At the end of January 2020, as I was writing the last third of this book, I was invited to moderate a panel discussion at the Robert Wood Johnson Foundation’s Sharing Knowledge health conference. In February, I joined the two panelists, Joia Crear-Perry and Susan Beane, both Black women physicians, on a planning call. Right away, Joia, a friend and the outspoken, activist founder of an organization called National Birth Equity, wondered why our panel had the dry-as-dust title “Healthcare Bias and Discrimination: Impacts on Maternal and Child Health.” “Why are we saying bias and discrimination?” she asked. “Why not just call it what it is—racism?” I remember that my stomach lurched. We would not be the first to say it out loud; others had called out racism in health care, most memorably, as mentioned previously, Dr. Mary Bassett, the former New York City health commissioner, in her 2015 New England Journal of Medicine essay, “#BlackLivesMatter—a Challenge to the Medical and Public Health Communities.” Still, it seemed aggressive, even hostile, to stake that claim in a room of mainly white health-care providers and public health professionals. It felt as if we were accusing these generally well-meaning people of being racist. The three of us knew that the underlying problem was racism, and I probably felt it most strongly at that moment, because I was in the middle of the deepest dive of my career, cataloging the reasons behind four hundred years of racial health disparities for this book. But I felt uncomfortable owning it. After much back-and-forth, Joia, bless her, convinced us that we should name the culprit behind the damage to Black bodies explicitly, and we settled on calling the panel “Racism and Bias in Healthcare and Its Impact on Maternal and Child Health.”
That conference ended up being the last big gathering I attended before the COVID pandemic hit. When I returned home to Brooklyn on March 6, about a dozen New Yorkers had been diagnosed with the virus. By the end of the month, New York City would be ground zero, with hospitals overwhelmed with patients, ventilators in short supply, refrigerated trucks parked around the city full of bodies waiting to be buried, and my social media pages inundated with fear, sickness, and death.
Now in lockdown, I was spending much more time on my computer. As coronavirus cases in the United States swelled, politicians, physicians, and health experts were warning the public to stay inside and starting to recommend wearing masks, even as the president and his administration were downplaying the danger. Many experts and leaders referred to the coronavirus as a great equalizer, insisting that the disease didn’t discriminate. They crafted this broad-based public health message to get all Americans to fall in line with safety rules. But I also started noticing a different conversation. In other circles, talk of the intersection of race and COVID had begun to simmer. My friend the writer Hilary Beard held the first in a series of Facebook live discussions in late March aimed at people of color. She was joined by Phill Wilson, the leading voice of the Black AIDS movement, and Camara Jones, MD, a former president of the American Public Health Association (APHA), a physician, and an expert in racial health inequality. These talks, called “Something Inside: Tools to Thrive, We Gonna Be Alright,” were intended to help Black, brown, and other people with marginalized identities protect themselves during the pandemic. Hilary hosted them, she explained, because “mainstream media and public health institutions focus exclusively on white America and leave us to fend for ourselves.” The first episode detailed how viruses spread and why Black Americans were at elevated risk for COVID. It received almost three thousand views.
I was also reading notes and comments posted by some of the nearly four thousand members of the Spirit of 1848 Listserv, a caucus of the APHA. Nancy Krieger, PhD, a professor of social epidemiology at the Harvard T. H. Chan School of Public Health, had launched this platform in 1994 to bring together people concerned about social inequalities in health. The inside-baseball name of the group refers to notable events in public health that occurred around that year in response to a worldwide cholera epidemic. One of the goals of the group and its Listserv was to make connections to overcome the isolation that these progressive-minded public health experts felt as they strategized to eliminate social inequity in health. As COVID increased throughout March, that platform caught fire, flooded with animated discussions about the ways people of color were disproportionately affected by this fast-moving disease. Still, it was early days: As Krieger saw a crisis rising, she tried to get the word out in academic and scientific circles by publishing papers predicting a racial divide in COVID outcomes. They were turned down by all of the major medical journals.
At the end of March, Aletha Maybank, MD, a former colleague of Dr. Bassett’s at the New York City Health Department and now chief health equity officer and vice president of the American Medical Association, reached out to me. She wanted help getting an op-ed published in The New York Times imploring laboratories, health institutions, state and local health departments, and the Department of Health and Human Services to collect and publish coronavirus race and ethnicity statistics. At the time, the only racial data was piecemeal, released by state and city governments. But the picture was becoming clear: In Milwaukee County, Blacks represented only one-quarter of the population but 45 percent of coronavirus cases and 70 percent of COVID-related deaths. And in Chicago, Blacks made up half of all cases and almost three-fourths of deaths, even though the city is 32 percent Black. The lack of coordinated release of racial data was fanning conspiracy theories on the ground; a fallacious idea had begun to circulate on social media that Black people were immune to the coronavirus, supposedly because melanin protected against it. This magical thinking became so rampant that on March 17, the day after announcing that he had tested positive for the disease, the actor Idris Elba posted a Twitter live video that denounced the rumors. “There are so many stupid, ridiculous conspiracy theories about Black people not being able to get it,” he said. “That’s dumb, stupid.”
