C. Brandon Ogbunu //
The notion that drivers of COVID-19 disparities are not only historical, but contemporary, came to light in the tragedy involving Susan Moore, a black woman family physician who had circulated a video on social media in early December 2020 that explained her racially biased treatment in the hospital. She died of complications related to COVID-19 on December 20, 2020, touching off a national dialogue about the reach of discrimination in healthcare.
Around events like these emerged a conversation about how to address disparities in COVID-19 burden. Activism and scholarship in this space invokes the language of health justice, implicit bias, and other ideas through which we can understand why an ostensibly biological thing—a virus—may wreak differential havoc along different socially constructed categories, like race and class.
The practice of studying and discussing pandemics like COVID-19 can use many languages. One lexicon, invented by experts in fields like molecular genetics, evolutionary biology, and epidemiology, describes pandemics as a series of microscale events that culminated in a virus, SARS-CoV-2 , which caused a novel disease in Homo sapiens, transmitted from person to person. This language has been the dominant, “official” one of the COVID-19 pandemic (at least so far). The pandemic’s scholar-laureates have been the Dr. Faucis among us, bespectacled and adorned with white coats, and trusted in most circles.
Those who speak the scientific language of COVID-19 have played a critical role in our progress against the disease. They crafted ideas that have withstood the onslaught of misinformation that has brewed in many corners of the world, and, in the United States, came from the federal government itself. And their collective efforts helped to engineer a highly effective vaccine with unprecedented speed.
But the scientific language has only been useful for selected aspects of the pandemic. And as we moved through and out of 2020, the shape and complexity of COVID-19 changed and required new lenses and vocabularies. Because events like the death of Susan Moore, and related patterns of inequality, could not be described at the level of genes and proteins.
Within the United States, inequalities manifested most egregiously within Black and Brown communities. Recent data suggest that 1 in 750 Indigenous Americans, and 1 in 850 Black Americans has died of COVID-19, whereas 1 in 1,325 white Americans has died. Early in 2021 the Black age-adjusted mortality rate is above 150 deaths per 100,000 individuals, with the Native American community mortality rate currently at 210.6 deaths per 100,000 individuals, a rate approaching twice that of non-Hispanic whites.
Even outside the United States, social inequalities have been a distinct signature of disease around the world, from religious minorities in the United Kingdom to indigenous groups in Brazil.
After months of speculation as to the cause of these disparities in the United States, recent studies suggest that they arise from a difference in infection risk, rather than biological differences in how deadly the disease is. These findings support the notion that racial disparities in COVID exist because of the underlying social forces that deliver serious infection to Black and Brown people in the United States, rather than because of anything intrinsic to their behavior or biology.
As scholars have documented for centuries, systemic racism—the product of mostly intentional policies that date back to America’s inception—dictates where we live, how we live and work, and which communities are exposed to violence and illness. In other words, racism, not race, has driven the differences in COVID-19 outcomes. Racism includes both the structural violence that has been driven by racist attitudes and policies and the everyday experiences of people in healthcare settings.
Of Black lives in COVID and the carceral state
The conversation and language around health justice and structural violence in COVID-19 did not arise in a vacuum; it was bolstered by national conversations around race, justice, and policing that followed the murders of George Floyd and Breonna Taylor and the mass anti-police brutality protest movement that followed—the largest and most widespread social movement in American history.
That these protests happened during the first major wave of COVID-19 in the United States was fuel for many analyses about how the events were connected, even with regard to the language used in public health messaging.
Even molecular, classically “scientific “ aspects of COVID-19 have an undeniable social signature because disease emergence events that foment outbreaks like Ebola or SARS-CoV-2 involve the human-animal interface, which is powerfully influenced by political and socioeconomic factors. The market for certain goods influences the interaction with nature and desire to encroach further into natural habitats for many species, where humans are increasingly encountering new microbes, some of which may cause disease.
Relatedly, the relationship between the pandemic and social justice is so intertwined that they are inseparable: not only does social structure influence the first emergence events, it also influenced who was at higher risk of becoming ill, the probability of successful chains of infection, and what resources those who were infected had access to (for prevention or treatment).
One such population that has been understudied, even within conversations about COVID-19 inequalities, is individuals living within the varied arms of the carceral state. Studies of COVID-19 and incarceration highlight a very specific ecology that renders even our progressive lenses fruitless. For example, the institution of social distancing is itself a privilege, based on an assumption that individuals can position themselves away from others via free will. Incarceration is specifically engineered to limit all of the key instruments of effective COVID-19 public health: limited access to a healthy physical environment, limited access to materials (this includes access to preventative items like masks and soap), limited access to physical space, and limited agency to do what one wants to (the type of freedom that allows us to social distance).
COVID-19’s social and political discourses have mostly been driven by partisan debates over how to manage COVID-19 and emergent discussions about ethnic disparities in COVID-19 outcomes. But even the most well-meaning arguments in these spaces are inadequate. The porous nature of public health language is reflected in striking findings about COVID-19 in jails and prisons. As of late in the fall of 2020, 80% of the largest outbreaks took place in prisons and jails. And controlling for population size, the COVID-19 case burden in prisons and jails is over five times that of the general population. Just as troubling is the lack of data being tracked in these settings, which prevents us from understanding all the other dynamics that could be taking place in these settings.
But questions about the ecology of the carceral state and COVID-19 transcend the walls of prisons and jails and exist even with regard to policing. Simulations of COVID-19 dynamics that include policing and incarceration produced startling results, with frontline workers, individuals returning home after incarceration, and law enforcement accounting for almost 70% of new infections in a representative city. Critically, this simulation identifies that the problems of COVID-19 within jails and prisons end up affecting disease dynamics outside of jails and prisons, a set of interactions for which there are few empirical studies.
These studies and simulations reveal the many gaps and blindspots in our attempts to build a comprehensive understanding of COVID-19 ecology. It requires not only the language of social justice but a deeper appreciation of the constraints and interactions that drive disease in all settings, the ones defined by history, contingency and the modern manifestations of structural violence.
Author bio: C. Brandon Ogbunu is an assistant professor at Yale University.
Image: A socially distanced protest against police brutality. Robin Utrecht for Getty Images.
