The Twin Cities once drew black families fleeing racism in the Jim Crow South, and with their combination of progressive policies and prosperity, regularly rank among the best places to live in America.
Taxes, for decades, have been redistributed from wealthy suburbs to poorer communities to combat inequality - an effort bolstered in recent years by raising state income taxes on the rich. The result: more money for schools, affordable housing and social services in lower-income neighborhoods.
But the prosperity fueled by the region's Fortune 500 companies and progressive policies has not translated into economic equality. Instead, the wealth gap between Minneapolis's largely white population and the city's black residents has deepened, producing some of the nation's widest racial disparities in income, employment and homeownership.
Such disappointments offer cautionary notes for those promising change in Minneapolis and other areas of the country in the aftermath of protests against police brutality and systemic racism - and raise questions about how far the movement to shift funding from police departments to other services can go toward delivering racial justice.
The shortcomings have given rise to an urgent debate about where Minneapolis went wrong and what measures would bring better results. Economists, lawyers and civil rights advocates in the Twin Cities say progressive tax policies could not make up for other aspects of structural racism, such as access to credit or jobs. Some say investments in affordable housing in low-income neighborhoods deepened segregation and poverty. Others argue for better enforcement of federal laws to combat discrimination in lending, employment and housing.
"Minneapolis seems to have been blindsided by these realities. They relish the fact that they are seen as this bastion of progressivism," said Marvin Owens Jr., senior director of economic programs at the NAACP, which released a report in December highlighting the Twin Cities' growing racial economic disparities. "The warning was if we don't address these issues, this was a tinder box that would explode."
The typical black family in the Twin Cities earned $39,851 in 2017, lower than the median income for African Americans nationally and less than half as much as the typical white family income of $82,371, which is much higher than white households nationally, according to the NAACP report. A quarter of black households lived in poverty, five times the poverty rate for white households.
Those enduring disparities, which erupted onto the national stage after George Floyd was killed in the custody of Minneapolis police last month, highlight the flawed premise, touted by President Trump and other Republicans, that economic prosperity is a remedy for racial inequality.
Having the "strongest economy in the world" is "the greatest thing that can happen for race relations, for the African American community," Trump said amid protests after a video emerged of an officer kneeling on Floyd's neck for more than eight minutes.
But the outcome for black residents in Minneapolis and St. Paul also undercuts the liberal argument that spending on progressive policies can create systemic change.
Civil rights and community leaders in the Twin Cities say racial equity cannot be achieved without gaining a greater understanding of how the country's racist foundations continue to affect the criminal justice, education and health systems. Too often, they say, progressive programs focus on "fixing" something perceived to be wrong with the black community rather than fundamentally reshaping underlying inequities in society.
"In order for Minneapolis and the region to actually change the trajectory for people of color, whites are going to have to be uncomfortable," said Gary Cunningham, chief executive of Prosperity Now, a national nonprofit focused on racial wealth equity. "They are going to have to have conversations about how their privilege maintains the status quo and how resources and wealth are distributed in their communities."
Cunningham, who grew up in Minneapolis and served as the city's associate schools superintendent and deputy civil rights director, said that for too long, there has been a "huge disconnect between the progressive policies that are put in place and the outcomes that they get."
"Good intentions don't change the conditions for young boys and girls growing up in north Minneapolis," he said.
Black residents, who account for less than a fifth of the Twin Cities' population, are worse off today by some measures than they were 20 and 30 years ago, even as the fortunes of their white counterparts held steady or improved, according to census data.
Nationally, the economic gulf between black and white Americans has changed little since a federal commission in 1968 identified "white racism" leading to "pervasive discrimination in employment, education and housing" as the cause of uprisings in African American communities.
Black residents in the Twin Cities are younger and more likely to be immigrants than white residents, but these differences still do not fully explain the racial economic disparities, according to a 2016 analysis by the Metropolitan Council, a regional government agency. Such disparities existed before the influx of immigrants from Somalia, Ethiopia and Liberia, leading the agency and other researchers to conclude that "systemic discrimination is part of the equation."
Minnesota's progressive reputation was cemented nearly five decades ago when a Time magazine cover featured then-Gov. Wendell Anderson on a fishing trip, with a headline touting "The Good Life."
