The COVID-19 pandemic has had a devastating impact on the Black community in the United States. As of now, 1 in 800 Black Americans has died of the virus, and it is the third leading cause of death for Black people. Black people have a COVID-19 death rate that is nearly three times the White rate. Recent research shows that Black life expectancy will decline by two years due to the impact of the virus on Black mortality.
The recent approval of the first vaccine in the US gives hope that the pandemic may soon be over. At the same time, Black Americans show deep skepticism of the vaccine, and in surveys less than half of Black people say that they intend to be vaccinated. Without high rates of vaccination the prospects of recovery from the virus would be remote, and given the disproportionate impact of the virus on Black communities, the unwillingness to take the vaccine seems odd. That is only if one ignores the history of medicine and its politics in this country.
Blacks have always faced worse health outcomes in the United States when compared to other racial groups. Even before we had Black mortality estimates, we know that enslaved Blacks were significantly shorter than whites in antebellum America. The brutal health conditions of slavery are well known. In addition to inadequate diets, enslaved Black women were forced to work to within a week of giving birth, and then placed back in the fields only a few weeks after giving birth. As a result, enslaved Black women gave birth to some of the smallest babies ever observed.
After Emancipation, views about Black people and their health evolved. Blacks were considered a dying race unworthy of health care. It depends on the care Blacks get when they access the medical system. Since the beginning of formalized medical training in the United States, there has been a persistent belief that Black bodies are inherently different from white ones. Blacks went from being seen as more immune to diseases like cholera to being seen as a “dying race” not worthy of medical care. No matter the cause, Blacks were simply a different type of human being. And while public sanitation, medical care, and the decline of infectious disease mortality increased longevity for Blacks and whites, it was not always intentional. Indeed, some of the benefits to Black health were unintended.
From the very start of Black interaction with the medical establishment immediately after the Civil War, Blacks found physician bias at every turn. Despite the fact that Black veterans were no more likely than white veterans to report pain or aches, Black veterans were more than twice as likely to be “doubted” by their physicians and more than three times as likely to be accused of “exaggerating” their illness. Physicians were also 6 times as likely to describe Black patients as “stupid” and 15 times more likely to describe Blacks as “ignorant.” When doctors have to take patients at their word, Blacks find their words mean less. This resulted in being viewed as less disabled, receiving a lower average pension relative to whites, and a significant gap in mortality.
The historical evolution or race-based medical thinking has effects today on medical diagnosis and practice. For instance, one of the leading causes of disability in the general population is Chronic Obstructive Pulmonary Disease (COPD), which includes emphysema, chronic bronchitis and non-reversible asthma. The machine used to assess breathlessness caused by COPD – the spirometer – requires physicians to “eye-ball” the race of the patient since lung capacity is still assumed to be different across races as was first described in an 1869 study. Blacks were assumed to have lower lung capacity than whites. Because the spirometer calibrates a lower lung capacity for Blacks as opposed to whites, Blacks today are rated as less disabled than whites when applying for disability, even though they have the same diagnostic scores as whites. To be clear, the diagnosis of COPD today is based on racial assumptions about Black lung capacity in 1869.
When the state has intervened in Black health, it has done so for the least scientific reasons. The famed Tuskegee experiment is one extreme case. In poor Macon County, Alabama, a forty year study took place from 1932 to 1972 in which Black men with syphilis went untreated, even though treatment for the condition was available and known. Funded by the Public Health Service (PHS) the study had very limited scientific value – it was not an experiment in the traditional sense, it was observational. It was also corrupted by the fact that there were interventions in the health of the men in the study, although they were not therapeutic for syphilis. The study also capitalized on Black community networks, using a Black nurse as the primary contact point for the participants. When WWII caused some men in the study to be diagnosed and offered treatment as part of military service, they were actively discouraged. When the study as publicized in 1972 there was a broad public backlash and a response which influences medical ethics to this day.
How could such a study be justified as having any value? Ironically, racial health disparities were cited as one reason for the study’s value. Since the men were from the rural “Black Belt” South, few had access to the basic medical care offered by the study. Similarly, since the men were educationally disadvantaged, the study continued for decades with numerous research reports and the PHS had little fear of the study being noticed by the local population. The men in the study had few advocates for their well-being, even among Black professionals. The National Medical Association, the national organization of Black medical doctors, supported the continuation of the study as late as 1969.
This is not only medical interaction, this is state-supported scientific misconduct. Similarly, the Tuskegee experiment was predicated on tropes of Black male promiscuity and morality, and racist notions about appropriate care for Black people. Even today, physicians simply do not believe what their Black patients tell them, they assign different treatments as a result, and Black health suffers the consequences. Sadly, this is nothing new in American medicine, and solving the problems of health inequities has been part of the civil rights agenda. Part of the solution is recognizing how systematic and structural these problems are. Vaccines cannot be separated from medical research, public health, and government policy towards Black Americans. Particularly at a time when health policy has been politicized and when the top health officials have been in conflict with government leaders.
Black Americans confront a COVID-19 pandemic that is laced upon other aspects of inequality. Blacks are overrepresented in occupations with significant risk of infection, such as meatpacking, and are also disproportionate in the prison system, which was the site of some of the earliest outbreaks of the pandemic. These two factors both reflect longstanding outcomes of occupational segregation and the mass incarceration movement, both political policies.
Less than half of Black Americans believe the benefits of dissemination outweigh the risks of increasing infections, and only around a third of Black Americans believe that medical scientists act in the best interest of the public. As with HIV/AIDS and other public health crises, Blacks have seen again and again that their health is not a priority of the public health establishment. To be clear, from the Civil War Pensions to Tuskegee to lead in the water in Flint, MI to COVID-19, all of these are the government’s public health response to Black health crises. This lack of responsiveness to Black health concerns makes it difficult to enact public health policy. Instead of asking why Black Americans show hesitancy to take the vaccine, we may want to ask why the government is so concerned about Black health now given a long history of neglect.