How Racism Kills

A conversation with Harvard social epidemiologist Nancy Krieger

Racism is deadly.

This is apparent when police kill unarmed people of color such as George Floyd and Breonna Taylor. But the lethality of systemic racism is also evident in the Covid-19 pandemic, which is killing African Americans at a staggering three times the rate of white people.

Nancy Krieger has been shining a light on the health impacts of racism and inequality since she was in college. I first met Krieger when she was a teaching assistant in a groundbreaking college class I took that explored the interplay between sexism, racism, and science. The class, taught by Harvard biologist Ruth Hubbard, was transformative for me and many of my classmates, as it connected the dots between science, politics, and activism. Krieger is now a professor of social epidemiology at the Harvard T.H. Chan School of Public Health and a leading authority on the health impacts of inequality.

This story is adapted from a live discussion that Krieger and I had on The Vermont Conversation, a public affairs radio show that I host.

Elemental: The mantra of the Covid-19 moment is “we are all in this together.” But Covid-19 has, in fact, highlighted deep fault lines in our society that show how unequally and differently we’re affected. For example, in Illinois, 14% of the population is African American, but they represent more than 40% of the state’s confirmed coronavirus cases. What accounts for these disparities?

Nancy Krieger: I want to address both parts of what you’re saying. Because I do think that there is a fundamental point of our common humanity, which is really critical to understand here — because there is so much scientific racism and attempts to racialize different populations, and act as if they’re biologically different. Everyone who is a human is potentially at risk of being infected by this coronavirus, which seems to have done a very nice job of figuring out how to get itself around in human populations, particularly in terms of its skill at asymptomatic transmission. It kills a lot of people, but many people that get sick don’t die. It’s not like, for example, if you got cholera and people would be literally dying in the street within 24 hours of being infected.

We as human beings are commonly at risk of this kind of infection if you think of us as biological organisms. But we’re also never just biological organisms. We are social beings as well — with social divisions in our society, and histories of structural injustice, particularly around racism. You have to understand the histories of enslavement and settler colonialism to better understand who’s at risk now for a much higher likelihood of adverse exposure to the virus, and who’s becoming infected.

What are the social determinants of who dies from Covid-19?

The preexisting health inequities that exist in this country exacerbate the likelihood of who will die. As human beings, we can all be infected — the virus doesn’t care. But the likelihood of being infected is absolutely socially structured by histories and current realities of injustice in our society. So, in terms of the exposure side, what matters is who is in jobs, who has to go to work without sick pay, without paid leave, who are considered to be essential workers (but apparently not essential enough to provide with adequate personal protective equipment), who are in public-facing jobs where they are still in close proximity to other people and where they’ve been required to go to work. Those are the people who are getting exposed now and are at high risk. These are predominantly lower-income people of color.

This explains who’s more likely to be exposed and who is unlikely to be able to work at home safely. That’s the fundamental thing: If you don’t have exposure, you don’t die from the disease.

What does seem to be the case with Covid-19 is that people who have preexisting health conditions are at greater risk of having more fatal illness. The preexisting conditions are twofold: ones that are intimately bound with health inequities, such as cardiovascular disease, diabetes, cancer, and potentially asthma. That puts people at higher risk of bad complications. Also, it seems that body size matters in terms of pressure on the lungs. In the U.S., most of the population is on average larger body size compared to many other countries in the world. That is also socially structured. And the determinants around risk of that have everything to do with the kinds of incomes people have, what kind of food they’re able to purchase, what food is sold in their neighborhoods. So those two things come together: the exposure and the likelihood of more serious illness, and both are socially structured by historical and current injustice.

We as human beings are commonly at risk of this kind of infection if you think of us as biological organisms. But we’re also never just biological organisms. We are social beings as well.

Talk about some of the public health measures that have been put in place, like lockdowns and stay-at-home orders, and how those have a disproportionate or inequitable impact on people.

