Portside

“History never really says goodbye. History says, see you later.”—Eduardo Galeano1

COVID-19 starkly reveals how structural injustice cuts short the lives of people subjected to systemic racism and economic deprivation.2–4   It is not, however, the only crisis at hand. 

Since the May 25, 2020, murder of George Floyd, a 46-year-old African American man, by the Minneapolis, Minnesota, police, protests have coursed through cities and towns across the United States, denouncing structural racism and police violence,5–7 fueled, too, by COVID-19’s disproportionate toll on US populations of color.2–4  In a context in which US police kill upwards of 1000 people per year—nearly three per day, disproportionately Black Americans, and vastly more than in any other wealthy country5,6—the last straw was Floyd’s horrific murder.7  Floyd died because he could not breathe, because police officer Derek Chauvin knelt on his neck for an agonizing 8 minutes and 46 seconds—in open view, as videoed for all to see, while three other police standing nearby failed to intervene. 

The current upsurge of protest builds on the leadership of so many groups, perhaps most prominently Black Lives Matter, founded in 2013 by three radical Black women organizers—Alicia Garza, Patrisse Cullors, and Opal Tometi—in response to the acquittal of Trayvon Martin’s vigilante murderer, George Zimmerman, and which rapidly grew in the wake of Michael Brown’s killing by Ferguson, Missouri, police officer Darren Wilson in 2014.8  Also feeding these protests is the post-2016 rise in hate crimes,9 coupled with overt expressions of racism, both by word and by policies, at the highest levels of the US government.2,10

COVID-19: TERRIBLE INEQUITIES, TERRIBLE DATA

The inequitable context of the COVID-19 pandemic in the United States is not a mystery.2,11  In 2019, 53 million US workers, including 44% of all workers aged 18 to 64 years, were employed in low-wage jobs, earning an median hourly wage of $10.22, yielding median annual earnings of only $17 950.12  Meanwhile, a 2017 analysis reported that“[t]he three wealthiest people in the United States—Bill Gates, Jeff Bezos, and Warren Buffett—now own more wealth than the entire bottom half of the American population combined, ”while 20% of US households, and 30% of Black and 27% of Latinx households, have “zero or negative net worth.”11(p4) 

The stunning COVID-19 inequities—which are inequities, because health inequities comprise differences in health status across social groups that are unjust, avoidable, and, in principle, preventable13—are, thus, no surprise.  Reflecting the impacts of structural racism, including the origins of the United States as a settler–colonial nation and slave republic, US Black and American Indian populations have long lived sicker and shorter lives than the US White non-Hispanic population.3,14,15  Despite serious problems affecting the accuracy of COVID-19 data,16 the pattern repeats with COVID-19.2–4,17–23  Higher burdens of COVID-19 cases and deaths, especially among working-age adults—and in surges of death overall—are documented among communities with high proportions of people of color, high poverty, crowded housing, and high levels of racialized economic segregation,4,17–23 even as their reduced access to COVID-19 testing (used also to classify COVID-19 deaths) would mitigate against such findings.2,16  This high excess toll at younger ages, moreover, cannot be discerned from counts of deaths, or crude or age-standardized mortality rates, as typically reported by health department and other COVID-19 data dashboards.4,19  These data gaps themselves are an injustice. 

The new US Census House-hold Pulse Survey offers insights into the inequitable social and economic tolls of COVID-19.24  It found that, for the week of May 28 to June 2, 2020, fully 44% of Black non-Hispanic and His-panic households reported they had no or little confidence they could pay the next month’s rent, more than twice the already alarming 20% reported for White non-Hispanic house-holds.24  In addition, household food insecurity—defined as often or sometimes not having enough to eat in the previous week—was reported by 20% of Hispanic and 26% of Black non-Hispanic households, versus 9.3% of White non-Hispanic households24—with levels for all groups higher than in 2018.25  Overall, among households with persons aged 18 years or older, rent insecurity was reported by 35% versus 13% of persons with less than versus four or more years of college; the corresponding proportions for food insecurity were 14% versus 3%.24  These metrics of misery, and the inequities in this misery, are severe. 

What do these terrible data mean for public health? The data are terrible in two ways. First, the data literally are terrible. High levels of missing racial/ethnic data plague the extant (and selectively obtained16) testing and hospitalization data; these limited racial/ethnic data are rarely, if ever, cross-stratified by age or sex/gender,19,20,26 and it has taken months of agitation to secure federal legislation mandating that SARS-CoV-2 laboratory tests must report data on race/ethnicity.26,27  To date, no national, state, or local health agencies report any data on COVID-19 by cases’ income or educational level, occupation (with the exception, in some locales, of data on health care worker vs not), disability status, sexual orientation or gender identity, incarceration status, or nativity.26  Yet, despite all of these data caveats, there are good grounds to be concerned about disproportionate impact across these social groups.2,3,28 

