On this edition of In Black America, producer/host John L. Hanson Jr. speaks with Mary-Frances Winters, founder and president of The Winters Group, Inc., and author of Black Fatigue: How Racism Erodes the Mind, Body, and Spirit.
Black fatigue is the physical and psychological toll on African Americans’ daily lives as a result of systemic racism. The damage wrought by racism isn’t only the atrocities so powerfully condemned in the demonstrations and protests around the world.
Winters talks about African Americans being middle class and that being from a two-parent family does not protect them from systemic racism; how millennials and Generation Z continue to suffer under the hand of systematic oppression; and how, as a baby boomer, she lived through three different generations of racial discrimination and unrest in North America.
The doctor put up billboards in the Mississippi Delta.
Amputation Prevention Institute, they read.
He could save their limbs, if it wasn’t too late.
The Black American Amputation Epidemic
by Lizzie Presser
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IT WAS A FRIDAY EVENING in the hospital after a particularly grueling week when Dr. Foluso Fakorede, the only cardiologist in Bolivar County, Mississippi, walked into Room 336. Henry Dotstry lay on a cot, his gray curls puffed on a pillow. Fakorede smelled the circumstances — a rancid whiff, like dead mice. He asked a nurse to undress the wound on Dotstry’s left foot, then slipped on nitrile gloves to examine the damage. Dotstry’s calf had swelled to nearly the size of his thigh. The tops of his toes were dark; his sole was yellow, oozing. Fakorede’s gut clenched. Fuck, he thought. It’s rotten.
Fakorede, who’d been asked to consult on the case, peeled off his gloves and read over Dotstry’s chart: He was 67, never smoked. His ultrasound results showed that the circulation in his legs was poor. Uncontrolled diabetes, it seemed, had constricted the blood flow to his foot, and without it, the infection would not heal. A surgeon had typed up his recommendation. It began: “Mr. Dotstry has limited options.”
Fakorede scanned the room. He has quick, piercing eyes, a shaved head and, at 38, the frame of an amateur bodybuilder. Dotstry was still. His mouth arched downward, and faint eyebrows sat high above his lids, giving him a look of disbelief. Next to his cot stood a flesh-colored prosthetic, balancing in a black sneaker.
Fakorede explained that he wasn’t the kind of doctor who cuts. He was there because he could test circulation, get blood flowing, try to prevent any amputation that wasn’t necessary. He hated that doctors hadn’t screened Dotstry earlier — when he’d had the stroke or lost his leg. “Your legs are twins,” he said. “What happens in one happens in the other.”
Dotstry needed an immediate angiogram, an imaging test that would show blockages in his arteries. He also needed a revascularization procedure to clean them out, with a thin catheter that shaves plaque and tiny balloons to widen blood vessels. His foot was decaying, fast. Though Fakorede ran an outpatient practice nearby, when doctors consulted him on inpatients at Bolivar Medical Center, the local hospital, he expected to use its facilities.
He asked his nurse to schedule the procedures. But by the time he had driven home to his ranch house on the northern edge of town, he hadn’t received an answer. Nor had he when he woke up on Saturday at 3:30 a.m., as he did every morning. By sunrise, he was restless at his kitchen counter, texting the hospital’s radiology director, explaining the need for an intervention on Monday, Martin Luther King Jr. Day. Within a few hours, he got a response: “I don’t have the staff or the supplies. I’m sorry.”
Now Fakorede was mad, walking briskly into his office, dialing friends on speaker phone, pacing around his conference room. He’d been raised in Nigeria, moved to New Jersey as a teenager and had come to practice in Mississippi five years earlier. He’d grown obsessed with legs, infuriated by the toll of amputations on African Americans. His billboards on Highway 61, running up the Delta, announced his ambitions: “Amputation Prevention Institute.”
Nobody knew it in January, but within months, the new coronavirus would sweep the United States, killing tens of thousands of people, a disproportionately high number of them black and diabetic. They were at a disadvantage, put at risk by an array of factors, from unequal health care access to racist biases to cuts in public health funding. These elements have long driven disparities, particularly across the South. One of the clearest ways to see them is by tracking who suffers diabetic amputations, which are, by one measure, the most preventable surgery in the country.
Look closely enough, and those seemingly intractable barriers are made up of crucial decisions, which layer onto one another: A panel of experts decides not to endorse screening for vascular disease in the legs; so the law allows insurance providers not to cover the tests. The federal government forgives the student loans of some doctors in underserved areas, but not certain specialists; so the physicians most critical to treating diabetic complications are in short supply. Policies written by hospitals, insurers and the government don’t require surgeons to consider limb-saving options before applying a blade; amputations increase, particularly among the poor.
Despite the great scientific strides in diabetes care, the rate of amputations across the country grew by 50% between 2009 and 2015. Diabetics undergo 130,000 amputations each year, often in low-income and underinsured neighborhoods. Black patients lose limbs at a rate triple that of others. It is the cardinal sin of the American health system in a single surgery: save on preventive care, pay big on the backend, and let the chronically sick and underprivileged feel the extreme consequences.
Fakorede grabbed his car keys and headed to the hospital. He walked straight to the lab. As he suspected, it had all the supplies that he needed. Why won’t they give me staff? he wondered. They wouldn’t do that to a surgeon.
He has little tolerance for this kind of transgression. He is militaristic, to an extreme. To him, nonhealing wounds are like heart attacks. “Time is muscle,” he repeats. He calls huddles when nurses forget to check a patient’s ankles: “If you haven’t assessed both legs, I don’t want to walk into that room.” He considers each of his procedures an act of war. When people stand in his way, he sends a barrage of text messages, punctuated by exclamation marks. And he uses his cellphone to collect evidence that the system is working against his patients, and his efforts.
He pulled out his iPhone and photographed the hospital’s wires and catheters, IVs and port protectors. He shot the images over to the hospital’s radiology director. Fakorede’s private practice was closed for the holiday weekend. He calculated that he had only a few days to carry out some plan before Dotstry’s remaining leg was amputated.
TWO MAPS EXPLAIN why Fakorede has stayed in the Mississippi Delta. One shows America’s amputations from vascular disease. The second shows the enslaved population before the Civil War; he saw it at a plantation museum and was stunned by how closely they tracked. On his phone, he pulls up the images, showing doctors, or history buffs, or anyone who will listen. “Look familiar?” he asks, toggling between the maps. He watches the realization set in that amputations are a form of racial oppression, dating back to slavery.
Fakorede was initially tempted to move to the Delta while practicing in Tennessee. He befriended a medical device sales rep named Maurice Hampton who had grown up in the Mississippi region. Hampton talked about how black families were leery of local hospitals and how few black doctors in the Delta specialized in vascular work. “It’s the norm to go to Walmart and see an amputation or a permacath in the neck,” he’d told Fakorede. “If you don’t see one, then you didn’t stay but two minutes.”
Then, a little over a year into his Tennessee job, Fakorede found himself at loose ends. He’d raised concerns that he was being billed for expenses that weren’t his and asked for an audit; though the audit later found that the clinic where he worked had claimed over $314,000 in improper expenses, he was quickly terminated. Fakorede sued the clinic for retaliation under the False Claims Act and lost. (The clinic’s lawyer said his client had no comment, but there were “numerous” reasons for Fakorede’s departure.) In the spring of 2015, he had a mortgage, a quarter of a million dollars in student debt and four months of severance pay. He also had an impulse to understand the Delta.
Fakorede spent four days driving through its long, flat stretches of farmland dotted with small towns and shotgun houses. The wood-slat homes and bumpy roads reminded him of his grandparents’ village in the Nigerian state of Ondo, where he’d spent summers as a kid. He drove scores of miles on the Mississippi highways without seeing a single grocery store; fast-food chains lit the busiest intersections. He was startled by the markers of disease — the missing limbs and rolling wheelchairs, the hand-built plywood ramps with metal rails. He thought of amputees like “an hourglass,” he said, “that was turned the day they had their amputation.” Mortality rates rise after the surgeries, in part, because many stop walking. Exercise improves circulation and controls blood sugar and weight. The less activity a person does, the higher the risk of heart attacks and strokes. Within five years, these patients were likely to be dead.
Fakorede weighed taking a lucrative job up north, near his parents, who had both been diagnosed with diabetes. He had professional connections there; he’d gone to Rutgers Robert Wood Johnson Medical School and done a residency at NewYork-Presbyterian Weill Cornell Medical Center. But the South, he felt, needed him. About 30 million people in America had diabetes, and Mississippi had some of the highest rates. The vast majority had Type 2; their bodies resisted insulin or their pancreas didn’t produce enough, making their blood sugar levels rise. Genetics played a role in the condition, but so did obesity and nutrition access: high-fat meals, sugary foods and not enough fiber, along with little exercise. Poverty can double the odds of developing diabetes, and it also dictates the chances of an amputation. One major study mapped diabetic amputations across California, and it found that the lowest-income neighborhoods had amputation rates 10 times higher than the richest.
The Delta was Mississippi’s poorest region, with the worst health outcomes. Fakorede had spent years studying health disparities: African Americans develop chronic diseases a decade earlier than their white counterparts; they are twice as likely to die from diabetes; they live, on average, three years fewer. In the Delta, Fakorede could treat patients who looked like him; he could find only one other black interventional cardiologist in the entire state. A growing body of evidence had shown how racial biases throughout the medical system meant worse results for African Americans. And he knew the research — black patients were more responsive to, and more trustful of, black doctors. He decided after his trip that he’d start a temporary practice in Mississippi, and he rented an apartment deep in the Delta.
He fantasized about building a cardiovascular institute and recruiting a multidisciplinary team, from electrophysiologists to podiatrists. But as he researched what it would take, he found a major barrier. Medical specialists with student debt, who graduate owing a median of $200,000, generally could not benefit from federal loan forgiveness programs unless they got jobs at nonprofit or public facilities. Only a few types of private practice providers — primary care, dentists, psychiatrists — qualified for national loan forgiveness. The Delta needed many other physicians. Though Bolivar County was at the center of a diabetes epidemic, there wasn’t a single diabetes specialist, an endocrinologist, within 100 miles.
