But the fact the pandemic has coincided with a growing movement demanding racial justice presents a unique opportunity for meaningful reform. Only by understanding and confronting this entangled web of racism and public health can we actually solve a problem that has been centuries in the making.
Rethinking our health-care system during and after the current pandemic requires no less radical a restructuring of society than that was required during 19th-century Reconstruction. The challenges of that era, including pandemic disease, offer guidance today, even when efforts failed, as we work to address historical inequalities and begin to confront injustice and enduring racism.
Following the end of the Civil War, local and state officials grappled with how to best facilitate the transition from slavery to freedom. The redistribution of land represented the best chance for formerly enslaved people “to best take care of ourselves,” explained a group of Black ministers in Georgia in 1865. It never came to fruition. After just a few months of land distribution in several states, President Andrew Johnson gave those lands taken from former Confederate enslaver planters back to them. The promise of economic freedom for African Americans was dashed in the refusal of federal will to counter white supremacy.
The shorthand “Forty Acres and a Mule” persisted, however, as a recognition the federal government had a responsibility to provide economic resources to build Black communities after the centuries of plundered labor they and their ancestors had already provided to the nation. But this idea provoked a swift backlash from largely Southern White leaders and the federal government, accompanied by a reign of terror that shaped the conditions that exacerbated the existing health gap between Black and White people.
In the absence of land reform, the newly freed people were forced to depend on help from the federal Freedmen’s Bureau for food, clothing and shelter. When the bureau was shut down in the 1870s, Black people had few resources to care for themselves. Left landless and impoverished, what ensued was what historian Jim Downs calls “the greatest biological catastrophe of the 19th century,” as epidemics of smallpox, cholera, yellow fever and other diseases ripped their way through starving and ill-housed people, leaving a million dead or injured.
White observers blamed excessive deaths from epidemic diseases on so-called biological vulnerabilities inherent in Black people’s bodies, which could only be mediated by re-enslavement at worst, and denial of access to work at best, to protect a “weaker” race. But in reality, these deaths were the result of economic policies. The creation of a class of Black yeoman farmers and shop owners in 1865, had it occurred, might have at least put a dent in the rise of Jim Crow, or transformed the poverty that later set in motion the migrations of Black people out of the South into crowded cities. Instead, the highly visible health and economic inequalities of the South, in turn, moved north and westward.
So the problem worsened. Limiting African Americans’ access to land ownership and economic opportunity everywhere exacerbated the conditions that spread epidemic disease: spatial segregation, poverty and a health-care system that all but ignored them. In the early 20th century public health practices focused on keeping Black and White people separated, refusing to address squalid housing conditions, restricting access to hospitals and routinely referring to Black people as pests and sources of contagion, which affected their access to employment in many sectors.
As a consequence, public health officials, epidemiologists, social scientists, physicians and the media since the early 1900s have continually rediscovered the “health inequalities,” “health gaps” or “health disparities” that continue to separate the life chances of Whites and people of color. Explanations for this gap still pivot among assertions of inherent genetic differences or underlying conditions and co-morbidities — echoing how observers interpreted the spread of epidemic disease in the aftermath of the Civil War.
Racist policies have continually deepened this disparity, ensuring the enduring health consequences of poverty: overcrowded and substandard housing, the inability to transfer wealth between generations, poor education and medical care, subprime mortgages and discriminatory loan practices, redlining of available housing, food deserts, environment pollution and jobs that make vulnerability to infectious diseases and stress related illnesses inevitable. Racism, not race, makes the difference.
Covid-19 has once again made this clear the connection between poverty and public health. Black and Latinx people are more likely to contract and die from the virus. Why? Because they disproportionately work in low-paying front-line jobs. Others cannot practice social distancing in cramped apartments and multigenerational homes. These factors are about economic inequality and have existed for more than a century with little improvement as the structures of racism have barely been changed.
Confronting covid-19 and addressing racism in our public health system today requires prioritizing and guaranteeing economic rights and full citizenship for Black Americans. Reforming public health systems must be part of the solution to racial injustice. Prioritizing vaccine availability at low or no cost to these hard-hit communities, tailoring health education messages, working in coalitions on broader issues and making sure our governments respond fairly are all essential first steps. Restructuring our health system will not only improve conditions for people of color. It will benefit all Americans.