Alarmed but Not Surprised: Reckoning with Residential Segregation and COVID-19 Racial Disparities
By Kristen Brown and Akilah Wise
The COVID-19 pandemic in the United States is amplifying and foregrounding the nation’s underlying inequalities, with emerging data showing that Black Americans are bearing the brunt of the virus. In Michigan, Black people make up 14% of the state’s population, but 32% of overall COVID-19 cases and 41% of COVID-19 deaths. In the nation’s capital, Black people make up 46% of the population but 79% of the district’s 304 COVID-19-related deaths. These data mirror national trends since Black Americans make up 13.4% of the U.S. population but 27.5% of COVID-19 cases.*
With an ill-prepared healthcare system and severely strained hospital resources, healthcare providers are making decisions about which COVID-19 patients will receive life-saving care. This assessment is often made by assessing patients’ “perceived survivability,’ or the likelihood that he or she could overcome COVID-19 given their prior medical history. This rightfully raises concerns about the structural racism embedded in making such decisions. The rationing of care based on survivability puts Black patients in a dangerous and unfair position, capitalizing on the geographic clustering of disease and disadvantage in Black communities brought about by residential segregation.
Beyond Pathologizing
Residential segregation is a form of institutionalized racism, and a product of centuries of formal and informal practices, like redlining and block-busting, that isolated and pushed Black people into areas of concentrated disadvantage. We still observe stark racial residential segregation patterns in most, if not all, major metropolitan areas in the U.S., in which segregated Black neighborhoods have fewer resources to maintain health. Because of residential segregation, Black people’s access to health-promoting resources and opportunities are limited, increasing the propensity to develop chronic diseases.
In fact, a vast public health literature points to the role of residential segregation behind today’s racial health disparities. One’s residential neighborhood determines access to healthy foods, opportunities for physical activity, and healthcare, as well as exposure to crime, air pollution, water quality, and economic opportunities. For example, residential segregation is associated with adverse birth outcomes, hypertension, cardiovascular health, childhood asthma, and diabetes mortality.
Public health has long acknowledged that racial residential segregation is a fundamental cause of racial disparities in health.
Evidence shows that without residential segregation, racial gaps in health outcomes would substantially decrease. In LaVeist’s “Exploring Health Disparities in Integrated Communities” study, racially and economically integrated census tracts in Baltimore were identified. Compared to national levels, racial disparities in health outcomes in hypertension, diabetes, obesity, and smoking — those conditions associated with COVID-19 deaths — were reduced or eliminated in these integrated neighborhoods.
Yet, leading health officials are not acknowledging the critical role of segregation in racial disparities of disease outcomes, and thus missing the opportunity to inform mainstream conversations about the contextual, built, and social, factors that shape health.
Dr. Anthony Fauci, Director of the National Institute of Allergy and Infectious Diseases, initially attributed the disproportionate severity of COVID-19 cases among Black people to “underlying medical conditions,” like diabetes and hypertension. By not contextualizing the deeper inequities that lead to racial disparities in comorbidities, this incomplete explanation leaves room for lines of reasoning that weaponize the pandemic against Black communities. For example, U.S. Surgeon General Jerome Adams resorted to age-old pathologizing of Black and Latino communities, telling people to “step it up” by following social distancing and hand-washing guidelines, and “avoid alcohol, tobacco, and drugs.”
In ascribing Black people’s COVID-related deaths to individual-level behaviors, without evidence, Adams ignored decades of literature that links racial disparities in health to social and structural factors.
Looking to The Future
The COVID-19 pandemic underscores how historical and contemporary racism has manifested in the structural patterning of disease and vulnerability. The pandemic has put racial/ethnic disparities into the public conversation, presenting an opportunity to address how decades of racist divestment and neglect produce health disparities.
We can no longer ignore the work that needs to be done to eliminate disparities in COVID-19 and chronic diseases like cardiovascular disease, diabetes, cancer in the United States. Experts say COVID-19 will be seasonal, like other respiratory infections, thus always a threat for those who are structurally vulnerable. As we enter this new era, now is the time to address these gross health inequities and their devastating impact on Black communities.
*All statistics reflect available reported data at the time this was written.
Kristen Brown is an epidemiologist whose work focuses on understanding how exposure to adverse social conditions are internalized biologically and how this knowledge can be leveraged to develop personalized prevention and treatment stratgies. She obtained her Ph.D. in Epidemiologic Science from the University of Michigan, master’s degree in Human Genetics from the University of Michigan, and bachelor’s degree in Biological Sciences from Rutgers University.
Akilah Wise is a global journalism fellow at the University of Toronto’s Dalla Lana School of Public Health and freelance writer in Atlanta, Georgia. She previously held a postdoctoral research fellowship at Emory University Rollins School of Public Health where she examined place-based correlates of HIV risk-related behaviors among people who inject drugs. Dr. Wise work centers on using reproductive justice to examine inequities in reproductive health and HIV in the United States. She has written about health inequities for The Nation, Rewire, Emory Health Digest, SPARK, and the Praxis Center at Kalamazoo College.