Fakorede leased a windowless space in the Cleveland Medical Mall, a former shopping center that had been converted to doctors’ offices. People came to him with heart complaints, but he also asked them to remove their socks. Their legs alarmed him. Their toes were black and their pulses weak. Their calves were cold and hairless. Some had wounds but didn’t know it; diabetes had numbed their feet. Many had been misdiagnosed with arthritis or gout, but when Fakorede tested them, he found peripheral artery disease, in which clogged arteries in the legs limit the flow of blood.
This is what uncontrolled diabetes does to your body: Without enough insulin, or when your cells can’t use it properly, sugar courses through your bloodstream. Plaque builds up faster in your vessels’ walls, slowing the blood moving to your eyes and ankles and toes. Blindness can follow, or dead tissue. Many can’t feel the pain of blood-starved limbs; the condition destroys nerves. If arteries close in the neck, it can cause a stroke. If they close in the heart, a heart attack. And if they close in the legs, gangrene.
Within a month, Bolivar Medical Center had credentialed Fakorede, allowing him to consult on cases and do procedures in the hospital. His most complicated patients came in through the emergency room. Some arrived without any inkling that they had gangrene. One had maggots burrowing in sores. Another showed up after noticing his dog eating the dead flesh off the tips of his toes. Fakorede took a photo to add to his collection. “It was a public health crisis,” he told me. “And no one was talking about amputations and the fact that what was happening was criminal.”
On weekends, Fakorede had been driving back to his five-bedroom home in Tennessee, but in August of 2015, he decided to go all-in on Bolivar County. He sold his house and black Mercedes G-Wagon, and applied for funding to build a practice in the Delta: Cardiovascular Solutions of Central Mississippi. He pitched himself as a heart guy and a plumber, removing buildup in the arteries. Four banks denied him loans, so he borrowed money from friends. He gave himself a two-year window to reduce amputations and publish his outcomes.
THE DELTA FLOOD PLAIN runs 7,000 square miles along the northwestern edge of the state, with sweet-smelling, clay-like soil cordoned between bluffs and the banks of the Mississippi River. By the 19th century, the primeval forests had been transformed into a cotton empire; at the start of the Civil War, more than 80% of people in many Delta counties were enslaved. Sharecropping emerged after emancipation, and black farmers cultivated small plots in return for a portion of their crop. They lived on credit — for food and feed and clothing — until the harvest, but even then, their earnings rarely covered their expenses.
For decades, African Americans in the South struggled to find and afford health care. The American Medical Association excluded black doctors, as did its constituent societies. Some hospitals admitted black patients through back doors and housed them in hot, crowded basements. Many required them to bring their own sheets and spoons, or even nurses. Before federal law mandated emergency services for all, hospitals regularly turned away African Americans, some in their final moments of life.
Fakorede was drawn to Bolivar County, in part, because of its history. He’d run out of gas there when he was first scouting the region, and later that evening, he’d Googled its background. For a brief moment, Bolivar was the center of a movement for public health care, driven by the conviction that racial equality was not possible without justice in health. In 1964, when a group of physician activists traveled to the Delta, Robert Smith, a black doctor from Jackson, saw rocketing rates of intestinal parasites and maternal death. “I understood for the first time what it truly meant to be black in Mississippi,” he told a magazine. Under President Lyndon B. Johnson’s War on Poverty, a Boston doctor secured funding to open a community health center in Bolivar, which he grew with the help of Smith. Clinicians worked with residents to take on housing, sanitation, exercise and nutrition. Its success spawned a national project of more than a thousand Federally Qualified Health Centers for the underserved. But funding shrank under President Richard Nixon, and the centers’ initiatives were scaled back to basic primary care.
By the time Fakorede moved to the Delta, in 2015, the state had the nation’s lowest number of physicians per capita. It had not expanded Medicaid to include the working poor. Across the country, 15% of African Americans were still uninsured, compared with 9% of white Americans. That year, Jennifer Smith, a professor at Florida A&M University College of Law, wrote in the National Lawyers Guild Review what Fakorede saw firsthand: “While the roots of unequal and inequitable health care for African Americans date back to the days of slavery, the modern mechanisms of discrimination in health care has shifted from legally sanctioned segregation to inferior or non-existent medical facilities due to market forces.”
Fakorede understood that to reach patients, he needed referrals, so he met primary care providers at hospitals and clinics. He asked them to screen for vascular disease, measuring blood pressure at the ankle and the arm. Many didn’t have the time; given the shortage of local physicians, some were seeing up to 70 patients a day. Others didn’t know much about peripheral artery disease or why it was important to diagnose. Some were offended by Fakorede’s requests. Michael Montesi, a family doctor, was grateful for the help, but he found it brash for the new doctor in town to start telling the veterans what to do. He recalled thinking, “Where were you the first 12 years of my practice, when I needed a cardiologist, when I needed an OB-GYN, when I needed a surgeon, when I had to do an amputation in the ER, or deliver a baby that was 23 weeks and watch the baby die because there was nobody there that could take care of him?”
The brushoffs disturbed Fakorede, but when he dug deeper, he realized that the doctors weren’t only overwhelmed; they had no guaranteed payment for this vascular screening. The Affordable Care Act mandates that insurers cover all primary care screenings that are recommended by the U.S. Preventive Services Task Force, an independent panel of preventive care experts. The group, though, had not recommended testing anybody without symptoms, even the people most likely to develop vascular disease — older adults with diabetes, for example, or smokers. (Up to 50% of people who have the disease are believed to be asymptomatic.) As specialists, cardiologists are reimbursed if they screen patients with risk factors. But by the time patients got to Fakorede, the disease was sometimes too far along to treat. Many already had a nonhealing wound, what’s known as “end stage” peripheral artery disease, the last step before an amputation.
When Luvenia Stokes came to Fakorede, she had already lost her right leg at the age of 48. Like many Delta residents, she grew up in a food desert, and without money for fresh produce, she’d developed diabetes at a young age. She said that a pedicurist nicked her toe, and the small cut developed an infection. Without good blood flow, it began bubbling with pus. Stokes told Fakorede that no doctor had performed an angiogram to get a good look at the circulation or a revascularization to clean out the arteries. A surgeon removed her second toe. Without cleared vessels, though, the infection spread. Within weeks, a new surgeon removed her leg.
Stokes lived in a single-wide trailer with her mother. Her wheelchair could not fit in the doorways, so she inched through sideways with a walker. Because she could hardly exercise, she gained 48 pounds in two years. The amputation hadn’t treated her vascular disease, and a stabbing pain soon engulfed her remaining leg, “like something is clawing down on you,” she said. When she finally made it to Fakorede, she told him that one doctor had prescribed neuropathy medication and another had diagnosed her with arthritis. “I’m not letting them get that other leg,” Fakorede told her. Stokes’ grandmother, Annie, who lives in a nearby trailer, had lost both her legs, above the knee, to diabetes. Her cousin Elmore had lost his right leg, too.
General surgeons have a financial incentive to amputate; they don’t get paid to operate if they recommend saving a limb. And many hospitals don’t direct doctors to order angiograms, the most reliable imaging to show if and precisely where blood flow is blocked, giving the clearest picture of whether an amputation is necessary and how much needs to be cut. Insurers don’t require the imaging, either. (A spokesperson for America’s Health Insurance Plans, a leading industry trade association, said, “This is not an area where there is likely to be unnecessary surgery.”) To Fakorede, this was like removing a woman’s breast after she felt a lump, without first ordering a mammogram.
Nationwide, more than half of patients do not get an angiogram before amputation; in the Delta, Fakorede found that the vast majority of the amputees he treated had never had one. Now, he was determined to make sure that no one else lost a limb before getting the test. This wasn’t a controversial view: The professional guidelines for vascular specialists — both surgeons and cardiologists — recommend imaging of the arteries before cutting, though many surgeons argue that in emergencies, noninvasive tests like ultrasounds are enough. Marie Gerhard-Herman, an associate professor of medicine at Harvard Medical School and a cardiologist at Brigham and Women’s Hospital, chaired the committee on guidelines for the American College of Cardiology and the American Heart Association. She told me that angiography before amputation “was a view that some of us thought was so obvious that it didn’t need to be stated.” She added: “But then I saw that there were pockets of the country where no one was getting angiograms, and it seemed to be along racial and socioeconomic lines. It made me sick to my stomach.”
Stokes wasn’t at immediate risk of losing her left leg when she met Fakorede, but pain prevented her from walking. She had a severe form of the disease, and Fakorede booked her for an angiogram and revascularization. He inserted a wire into her arteries and cleaned out the clogged vessels, letting oxygen-rich blood rush to her remaining foot. While she was recovering in Fakorede’s lab, she thought about her neighbors who had the same problems. “I really don’t like what’s happening to us,” she said to me. “They’re not doing the tests on us to see if they can save us. They’re just cutting us off.”
Patients didn’t know about vascular disease, or why their legs throbbed or their feet blackened, so Fakorede went to church. The sales rep, Hampton, introduced him to pastors, and several times each month, he stood before a pulpit. He told the crowds that what was happening was an injustice, that they didn’t need to accept it. He told them to get screened, and if any surgeon wanted to cut off their limbs, to get a second opinion. In the lofty Pilgrim Rest Baptist Church, in Greenville, he asked the congregation, “How many of you know someone or know of someone who’s had an amputation?” Almost everyone raised their hands.