We are facing, as a world, a new virus for which there is no vaccine and no clear treatment. A certain proportion of people are dying. And there is the real threat of overwhelming hospital systems as occurred in Italy and in New York. This has spillover effects, such as reports that the vaccination rate is way down for little kids. In Massachusetts, people are not getting care because of concerns about what’s going on at the hospitals. There are public health reasons for wanting to try to reduce the transmission of the virus, not only because of the likelihood of an individual getting infected, but also what it will do in terms of overwhelming health systems that people need because they are still having heart attacks and strokes, getting cancer, and people still need their diabetes treated. It’s important to have a larger vision that’s not just focused on the Covid outcomes.

I would put the focus on the social failings as opposed to what the public health recommendations have been. This underscores two critical points. First, this is why one has a welfare state that, if we had a more equitable society, is actually supportive of people who do need health care. And, people need to be able to stay home from work without risk of losing their job because of a public health emergency.

Upheavals can result in big transformations, both good and bad. What transformation could come out of this that could positively address the kind of inequities that you see?

The pandemic is showing the connections between so many issues: between the questions of borders, of who has access to health, and the need for something that resembles universal health care and not having your health insurance tied to your job but just having it by virtue of living here. Also, the connection between what’s going on in jails and prisons and the outside world, and the need for reform. But also, in medicine, you’re watching people being able to do telehealth now in ways that were not permitted before that could potentially increase access. So there’s both these very small changes, but then also potentially big changes in terms of coalitions that are talking to each other to connect issues around public health, economic security, borders, and detention policies. It’s just elevating those issues and making clear that without addressing structural racism, you don’t have solutions.

Explain how structural racism and environmental racism are drivers of the outcomes we’re seeing.

That has everything to do with what kind of neighborhood conditions people have. The histories, for example, of redlining and how that has shaped residential segregation by race and also by economic position in this country, and what this has meant for the kinds of jobs and incomes people have, the lack of affordable housing, the lack of having a sufficient living wage, which is part of the issue of the inability to self-isolate if you’re sick or if you’re living in a very crowded household.

All those — who are the essential workers that are low-paid, who have little control over their workplace, who are not given adequate protective personal equipment, who are not given paid sick leave, who are not getting adequate health insurance coverage — are predominantly people of color. All these factors come together to help create the conditions that are driving the statistics.

The likelihood of being infected is absolutely socially structured by histories and current realities of injustice in our society.

We’re in a moment now where even the statistics have become politicized. Where do you see this going, where the basic tools of your trade of epidemiology are now contested, and it’s now seen as a right-wing litmus test to sacrifice health for business?

This may sound quaint, but I actually do think that we live in a real world. When people start dying, it’s noticeable — even if the deaths are being papered over as this disease starts to move into more communities. There’s actually a very interesting study looking at the cellphone data for people who came to the demonstrations against lockdowns in Michigan and then went back to more far-flung places. They may well bring Covid-19 with them. This is called reality. It takes time for the virus to manifest and to transmit. You might not see that showing up as cases for another few weeks. You might not see it showing up as deaths for another four to six weeks. But it will show up. The disease is not going to go away just because people want to ignore the reality of it.

Covid-19 is different from many endemic health inequities. For example, when you get heart disease or cancer or diabetes, it’s not infectious. It’s not going to potentially sicken and kill a health care worker. When people make analogies like “there’s more people that die of car crashes than of coronavirus” — well sure, there are car fatalities. However, it’s not like once the fatality has happened, the car gets up and starts chasing the ambulance driver and the hospital workers and tries to kill them. People can do all kinds of political demagoguery and try to deny the realities of deaths. But the real life issues of people at risk and dying, including health care workers, are going to continue to have ripple effects everywhere across this country.

Finally, when this is over, however that happens, what in your view is one good thing that could come of this?

An appreciation across the board for the importance of government that provides fundamental services so that people can be healthy and thrive. Getting rid of government and having austerity and gutting public health doesn’t do that. Health is one of the things that we should value. Having an economy that’s geared toward having people thrive — as opposed to having a very small number of people make enormous fortunes — is a much better way to organize this world and have it be more sustainable for our species.

NYT bestselling author. Journalist. Skier. Host, The Vermont Conversation podcast at VTDigger.org. www.dgoodman.net

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