Second, even the scant data that do exist terribly expose the lethal politics that treat people of color and other low-income essential workers nevertheless as expendable, who matter solely to keep businesses open, not because their own lives matter.2–4,29,30  At issue are not only hospital workers (including janitors, orderlies, and other staff—not just health care workers) and first responders, but also grocery store workers, warehouse workers, bus drivers, subway conductors, postal workers, security workers, custodians, factory workers, home health aides, and the many others whose work must be done at their workplace and is vital for society to function.28–32  Fully 75% of US workers, comprising 108.4 million people, have jobs that cannot be done from home, and these tend to be lower-income jobs, disproportionately filled by workers of color—for whom lack of a living wage and lack of affordable housing translate to crowded households.2,3,31,32  Meatpacking plants have been the site of terrible COVID-19 outbreaks, reflecting industry opposition to supplying adequate personal protective equipment and to creating conditions in which workers could safely do their jobs and stay home if sick.33  A similar disregard exists for the lives of inmates and immigrant detainees—who, reflecting policies of mass incarceration, are disproportionately Black, Brown, and low-income.34,35 

Tellingly, the same conservative groups who have been funding scientific denialism about climate change, attacking environmental regulation, and distorting democratic governance by abetting voter suppression and gerrymandering—all to protect their private interests—have also been contributing to funding anti–lock down protests and related public health COVID-19 regulations that interfere with their ability to maximize profits.36–38  These deathly plutocratic politics are antithetical to protecting people’s health, let alone promoting health equity.36

SOCIAL MOVEMENTS AND EMBODYING HEALTH JUSTICE

This past June, propelled by the massive protests over police brutality, the COVID-19 pandemic, and the intensification of economic inequities disproportionately harming US communities of color and their health, 20 US cities and counties and three states have declared or are in the process of declaring that racism is a public health crisis.39,40  Major public health, epidemiological, and medical societies have, for the first time ever, made similar declarations.41–43  New conversations are erupting in main-stream media, in city councils, in state legislature, and in Congress over the longstanding but previously marginalized vision of shifting funds from excessive militarized policing to community investment and community safety, informed by principles of social justice, human rights, and participatory budgeting,5–8,35,44–47  Whether this new awareness translates into meaningful change will depend on the sustained mobilization of social movements that recognize both painful histories of past injustice and powerful histories of resistance, thereby inspiring hope for repair and a better equitable and sustainable future.44–47

COVID-19, like previous pandemics, has pulled the thread, revealing profound inequities in every country it touches—while also pointing to our common humanity.3  As with COVID-19, so too with climate change: all humans are threatened, but these risks are deeply and inequitably societally-structured.3,36,46,47  If the past is any guide, unjust systems that people have made can be unmade and transformed. 

Clear analysis of the sociopolitical context of COVID-19 inequities is crucial for engaging with the multi–racial/ethnic upsurge of people across the United States and globally,7,47 especially youths, demanding justice and a world in which they can literally breathe. I am heartened by how they are making visible the embodied connections our bodies make each and every day, between our health and our societal and ecological con-texts.3,48   They will propel public health forward. 

Between COVID-19, structural racism, police brutality, climate change, plutocratic politics, and threats to democratic governance, it is time—past time—to say ENOUGH. 

In 2001, the first World Social Forum, held in Porto Alegre, Brazil, declared “Another world is possible.”49  This was a rejoinder to the “There is no alternative”(TINA) mantra of the1980s’ architects of a hyper-globalized market economy devoted to maximizing private wealth, coupled with deregulation, austerity budgets, and destruction of the welfare state—which, in the United States, was done in racialized terms—and this agenda still wreaks woe for the many and riches for thefew.49–51  Yet, as the current shocks of COVID-19 and the past weeks of protest underscore, the future is not a fact foretold: it is what people shape, by our actions, mindful—or ignorant—of our histories. 

For those of us in public health, one way to contribute our skills and insights to the changes so urgently needed—in both society overall and the institutions where we work—is to start by respecting the leadership of the myriad groups in coalition, nationally and locally, who are together propelling the current social movement, such as the Movement for Black Lives, the Poor People’s Campaign, and the Green New Deal.47,52–54  Engaging with their integrative policy platforms—which all call for social justice in its myriad forms, including health justice47,52–54—offers needed vision and concrete paths toward fruitful action, so that everyone can thrive. 

May George Floyd—who at the time of his death was infected (but not killed) by SARS-CoV-2, Ahmaud Arbery, Breonna Taylor, and the thousands and thousands whose lives were cut short by police violence rest in justice. May the untold numbers of families, friends, neighbors, and networks of all who have sickened and died from COVID-19 come together in their grief to help repair this world.  And for all of us in public health, as we ratchet up our work for the people’s health, we would do well to remember the wise words of Frederick Douglass(1818–1895), who in 1857, in his “West Indian Emancipation” speech, declared: “Power concedes nothing without a demand. It never did and it never will.”55(p22)   Or as Mother Jones(1837–1930), the famous (and to the wealthy, infamous) socialist community and labor organizer, rousingly said, at age 88 in her 1925 autobiography, the time is now to “pray for the dead, and fight like hell for the living!”56(p41)

Nancy Krieger is professor of social epidemiology and American Cancer Society clinical research professor in the Department of Social and Behavioral Sciences, Harvard T. H. Chan School of Public Health, Boston, MA. Correspondence should be sent to Nancy Krieger, PhD, Professor of Social Epidemiology, American Cancer Society Clinical Research Professor, Department of Social and Behavioral Sciences (Kresge 717), Harvard T. H. Chan School of Public Health, 677 Huntington Ave, Boston, MA 02115 (e-mail: nkrieger@hsph.harvard.edu).

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