Most of the women in Maria Jose Bastias’s English language class, at Mujeres Unidas y Activas, a nonprofit in San Francisco, did not know that they could get a coronavirus test without health insurance, or that they were legally entitled to paid sick leave if they contracted the virus, regardless of their immigration status. They worked grueling hours at menial jobs that offered little security; it had not occurred to many of them to even ask about such benefits, let alone to expect them.
But they all had heard about what happened at the nearby McDonald’s: Employees there asked their boss for face masks to wear at work, and were given dog diapers and coffee filters to use instead.
The story didn’t surprise the women, who were undocumented, came mostly from Central America and had long been acquainted with the vagaries of American employment. But it did upset them. Their own communities had been hit hard by the virus; almost all of them knew someone who had died from it. And many of them had begun to doubt their own bosses’ assurances about the level of risk they themselves faced. Among other things, they had been told that the virus was a hoax; that masks were useless in any case; and that positive test results were often false and could therefore be ignored.
Ms. Bastias asked the women what they were doing to protect themselves. Just praying, they told her. Their indifference did not reflect a lack of fear. They were plenty scared: One woman confessed that she had never taken her 4-month-old baby outside — not even for a doctor’s visit. But they had to work, and they had no power to make their work safer. Ms. Bastias has been trying to change that, by facilitating dialogues between the women, and by weaving lessons about public health and self-advocacy into her language instruction.
With the pandemic stretching into its tenth month, the community where she works needs all the help it can get. The global death toll has topped a million, and this week the United States president, and several of his close contacts, tested positive for the coronavirus.
It’s tempting to see in this latest development proof of the virus’s indifference: a foe so powerful it attacks presidents and paupers alike. But the numbers behind the ever-rising case counts and death tolls tell a very different story.
Black and Latino Americans are roughly two to three times more likely than their white counterparts to contract the coronavirus, roughly four times more likely to be hospitalized by it, and nearly three times as likely to die from it. Latino children who contract the virus are eight times more likely to be hospitalized than white children, and Black children five times more likely. And of the 121 children who died from the virus through July, nearly 80 percent were children of color — 45 percent Latino and 29 percent Black, according to the Centers for Disease Control and Prevention.
Doctors and scientists who track case counts and death tolls are uniformly horrified by this disparity, and many worry that the true gap is probably even greater than the available data indicates. “We are looking at a historic decimation of the Hispanic communities in the United States,” says Dr. Peter Hotez, an infectious disease doctor at Baylor College of Medicine in Houston. “Not only are they dying at much higher rates, but they are also dying younger, which means we are losing working-aged adults and parents of school-aged children.”
Deep, Tangled Roots
Racial health disparities are neither new nor unique to this pandemic. Black and Latino Americans have faced higher rates of chronic illness and infant mortality for generations. Doctors and public health experts have been working for almost as long to both characterize and address these disparities, says Margaret Handley, an epidemiologist at the University of California, San Francisco. And they are determined to leverage the coronavirus crisis toward meaningful progress. “If one good thing comes out of Covid, it may be that we finally build the momentum to do this,” Dr. Handley said.
But before the nation can possibly close its racial health gap, we have to understand it.
When it comes to the coronavirus, the cause-and-effect relationships may seem so obvious as to barely warrant discussion: The workers who were deemed essential, and thus pressed to continue working outside of their homes even as most others sheltered in place — the transit, farm and food plant workers, the nursing home aides and cashiers and delivery people — came disproportionately from low-income communities of color. Many of them were also already nestled into a cluster of other risk factors — poor nutrition, inadequate health care, crowded housing — that made them especially vulnerable to the virus and its worst effects.
But the roots of all these disparities are deep and difficult to disentangle. Chronic illness might stem clearly from diet and a lack of health insurance, but that doesn’t explain why Black and Latino Americans are more likely to suffer from food insecurity, or to work in low-paying jobs, in the first place. To answer those questions, you have to dig deeper — into housing, immigration, education and labor policies that date, in some cases, to the nation’s founding. “The ultimate driver is systemic racism,” says Robert Fields, a population health specialist at Mount Sinai Medical Center in New York. “But you can go upstream into infinity.”
Research into what drives racial health gaps in the United States has been “paltry,” Dr. Fields told me. “There’s been a general push toward ignoring race altogether in medicine, so in a lot of cases we don’t even collect that information, let alone assess our performance on it.”
The C.D.C. — normally the national hub for such data — has not helped matters. The agency’s data on racial breakdowns of coronavirus cases is woefully incomplete. The agency has said it can’t force individual states to report that data in greater detail. But critics say that health officials have been deliberately vague and confusing. “You have to be a Talmudic scholar to understand what they are trying to say,” said Dr. Nancy Krieger, an epidemiologist and expert in racial health disparities at Harvard University.
Among other things, the agency has tinkered with the way racial data is presented — so that white Americans sometimes appear to face the highest risk. “They focus on the counts,” Dr. Krieger said. “To really understand what’s going on, you need rates. How many people from which group over what time period, and how big is that group over all?” It’s true that a majority of people who have died from coronavirus in the United States are white — there are a lot of white people here. But the risk of dying is far greater for Black and Latino Americans.
Muddy though the numbers may be, a portrait has begun to emerge of the forces driving health inequality. And lessons on how to address those forces are coming into focus.
