Why Social Distance Demands Social Justice: Systemic Racism,COVID-19,and Health Security in the United States

The trajectories of infectious disease and racial injustice in the United States have been inextricably entwined for centuries. Smallpox, for example, is thought to have arrived with Europeans to the Americas in the 16th century bringing devastating effects to Indigenous populations. ¹ By the 17th century, numerous reports detail efforts by colonists to deliberately infect Native Americans, becoming one of the earliest documented histories of intentional biological warfare. Further links between infectious disease and racial injustice can be traced to the 1721 smallpox epidemic that ravaged Boston. During this time, the Puritan minister Cotton Mather advocated widely for inoculation, a procedure wherein dried pus from a smallpox patient was scraped into a healthy person's skin to build immunity. ² Mather had learned of inoculation from an enslaved man named Onesimus, who brought knowledge of the practice from Africa. After Zabdiel Boylston, a local physician, successfully tested the procedure on his own son and 2 enslaved household members, he and Mather launched a public inoculation campaign. However, they encountered pushback from White Bostonians, some of whom questioned the validity of African medical practices and speculated that inoculation was a ploy to kill slaveowners. Another physician, William Douglas, went so far as to satirically advocate for using inoculation as a weapon against Native Americans, proposing cash rewards for each death.^2,3 Ultimately, though, only 1% to 2% of inoculation recipients died of smallpox during the outbreak, compared to 15% of Bostonians who were infected naturally. ³

Over a century later in 1865, amid the aftermath of the Civil War, President Abraham Lincoln petitioned Congress to establish the Bureau of Refugees, Freedmen, and Abandoned Lands—more commonly known as the Freedmen's Bureau—to provide formerly enslaved persons with food, shelter, education, healthcare, and employment. During its 7-year tenure, the Bureau responded to a years-long smallpox epidemic that emerged in Washington, DC, and raged across the country, abetted by unsanitary wartime conditions, close cohabitation, and mass postwar migration across the South. ⁴ A major public health consequence of this effort was the perpetuation of medical bias and racial disparities in smallpox transmission. In the Carolinas alone, some 30,000 freedpeople died of smallpox over a 6-month period, while hundreds more Black and Native Americans across the South and West were infected each month. ⁴ Bureau leaders and federal officials inflicted considerable harm through their response to the crisis, promoting the falsehood that smallpox was a consequence of emancipation, intentionally underreporting cases among White patients to bolster this claim, and neglecting or altogether shuttering hospitals serving freedpeople.

This malfeasance (ie, systemic racism) has permeated political, medical, and public health responses to other infectious disease threats in the United States, with often deadly consequences for racial and ethnic populations and other socially at-risk groups. At times, it has manifested in the form of unethical and dangerous research, as exemplified by the Tuskegee Syphilis Study ⁵ and US-led Guatemala syphilis experiments ⁶ or the lesser-known but similarly unethical isoniazid trials conducted in a tuberculosis-afflicted Navajo community in Many Farms, Arizona. ⁷ In other cases, it has manifested as active neglect. During the early days of the HIV/AIDS pandemic in the United States, for example, the Reagan administration initially refused to acknowledge the existence of the disease, which disproportionately killed stigmatized gay, bisexual, and other men who have sex with men across the country, then slashed federal health and research budgets and blocked congressional appropriations for HIV/AIDS programming. Over time, stark racial disparities in HIV incidence have emerged: in 2018, for example, Black and Hispanic/Latino men who have sex with men comprise 26% and 22% of new infections in the United States, respectively. ⁸ Furthermore, between 2014 and 2018, Black women reported new HIV infections at a rate 13 times higher than White women and 4 times higher than Latina women. Similar neglect manifests in the chronic underfunding of the Indian Health Service, the federal agency responsible for healthcare among members of federally recognized tribes—a responsibility forged through dozens of legal treaties in exchange for Indigenous lands that now comprise the United States. ⁹ Alarmingly, this malfeasance has also manifested across nearly every domain of public health in the United States, from maternal health outcomes and climate change to police brutality and food insecurity.

Over time, the resonance between the fights for health equity and civil rights in the United States has grown increasingly evident. At a Chicago press conference in March 1966, just over a century after the birth of the short-lived Freedmen's Bureau, Dr. Martin Luther King, Jr. lambasted the American Medical Association for providing inferior medical care to Black Americans, declaring,

We are concerned about the constant use of federal funds to support this most notorious expression of segregation. Of all the forms of inequality, injustice in health is the most shocking and the most inhuman because it often results in physical death. ¹⁰

History, it seems, has an unfortunate proclivity for repetition, and Dr. King's denouncement proved prophetic: in March 2020, 54 years after that press conference, the World Health Organization declared COVID-19 a pandemic. ¹¹ Just months later, 2 events were indelibly seared into America's memory: the murder of George Floyd by a Minneapolis police officer on May 25th, followed 3 days later by the announcement that the United States had surpassed 100,000 deaths due to COVID-19, with Black, Latinx and Native Americans in the United States by far the most impacted. Meanwhile, hate crimes broke out against Asian Americans, who racist terrorists ignorantly and falsely blamed for introducing the virus in the United States. The phrase “I can't breathe” suddenly became shorthand for the unreconciled, systemic racist forces underpinning police brutality, hate crimes, and a respiratory pandemic.