Anderson, a Democrat, had worked with the Republican-controlled legislature to pass laws known as the "Minnesota Miracle." Among the key provisions: a redistributive tax policy introduced in 1971 that required wealthy communities in the Twin Cities region to share their commercial property tax revenue with the poorest areas. Income and sales tax revenue from rich suburbs across the state also was shared with less-affluent cities and rural communities to fund schools, police and housing.
"The whole idea was we are going to invest in the future so everyone does better," Cunningham said.
It would be the beginning of a suite of policies that over subsequent decades increased investments in housing, schools and small businesses in disadvantaged communities.
But the main beneficiaries of many of the policies were working-class whites, said Samuel Myers Jr., an economist at the University of Minnesota whose research on what he calls "the Minnesota paradox" focuses on the problem with race-neutral remedies to racial inequality.
In the 1970s, following civil unrest over systemic racism and a lawsuit on school segregation, the Twin Cities embarked on a new set of reforms, building subsidized housing for low-income families throughout its wealthier white communities, said Myron Orfield, a law professor at the University of Minnesota who leads the Institute on Metropolitan Opportunity.
But political and philanthropic leaders abandoned the region's well-known integration policies in the 1990s in favor of directing additional tax dollars to finance social services, housing and schools in low-income communities of color, he said.
"There's nothing wrong with gigantic redistributive programs, but they don't overcome the problems that segregation causes," said Orfield, a former civil rights attorney. "The structures of people's lives did not change - they didn't have better jobs, they didn't live in safer neighborhoods, they weren't more likely to graduate from high school. If you allow segregation to get worse, inequality is going to get worse."
Even more state aid poured into poor communities in 2013, when then-Gov. Mark Dayton raised taxes on the wealthiest Minnesotans. The Democrat and Target fortune heir had campaigned to "Tax the Rich!" - saying everyone should pay their "fair share" to keep society "functional." The income tax rate, already fairly high for top income earners compared with other states, increased from 7.85 percent to 9.85 percent for individuals making more than $150,000.
The Minnesota Center for Fiscal Excellence, a business-backed think tank, called it the country's "most progressive" state income tax.
And yet today, the region lands near the bottom nationally when it comes to racial economic disparities, especially homeownership.
Despite a slew of programs to help first-time home buyers, only a quarter of black residents in the Twin Cities own their homes, compared with more than three-quarters of white residents - and much lower than the national black homeownership rate of 42 percent.
Orfield said one of the reasons the programs have not significantly boosted black homeownership is that they encourage prospective home buyers to invest in segregated, low-income neighborhoods where property values have depreciated over time.
Others say the state's homeownership assistance programs failed to close the racial gap because many black families lack the financial assets to participate.
The average house in north Minneapolis goes on the market for about $250,000, whereas the average black resident qualifies for a home loan of about $180,000, according to Steven Belton, president and chief executive of the Urban League Twin Cities. Government assistance typically covers only half the gap, which leaves prospective home buyers having to rely on their personal network or net worth to make up the difference, he said.
"For white people, the homeownership program is working really well," Belton said. "The policy doesn't really address the problem: If we know the disparity is in black homeownership, the dollars should be targeted toward African Americans."
Black leaders say programs targeting equity tend to focus on neighborhoods - not race.
"A state like ours is so hesitant to assign a race lens to our incentives that we too often defer to geography," said Tawanna Black, founder and chief executive of the Center for Economic Inclusion. "Attaching Zip codes as qualifiers is not enough. Part of the challenge is this isn't a region or state that has gone above and beyond to create policies to drive racially equitable results."
In addition to investing in homeownership programs, Minnesota has created financial incentives for the construction of affordable housing that critics say end up exacerbating segregation. Each year, tens of millions in local and federal subsidies are directed toward poor black, Latino and Southeast Asian neighborhoods in the Twin Cities, Orfield said.
Affordable housing developments are more likely to be approved in poor, minority neighborhoods where they qualify for more government subsidies, enabling developers to turn bigger profits, Orfield said. "The city and big foundations put extra money on the table," he said. "If you build in a white neighborhood, you have to go to 15, 20 public meetings to get the white neighbors not to have a stroke."