At first, Fakorede took a confrontational approach with colleagues. Some seemed skeptical that he could “prevent” amputations; it’s a tall claim for a complex condition. Once, when a doctor had disregarded his advice, he’d logged it in the electronic health record, so the oversight would be on display for anyone who looked up his patient’s chart. Fakorede could fume when people questioned his authority; self-confidence carried him, but it sometimes blinded him to his missteps. Over time, though, Fakorede tried to rein in the arrogance. “You peel off a layer that may be comprised of: I’m from up North, I know it all, you should be thankful we’re here to provide services that you probably wouldn’t get before.” He picked up some Southern manners. Fakorede began texting doctors with photos of their patients’ feet along with X-rays of their arteries, before his intervention and afterward. Referrals picked up, and within a year, he’d seen more than 500 patients.
But Bolivar Medical Center, he learned, was turning away people who couldn’t pay a portion of their revascularization bill upfront. Several former employees told me the same. “It’s a for-profit hospital, it’s no secret, it’s the name of the game,” Fakorede said. “But a for-profit hospital is the only game in town in one of the most underserved areas. So what happens when a patient comes in and can’t afford a procedure that’s limb salvage? They eventually lose their limbs. They’ll present back to the emergency room with a rotten foot.” And a surgeon would have no choice but to amputate. (A hospital spokeswoman said that last year, it gave $25 million in charity care, uncompensated care and uninsured discounts. Asked if it turned away patients who couldn’t pay for revascularization, she did not respond directly: “We are dedicated to providing care to all people regardless of their ability to pay.”)
The practice was discriminatory, he reasoned, and also financially backward. At $237 billion in medical costs each year, diabetes is the most expensive chronic disease in the country; one of every four health care dollars is spent on a person with the condition. Left untreated, the costs pile on. Medicare spendsmore than $54,000 a year for an amputee, including follow-ups, wound care and hospitalizations; the government program is the country’s largest payer. Then come the uncounted tolls: lost jobs, a dependence on disability checks, relatives who sacrifice wages to help with cooking and bathing and driving.
By the time Carolyn Williams came to see Fakorede, in 2016, she’d been uninsured with diabetes for 20 years; she’d worked at a housing nonprofit and for a food assistance program, but neither had offered coverage. At the age of 36, she’d needed a triple bypass surgery, and at 44, she had three toes amputated. Untreated leg pain left her needing a wheelchair; she pulled out of Delta State University, where she was pursuing a degree in social work. Fakorede reconstituted blood flow in her legs and got her walking. But the diabetes was already destroying her kidneys. She joined the government’s disability rolls. She also went on dialysis, at a yearly cost to Medicare of $90,000.
On the days when Fakorede wanted to give up and leave, he drove to an Emmett Till memorial in Money, Mississippi. After 14-year-old Till was mutilated and murdered, in 1955, his mother had insisted on opening his casket. “Let the people see what I’ve seen,” she said, and his image brought national outrage to racist violence in the South. Fakorede thought often about how that decision sparked the Civil Rights movement. He thought about it as he exhibited his photos of rotten feet and limbless bodies, his own proof of what he considered a modern atrocity. He didn’t want to live by Bolivar Medical’s policies. He decided that in order to treat as many people as possible, irrespective of income or insurance, he needed to build a lab of his own.
THIS JANUARY, THAT LAB was now Dotstry’s best shot. The hospital’s consulting surgeon expected to amputate his leg below the knee. He had written that because Dotstry’s kidneys were impaired, the contrast dye in an angiogram would be dangerous. But Fakorede could replace the dye with a colorless gas, which wouldn’t jeopardize Dotstry’s health.
It would have made the most sense to perform the procedure at the hospital; Dotstry had been admitted and was occupying a bed. But after Fakorede opened his outpatient lab and hired away two techs and a nurse, a spokeswoman said the hospital stopped doing certain interventions. She told me it shouldn’t have surprised Fakorede that they couldn’t schedule Dotstry’s case, and that if he had been unable to treat a patient in his lab, the hospital could have worked with him to find another. Fakorede told me he’d never received such a message. When a doctor asks him to treat an inpatient with an acute condition, his responsibility, as he sees it, is to do it in the hospital. “If I don’t have a hospital that wants to coordinate,” he asked, “what do I do?”
The answer, at least this time, was to get his patient out of there. He called Dotstry’s doctor and convinced her to discharge him for the intervention. Then, at noon on Saturday, Fakorede walked back into Room 336. Dotstry’s sister, Judy, was standing by his bed. She wore tall leather boots over acid-washed jeans, with a thick, black wig in a braid down her back.
Fakorede handed over his card. “I called the hospital to see if we can do this case on Monday,” he said, “and they said no.”
Judy inhaled. “What now?”
Fakorede laid out the plan for a Monday morning angiogram in his own procedure room. He would open up as many vessels as he could. If he could get circulation to Dotstry’s foot, he might be able to save it. He wasn’t sure about the toes.
When Dotstry had suffered his stroke several years back, Judy had become his caregiver. She’d stopped taking jobs in home care and supported her brother without pay — shuttling him to doctors’ appointments, controlling his sugars, managing his medications. After his amputation, she’d helped him learn to walk again. In place of a salary, she’d drawn disability for an old work injury; she’d been electrocuted while operating a machine, and the nerves in her arm were damaged, making her hands tremble. But she couldn’t stay unemployed forever. This past fall, she had gone back to work, cleaning the local post office.
After Fakorede left, Judy looked over at her brother, who sat slumped over the side of the cot, a blue gown slipping off his bony shoulders. Their father had been a sharecropper, and Dotstry had dropped out of elementary school to help on the farm, harvesting soybeans, rice and cotton. Of 10 kids, he was the oldest boy, and he took care of the others, bringing in cash and cooking them dinner. They almost never saw a doctor. Instead, they’d relied on cod liver oil, or tea from hog hoofs, parched over a fire.
Dotstry had spent his career driving tractors, hauling crops and plowing fields, but he wasn’t insured and still rarely saw doctors. At 60, when he was diagnosed with Type 2 and prescribed insulin, he didn’t know how to manage the medicine properly; he had never learned to read. Insulin pumps were too expensive —more than $6,000. His blood sugar levels often dropped, and he sometimes passed out or fell on the job. Little by little, his employer cut back his duties. In 2015, he had a stroke; diabetes had raised his risk. A year later, his right foot blackened and was amputated at the ankle. The infection kept spreading, and soon, his lower leg went. He could no longer work.
Two of his sisters had died after complications of diabetes. Judy had stood over their beds like she was now standing over Dotstry’s. He’s still here, she reminded herself.
She pulled out her phone and called another brother. “They gonna amputate his foot, cause it’s bad,” she said. “Toe’s rotted.”
Dotstry looked up from the bed. “No!” he shouted. “They can’t take that off. Why?”
“Why you think your foot look like that? Why you think it smells? It stinks!” she said. Dotstry reached down to unwind the gauze. Judy wondered why he hadn’t told her that his foot was infected sooner. She lowered her voice. “You were doing pretty good. If you wasn’t, I could have tried to get back in there and do something.”
Her daughter, Shequita, ran into the room, huffing. She was loud and pissed off. “Whose foot is that?” she shrieked. She kneeled by the cot and helped Dotstry scoot up onto his pillow, stretching out his legs. He was usually a prankster, a hard-headed contrarian, the uncle who’d picked her up and spun her around like an airplane. She was thrown off by how quiet he’d become.
“Your daughter wants to know if you want to come stay with her, if you want to come to Texas,” Shequita told him.
Dotstry knew the offer was on the table, but he hadn’t yet accepted. A few days earlier, a tornado had torn the roof from his trailer, and he was, for the moment, without a home.
“She said it’s a lot better doctors up there,” Shequita continued, “and if she gotta stop working to take care of you, she can do that.” She gripped her hands around the frame of the bed and leaned over it, locking her eyes with his. “I need you to be thinking hard about this, sir. This ain’t you. I need you to get back to you.”
“He ain’t gotta go to Texas,” Judy interrupted.
Shequita shot back: “You gonna take care of him?”
Judy was silent. She knew that she couldn’t, not like before. She needed her paycheck for home repairs; a flood had warped her wooden floors. But Dotstry’s daughter was younger, and Judy thought that if she quit her job at Walmart, she’d get restless. Besides, Dotstry knew no one in Texas. She pictured him in a wheelchair, staring off, confused about where he was. Judy figured if he went, he’d go on and die.
She crossed her arms. “He’ll be all right if they don’t have to amputate that leg,” she said.
Shequita looked at her mother. She walked over to where she stood, by a shaded window, and threw her arms around her neck. Then, she left the room. Judy hoisted herself up onto the foot of her brother’s cot. She swung her legs up so that she faced him, and she laid herself down.
ABOUT EVERY FIVE YEARS, the doctors and researchers who make up the U.S. Preventive Services Task Force reassess their screening guidelines. In 2018, the members returned to peripheral artery disease and the blood flow tests that Fakorede had asked local primary care doctors to conduct. Once again, the panel declined to endorse them, saying there was not enough evidence that the tests benefited the average asymptomatic American.
In their statement, they acknowledged that public commenters had raised concerns that the disease “is disproportionately higher among racial/ethnic minorities and low-socioeconomic populations” and that this recommendation “could perpetuate disparities in treatment and outcomes.” In response, the panel said it needed better evidence. But as the National Institutes of Health has found, minorities in America make up less than 10% of patients in clinical trials.
Dr. Joshua Beckman, the director of vascular medicine at Vanderbilt University Medical Center, was an expert reviewer of the evidence base for the task force, and its final report struck him as irresponsible. It hardly noted the advantages of treatment after screening; the benefits were right there in the data that he saw. The panel discounted the strongest study, a randomized control trial, which demonstrated that vascular screening, for men ages 65 to 74, reduced mortality and hospital days. (The study bundled peripheral artery disease screening with two other tests, but in Beckman’s eyes, the outcomes remained significant.) He was confused about why the task force had published its evaluation of screening the general public, when it was clear that the condition affects specific populations. Several American and European professional society guidelines recommended screening people with a higher risk. “You wouldn’t test a 25-year-old for breast cancer,” he told me. “Screening is targeted for the group of women who are likely to get it.”