More Unions, Better Broadband
On the surface, some of the most promising tools for closing the racial health gap have nothing to do with health. For example, says Alicia Fernandez, a primary care doctor at Zuckerberg San Francisco General Hospital, if you want to stop the coronavirus from tearing through factories and farms, unionize those workplaces.
Almost no concrete worker protections were put in place when the nation entered its tortuous lockdown phase. The Occupational Safety and Health Administration issued some guidelines, such as mask, social distancing and infection control programs that were advised by the C.D.C. But federal agencies left it to the states to make binding rules — and in turn most states left it to the companies themselves. Some employers have done far better than others at providing personal protective equipment, honoring paid sick leave edicts and supporting workers who express concern.
Dr. Fernandez says that unions can make the difference. “Data shows that for nursing home workers, being in a union was associated with better protection and less infections,” she told me. Anecdotally at least, the same seems to be true of farms. According to the United Farm Workers Foundation, nonunionized farmworkers (who make up 99 percent of all farmworkers) are less likely to receive masks and other protective gear from their employers, less likely to be informed about outbreaks where they work and more likely to face retaliation if they voice concerns.
Kenia Peregrino, an undocumented college student who migrated from Mexico to Washington’s Yakima Valley when she was 4, saw this disparity firsthand, when her mother developed Covid-19 after months of sorting apples in a packing warehouse. Her mother’s employers did not provide their employees with masks, nor offer routine testing, nor implement any social distancing protocols, even as outbreaks hit a string of neighboring farms.
The virus debilitated Ms. Peregrino’s mother, who lost a month and a half of work, which she wasn’t paid for, and who has yet to fully recover. “She used to be very high energy,” Ms. Peregrino said. “Now she gets tired a lot and has to go slow.” She still considers her family lucky. Her mother did not need to go to the hospital — a terrifying prospect for undocumented workers — and she did not lose her job altogether, something that often happens to those who get sick or complain. But Ms. Peregrino, who volunteers with the United Farm Workers Foundation and recently addressed Congress about the plight of migrant farmworkers, said that if her mother had belonged to a union, she might not have gotten sick at all.
Another tool for closing the health gap is even simpler: better Wi-Fi. When a tidal wave of coronavirus swept through New York City this past spring, Mount Sinai Medical Center where Dr. Fields works, shifted as many patients in as many departments as it could to telehealth. “We were doing more telehealth visits per day in the spring than we did in all of 2019,” he said. “With regulatory changes and the latest technology, it became this powerful tool for providing a comprehensive access point for all health care needs.”
Community health centers that serve low-income predominantly Black and Latino populations were not able to do the same, in part because they didn’t have sophisticated I.T. departments or sufficient cash reserves, but also because their patients did not have reliable enough broadband to participate. Widespread telemedicine checkups could be the key to reducing chronic diseases like obesity and diabetes in hard-hit communities, which would in turn reduce the risk of complications for those who catch the virus.
Affordable housing would also help prevent the spread of Covid-19 and other diseases, by reducing the crowding that many immigrant families are forced to live in. Less draconian immigration policies would help encourage more Latino workers to seek medical care when they are exposed to the virus or when they develop symptoms, which would in turn reduce their chances of passing the virus on. And stronger efforts to address vaccine hesitancy and to include minority communities in vaccine clinical trials would go a long way toward ensuring that any coming vaccine is accepted by the communities that stand to benefit the most from it.
Same Storm, Different Boats
Shortly after testing positive for coronavirus, President Trump was whisked away to Walter Reed National Military Medical Center, where he will receive a cocktail of cutting edge therapies and be closely monitored until he recovers.
In California, Maria Bastias and her students are keeping a decidedly cruder vigil against the virus. They are practicing the best ways to ask co-workers to wear masks — making careful note of the difference between “Why aren’t you wearing a mask?” and “I would appreciate it if you wore a mask.” They are obtaining, with Ms. Bastias’s help, a firmer grasp on their own rights and responsibilities. In one recent class, she gave them an oral true/false exam. When the newer students answered that the statement “I need health insurance to get tested” was true, Ms. Bastias pulled up the C.D.C. website and read it aloud to them, correcting the misperception.
They are also finding strength in community. “They talk about things that happen to them at work, and they help each other work through it,” Ms. Bastias said. One woman had a boss who insisted that mask-wearing would scare customers away. Another had a boss who offered his workers $50 to come into work after a few employees tested positive. Another wanted to know how to broach the subject of staggering lunch breaks so that the staff room didn’t get overcrowded. “They are asking the right questions, and thinking very smartly about public health,” Ms. Bastias told me. “It’s figuring out what to do next that’s the hard part.”
At a recent panel discussion hosted by the Congressional Hispanic Caucus, doctors and elected officials found themselves grappling with the same issue. Dr. Hotez from Baylor described reading the daily mortality reports from his office in Houston: Hispanic, the list read. Hispanic. Hispanic. Hispanic. Hispanic. Hispanic. Out of 19 deaths on the day in question, he said, 12 were Latino and several were younger than 65.
Lawmakers wanted to know what was being done to curb that imbalance. Who would ensure that community health centers, where a disproportionate number of Black and Latino patients go, receive an adequate supply of any coming vaccine, what could be done to improve access to vaccine clinical trials for those same constituents, and how would they combat vaccine hesitancy? Whether the existing racial health gap expanded or contracted, would depend in part on the answer to such questions. “We are all facing the same storm,” one caucus member said. “But we are not all in the same boat.”
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