conditions by which specific populations are impacted by structural, avoidable, and unnecessary inequities resulting in disproportionate illness and hardship. Due to their marginal position in American society in terms of both power and resources, these populations face unequal, unfair, and preventable deficits in their health status. These inequities begin in childhood and extend throughout the life course. There are a number of child health and development measures, such as infant mortality, immunization coverage, respiratory illness, school readiness, mental health, and low birth weight that affect these populations. They extend through adolescence to include higher rates of mental and behavioral health issues, such as depression, substance misuse and suicide. As adults, higher rates of chronic diseases, such as diabetes and heart disease and deaths, are far too common.
The title of a recent viewpoint in JAMA (The Journal of the American Medical Association), titled “Failing another national stress test on health disparities,” demonstrated how people of color have been disproportionately affected by COVID-19. Infection and death rates in the 131 predominantly Black counties across the U.S. are three-fold higher and six-fold higher, respectively, than the overall U.S. rates. The Navajo nation, that has seen almost 9,000 cases and more than 440 deaths, has one of the highest fatality rates in the U.S., to include the loss of many elders and native healers. Nationally, almost one in five deaths of Native Americans and Hispanics are caused by COVID-19. In Washington, Hispanic and Native Hawaiian people are 14 times and 17 times, respectively, more likely to become cases as compared to Whites.
Where and how people of color and other marginalized groups live matters, as race often determines home. Differences in health exist in communities with unstable housing, low income, unsafe neighborhoods, and substandard education. Longstanding societal and institutional policies and practices lead to health inequities. These differences in health status are unfair, preventable, and lead to
“embodied inequality.” This inequality is based on socioeconomic position, race/ethnicity, nationality, nativity, immigration and citizen status, age, and gender. Discrimination and social injustice lead to poor health outcomes and are multigenerational.
The COVID-19 pandemic has highlighted the connections between inequities of health, society and the economy – a society with long-standing inequities makes people more susceptible to contracting and dying of this infection. We have emphasized physical distancing, which is easy to do when you are able to work from home but is a privilege that for many does not exist. To make ends meet, many members of marginalized groups have had to place themselves in harm’s way and work in-person under challenging conditions to ensure essential resources remained available for others. Racial inequities in heart disease, diabetes, and their associated risk factors have their origin in the legacy of discrimination, racial injustice, and inequities in social opportunity. Decades of multigenerational chronic stress and trauma have taken their toll.
COVID-19 has revealed Black and Brown lives matter. The Spokane County Board of Health’s RESOLUTION #20-07: ADOPTING A SPOKANE REGIONAL HEALTH DISTRICT HEALTH EQUITY RESPONSE to address racism and health inequities serves as a message to the entire community. We cannot accept the status quo. We need to acknowledge our history and actively dismantle underlying structural racism that prevents every member of our society from achieving their potential.
Dr. Bob Lutz is the Spokane County health officer.
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