Dr. Alex Krist, the chair of the task force, repeated the group’s position in an email that the data was not strong enough to endorse screening, even for at-risk patients. “The Task Force does not do its own research, so we can’t fix these research gaps, but we can — and did — ring the alarm bell to raise awareness of this vital issue among researchers and funders.”
Vascular surgeons who have spent their careers studying limb salvage have come to see preventive care as perhaps more important than their own last-ditch efforts to open blood vessels. Dr. Philip Goodney, a vascular surgeon and researcher at Dartmouth and White River Junction VA Medical Center, made a name for himself with research that showed how the regions of the country with the lowest levels of revascularization, like the Delta, also had the highest rates of amputation. But revascularizations aren’t silver bullets; patients still must manage their health to keep vessels open. Now, Goodney believes his energy is better spent studying preventive measures earlier in the disease’s progression, like blood sugar testing, foot checks and vascular screening. Many patients have mild or moderate disease, and they can be treated with medicine, counseled to quit nicotine, exercise and watch their diet. “We need to build a health system that supports people when they are at risk, when they are doing better and when they can keep the risk from coming back,” he told me. “And where there’s a hot spot, that’s where we need to focus.”
Fakorede scrolled through the task force’s statement. “You want more data? Really? Who has the highest amputation rates in America?” he asked. “That’s your data.” He had taken to the national stage, speaking at conferences about what he’d witnessed in Bolivar. On behalf of the Association of Black Cardiologists, he testified before Congress, convincing U.S. Rep. Donald M. Payne Jr., a Democrat from New Jersey, along with U.S. Rep. Gus Bilirakis, a Republican from Florida, to start a Congressional Peripheral Artery Disease Caucus. The group is pushing for the task force to reevaluate the evidence on screening at-risk patients, for federal insurers to start an amputation prevention program and for Medicare to ensure that no amputation is allowed before evaluating arteries. Other groups are advocating for legislation that would require hospitals to publicly report their amputation rates.
In Bolivar, Fakorede had seen more than 10,000 cardiovascular patients from around the Delta. Dr. DeGail Hadley, a primary care provider in town, told me that before Fakorede arrived, he wasn’t sure what was best to do for patients with rotting feet. “It was always a process of transferring the patients to Jackson or Memphis, which can be difficult.” Both cities were two hours away. Now, Fakorede was performing about 500 angiograms annually in town. Last year, he published a paper in Cath Lab Digest describing an 88% decrease in major amputations at Bolivar Medical Center, from 56 to seven. (Fakorede did not provide me with all of his sources.) The hospital has different internal figures, which also reflect a significant decrease. Between 2014 and 2017, the hospital recorded that major amputations had fallen 75% — from 24 to six.
Fakorede couldn’t catch everyone in time, and he was haunted by the patients who got to him too late. A week before he’d met Dotstry, Sandra Wade had come in with an open sore on her right big toe. She came from a family of diabetics. Her mother had died after a diabetic coma. Her cousin had just lost a leg. Her oldest sister, who’d raised her, had given up on walking when a tired, burning, itching sensation consumed her legs. Now, Wade felt it, too.
“I don’t want to give up like that,” Wade had said, reclining in a cot in Fakorede’s pre-procedure room. “I want my toes. I don’t want to lose not one limb. I choose life.” She elongated her O’s. She was 55 and had a high, gentle voice, a wide smile and big, curled lashes under loose, curled hair. She had spent most of her career in food service and retail, recently managing a Family Dollar, but after diabetes took her eyesight, she’d had to quit. She wondered if the sodas and chips that had fueled her at the store had accelerated her disease. Or if she’d focused so much on her son, who was developmentally disabled, that she’d neglected herself. She didn’t like to offload blame onto her genes. “Somebody’s gotta try to change the cycle,” she’d said. “I really want to be the one.”
Fakorede inserted an IV into the top of her leg. He opened up each of her blocked arteries, one at a time, until he got to the most important one, which ran along her inner calf. It was supposed to supply blood to her open wound, and she needed it to heal. Without it, she’d likely lose her toe. If she didn’t control her sugars, she could lose her lower leg next. Fakorede was hopeful as he slid a wire through the vessel in her knee, and into that crucial artery in her calf. But then, about a third of the way down, it stopped. It was as if the vessel itself had evaporated.
UNDER A CRISP, WIDE SKY, on Martin Luther King Jr. Day, churches around town were opening their doors for services. Fakorede’s office was scheduled to be closed, but he’d called in his nurses and radiology technicians, even those out hunting deer, to staff Dotstry’s case.
“What’s up, young man?” Fakorede greeted Dotstry, who was slowly fading into his Ambien, and he handed Judy a diagram of a leg. “The prayer is that we can find this many vessels to open up,” he said, pointing to the paper. “As soon as I’m done, I’ll let you know what I find.”
In the procedure room, he put on his camouflage-patterned lead apron, and with an assistant, he inserted an IV near Dotstry’s waist. He wound a wire across Dotstry’s iliac artery, into the top of his left leg. The femoral artery was open, even though it had hardened around the edges, a common complication of diabetes. They shot a gas down the arteries in Dotstry’s lower leg so the X-ray could capture its flow. Fakorede looped his thumbs into the top of his vest, waiting for the image. Other than a small obstruction, circulation to the toes was good. “They don’t need to whack off the knee,” he said, staring at the screen. Dotstry would lose one toe.
After they’d cleaned out the plaque, Fakorede called Judy into the lab and pulled up the X-rays. Dotstry snored in the background. The doctor showed Judy a playback of the blood moving through the vessels. She could tell that his foot had enough flow. She folded over, running her palms along her thighs. “Y’all have done a miracle, Jesus.”
Dotstry would need aggressive wound care, help controlling his sugars and a month in rehab following his toe amputation. In the meantime, Judy and her daughter would have to learn to manage his antibiotics and find him an apartment. He’d still be able to tinker with his cars, as he did most afternoons. And as far as Judy was concerned, he wasn’t moving to Texas.
Fakorede scrubbed out. He sat at his desk to update Dotstry’s doctors. He called an infectious disease specialist, 35 miles south, to check on whether he could see Dotstry the following morning. Then, he dialed the hospital and asked for one of the nurses. He explained what he’d found: that Dotstry didn’t need a leg amputation.
“Oh, great,” the nurse replied. “The surgeon was calling and asking about that. He called and tried to schedule one.”
Fakorede had been typing up notes at the same time, but now he stopped. “He was trying to schedule it when?” he asked.
“He was trying to schedule it today.”
ABOUT THE REPORTING
For this story, Lizzie Presser spent over a month in Mississippi, in December and January, speaking with dozens of patients and shadowing doctors, in clinic and in procedures. She interviewed over a dozen medical professionals whose work has intersected with Fakorede’s, including nurses, limb-salvage specialists, primary care providers and the hospital’s consulting surgeon, Dr. Roger Blake, who corroborated all facts related to his treatment plan for Henry Dotstry. She asked Bolivar Medical Center if it believed it provided Dotstry with adequate care. Even with Dotstry’s permission, the hospital declined to comment on his case, citing patient privacy.
The scenes in the story are informed by her own observations and interviews with the subjects to fill in details, including their thoughts at the time.
To put her observed reporting into national context, she reviewed the salient medical research and interviewed more than a dozen experts in all corners of the health care system, from those who treat diabetic patients to those who inform and set policies around care.
Lizzie Presser covers health, inequality and how policy is experienced for ProPublica.
The Rev. Dr. Kejuane Artez Bates was a big man with big responsibilities. The arrival of the novel coronavirus in Vidalia, Louisiana, was another burden on a body already breaking under the load. Bates was in his 10th year with the Vidalia Police Department, assigned as a resource officer to the upper elementary school. But with classrooms indefinitely closed, he was back on patrol duty and, like most people in those early days of the pandemic, unprotected by a mask. On Friday, March 20, he was coughing and his nose was bleeding. The next day, he couldn’t get out of bed.
Bates was only 36, too young to be at risk for COVID-19, or so the conventional wisdom went. He attributed his malaise to allergies and pushed forward with his second full-time job, as head pastor of Forest Aid Baptist Church, working on his Sunday sermon between naps. Online church was a new concept to his parishioners, and during the next morning’s service, he had to keep reminding them to mute their phones. As he preached about Daniel in the lion’s den — we will be tested, but if we continue to have faith, we will come through — he grimaced from the effort. That night he was burning up with fever. Five days later he was on a ventilator; five days after that, he died.
While COVID-19 has killed 1 out of every 800 African Americans, a toll that overwhelms the imagination, even more stunning is the deadly efficiency with which it has targeted young Black men like Bates. One study using data through July found that Black people ages 35 to 44 were dying at nine times the rate of white people the same age, though the gap slightly narrowed later in the year. And in an analysis for ProPublica this summer using the only reliable data at the time accounting for age, race and gender, from Michigan and Georgia, Harvard researcher Tamara Rushovich found that the disparity was greatest in Black men. It was a phenomenon Enrique Neblett Jr. noticed when he kept seeing online memorials for men his age. “I’ll be 45 this year,” said the University of Michigan professor, who studies racism and health. “I wasn’t seeing 60- and 70-year-old men. We absolutely need to be asking what is going on here?”
To help illuminate this gap in knowledge and gain a deeper understanding of why America has lost so many young Black men to COVID-19, ProPublica spent months gathering their stories, starting with hundreds of news articles, obituaries and medical examiners’ reports, then interviewing the relatives and friends of nearly two dozen men, along with researchers who specialize in Black men’s health. Our efforts led us to a little-known body of research that takes its name from one of the most enduring symbols of Black American resilience.
In interviews about the young men who died from the virus, a portrait emerged of a modern John Henry: hard-working, ambitious, optimistic and persistent, trying to lift others along with themselves. They were the very people communities would have turned to first to help recover from the pandemic: entrepreneurs who were also employers; confidants like coaches, pastors and barbers; family men forced into a sandwich generation younger than their white counterparts, because their parents got sick earlier and they had to care for them while raising kids of their own.