At the time of this writing, the United States had reported over 33 million confirmed COVID-19 cases and exceeded 594,000 deaths. ¹² Nationally, Pacific Islanders, Latino, Black, and Native Americans report COVID-19-associated mortality rates that are double or more that of their White and Asian counterparts, adjusted for age. ¹³ Alarmingly, these inequities were also mirrored in the early days of the United States' fragmented vaccine rollout and subsequent vaccine uptake: between December 2020 and January 2021, the US Centers for Disease Control and Prevention reported that among 6.7 million vaccine recipients in the United States who disclosed their race, 60.4% were White, while 11.5% were Hispanic or Latino, 6% were Asian, 5.4% were Black, 2% were Native American, and 0.3% were Native Hawaiian or Pacific Islander. ¹⁴ As the nation's vaccination efforts have progressed, these disparities have also evolved. As of April 2021, for example, 32% of Native Americans had received at least 1 dose of vaccine, compared to 19% of White people, 16% of Asian people, 12% of Black people, and 9% of Hispanic people in the United States, a feat attributed largely to Tribal leadership and vaccine allocation strategies that closely align with Native community priorities. ¹⁵ However, unresolved structural inequities continue to impede vaccine access and uptake among many other populations of color. ¹⁶

Health security—a field dedicated to preventing, detecting, and responding to a range of naturally occurring, accidental, and deliberate public health emergencies—has much to learn from its past, and the ongoing pandemic presents an opportunity to name and rectify some of these transgressions. As the world continues to combat COVID-19, and as health security becomes an increasingly prominent paradigm in the United States' public health and national security enterprises, the need to examine and dismantle racist health security practices grows increasingly urgent. Moreover, the pandemic has underscored that populations are only as safe from infectious disease threats as their most oppressed members, whose trust—the cornerstone of a functional health system—must be earned through equitable health security programming, policymaking, and practice.

This supplement of Health Security—produced jointly by the Johns Hopkins Bloomberg School of Public Health's Center for Health Security, Center for Health Equity, Center for American Indian Health, and Center for Public Health and Human Rights—aims to shed light on how systemic racism contributes to inequities in morbidity and mortality, curtails access to lifesaving preventive and curative measures, and undermines the health and agency of hard-hit populations of color as the United States responds to COVID-19. Featured in the supplement, for example, are analyses from Irwin et al ¹⁷ , Kranjac and Kranjac, ¹⁸ and Dickinson et al, ¹⁹ which examine how structural factors and socioeconomic vulnerabilities shape COVID-19 response systems and associated health outcomes in select US counties and states. A letter from Chambers ²⁰ responding to a previously published article on mass vaccination operations in the United States underscores the importance of incorporating racial equity considerations into routine planning and preparedness efforts. Meanwhile, Blackburn et al ²¹ and Ross et al ²² consider how xenophobic rhetoric and policies create unique health security challenges for undocumented individuals and immigrants across the country. Additionally, Saltzman et al ²³ and Rowell-Cunsolo et al ²⁴ apply a racial equity lens to mental health disparities in the time of COVID-19 and access to harm reduction treatment, respectively, while Galiatsatos et al ²⁵ present a before-and-after snapshot of critical care admissions among racial/ethnic populations. Pimentel Walker et al ²⁶ and Feinberg et al ²⁷ examine the roles of culturally competent risk communication in addressing COVID-19 disparities among refugee populations, while Jones et al ²⁸ and Mahayosnand et al ²⁹ discuss strategies for strengthening academic institutional responses, both to COVID-19 and the associated surge in violence against racial and ethnic populations in the United States. Finally, Tanana et al ³⁰ describe how the pandemic has exacerbated longstanding water access disparities among Tribal communities across Indian country.

These papers illustrate various ways in which both COVID-19 and the ensuing response at national, state, and local levels have exacerbated racial inequities and transformed public experiences of care-seeking, advocacy, and wellbeing in the United States. There is an oft-quoted adage in public health: “what gets measured gets done.” The evidence has spoken. Now, the health security community must listen, learn, and most importantly, act.