Like Dr. Maybank, a small but influential group of politicians, medical organizations, and advocacy groups were also agitating, mostly behind the scenes, for more statistics based on race. On March 27, Senators Kamala Harris, Elizabeth Warren, and Cory Booker and Representatives Ayanna Pressley and Robin Kelly, all Democrats, sent a letter to Alex Azar, secretary of the Department of Health and Human Services, urging the agency to reveal racial data on testing and treatment for the virus. Shortly after, the American Medical Association, the American Academy of Pediatrics, the National Medical Association, and other groups sent a similar letter, pressing for coronavirus data by race. The NAACP, Dr. Crear-Perry, and other individuals and organizations separately wrote to Surgeon General Jerome Adams and the CDC chief, Robert Redfield, around the same time, adding a warning that data showing disproportionate COVID numbers might lead to racially motivated stereotyping and harassment. That would prove ominously prescient.
I listened and read and knew in my gut that the concerns were, sadly, justified. Years of reporting on HIV/AIDS in African Americans helped frame my understanding. Epidemics, as COVID was shaping up to be, are not equalizers; instead, they strike at the fissures of inequality. They do discriminate: the spread of disease exposes preexisting patterns of marginalization, bias, and inequality.
On the last day of March, I sent a note to Jessica Lustig, my editor at The New York Times Magazine, to give her a heads-up about the discussions about race and COVID that I was hearing. At the time, few news outlets had covered the local data or written about the racial disparities that were beginning to emerge. I explained to Jessica that Hilary Beard and Camara Jones had tried to place an op-ed about the topic in the Times and a number of other media outlets but were turned down. Their piece ran in a lesser-known publication targeted to progressive people of color. I warned Jessica that they and others who took part in their Facebook live gatherings mentioned a few times that “mainstream media doesn’t care about this.” I suggested that she commission an essay by Nancy Krieger, Mary Bassett, Camara Jones, or David Williams of Harvard about the topic and that I’d consult. She responded right away and asked for a more fleshed-out pitch, not for an essay, but for a story I would report and write that answered the questions, why is this disease so devastating to Black Americans, and what set the stage for the negative health outcomes?
By the end of the week, I had an assignment, and a very short deadline: not the usual months and months; because the disease was evolving so quickly, the article would be due in just three weeks. As is my style, I set out to figure out whose story to share to add a human face to the larger themes. By then Louisiana, where I had spent so much time reporting on maternal and infant mortality, had become the first state to release data by race, and the numbers showed a vastly unequal distribution in deaths. While African Americans were 32 percent of the population, they made up 70 percent of the dead. Both Joia Crear-Perry and Audrey Stewart of the Birthmark Doula Collective asked if I knew what was going on with the Zulu Social Aid and Pleasure Club. Founded in 1909, the club is a brotherhood of some eight hundred men, nearly all of them Black, known for community service, civic engagement, celebrating Black pride and excellence, and throwing massive events during Mardi Gras. I looked at the group’s Facebook page and saw the Zulu’s chaplain had posted a series of messages asking for prayers for several members who were ill followed by brown praying hands emojis. As I continued scrolling, he also announced that several others “had gotten their wings,” including Brother Cornell Charles. Eventually, I saw an announcement for the virtual funeral of Mr. Charles, whom everyone called Dickey, a nickname from childhood. On April 3, along with hundreds of others, I watched his service at Zion Travelers First Baptist Church and learned about the life of this kind, decent husband, father, and community leader who had died of COVID at age fifty-one. During New Orleans’s carnival season, he had been a hardworking, behind-the-scenes player for joyful Zulu celebrations, including the Mardi Gras parade. That year, the six weeks of festivities brought more than a million visitors from around the world streaming into the warm, welcoming city to celebrate face-to-face, elbow to elbow with local residents in a succession of street parties and parades.
Dickey had attended almost every one of the Zulu club’s carnival season activities, a series of meticulously planned and eagerly awaited ceremonies, balls, festivals, and other events, beginning in January. On February 25, the final day of carnival season, he rose early, put on the Zulu club’s signature uniform, a honey-yellow jacket, black sash, and armband that meant he was part of the group’s parade organizing committee, and spent the next ten hours fussing over the logistics of the exuberant, chaotic Krewe of Zulu parade. When the Zulus rolled onto Jackson Avenue to kick off Mardi Gras festivities, for Black New Orleans the party started. Tens of thousands of people lined the four-and-a-half-mile route, reveling in the animated succession of jazz musicians, high-stepping HBCU marching bands, and loose-limbed dancing characters dressed in Zulu costumes, complete with grass skirts and blackface makeup, a satirical spit in the eye to the past when Mardi Gras was put on by clubs of white men who barred Black people (and women) from taking part in the festivities. As revelers stood shoulder to shoulder and several feet deep on that late February day, hoping to catch a painted coconut, the “throw” that is the Zulu parade’s signature and coveted prize, no one had any idea that this joyous gathering would turn out to be a coronavirus hothouse.