They were ordinary men. Time and again, it was their fight that was remarkable.
Bates, the only child of a single mother who supported him as a teacher’s aide, made it to Alcorn State University on football and choir scholarships. When his mother got sick with breast cancer, he had to drop out; after she died, he was almost destitute. Over the years, he built himself into multiple men at once, each a pillar to many others: the pastor whose flock depended on his counsel; the mentor known to school kids as Uncle Officer Bates; the assistant football coach and band director; the adoring father to 5-year-old Madison — his “heartbeat,” he called her. Recently he and his wife, Chelsea, a second grade teacher, had launched One Love Travel, organizing excursion packages and cruises as part of their long-term plan to build generational wealth.
He carried the stress of his efforts in his blood vessels, in his kidneys, in the extra pounds that accumulated with each passing year; he had diabetes and hypertension and at 6-foot-6, he was more than 100 pounds overweight. His official cause of death, on April 1, was COVID-19-related pneumonia and acute respiratory distress syndrome.
But Chelsea knows that the virus, no matter how powerful, didn’t kill her husband on its own. It was the years of working nonstop, taking care of other people more than himself, that wore his body down. And when the virus attacked, he couldn’t fight back.
In the summer of 1978, the social epidemiologist Sherman James, then a 34-year-old researcher at the University of North Carolina at Chapel Hill, met the man who would shape his life’s work. At 70, John Martin was a retired farmer who suffered from debilitating osteoarthritis and hypertension. He had peptic ulcers so severe that doctors had to remove 40% of his stomach. Recounting his story in his backyard rocking chair, his cane resting on his lap, the old man had no doubt why his health was so bad: “I worked too hard.”
Born in 1907, Martin grew up in a family of sharecroppers who were only paid half of what their labor in the tobacco fields earned. Throughout the South at the time, most Black farmers lived at the economic mercy of landowners who were employers, landlords and vendors all at once. Martin watched as the system ruthlessly exploited his father; after one particularly harsh winter spent hungry, Martin vowed he would be different. Borrowing $3,725 in 1941, he purchased 75 acres. He had 40 years to settle the mortgage but accomplished the near-impossible: He paid it off in five. “That’s the reason my legs [are] all out of whack today,” he told James.
James listened, spellbound, until Martin’s wife called out, “John Henry, it’s time for lunch.” At that moment, something clicked. Holy cow, James remembers thinking. “It was just like the ancestors were speaking to me.” The power of Martin’s story wasn’t simply that it echoed the legend of John Henry; it also echoed the life experiences of most of the working-class African American men James knew.
Five years out of graduate school, James was among a small group of researchers focusing on one of the most enduring public health problems in the United States: why health outcomes for Black men are so poor. Black men live shorter lives than all other Americans — 71.5 years versus 76.1 years for white men — and have for generations. Black men’s life expectancy didn’t reach 65, the eligibility age for Medicare, until 1995, 30 years after the federal health program for the elderly became law; white men were living into their mid-60s by 1950. The shorter lifespans reflect a broader disparity: Black people have much higher rates of hypertension, obesity, diabetes and strokes than white people do, and they develop those chronic conditions up to 10 years earlier. The gap persisted this year when the Brookings Institution examined COVID-19 deaths by race; in each age category, Black people were dying at roughly the same rate as white people more than a decade older.
For generations, public health experts mostly ignored the disparities. When they did pay attention, they invariably blamed the victims — their “unhealthy” behaviors and diets, their genes, the under-resourced neighborhoods they “chose” to live in and the low-paying jobs they “chose” to work. Their chronic illnesses were seen as failures of personal responsibility. Their shorter life expectancy was written off to addiction and the myth of “black-on-black” violence. Many of those arguments were legacies of the slave and Jim Crow eras, when the white medical and science establishment promoted the idea of innate Black inferiority and criminality to rationalize systems built on servitude and segregation.
Pondering the lessons of John Henry Martin, James began to see what many of his colleagues had been missing. It wasn’t just living in poverty that wore down Black men’s bodies, he hypothesized, but the struggle to break out of poverty. It wasn’t just inequality that made them sick, but the effort to be equal in a system that was fundamentally unjust. “It’s this striving to make something of themselves … to live their lives with dignity and purpose and to be successful against extraordinary circumstances,” James said. “They’re trying to make a way out of no way. It’s the Black American story.”
America has changed profoundly since Martin’s day. Yet the machinery of racial inequality continues to be omnipresent. It’s in the hospitals where Black newborns have significantly lower mortality if they’re cared for by Black doctors rather than white ones. In the redlined neighborhoods where poverty and pollution are concentrated — but not affordable housing or grocery stores or reliable internet. It’s in the crumbling, exploitative economies that force parents to risk their lives working long hours for low pay without sick leave. In mass incarceration and voter suppression. In the innumerable hurdles, one piled upon another, that make Black Americans’ climb up the socioeconomic ladder more daunting than ever, their successes more fragile and their setbacks more consequential.
“Everyone thinks about racism as something that is personally mediated, like someone insulting me,” said Linda Sprague Martinez, a professor at Boston University’s School of Social Work who conducts community health research with adolescents and young adults. “But the way in which it’s really pervasive is how it disrupts life chances and opportunity. … These are systems that are designed for you to fail, essentially, and for you to be erased and to be maintained in a certain position in our society.”
Challenging such a relentless machine, through “high-effort coping,” James concluded, requires three categories of personal traits that are major themes of the John Henry legend: tenacity, mental and physical vigor and a commitment to hard work. To measure them, he developed the John Henryism scale, with scores determined by how strongly people identify with 12 statements, including: “Once I make up my mind to do something, I stay with it until the job is completely done,” and, “It’s not always easy, but I usually find a way to do what really needs to be done.”
To score high in John Henryism, you don’t have to be Black or male or economically disadvantaged. But over the years, James and other researchers have found that Black people, especially those who are poor and working-class, do score high and tend to suffer greater cardiovascular risks, perhaps because the innumerable hurdles in their paths require greater effort to overcome. “The stress,” James said, “is going to be far more overwhelming than it has a human right to be.”
Stress is a physiological reaction, hard-wired in the body, that helps protect it against external threats. At the first sign of danger, the brain sounds an alarm, setting off a torrent of neurological and hormonal signals that whoosh into the blood, stimulating the body to fight or give flight. The heart beats faster and breathing quickens; blood vessels dilate, so more oxygen reaches the brain and muscles. The immune system’s inflammatory response is activated to promote quick healing. When the threat passes, hormone levels return to normal, blood glucose ebbs and heart rate and blood pressure go back to baseline. At least, that’s how the human body is designed to work.
But overexposure to cortisol and other stress hormones can cause the gears to malfunction. “Your body’s over-producing, always working hard to bring itself back down to the normal level,” said Roland J. Thorpe Jr., a professor at the Johns Hopkins Bloomberg School of Public Health and founding director of the Program for Research on Men’s Health at the Hopkins Center for Health Disparities Solutions. The constant strain “resets the normal,” he said. As blood pressure remains high and inflammation becomes chronic, the inner linings of blood vessels start to thicken and stiffen, which forces the heart to work harder, which dysregulates other organs until they, too, begin to fail. “Your body starts to wear down,” Thorpe said — a phenomenon known as weathering.
The cumulative effects of stress begin in the womb, when cortisol released into a pregnant woman’s bloodstream crosses the placenta; it is one of the reasons a disproportionate number of Black babies are born too early and too small. Then, exposure to adverse childhood experiences — anything from abuse and neglect to poverty and hunger — continues the toxic stream; too much exposure to cortisol at a critical stage in development can rewire the neurological system’s fight-or-flight response, essentially causing the brain’s stress switch to break. The more stress a youngster endures, the more likely he or she is to have academic, behavioral and health problems from depression to obesity.
Weathering isn’t specific to race, but it is believed to take a particular toll on Black people because of the unique, unrelenting stress caused by racism that wears away the body and the spirit, “just like you have siding on the house, and the rain or the sun beats on it, and eventually it starts to fade,” said Dr. Jerome Adams, the U.S. surgeon general under the Trump administration. Shawnita Sealy-Jefferson, a social epidemiologist at Ohio State University, says the human body isn’t designed to withstand such biological and emotional assaults: “It’s the same thing as if you revved the engine of your car all day, every day. Sooner or later, the car is going to break down.”
The effects of stress can be seen at the cellular level. Researchers have found that in Black people, telomeres — repeated sequences of DNA that protect the ends of chromosomes by forming a cap, much like the plastic tip on a shoelace — become shortened at a faster rate, a sign of premature aging. In a 2018 study examining changes in seven biomarkers in cardiac patients over a 30-year period, researchers found that Black patients weathered at an average of about six years faster than whites. And it was the extraordinarily high rates of hypertension in the Black community that prompted scientists to look at the impact of stress in the first place. By age 55, about 76% of Black men and women develop high blood pressure, versus 54% of white men and 40% of white women, which increases the risk of heart attacks and strokes.
Sustained stress has strong links to obesity, which Black children and adults have at much higher rates than whites. Some of this is physiological: The interplay between cortisol and glucose is complex and insidious, triggering metabolic changes that can lead to diabetes and other chronic diseases. Some of it is psychological and behavioral: Stress is strongly associated with depression and other mental health disorders. “The way that people deal with stress is by strategies that make us feel better,” such as comfort eating, said Thomas LaVeist, dean of Tulane University School of Public Health and Tropical Medicine. Stress and anxiety cause sleeplessness, which itself is correlated with weight gain. The result is often a cascade of health problems — hypertension, cardiovascular disease, metabolic syndrome — that strike early and feed off of each other.
Because Black Americans experience many forms of stress, often at once, researchers have more questions than answers about the specific role John Henryism plays in these outcomes. The study of Black men’s health remains an under-examined frontier, with little in the way of funding or will because “Black men are not viewed as sympathetic,” said LaVeist, and because so few go into the health research professions. He and Thorpe, the Johns Hopkins professor, co-founded the Black Men’s Health Project, the first large-scale national study focused solely on Black men’s needs, with a goal sample size of 5,000. They hope to learn how stressors like segregation and adverse early life experiences impact health outcomes.