On the flip side, Orfield's research also shows that developers have taken advantage of public subsidies to rehabilitate historic structures in gentrifying Minneapolis neighborhoods and turn them into artists lofts with yoga studios, rooftop fire pits and skyline views - accommodations that draw overwhelmingly white tenants. These developments represent the highest end of "affordable housing" in the Twin Cities - too expensive for most low-income residents to afford with government housing vouchers, Orfield said.
Minneapolis drew national attention for its 2018 move to eliminate single-family zoning, billed as another progressive policy to remedy racial disparities. But Orfield said simply building duplexes and triplexes is unlikely to promote integration because the new construction may not be affordable. Some of the densest neighborhoods in the city are the whitest, he said.
Not everyone agrees that racial integration is the solution to inequality.
Myers, the University of Minnesota economist, said racial economic disparities are a direct result of government-sanctioned redlining and urban planning that limited or wiped out black wealth, and also a result discrimination in so many facets of American life, including employment and lending. Stricter enforcement of federal civil rights laws should be prioritized, including funding for such oversight, he said - and discrimination should be criminalized.
"The policies advanced by progressives in Minnesota have focused on credit repair, homeownership training and other factors that assume that the problem of racial disparities in homeownership are due to black deficiencies," Myers said. "The liberal and progressive policies tend to work to help improve the capacities of minorities without changing the underlying structures that are in place that created the disparities to begin with."
He said it's hard for progressive Minnesotans to accept that ongoing discrimination is a cause of persistent racial disparities. "The main thing that explains the Minnesota paradox is the fact that, unlike Mississippi or Alabama, where there are overt racists, racism in Minnesota is never open or explicit."
Now protesters across the country are pushing for another progressive policy - defunding the police, a step that's gaining traction in Minneapolis and other cities.
Most members of Minneapolis's Democratic-led city council were quick to signal that they intend to dismantle the city's police department as other cities such as Los Angeles and New York announced cuts to the police budget so money could be redirected to black communities.
Some activists are skeptical that dismantling the Minneapolis police would channel funds into improving the economic prospects of black residents. After all, the Minnesota legislature failed to do so when the state saw a $1 billion revenue surplus in 2016, said the Urban League's Belton.
The legislature appropriated $35 million to address racial inequities, but lawmakers decided that "equity included every community and their mother," Belton said.
Every marginalized group got in line for the money, Belton said. The Urban League ended up splitting $4.2 million with four other nonprofit organizations, he said, a circumstance that yielded too little to make a significant difference.
"If you look at the numbers overall, there was zero impact," Belton said. "We pat ourselves on the back for being progressive in a state that extols the virtues of diversity, equity and inclusion, but we have no reason to be self-congratulatory.
"Minnesota works for white people - at the expense of black people."
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When pathologist Amy Rapkiewicz began the grim process of opening up the coronavirus dead to learn how their bodies went awry, she found damage to the lungs, kidneys and liver consistent with what doctors had reported for months.
But something was off.
Rapkiewicz, who directs autopsies at NYU Langone Health, noticed that some organs had far too many of a special type of cell rarely found in those places. She had never seen that before, yet it seemed vaguely familiar. She raced to her history books and - in a eureka moment - found a reference to a 1960's report on a patient with dengue fever.
In dengue, a mosquito-borne tropical disease, she learned, the virus appeared to destroy these cells, which produce platelets, leading to uncontrolled bleeding. The novel coronavirus seemed to amplify their effect, causing dangerous clotting.
She was struck by the parallels: "Covid-19 and dengue sound really different, but the cells that are involved are similar."
Autopsies have long been a source of breakthroughs in understanding new diseases, from HIV/AIDS and Ebola, to Lassa fever - and the medical community is counting on them to do the same for covid-19, the disease caused by coronavirus. With a vaccine likely many months away, autopsies are becoming a critical source of information for research into possible treatments.
When the pandemic hit the United States in late March, many hospital systems were too overwhelmed trying to save lives to spend too much time delving into the secrets of the dead. But by late May and June, the first large batch of reports - from patients who died at a half-dozen different institutions - were published in quick succession. The investigations have confirmed some of our early hunches of the disease, refuted others - and opened up new mysteries about the novel pathogen that has killed more than 500,000 people worldwide.