About ten days after the Krewe of Zulu parade, Dickey told his wife he wasn’t feeling well. A courier for GE Healthcare, Dickey rose most days around 2:00 a.m. to deliver medical supplies to hospitals and clinics on the morning graveyard route. His second shift—as a supervisor at the New Orleans Recreation Development Commission and baseball, football, and girls’ basketball coach at Lusher Charter School—left him little time for rest. Layering on a month-and-a-half whirlwind of Zulu carnival activities was taxing for Dickey, though he rarely let on. He was an easygoing, humble mountain of a man and father of two daughters. At six feet and 260 pounds he carried his weight well, and his middle-age body hadn’t shifted far from his days as a three-sport high school athlete. But he also had a number of health conditions, including hypertension, diabetes, and kidney disease, that he mostly managed quietly. His wife, Nicole, who worked as a medical administrator, kept a watchful eye on him, but also says he worked hard to care for himself. He was very good about taking three different blood pressure medications, two kinds of insulin, and another medication for his kidneys. Nicole said she didn’t have to fight him, never had to fuss.
Burnell Scales, Nicole’s father and also a Zulu member, knew something was wrong Sunday, March 8, when he showed up at the Charleses’ expecting to see his son-in-law stirring a giant pot of gumbo or red beans or heaping shrimp, crawfish, and crabs onto plates for the parade of friends, family, and Zulu members who came by every week after church for an open-door hangout and to watch Saints games during football season. When he found out Dickey wasn’t in the kitchen as usual but in bed, he started to worry.
On March 12, Dickey told Nicole he still didn’t feel well, and his fever had been up and down, spiking as high as 102. His wife stayed close to him, administering fluids and Tylenol, assuming he had the flu. That day she insisted he go to urgent care, where he was tested for the flu. When he didn’t have it, he was sent home with no mention of COVID. Nicole’s anxiety kicked in the following day when Dickey lost his appetite. He loved food, and even if he was sick, he would eat. She also worried that he needed to eat something because he couldn’t take medications to control his blood pressure, diabetes, and kidney problems on an empty stomach. That Friday Nicole told him, “Baby, if you aren’t feeling good tomorrow, we’re going to the hospital.”
On Saturday, March 14, when her husband told her he felt faint, Nicole dragged him to the emergency room at Ochsner Medical Center. The hospital was on lockdown as a result of the growing number of coronavirus cases that had begun to grip the city. That day the Louisiana Department of Health reported 103 cases of the virus, 75 of them in Orleans Parish, and the first death. In the ER, Dickey was again tested for the flu, and again he didn’t have it. No one suggested a COVID test, though doctors and other providers were all wearing protective gear. By that evening, he was lying in a hospital bed, attached to fluids. He never left.
On Sunday, March 15, Dickey’s oxygen levels had become unstable, fever spiking and breaking, but still none of the health-care providers mentioned COVID or suggested a test. Late that evening, a chest X-ray showed pneumonia, his lungs flooded with fluid. Nicole, who had been sleeping on a reclining chair in the room next to her husband, said one of the doctors told her it was time for an honest conversation. “They said, ‘Your husband is much sicker than he looks,’ ” she remembers. “ ‘His lungs will not be functioning much longer. We need to vent him.’ ” That was also the day her husband was finally tested for COVID-19.
Nicole was able to stay with her husband for the next three days, locked to his side. Attached to the ventilator, but unable to speak, he looked surprisingly peaceful and even vital. She kept up a vigil of prayer, whispering, “I love you,” over and over. She played gospel music on Pandora on her phone, taking comfort in the song “The Blood Still Works.” “It’s still healing,” she sang to him. “There is power in the blood of Jesus, the blood still works.” She also had Dickey’s phone with her and did her best to field an avalanche of calls from worried family and Zulu brothers. She told them to please keep Dickey in prayer.
On Wednesday, March 18, while Nicole was in the midst of praying, Dickey opened his eyes. “I said to him, ‘Baby, you opened your eyes for me. I love you so much,’ ” and that was the last time she saw his eyes open. On Thursday, March 19, hospital administrators told Nicole she could no longer visit her husband because of a shortage of personal protective equipment. That day, Louisiana’s caseload had increased to 392 cases from 280 the day before. At a news conference, the governor of Louisiana announced that the state’s health-care system could be overwhelmed in seven to ten days on the current trajectory.