If this segregated body of emerging knowledge were to grow and infiltrate the mainstream medical and research communities, James can only imagine how beneficial that would be. Health professionals could build deeper relationships with their patients by better understanding the sources of stress that wreak havoc on their cardiovascular systems. They could test for high blood pressure, diabetes and cholesterol levels more frequently and at younger ages. “Until we can have a society that is more just racially,” James said, “we do need to find these intermediate steps.”
As ProPublica examined the lives lost to COVID-19, themes emerged in the pressure points faced by many young Black men. The wearing down typically begins when they are boys and must become little John Henrys to navigate white spaces or push through the adverse experiences endemic to Black communities. It continues when they grow into men, as most need to navigate the public’s projections of danger with unwavering vigilance. The more they succeed, the more responsibility they feel to lift their families and communities with them, and with that, comes more stress.
As James listened to the stories ProPublica was gathering, he instantly recognized the cycle of striving and succumbing that he has been writing about for 40 years. “They could have done so much more had the struggle not been so intense,” James said. “They were cut down too soon.”
Thomas Fields Jr. was barely a year old when his father first went to prison. The loss altered the trajectory of his life in ways that many children wouldn’t have been able to overcome. His mother, just 17 when he was born, moved with him from the suburbs of Washington, D.C., to Detroit, where her own mother had recently relocated. The city was in freefall: manufacturing jobs were disappearing; crime was surging; middle-class and white flight was stripping away the city’s tax base, eroding vital services and causing schools to fail. Just waiting at the wrong bus stop could get you robbed or shot.
“When you’re a young male living in Detroit, if you live past 18, it’s like you’re 50 years old,” Fields, then 31, said on a Facebook Live chat last year. “I swear that’s how it feels.”
Mitigating childhood adversity requires deep wells of resilience; researchers say one of the best ways to build those reserves is having a nurturing caregiver. In this, young Thomas was exceptionally lucky. His mother worked two jobs and still managed to watch him like a hawk; she told him constantly that she loved him. His grandmothers looked after him after school and during summer breaks. His father, Thomas Sr., did his best to be involved from behind bars, urging him to not make the same mistakes. “I wanted this Thomas Fields to break the mold,” he said.
To do that, Thomas became a little John Henry. He got decent grades, stayed out of trouble and taught himself to cook — healthy food, not the junk so many of his peers ate. After high school, he attended Grambling State University in Louisiana for a couple of years, then joined the U.S. Navy, where he went from being a talented amateur chef to a trained professional. He also became a father. When there were setbacks, he was already planning his next move. It’s a strategy that Black adolescents absorb like the air they breathe and the water they drink, Sprague Martinez said. “The mentality is: ‘Even if this system is not designed to work for me … I’m going to win this game. I haven’t gotten the prize yet? I must not be working hard enough.’”
High-effort coping can confer mental health benefits even for children raised in the direst of circumstances. Dosha DJay Joi endured the kind of trauma that dooms many children — beatings, neglect, sexual abuse. Born in Chicago, he spent much of his adolescence in group homes in the Wisconsin system. For years he was afraid to talk about the abuse and scared to tell his birth mother he was queer. He learned to channel himself into education and advocacy, helping other LGBTQ and foster kids; he especially wanted to make sure children remained connected with their siblings. He was inspired to study social work because of what he’d been through, said his mother, Kecha Kitchens. “Then a family member got sick, and he didn’t like how the nurses were treating the other patients in the nursing home, so he wanted to become a nurse.”
By the age of 28, Joi had a bachelor’s degree in human services, he had trained as a substance abuse counselor and he was working toward his nursing degree. He served as a court-appointed special advocate for kids aging out of foster care and lobbied lawmakers in the Wisconsin capitol and Washington D.C., forming a special bond with Rep. Gwen Moore, who represents Milwaukee in Congress. But the years of hardship took an enormous physical toll; Joi suffered from hypertension, heart and lung problems and at his heaviest, he weighed more than 500 pounds. When COVID-19 arrived in the Midwest, he was particularly vulnerable. He died on May 14.
For young John Henrys, the psychological benefits of high-effort coping seem to be complicated by what’s happening inside the body. “Typically when you study resilience in any group, and [subjects are] doing well by our typical metrics” — going to college, getting a good job, not taking drugs — “we say, ‘Woo-hoo,’” University of Georgia researcher Gene Brody said. “Logically, we thought this would transfer to have health benefits.” But for Black young adults trying to climb the economic ladder, they found just the opposite. “When you look under the skin, doing blood draws and using other kinds of measures, they look like their health is starting to suffer.”
In more than 25 years spent tracking the health of Black families in rural Georgia, Brody and his colleagues found that adolescents identified by their teachers as being success-oriented already had higher “allostatic loads” — science jargon for wear-and-tear on the body — at age 19 than their peers. By age 25, those from more disadvantaged backgrounds who scored high on the John Henryism scale were more likely to have metabolic syndrome, a cluster of conditions that are precursors to diabetes and heart disease, than people from less disadvantaged backgrounds. Brody and his colleagues have dubbed this phenomenon“skin-deep resilience.” The same effects are not found for young white strivers.
In his late 20s, Fields was diagnosed with such a severe case of diabetes that his military career came to a screeching halt. When he returned to Detroit last year, he was a little brawnier, with more tattoos. “Diabetes was something that he was going to beat, because he wasn’t going to lose to anything,” said the Rev. Torion Bridges, one of his best friends for 20 years. He became a personal chef and motivational speaker, started a podcast and wrote a cookbook. He helped out his mom, who had multiple sclerosis. And he took a job as a “school culture facilitator,” working with kids who had discipline problems, at Paul Robeson Malcolm X Academy, the pioneering Afrocentric public school he had attended. He was especially good with troubled boys who didn’t have a father at home, said principal Jeffrey Robinson, his onetime homeroom teacher, later his boss. “He could identify with the feeling of the loss.”
In March, Fields and his mother caught the coronavirus at the same time.
She recovered. He did not.
To navigate life as a Black man is to be constantly vigilant. The ubiquity of racism means that everyday interactions, while driving or shopping or birdwatching, can have potentially dangerous outcomes. So John Henrys live in a heightened state of awareness, continually adjusting. It might mean placing family photos near the front door to quickly prove your son belongs should police ever respond. It often means being able to “strategically assimilate” — to assume a public identity aimed at neutralizing stereotypes of blackness and defusing irrational white fears. This, W.E.B. DuBois explained more than a century ago, is “double-consciousness, this sense of always looking at one’s self through the eyes of others, of measuring one’s soul by the tape of a world that looks on in amused contempt and pity.”
New York Times columnist Brent Staples would whistle Vivaldi in graduate school to signal that he was too cultured to be threatening. Darrell Hudson, who researches health disparities at Washington University in St. Louis, scans the closet each day before teaching class to select what he calls his “Non- Threatening Black Guy Uniform.”
“What’s not appreciated fully, I think, is how much energy it takes,” said Derek M. Griffith, professor and director of the Center for Research on Men’s Health at Vanderbilt University. “All of these different things that you have to do to modulate your body and so forth, all that additional attention that you have to pay to that, is a burden that most people don’t have to bear. It is a cause of weathering that we don’t fully appreciate.”
A 2014 study found that vigilance was positively associated with the prevalence of hypertension for Blacks but not whites. The more vigilant Black people were, the more the disparity grew. And researchers have found that Black people who are on guard against anticipated discrimination have higher blood pressures while they sleep. “When you experience racism or discrimination and it could cost your life, it’s good to be vigilant; but a prolonged and heightened state of vigilance is not good,” the University of Michigan’s Neblett said. “It can kill you in the end.”
Leslie Lamar Parker grew up in the Minneapolis suburbs, in a state that was 84% white. Like many John Henrys in this story, he was large — tall and wide — in a way that made him stand out to cruel classmates and clueless teachers. Bigness can be perilous for Black boys, who are often seen as older, stronger and less innocent than their white counterparts, stereotypes that underlie higher rates of school discipline and police violence. Parker learned to play the class clown and questioned authority. “School couldn’t hold his attention, not because he wasn’t smart. He wouldn’t go,” his mother, Tyuon Brazell, said. Because he wasn’t on track to graduate, she did what other parents might not and suggested he drop out his junior year. That’s when he started to thrive, earning his GED, graduating from college and becoming an IT specialist in his old school district, where he mentored students of color, ordering them lunch from DoorDash and supervising the tech club. “That was really important to him,” said his wife, Whitney, “making sure they didn’t fail any other brown kids like they failed him.”
One key to his coping was overcorrecting for how he might be perceived. Strangers would approach him to say how lovely it was to see him with his son and daughter, a microaggression masquerading as a compliment. He was so sensitive to stereotypes about absent Black fathers, his wife said, he was “a present parent on steroids.” To walk through the world as a Black man is to be simultaneously hypervisible and invisible, under surveillance yet never really seen. So he turned his wardrobe into a “conversation starter,” an expression of his irreverent personality but also armor against snap judgments about his imposingness. He carried a Spongebob SquarePants backpack to work and often wore a pro-wrestling or superhero T-shirt during off hours.
Parker was constantly scanning the horizon for threats against his family and his kids at school, wondering whether there was something more that he could do for them. He projected a cool demeanor, his argumentative wit camouflaging worries that his mother knew kept his head in overdrive. “I kept telling him: ‘Son, you need to rest. You don’t have to do everything in a day.’” He was diagnosed with high blood pressure at just 27 and worried it, and the extra pounds, would keep him from seeing his two children grow up. He died in May from COVID-19 at the age of 31.