Among the most important findings, consistent across several studies, is confirmation the virus appears to attack the lungs the most ferociously. They also found the pathogen in parts of the brain, kidneys, liver, gastrointestinal tract, spleen and in the endothelial cells that line blood vessels, as some had previously suspected. Researchers also found widespread clotting in many organs.
But the brain and heart yielded surprises.
"It's about what we are (BEG ITAL)not(END ITAL) seeing," said Mary Fowkes, an associate professor of pathology who is part of a team at Mount Sinai Health that has performed autopsies on 67 covid-19 patients.
Given widespread reports about neurological symptoms related to the coronavirus, Fowkes said, she expected to find virus or inflammation - or both - in the brain. But there was very little. When it comes to the heart, many physicians warned for months about a cardiac complication they suspected was myocarditis, an inflammation or hardening of the heart muscle walls - but autopsy investigators were stunned that they could find no evidence of the condition.
Another unexpected finding, pathologists said, is that oxygen deprivation of the brain and the formation of blood clots may start early in the disease process. That could have major implications for how people with covid-19 are treated at home, even if they never need to be hospitalized.
The early findings come as new U.S. infections have overtaken even the catastrophic days of April, amid what some critics say is a premature easing of social distancing restrictions in some states mainly in the South and West. A new modeling study has estimated that about 22% of the population - or 1.7 billion people worldwide, including 72 million in the United States - may be vulnerable to severe illness if infected with covid-19. According to the analysis published this month in the Lancet Global Health, about 349 million, or 4% of those people would require hospitalization - underscoring the stakes as autopsy investigators continue their hunt for clues.
At their best, autopsies can reconstruct the natural course of the disease but the process for a new and highly infectious-disease is tedious and requires meticulous work. To protect pathologists and avoid sending virus into the air, they must use special tools to harvest organs and then dunk them in a disinfecting solution for several weeks before they are studied. They must then section each organ and collect small bits of tissue for study under different types of microscopes.
One of the first American investigations to be made public, on April 10, was out of New Orleans. The patient was a 44-year-old male who had been treated at LSU Health. Richard Vander Heide remembers cutting the lung and discovering what was likely hundreds or thousands of microclots.
"I will never forget the day," recalled Vander Heide, who has been performing autopsies since 1994. "I said to the resident, 'This is very unusual.' I had never seen something like this."
But as he moved onto the next patient and the next, Vander Heide saw the same pattern. He was so alarmed, he said, that he shared the paper online before submitting it to a journal so the information could be used immediately by doctors. The findings caused a stir at many hospitals and influenced some doctors to start giving blood thinners to all covid-19 patients. It is now common practice. The final, peer-reviewed version involving 10 patients was subsequently published in the Lancet in May.
Other lung autopsies - including those described in papers from Italy of 38 patients, a Mount Sinai Health study on 25 patients, a collaboration between Harvard Medical School and German researchers on seven and an NYU Langone Health on seven - have reported similar findings of clotting.
Most recently, a study out this month in the Lancet's eClinicalMedicine, found abnormal clotting in the heart, kidney, liver, as well as the lungs of seven patients, leading the authors to suggest this may be a major cause of the multiple-organ failure in covid-19 patients.
The next organ studied up close was the heart. One of the most frightening early reports about the coronavirus from China was that a significant percent of hospitalized patients - up to 20% to 30% - appeared to have a heart issue known as myocarditis that could lead to sudden death. It involves the thickening of the muscle of the heart so that it can no longer pump efficiently.
Classic myocarditis is typically easy to identify in autopsies, pathologists say. The condition occurs when the body perceives the tissue to be foreign and attacks it. In that situation, there would be large dead zones in the heart, and the muscle cells known as myocytes would be surrounded by infection-fighting cells known as lymphocytes. But in the autopsy samples taken so far the dead myocytes were not surrounded by lymphocytes - leaving researchers scratching their heads.
Fowkes from Mount Sinai and her colleague, Clare Bryce, whose work on 25 hearts has been published online but not yet peer reviewed, said they saw some "very mild" inflammation of the surface of the heart but nothing that looked like myocarditis.