On Tuesday, March 24, a team of hospital medical providers called Nicole. Dickey’s blood pressure had dropped, and his kidneys had failed. They told her he wasn’t going to make it and he would be removed from the vent. After inquiring about their exposure to coronavirus, administrators allowed Nicole and Dickey’s adult daughters, Bethaney and Le’Treion, to come to his room. Wearing gowns, gloves, and masks, they prayed over his body and said goodbye. At 1:33, when Dickey took his last breath, Nicole, his wife of thirty years, was alone by his side. She left her husband in God’s hands and asked Him to let Dickey rest, let him go in peace. The following day, as Nicole faced down staggering grief, she received a call that Dickey’s COVID test had come back positive.
Nicole shared her story of love and loss with me at the beginning of April, not long after her husband’s funeral. The Zulu Social Aid and Pleasure Club had its origins at the intersection of discrimination and death. After emancipation, formerly enslaved Africans, financially crippled in the face of continued Jim Crow oppression, struggled to bury their dead. So they pooled their money by forming social aid clubs to provide dignified, respectful funerals. But COVID had broken the Zulu club’s long-standing tradition of sending off fallen brothers with second-line funerals, the New Orleans tradition of celebrating lives of those who have died with a spirited procession of pageantry, jazz, and dance. On April 3, fewer than a dozen people came together at Zion Travelers First Baptist Church to say goodbye to Dickey Charles. They sat scattered throughout the pews in the chapel in observance of the guidelines the City of New Orleans had put into place on March 16, which restricted gatherings. But Nicole and her family managed to livestream the service, and another six hundred people watched from home.
As I continued my reporting, Dr. Maybank’s op-ed ran in the Times on April 7, and the next day the CDC released the first chunk of statistics on COVID and race. The limited data set, of 1,482 coronavirus patients hospitalized in fourteen states, indicated that despite making up 18 percent of those studied, Black people accounted for a third of all severe cases. Data from the Louisiana Department of Health showed that the neighborhoods in Orleans Parish with the largest numbers of Black residents had been hit hardest.
As I traced a trail of blame for the deaths among the Zulus, I examined the state of the pandemic and the response of the White House at the time Dickey and his brothers were unwittingly attending what we would later understand to be “super-spreader” events. On Friday, February 21, the Charles family joined some twenty thousand people packed into the New Orleans Ernest N. Morial Convention Center, the only venue large enough to hold the crowd that came to eat and drink and dance—floor-length ball gowns and tuxedos required—and witness the crowning of the Zulu king and queen of Mardi Gras. On the Sunday after the ball, President Trump set the tone for the country, the state of Louisiana, and the city of New Orleans when he said at a press conference, “The coronavirus is very much under control in the USA.” On Monday, February 24, when an estimated 200,000 people spent the day at the Zulu-hosted Lundi Gras, enjoying a smorgasbord of New Orleans food and music on three stages at Woldenberg Park along the Mississippi River, the president reiterated on Twitter that the disease was “under control.” The next day, an official from the Centers for Disease Control issued a far bleaker warning than any before about the spread of the virus in the United States, noting that disruptions to life could be severe. Yet the president was still downplaying the risk. He continued to reassure the country that the number of confirmed cases “within a couple of days is going to be down close to zero.” On March 9, the day Louisiana confirmed its first case of COVID-19 and as Dickey got sicker and sicker, Trump compared the virus to the flu on Twitter and also tweeted, “The Fake News Media and their partner, the Democrat Party is doing everything within its semi-considerable power (it used to be greater) to inflame the CoronaVirus situation, far beyond what the facts would warrant.” By the time my story closed on April 24, I was livid. The day before, at a White House press briefing, President Trump erroneously suggested that injecting the human body with a disinfectant like bleach or rubbing alcohol could combat the virus, in his words, “knocking it out in a minute.” By then, at least thirty members of the Zulu club had been diagnosed with COVID-19. Eight had died or would soon be dead.
My story ran in the Times magazine on Sunday, May 3, with the cover line “Who Lives? Who Dies?” in black letters on a stark white background. Along with Dickey Charles’s story and the fate of the Zulu club, the piece looked at the ways coronavirus had disproportionately affected Black people, examining the history of racial health disparities in America and emphasizing the cruel realities that had been brought into sharper focus during the pandemic: higher rates of many diseases, in this new context known as underlying conditions; discrimination in medical care; and the social determinants of health, including pollution, that make Black communities less healthful.
Three weeks after the article appeared, as COVID-19 had turned from epidemic to pandemic proportions, a Black man named George Floyd was arrested for a minor offense in Minneapolis and was subsequently murdered by a white police officer. A viral cell-phone video of Floyd’s death set off protests across the United States. The glaring injustice of his murder forced a conversation about institutional racism and racial justice to the surface, and his dying words, “I can’t breathe,” became a rallying cry, galvanizing a movement. In a horrifying intersection between Floyd’s death and COVID-19’s disproportionate blow on the Black community, autopsy results in June showed that George Floyd had COVID when he was killed.