Joshua Bush, who died in April of COVID-19, slammed up against racial stereotypes in his work as a nurse in South Carolina. There were funny looks from people who didn’t expect to see a Black man when he arrived at job interviews and white patients who refused to let him touch them. He told them, “That is your choice, but you’re missing out on great help,” his mother, Linda, recalled. He and his wife, LaKita, saw the health care industry as their route to upward mobility. She worked in hospital administration; at 30, he was studying to become a registered nurse, working as an LPN.
Bush also suffered from a rare enzyme abnormality that caused severe muscle cramps from overexertion, and because of it, trips to the emergency room weren’t uncommon. He’d come to accept that the first image doctors and nurses saw — someone Black and overweight — influenced their bedside manner. They treated him like he had no medical knowledge and lectured him about diabetes, though it had nothing to do with why he was seeking care. His experience informed the way he cared for his own patients, part of his “fight against the system,” his wife said. At the same time, she could see her husband’s stress “all over his body.”
Lifting as we climb, onward and upward we go. Words that started as a call-to-action at the rise of the Jim Crow South have become an enduring part of the African American experience — and can serve as a unique form of stress. The proverb was born of Black suffragist Mary Eliza Church Terrell’s belief that it was incumbent upon the growing Black middle and upper class to use their position to fight racial discrimination and help others rise through education, work and community activism. It is why Thomas Fields was told as a boy that he was “duty-bound” to give back to the community once he got an education. Why Dosha Joi advocated for young people in the system “because someone helped bring out the sunshine in me.”
“You’re socialized to say it’s not just about you. It’s really about what you’re going to do for your broader community and for your family,” Washington University’s Hudson explained. “People take it very seriously, trying to light a path for those behind them — even when they’re not necessarily in the most stable situation themselves. … But they’re lifting as they climb. That’s taxing. That’s a visceral stress.”
In the Brookhaven, Mississippi, of Eugene Thompson’s youth, Black business owners understood that Brookway Boulevard — at least the stretch that ran through downtown — was for white businesses. The election of Barack Obama was a turning point; Thompson figured if a Black man could become president of the United States, surely he could rent a modest space on “the Boulevard.” Publicly, his goal was to grow his client base by cutting white people’s hair, too. His family knew his aspirations were grander. “He wanted to do something in Brookhaven to help Black people to get off their knees,” his mother, Odell Edwards, said. “We are on our knees.”
It’s not easy earning a living in Mississippi, where the single most common job is working as a cashier and the $7.25 minimum wage hasn’t budged in a decade. Cutting hair came naturally for Thompson, who started on himself at 12. He attended a local beauty academy before he could afford to go to barber school and over the years took the same methodical approach to growing his business — buying secondhand equipment, doing the construction himself, all without bank loans, mentoring or government support.
But Thompson’s real ambition was to start his own school. “He always tried to encourage the boys in the community, or people who had been in prison and couldn’t find a job — ’I can teach you how to cut hair and you can have your own business,’” his younger sister, Dedra Edwards, said. After three years spent earning his teaching credential, Thompson opened his TaperNation Barber Academy for students last fall. Then he realized graduates needed places to work, so he launched his next project: renovating a second shop nearby where other barbers and hair stylists could rent chairs.
“It was running him ragged,” Odell said.
At 46, Thompson was severely overweight and suffered from lifelong respiratory problems as well as anxiety and sleeplessness. High blood pressure and diabetes ran in his family, but Thompson’s true health status was unclear — like more than 15% of Black people in Mississippi, he wasn’t insured and avoided going to the doctor except in an emergency. When he started feeling symptoms of COVID-19 in late March, he shrugged them off at first; he’d been having heart palpitations and panic attacks, which his family attributed to stress from work.
After he died in early April, leaving behind six children, TaperNation had to shut down. “You have to have a barber’s instructor license to keep it going, and no one else in the family has one,” his sister said. “We had to sell almost everything.”
Recent disasters — Hurricane Katrina, the Great Recession — have shown that Black communities aren’t just more vulnerable than white populations to economic and social dislocations; they recover more slowly. The impacts of the pandemic are likely to be magnified because so many deaths have occurred among Black people under age 60, the peak earning years when people raise families, start businesses, amass social capital and create lasting legacies. In addition to the lives it took, COVID-19 has robbed wealth that John Henrys were only beginning to accrue and toppled what they had begun to build for themselves and those around them.
In many cases, they were the structural beams, holding everything up. “These are people who help pay bills for people who aren’t their biological family members,” said Sealy-Jefferson, the Ohio State social epidemiologist. “They bring food when somebody dies. They watch kids when a single mother has to work.” Some of the biggest losses are intangible, she said: “social support, emotional support, resource sharing, encouragement, storytelling, role modeling— all of these things that are vital for African Americans in particular, given our history in this country.”
Fields couldn’t comfort students reeling from a crisis that has killed more than 1,600 of their loved ones and neighbors. “It’s a tremendous loss,” said Robinson, his principal. Bates’ wife, Chelsea, was too bereaved to go back to work when school resumed, which meant living off of her husband’s death benefits and savings; she focused on trying to help Madison process a grief she’s too young to understand. “Sometimes she lays on the floor and kicks and screams that she wants her daddy, that she misses daddy and why did he have to leave?” she said. “I tell her, I’m sorry, I wish that mama could do something to bring him back. I really do.”
Weekday mornings have been quiet without Kendall Pierre Sr. puttering around the house before sunrise so he could open his barbershop by 5 a.m. That’s when workers from nearby chemical plants would stop in for a cut or shave after their graveyard shifts. Sundays are different without his sermons at Mt. Zion Baptist Church, in the little town of Ama, Louisiana, followed by a family breakfast his son always looked forward to. “My grandmother would come. Some of my aunties and cousins. He would put Aunt Jemima batter in the waffle iron and say: ‘See? This is better than Waffle House!’”
Since his dad died in May of COVID-19, Kendall Pierre Jr., a 20-year-old student at Louisiana State University, has felt an overwhelming absence and, at the same time, his father’s equally consuming presence. “I can still hear him,” he said.
Don’t drive with your hoodie on.
Work twice as hard.
Real men don’t wear slippers in public; put on some shoes.
The only child of a single mother, 45-year-old Pierre Sr. took his role as father figure seriously. To nieces and nephews, he was Uncle Dad. To his sons’ basketball teams, he was Coach Kendall with the pep talks.
If a task has begun, never leave it until it’s done.
Be the labor great or small, do it well or not at all.
When players couldn’t afford uniforms or travel for tournaments, he would pay. “Their parents would send them with all they could, which was sometimes only $5,” Pierre Jr. said. They could count on him for food, deodorant, even a haircut. “He would bring his clippers to make sure all the players looked nice.”
When the killing of George Floyd roiled the country, Pierre Jr. had no doubt about how his father would have reacted. He would have talked to officials at the sheriff’s office, school board administrators, government leaders. He would have organized community meetings at the church.
We’re living in troubled times.
His son thought about that when his friend texted him about organizing a Black Lives Matter protest. “Since my dad passed, I’ve had this newfound courage, and this urge to act on things … to just do things outside of my comfort zone,” he said.
On a Saturday morning in June, 400 people joined in the 2.6-mile march from Westbank Bridge Park to St. Charles Parish Courthouse. A local reporter covered it and interviewed Pierre Jr. for a story. “If we don’t speak about systemic racism and police brutality, no change will ever happen,” he said. “I feel like it’s something that I have to do and be a part of something bigger than just me.”
He knows his father would have been proud. His mother was. But she worries, too. Her husband didn’t make enough time for doctor’s appointments to monitor his Type 2 diabetes, nor did he get much sleep. “I would tell him, ‘Kendall, you need to rest,’” recalled Sabrina, his wife of 24 years and a registered nurse. “He would say he could rest when he’s dead and gone.”
She knows how much goes into taking care of yourself as a Black man and thinks about that every time her sons walk out the door; her daughter, too. “Lord, I pray for them. … I tell them: ‘Put the seat belt on, drive the speed limit. Make sure you don’t get any tickets.’ I don’t want them to get stopped by a cop.” Her husband’s stature in the community conferred a kind of protection. “Because of my husband and who he was, people would be looking out for my sons. We don’t have that anymore.”
Zipporah Osei and Mollie Simon contributed reporting.
Art Direction by Lisa Larson-Walker.
About the Art
Elliott Jamal Robbins, 32, is an artist who works in a variety of media, including drawing, printmaking, sculpture and video/animation. He has exhibited artworks in group and solo exhibitions in New York, Chicago, Miami, Berlin and the Netherlands. This is how he described his thinking behind the art in this story:
For me, the story of John Henry presents problems. Namely, its focus on the physical attributes of the man and celebrating the labor that killed him. In the original tale, John Henry is almost Christlike in his willingness, if not gleeful, in sacrificing his own body. In my own work, I’m always more drawn to the mundane scene. Rather than consider the figure of John Henry as a type or didactic prop to expound the ills of systemic racism, I decided to focus a narrative as though from the point of view of the subject, and we witness his day-to-day experiences as he does.
Beginning on the bus, we are reminded of this as the site where African Americans fought for the basic human right to sit where they chose. From one mode of transportation to another, the horseback rider recalls the notion of the American west, which most often represents a connection to the land, and freedom. In contrasting the horse from the rider, we see that while one figure experiences a kind of liberation, another body is at work which propels this motion. This relationship between horse and rider is a corollary for the relationship between John Henry and the train, a mechanical achievement that would bring with it the promises of cross country travel, commerce and economic prosperity.
The story of John Henry is a means of making visible the unseen labor, exploitation and oppression of nation building. In this way I want to consider the real impact of systemic racism on those experiencing it daily, as well as decentralize the notion of racial violence from images of murdered black men and women. Instead, I want to consider how violence is enacted everyday, and its key actors are those who participate in systems which are propped up by the degradation of others.
Clarification, Dec. 24, 2020: This story was updated to clarify a figure on Black infant mortality.
