COVID Health Disparities Don't Mean What You Think

Epidemiology is the science that proves shit flows downhill. Stated a little less baldly, one of the most important insights from epidemiology is that disease and premature death are often concentrated in low income, minority and other vulnerable populations. This insight leads to the single most important strategy for improving population health, which is to focus on the health of those vulnerable populations. Applying this strategy to a pandemic we find that to save the most lives we must ensure that vulnerable people, most of all, understand the risks and have the tools to protect themselves. Sadly, because of structural inequities, public health isn’t as good at protecting the vulnerable as we need to be. We know this and are constantly trying to improve. This is reflected in how we communicate about our mission. For example, on top of health equity and social justice components baked into national accreditation, our leading local public health association (NACCHO) embraces and promotes five “Compass” principles for ensuring health equity during the pandemic.  

Another reflection of public health’s concern about inequality is how we tell the story of the pandemic. In particular, when public health talks about COVID mortality we emphasize higher rates of death among populations of color. During the first month of the pandemic, April 2020, COVID mortality in the African-American community was nearly three times higher than in the White community. Public health held itself accountable for this disparity. One public health official I spoke with said the disparity was because the public health response was “dripping with racism”. I think the word “dripping” is over the top, but that attitude illustrates how seriously many took those deaths.

As I think about this, though, I wonder if this telling of the story of COVID stops us from really understanding what happened—both the bad and the good. I think taking a longer look at COVID health disparities can help us see both why we were so ineffective, and also what the possibilities are for the future.  

From the earliest days of the pandemic, a growing number of researchers found that COVID was starting to gain traction and take off, not in the African-American community, but in mostly White, mostly rural and Republican areas. The Brookings institution began reporting on this in September 2020, and this finding was tested and retested by others like Pew Research. It was one of the most robust epidemiological findings of the pandemic.

COVID deaths started increasing in red areas for three interconnected reasons. The first was that then President Trump’s advisors encouraged his predilection to frame COVID safety measures as an attack on freedom. The second was local politicians in red areas saw an opportunity to align themselves with Trump’s base and took up the cause. The third reason was the rapid emergence of a political machine built to dismantle public health protections. In Michigan, for example, political entrepreneurs like Matt and Meshawn Maddock, Ron Armstrong and David Kalman sought funding from GOP PACs to create Stand Up, Unlock Michigan and other anti-public health organizations. Because of their actions, these people literally spread COVID to others. Their propaganda meant most people living in red areas did not try to protect themselves from COVID by staying home or wearing masks, and only half of them got vaccinated. To this day rates of COVID mortality remain much higher in red areas than in blue.

This point has been made many times already. What I want to do here is contrast this fact with what happened in the African-American community. While rates of COVID mortality in red areas rose, mortality declined in the African-American community. By the end of 2020 when the second wave hit, COVID mortality in the African-American community was less than a third of what it was in the spring of that year. Meanwhile mortality in red communities had exploded to more than double the African-American rate. This fact dramatically demonstrates the importance of good public leadership in a crisis and the deadly consequences that arise when leadership fails.

The reason COVID declined in the African-American community was because of the actions of the community and its leadership. After the horrors of the first wave of COVID the African-American community understood it needed to organize itself to keep people safe. All kinds of people—community organizers, clergy, politicians—put themselves forward to fight COVID. In Detroit, organizations like the Community Health Corps focused on housing and clean water for people sheltering, the Detroit Association of Black Organizations launched the Choose Healthy Life COVID testing and education campaign, and churches like New Mount Moriah aggressively pushed vaccination. In Flint the Greater Flint Health Coalition leveraged neighborhood organizations to fight vaccine misinformation.

I was working in rural central Michigan. I don’t know the names of many of the people doing grass roots organizing in the African-American community. But I do know the names of some public health leaders who supported the community effort and I want to honor them here: Vernice Davis Anthony who came out of retirement, physician and scholar Dr. Abdul El-Sayed, Dr. Joneigh Khaldun who worked from her perch in state government, and Dr. Kanzoni Asabigi who fought for a better response from Detroit government.

It is true that in red and rural areas there were many who understood what was happening and community organizations did all they could to help, just like they did in blue areas. But local politicians who may have wanted to help often felt it was too risky and didn't speak up for them. As one elected leader said to me, “I really want to help you with this but I just don’t know what I can do. My party seems to have lost its mind.” To be clear I am not saying people lost their minds. I know from firsthand experience that everyone was doing what they believed to be right. What I mean is that the consensus that public health was trying “to take our freedom” was so forcefully policed that political leaders feared they would pay too high a price for telling the truth.

It is also true that vaccine hesitancy and misinformation remain a problem in the African-American community. But in contrast to red areas, local leadership was united in working to fight COVID. The result is that today attitudes toward COVID safety and vaccination rates in the African-American community as a whole are similar to White or general community attitudes as a whole. From a deep deficit the African-American community climbed to a better—if not perfect—place. 

In these times when so many things--gun violence, drug overdoses, child health, life expectancy--are moving in the wrong direction, let us lift up this powerful example of how people did the right thing and how they saved lives because of it. 

NOTES: Sources for this article are included in the "Bibliography and Citations" linked in the right-hand column of this website, particularly the data compiled by the WK Kellogg Foundation and Pew Research. African-American COVID mortality in Michigan comes from the tables in the Data and Modeling Updates found at michigan.gov/coronavirus/stats.