After I returned to working on this book, I could see that I was living through its latest chapter. When a robust set of data about race and COVID appeared, this longtime health disparity was on full display. African Americans were more likely to come into contact with the virus and were hospitalized at much higher rates than white people, and the Black death rate was twice as high as the white rate. This pileup of deaths led to an even greater racial disparity in life expectancy: In the aftermath of COVID, life expectancy had fallen for everyone, but Blacks lived an average of 2.7 years less, compared with 0.8 for whites, according to CDC data about the first half of 2020 released in 2021. The life expectancy gap between Black and white Americans, which had been decreasing, had expanded to 6 years, the widest racial disparity since 1998.
What’s more, conditions like diabetes, stroke, and heart disease that strike Black Americans at younger ages led to Black people like Dickey Charles dying young from this new virus. An analysis of CDC data showed that in every age category, Black people were dying from COVID at roughly the same rate as white people more than a decade older. Among those aged forty-five to fifty-four, Black death rates were at least six times higher than for whites.
When I saw these numbers pointing to worse COVID outcomes for Black people at younger ages, I immediately thought of Arline Geronimus’s weathering theory. When I reached out to her, she told me she wasn’t surprised by what we were seeing. If Black people’s bodies have been prematurely aged by the chronic stress of battling back racism in America, leading to the very underlying health conditions that make COVID more deadly, then weathering would make the virus more deadly.
The early response to the statistics from politicians and even some scientists, however, was more in line with the stale idea that something intrinsic to blackness was leading to the higher hospitalization and death rates among African Americans. The notion that Black bodies are genetically inferior was born centuries ago and advanced by doctors and scientists as a way to justify slavery, as we have seen. In an April radio interview, Louisiana’s senator Bill Cassidy, a physician by training, insisted without evidence that genetic reasons put African Americans at risk of diabetes and triggered serious coronavirus complications. An article in The Lancet attributed racial disparities in COVID-19 deaths partially to “genetic make-up.” Dr. Anthony Fauci, the country’s leading expert on infectious disease, shot down that false belief in July, explaining during an interview, “It’s not genetic.” His background as an HIV/AIDS researcher and his understanding that viruses, including both COVID and HIV, disproportionately impact Black and other marginalized communities, informed his views.
Prominent physicians also began to spout a wounding trope to explain the underlying conditions that worsened COVID-19 outcomes: that Black people were doing something wrong—being careless, ignorant, and irresponsible. Surgeon General Jerome Adams, who is Black himself, chimed in early, implying that individual behavior was leading to higher deaths from COVID-19 among African Americans. At a White House press briefing on April 10, he told “communities of color…to step up and help stop the spread so that we can protect those who are most vulnerable.” Dr. Adams added that African Americans and Latinos should “avoid alcohol, tobacco, and drugs.” He went on, “We need you to do this, if not for yourself, then for your abuela. Do it for your granddaddy. Do it for your big mama. Do it for your pop-pop.” Dr. Adams walked back his comments, but they stung, especially coming from a Black physician who had spoken openly of his own struggles with pre-diabetes, hypertension, and asthma.
And just as some of the experts had warned, after cities with sizable populations of Black people began to report large numbers of COVID-19 infections at the beginning of April, and statistics showed disproportionate death rates for African Americans, a counternarrative began to arise: the national, state, and local shutdowns were too draconian; the coronavirus pandemic was not as much of a threat—at least not to all Americans—as had been argued. Protesters, encouraged by the Trump administration, insisted that others—read: Black and brown people—should take “personal responsibility” in order to turn around the COVID numbers and open up the economy. A smattering of demonstrations broke out the week of April 13, as protesters gathered in a handful of states to push back against stay-at-home orders.
Antiscience rhetoric, including the false idea that wearing a mask does not stop the spread of the virus, trickled down from the White House and into the streets. President Trump and members of his administration downplayed the dangers posed by the coronavirus and undermined efforts to contain it by belittling masks and social-distancing rules, and eventually urging his supporters to protest state lockdown rules put in place to keep residents safe during the pandemic. I watched a video of a “You Can’t Close America” rally in Austin, Texas, on April 18, where hundreds of demonstrators, nearly all white, defied social-distancing guidelines by gathering on the steps of the capitol. The protesters—many without masks and outfitted with Trump hats and flags—shouted, “Let us work” and “Fire Fauci.” A woman wearing a “Keep America Great” cap waved a sign reading, “My Life, My Death, My Choice, Personal Responsibility,” and another protester held a hand-drawn poster that read, “My Life! Not Yours!”