NYU Langone's Rapkiewicz, who studied seven hearts, was struck by the abundance of a rare cell called megakaryocytes in the heart. Megakaryocytes, which produce platelets that control clotting, typically exist only in the bone marrow and lungs. When she went back to the lung samples from the coronavirus patients, she discovered those cells were too plentiful there, too.
"I could not remember a case before where we saw that," she said. "It was remarkable they were in the heart."
Vander Heide from LSU, who reported preliminary findings on 10 patients in April and has a more in-depth paper with more case studies on the topic under review at a journal, explained that "when you look at a covid heart, you don't see what you'd expect."
He said a couple of patients he performed autopsies on had gone into cardiac arrest in the hospital, but when he examined them, the primary damage was in the lungs - not the heart.
Of all the novel coronaviruses's manifestations, its impact on the brain has been among the most vexing. Patients have reported a host of neurological impairments including reduced ability to smell or taste, altered mental status, stroke, seizures - even delirium.
An early study from China, published in the BMJ, formerly the British Medical Journal, in March, found 22% of the 113 patients had experienced neurological issues ranging from excessive sleepiness to coma - conditions typically grouped together as disorders of consciousness. In June, researchers in France reported that 84% of patients in intensive care had neurological issues, and a third were confused or disoriented at discharge. Also this month, those in the United Kingdom found that 57 of 125 coronavirus patients with a new neurological or psychiatric diagnosis had had a stroke due to a blood clot in the brain, and 39 had an altered mental state.
Based on such data and anecdotal reports, Isaac Solomon, a neuropathologist at Brigham and Women's Hospital in Boston, set out to systematically investigate where the virus might be embedding itself in the brain. He conducted autopsies of 18 consecutive deaths, taking slices of key areas: the cerebral cortex (the gray matter responsible for information processing), thalamus (modulates sensory inputs), basal ganglia (responsible for motor control) and others. Each was divided into a three-dimensional grid. Ten sections were taken from each and studied.
He found snippets of virus in only some areas, and it was unclear whether they were dead remnants, or active virus when the patient died. There were only small pockets of inflammation. But there were large swaths of damage due to oxygen deprivation. Whether the deceased were longtime intensive care patients, or people who died suddenly, Solomon said, the pattern was eerily similar.
"We were very surprised," he said.
When the brain does not get enough oxygen, individual neurons die and that death is permanent. To a certain extent, people's brains can compensate but at some point, the damage is so extensive that different functions start to degrade.
On a practical level, Solomon said that if the virus is not getting into the brain in large amounts, that helps with drug development because treatment becomes trickier when it is pervasive, for instance, in some patients with West Nile or HIV. Another takeaway is that the findings underscore the importance of getting people on supplementary oxygen quickly to prevent irreversible damage.
Solomon, whose work was published as a June 12 letter in the New England Journal of Medicine, said the findings suggest the damage had been happening over a longer period of time, which make him wonder about the virus's effect on people who are less ill. "The big lingering question is what happens to people who survive covid," he said. "Is there a lingering effect on the brain?"
The team from Mount Sinai Health, which took tissue findings from 20 brains, was also perplexed not to find a lot of virus or inflammation. However, the group noted in a paper that the widespread presence of tiny clots was "striking."
"If you have one blood clot in the brain, we see that all the time. But what we're seeing is some patients are having multiple strokes in blood vessels that are in two or even three different territories," Fowkes said.
Rapkiewicz said it is too early to know whether the newest batch of autopsy findings can be translated into treatment changes, but the information has opened new avenues to explore. One of her first calls after noticing the unusual platelet-producing cells was to Jeffrey Berger, a cardiac specialist at NYU who runs a National Institutes of Health-funded lab that focuses on platelets.
Berger said the autopsies suggest anti-platelet medications, in addition to blood thinners, may be helpful to stem the effects of covid-19. He has pivoted a major clinical trial looking at optimal doses of anticoagulants to look at that question as well.
"It's only one piece of a very big puzzle, and we have a lot more to learn," he said. "But if we can prevent significant complications and if more patients can survive the infection, that changes everything."