Saner, more knowledgeable, and more experienced voices rejected the belief that a lack of personal responsibility led to higher rates of coronavirus cases in areas where Black people and other people of color lived. Instead, they pointed to racial segregation, a by-product of systemic racism, as the problem. As discussed in chapter 5 of this book, Black people are more likely than whites to live in communities with high rates of poverty, where physical and social structures are crumbling, where opportunity is low and unemployment high. Even educated, affluent Black people live in poorer neighborhoods, on average, than white people with working-class incomes.
The conditions in the social and physical environment where Black people live, work, attend school, play, and pray—social determinants of health—have long had an outsized influence on health outcomes. And their impact became painfully obvious when the pandemic hit. Black Americans were more likely to be exposed to the virus. Segregation created crowded communities with multiple generations of family members, making social distancing and protecting elders difficult. Black people were also more likely to be essential workers employed in service jobs—in transportation, government, health care, and food-supply services—as well as in low-wage or temporary jobs. Rather than telecommuting from home on Zoom, they were riding public transportation and working face-to-face, raising their risk of coming into contact with COVID. Unsurprisingly, the neighborhoods on the South Side of Chicago, where my mother was born and raised and where earlier in this book I mentioned that residents live thirty fewer years than their peers nine miles north, were the hardest hit as COVID raged.
Health-care facilities in Black communities are often crumbling or nonexistent, which, at the start of the pandemic especially, meant that people there were unable to find out if they had been infected with the virus, which made it difficult to protect themselves and others. Studies showed that white communities had more testing sites per capita than Black and Latinx ones, and some Black rural areas were labeled “testing deserts” because of the scarcity. As COVID rose to crisis proportions in Philadelphia, a local Black physician, Ala Stanford, MD, created DIY testing sites in Black communities. She recruited volunteer doctors, nurses, and med students and used her personal savings and donations collected through a GoFundMe campaign to test for COVID in church parking lots and in tents on street corners in Philly. Between April and October, her group, Black Doctors COVID-19 Consortium, tested more than ten thousand people.
The most recognizable social determinant of health is damage to the environment itself, and as scientists and policy makers have known since the 1980s, Black and poor communities live closest to polluting manufacturers and shoulder a disproportionate burden of the nation’s dirty air. A paper released in April 2020 made an explicit link between air pollution and poor COVID-19 outcomes. Researchers at the Harvard T. H. Chan School of Public Health found that a majority of the conditions that increase the risk of death from COVID-19 are also worsened by long-term exposure to air pollution. After analyzing more than three thousand U.S. counties, the researchers concluded that even a small increase in exposure to fine particulate matter—tiny particles in the air—leads to a significant increase in the COVID-19 death rate.
The well-documented, long-standing bias and discrimination in health care also revealed itself during the pandemic. With a nod toward both the unequal impact of COVID-19 on African Americans and the history of discrimination in medical care, the CDC created a set of health equity principles to guide providers when treating patients of color during the pandemic. But racial bias baked into algorithms used to calibrate medical machines proved more difficult to avoid. Similar to the way racism has been embedded in the spirometer dating back to slavery, the pulse oximeter, a medical device used to measure oxygen levels in the blood of COVID-19 patients, has a design flaw that causes it to take inaccurate readings in African American patients. The device helps health-care providers gauge the severity of a coronavirus infection and decide whether to admit patients or send them home. A study published in December 2020 found that people with darker skin were three times more likely to receive misleading results. The test, which works using small beams of light that pass through the blood, was designed with white skin as the default.
But the case of Susan Moore, MD, provided the most observable and egregious example of the mash-up of COVID and racism in our current medical system. In late November 2020, Dr. Moore, a licensed physician in the Indianapolis area, would learn that years of medical training and credentials she worked hard to earn would fail to protect her from the medical system itself. On November 29, Dr. Moore tested positive for COVID-19 and checked herself into Indiana University Health North Hospital. On December 4, she posted a video on her Facebook page that showed her lying in her hospital bed, a breathing tube inserted in her nose. In the widely circulated video, she described disrespectful treatment by a white physician who rejected her plea for additional doses of a standard antiviral medication used to treat COVID. And despite what she described as excruciating pain, he told her he was “uncomfortable” giving her additional pain medication and tried to send her home. Through tears Dr. Moore said he made her feel like a drug addict. Looking directly into the camera, her voice laced with anger, Dr. Moore denounced the U.S. health-care system that had forsaken her: “I put forth and I maintain if I was white, I wouldn’t have to go through that. This is how Black people get killed.” Dr. Moore died two weeks later at age fifty-two. After her death, an external review concluded that Indiana University Health was not responsible for her death but that Dr. Moore’s providers at the facility lacked “awareness of implicit racial bias” and stated that “there was a lack of empathy and compassion shown in the delivery of her care.” An earlier statement from the president and CEO of the organization seemed to place blame for her death on Dr. Moore herself, explaining that the nursing staff at the facility might have been intimidated by her medical expertise.
When a COVID-19 vaccine was introduced to the public in 2021, predictably, Black people received fewer shares of vaccinations compared with other Americans. First, the vaccine was not consistently available in both rural and urban Black communities. Distribution relied on existing infrastructure, which was lacking in some predominantly Black areas. In Washington, D.C., 40 percent of early vaccine appointments were snapped up by residents of its wealthiest and primarily white ward, even though Black residents of the city accounted for 74 percent of deaths, 48 percent of cases, and nearly half of the population. A similar trend occurred in New York City, where I live. Disproportionate numbers of Black people were also wary of taking the vaccine, not trusting a medical system that had caused them harm dating back centuries. In December 2020, a poll released by the Kaiser Family Foundation showed that among racial and ethnic groups Black Americans were the most hesitant to get vaccinated against COVID. In the survey, more than one-third of African Americans said they would probably or definitely not get the vaccine even if it was determined to be safe by scientists and widely available for free. As with other medical studies, Black people were underrepresented in the clinical trials for the two initial COVID-19 vaccines produced by Pfizer and Moderna compared with their share of the population. The vast majority of the participants were white, even though Black people had worse outcomes from the disease.
The sickness and addiction I witnessed in West Virginia also intensified with COVID-19. Data compiled by the CDC showed a sharp rise in opioid deaths at the time when COVID lockdowns began in March 2020. Anxiety and despair over the pandemic might have contributed to greater drug use, and lockdowns made it challenging for people to receive in-person treatment for existing substance abuse problems. Social isolation made it more likely that people would use these substances alone, with less chance of a rescue in case of an accidental overdose. Increased drug use led to a spike in HIV transmission. In Kanawha County, West Virginia, where I visited in October 2020, the HIV outbreak expanded to crisis proportions during the pandemic. In early 2021, the chief of HIV prevention at the CDC called the outbreak of the virus in Kanawha “the most concerning in the United States.” West Virginia’s governor, Jim Justice, turned a blind eye to the surge of overdose deaths and HIV cases: in April 2021 he signed a bill that hampered harm-reduction efforts, making it harder to get clean needles.
Finally, the pandemic has exacted a toll on African Americans in ways that are less evident. Black people were more likely than other Americans to know someone who had contracted COVID and/or died of the virus. Nearly half of Black respondents in a survey conducted by the Commonwealth Fund reported experiencing an economic challenge because of the pandemic, substantially more than the 21 percent of white respondents. In the same poll, Black respondents reported pandemic-related mental health concerns at a rate approximately ten points higher than whites.
Still, I remain optimistic. After my May cover story on the New Orleans Zulu club and why COVID was hitting Black Americans so hard, I felt a profound shift in the level of receptiveness to its ideas. I was invited to present lectures and conduct workshops about inequality and health at least three dozen times—at Harvard, Yale, Howard, Northwestern, Tulane, UCLA, MIT, the CDC, and other agencies, community groups, and colleges. I also addressed journalism students and reporting fellows numerous times; they were hungry to understand how to cover racial health disparities, specifically how to interview “real people” like Nicole Charles with respect and empathy.
During these presentations I am often asked if I feel hopeful about the future. Without a second thought, I continue to answer yes. Together, America’s racial reckoning and a pandemic that has exposed long-standing racial health inequality have thrown an accelerant on a slow-burning fire of awareness, forcing America to grapple with issues of race and justice and understand the origins of racism and its continued impact on the well-being of people and communities. My debate in February 2020 about whether my colleagues and I should explicitly label bias in the health-care system as racism in the title of our talk now seems like a lifetime ago. Just six months later it had become commonplace to call out racism as a public health threat, not only in the most progressive circles like Krieger’s Spirit of 1848 forum, but in nearly every discussion of inequality and health. The theories of many racial health equity experts who have been toiling for decades, often behind the scenes, have been thrust into the limelight. David Williams and Arline Geronimus have seen their profiles rise and their theories and voices uplifted during the pandemic. Nancy Krieger was interviewed in The New Yorker in the spring, and despite those early rejections she had two dozen scientific studies and expert essays published about COVID in 2020, several with her colleague Mary Bassett. In response to the ill-treatment and ultimate death of Dr. Susan Moore, Joia Crear-Perry, Camara Jones, and Aletha Maybank teamed up with another Black female physician, Uché Blackstock, to write a scathing Washington Post editorial in December 2020 asking, “If a physician can’t be heard by her own peers to save her life, then who will listen?” They titled their piece “Say Her Name,” a callback to Breonna Taylor, the Black medical worker who was shot dead by a member of the Louisville Metro Police Department in March during a botched raid on her apartment. As with George Floyd, her death set off wide-scale demonstrations over policing and racial injustice.
Whereas in the past, race was considered a risk factor for a number of health conditions and early death, now it is clear that we must speak the harder truth: it’s not race, something about being Black, or something wrong with the Black body, but racism that makes people sick and shortens their lives. Even after science finds a cure for COVID-19, racism in medicine is the harder virus to kill. But now is the time. The pandemic and the gross injustice of the state-involved killings of George Floyd, Breonna Taylor, and others have opened hearts and minds across the races to create an opportunity like no other to discuss and confront racism in America; now is the time to create transformative change in health, health care, and health equity in our nation. During the pandemic, California moved ahead of the country, requiring implicit bias training for health-care providers as part of their mandatory continuing education certification beginning in January 2022. The rest of the nation should follow suit.
I’d like to end with the words of Clyde W. Yancy, MD, chief of cardiology in the Department of Medicine at Northwestern’s Feinberg School of Medicine. His essay on Black Americans and COVID-19 was published online in The Journal of the American Medical Association on April 15, which prompted me to interview him for my article about the Zulu club. As a boy growing up in Baton Rouge, Louisiana, and later as a student at Southern University and the Tulane University School of Medicine, Dr. Yancy remembers being fascinated with the decorated coconuts that were the sought-after prize of the Krewe of Zulu parade. During an interview he told me that that memory has been marred by his longtime study of racial health disparities and his knowledge of the unequal pain that has come to define the American outbreak of COVID-19. The tragedy of the Zulu members—and the larger heartbreak of the pandemic’s effects on African Americans—must be a moment of epiphany, a wake-up call and call to action. We can no longer look away from the impact of the racial health disparities that have been part of the American story since the beginning of our nation. This is not how a just society treats a segment of its population. As Dr. Yancy said, “COVID-19 has taken off the Band-Aid that was covering the wound, pointed out how deep it is, and left us no other choice but to finally say, we get it, we see it.”
ACKNOWLEDGMENTS
This book took me a long time to conceptualize, research, and write and is the culmination of years of thinking, reporting, and, especially, listening. It could not have come into the world without the faith and commitment of many people.
I am fortunate to have The New York Times Magazine as my home base, and I thank my colleagues for their own exceptional work and for getting my stories out of my head and onto the page. I am particularly grateful to be part of the 1619 Project, conceived by Nikole Hannah-Jones, which expanded my thinking. I extend special appreciation to my editor Jessica Lustig, who stays by my side every step of every story—with encouragement, attention to detail, long phone calls, and sparkling wine.
To the students, staff, and faculty at the Craig Newmark Graduate School of Journalism at CUNY and the City College of New York, thank you for showing me the importance of learning as you teach.
I am deeply indebted to a number of scientists, physicians, historians, and activists for their unshakable commitment to the ideas and concepts in the book. Thank you to Byllye Avery, Mary Bassett, Robert Bullard, Catherine Coleman Flowers, Harold Freeman, Vanessa Northington Gamble, Helene Gayle, Arline Geronimus, Evelynn Hammonds, Camara Jones, Nancy Krieger, Greg Millett, Dorothy Roberts, Loretta Ross, Harriet Washington, David Williams, and Phill Wilson for lighting my way.
I offer immense gratitude to everyone who shared their personal stories with me, peeling back the layers of your lives and sometimes your pain in order to lift up my work and make it relatable and meaningful. U-Meleni, your poetry leaves me breathless.
To my agent, Alia Hanna Habib—thank goodness you didn’t listen when I insisted I didn’t want to write a book. I am grateful to have you as my ride or die.
Many thanks to the team at Doubleday, especially Kris Puopolo, for your wisdom, careful reading, and hand-holding. Not only are you one of the finest editors in the business but also an attentive, patient collaborator. As an anxious writer, I extend gratitude to Julie Tate and Maryanne Warrick for your help with the details and to several others who supported me by fact-finding and organizing and in other invaluable ways—Shelby Boamah, Ayana Byrd, Avery Homer, Amari Leigh, Rachel Pride, and particularly Audrey Stewart, thank you.
My writer friends, who are very busy with their own work, took the time to offer encouragement, long walks, and longer talks: Allison Abner, Jeannine Amber, Hilary Beard, Andrea Bernstein, Sarah Broome, Benilde Little, Sarah Schulman, Liz Welch, and Teresa Wiltz, I appreciate you. Love to Laura Petrillo for weekly mental health check-ins.
To the Sunday dinner crew—Jackie, Juliet, Jane, Toshi R., Tashawn, Toshi G., and Jackson—I am grateful to you for food, family, and unfailing support. I could not ask for a better family. Mom, Alicia, Kali, Nic, Lorry, and Faye Michelle, I love you, I thank you. And, finally, to Jana—your unwavering belief in me and steady presence kept me going from the beginning of the process to the very end. Thank you for being there and for being you.