According to the CDC, race and ethnicity are risk markers for other underlying conditions that affect health including socioeconomic status, access to health care, and exposure to the Covid-19 virus. For example, American Indian or Alaska Natives are 4 times more likely to be hospitalized for Covid-19 and 2.6 more times to die, compared to White non Hispanic persons. Black or African American non Hispanics are 3.7 times more likely to be hospitalized and 2.8 times more likely to die from Covid-19 compared to White non-Hispanic persons.The disparate impact of the Coronavirus has drawn national attention to how public health resources are used in times of emergency. In light of these circumstances, if states were to prioritize racial minorities in public health emergencies, such as distribution of vaccines during a pandemic, for example, would that focus survive equal protection challenge? Put succinctly, can we triage public health services based on race?
As an example, California’s Covid-19 vaccination plan includes this statement: “One of the primary efforts of the Community Vaccine Advisory Committee will be to help ensure vaccine planning supports all Californians, but particularly for individuals in communities that are disproportionally impacted, including Latinos, African, Americans, Native Hawaiians, Pacific Islanders, and other Asians including Filipinos.” Will this plan pass constitutional muster?
The Supreme Court has countenanced the use of race in public programs when it is narrowly tailored to achieve a compelling governmental interest. The downside of this standard of review is that public health agencies, particularly those offering services to the underprivileged or victims of poverty, may be barred from giving preferential treatment in services to groups based on ethnicity, even if those groups may be in dire need of those services.”
Professors Schmidt, Gostin and Williams, writing on whether it is lawful and ethical to prioritize racial minorities for Covid-19 vaccines, note that “there is no direct precedent in which courts have considered race in allocating scarce health care resources. They write that “[s]trict judicial scrutiny would not permit vaccine priority strategies. First, a healthcare worker could not give priority to vaccinating persons from minority groups, for instance, by skipping White people waiting in line at a health care facility. Second, public health agencies could not provide vaccines exclusively, or in large shares, to geographic areas identified by race alone.” Nevertheless, they suggest that a vaccine distribution formula could lawfully prioritize populations based on factors like geography, socioeconomic status and housing density status that would favor minorities de facto, but not explicitly include race.”
The geographic/ proportional distribution suggested by Schmidt et al., would be consistent with other race neutral suggestions or solutions for other affirmative action-based programs, such as school admissions. In Fisher v. University of Texas at Austin, 136 S.Ct. 2198 (2016) (Fisher II), the Court affirmed diversity in higher education as a compelling state interest, and held the race-conscious admissions program in use at the time of petitioner’s application lawful under the Equal Protection Clause. We could analogize the geographical distribution to University of Texas, Austin’s use of top 10% plan, where the university used a race neutral method of equalizing the structural inequities by guaranteeing acceptance of students who graduate in the top 10% of their graduating class. This plan cures the obstacles that minorities often face in getting admitted to elite universities: parental educational background, attending under-resourced schools because they are located in economically depressed neighborhoods, kids having to work to support the family, language barriers, low socio-economic status, etc.
However, this legal analogy flounders in times of a pandemic. Unlike the school admission cases (where the lack of diversity that elite schools are trying to improve is a self-inflicted wound), Covid-19 is an emergency, a disaster of epic proportions. As of this writing, there are over 21 million confirmed cases and over 356,000 deaths in the United States. During a pandemic, there is more urgency and a race neutral alternative might not be as equally effective. For example, vulnerable populations might slip through the cracks while waiting for their priority groups. One can conclude that race-based policies have the greatest chance of passing strict scrutiny during pandemics. But will they? This will depend on how the Justices view racial inequalities during a pandemic. For example, after acknowledging the serious nature of the pandemic, Justice Kavanaugh, in his concurring opinion in Roman Catholic Diocese of Brooklyn, New York v. Cuomo writes, “[B]ut judicial deference in an emergency or a crisis does not mean wholesale judicial abdication, especially when important questions of religious discrimination, racial discrimination, free speech, or the like are raised.”
All in all, focusing on vulnerable populations in vaccine distribution is likely to succeed only if it doesn’t explicitly use racial categories. Even though using a race neutral distribution plan presents little or no constitutional challenges, if success (and here success is defined as getting the vaccine to the most neediest people to reduce the pandemic) means focusing on vulnerable groups, whether delineated by race or socioeconomic status, shouldn’t such a distribution plan be countenanced? Put differently, if admission to colleges and universities based on race can be narrowly tailored to achieve a compelling governmental interest, then surely a plan that benefits a race can be upheld on the basis of urgency due to COVID-19. Then again, maybe not. In July 2020, Oregon state lawmakers passed the Oregon Cares Fund. This state fund was meant to steer coronavirus relief money directly to black Oregonians and black-owned businesses. The state earmarked $62 million of its $1.4 billion in federal Covid-19 relief money to provide grants to black residents, business owners and community organizations enduring pandemic-related hardships. However, a Mexican-American and two white business owners sued the state, arguing that the fund discriminated against them. Although the lawsuit has not been decided yet, the outcome will have far reaching implications on any state planning to distribute vaccines or any public health services based on racial categories.
Like many Black and rural Americans, Denese Rankin, a 55-year-old retired bookkeeper and receptionist in Castleberry, Ala., did not want the Covid-19 vaccine.
Ms. Rankin worried about side effects — she had seen stories on social media about people developing Bell’s palsy, for example, after they were vaccinated. She thought the vaccines had come about too quickly to be safe. And she worried that the vaccinations might turn out to be another example in the government’s long history of medical experimentation on Black people.
Then, one recent weekend, her niece, an infectious disease specialist at Emory University in Atlanta, came to town. Dr. Zanthia Wiley said one of her goals in making the trip was to talk to friends and family back home in Alabama, letting them hear the truth about the vaccines from someone they knew, someone who is Black.
Across the country, Black and Hispanic physicians like Dr. Wiley are reaching out to Americans in minority communities who are suspicious of Covid-19 vaccines and often mistrustful of the officials they see on television telling them to get vaccinated. Many are dismissive of public service announcements, the doctors say, and of the federal government.
Although acceptance of the vaccine is notching up, Black and Hispanic Americans — among the groups hardest hit by the coronavirus pandemic — remain among the most reluctant to roll up their sleeves. Even health care workers in some hospitals have declined the shots.
But the assurances of Black and Hispanic doctors can make an enormous difference, experts say. “I don’t want us to benefit the least,” Dr. Wiley said. “We should be first in line to get it.”
Many physicians like her now find themselves not just urging friends and relatives to get the vaccine, but also posting messages on social media and conducting group video calls, asking people to share their concerns and offering reliable information.
“I think it makes a whole lot of difference,” said Dr. Valeria Daniela Lucio Cantos, an infectious disease specialist at Emory. She has been running online town halls and webinars on the subject of vaccination, including one with Black and Hispanic employees of the cleaning staff at the university.
She believes they are listening, not only because she is Hispanic and speaks Spanish, she said, but also because she is an immigrant — her family is still in Ecuador. “Culturally, they have someone they can relate to,” Dr. Cantos said.
Many of the vaccine-hesitant are linchpins of health in their own families. Ms. Rankin, for example, helps care for Dr. Wiley’s grandmother, who is blind, and her grandfather, who cannot walk. Ms. Rankin looks in on Dr. Wiley’s mother, whose health is fragile. And she is the single mother of three girls, including a 14-year-old who still lives at home.
“If my aunt got infected, my family would be in tough shape,” Dr. Wiley said.
Dr. Wiley met with Ms. Rankin, her daughter and her mother in the living room of a brick ranch house on a quiet street — socially distanced and wearing masks. Dr. Wiley answered questions and explained the science behind the vaccine.
No, she said, the vaccine is not made of live coronaviruses that might infect people. No, just because someone was vaccinated and became sick, it does not mean the vaccine made them ill.
And yes, the vaccine was tested on tens of thousands of people and the data carefully scrutinized by scientists with nothing to gain and everything to lose by pushing it through prematurely.
Dr. Wiley told them she was looking forward to being vaccinated herself.
Dr. Virginia Banks, an infectious disease specialist in Youngstown, Ohio, who is Black, understands the community’s long-held distrust in the medical establishment.
But she has seen too many people — and not all of them old — suffer and die in the pandemic, she said. And Dr. Banks worries about her own risk while caring for patients. “I feel like I am playing Russian roulette,” she said.
So she recites stories to those who are hesitant about getting inoculated, like one about a patient she recently treated, gasping for breath. He asked her, “Am I going to come out of this alive?” She told him she did not know.
“We have to tell these stories” to Black Americans, she said. “And it has to come from someone who looks like them.”
“My friends and family say, ‘Even if the risk is one in a million, I am not taking it,’” she added. “I say, ‘I understand your mistrust, but this is beyond Tuskegee. This is beyond “The Immortal Life of Henrietta Lacks.” We are in a pandemic now. We have to put our faith in the science.’”
Dr. Banks stresses the ripple effects of individual decisions: “If you don’t take that vaccine and it is safe, we will be wearing masks for some time to come. If you want your life back, if you want normalcy back, you have to rely on trusted messengers like myself.”
Dr. Leo Seoane, a critical care doctor at Ochsner Health in New Orleans who is Hispanic, has already been vaccinated. When he began talking to friends and family and others in the community, virtually all of them said they would not get the shot.
They worried that the vaccine was developed too quickly, that it was not safe, that it might not be effective or might infect them with the coronavirus. Now, after gentle persuasion, “to a person, they all changed their minds.”
But few think all it will take is a conversation or two with a trusted doctor to convert vaccine skeptics into believers.
“When they first started talking about the possibility of a vaccine in April, I said, ‘No way,’” said Phelemon Reins, a 56-year-old federal government worker. He was leery of the speed of vaccine development, and he knew too well the history of mistreatment of Black people by the medical system.
“The Trump Administration has not done anything to inspire anyone to have confidence in anything coming out,” he added. “I dismiss everything they say.”
But Dr. Banks, a friend, has made him rethink his reluctance. “In the end, it will be people like her that I depend on,” Mr. Reins said. “I trust her.”
“How do they convince the African-American community?” he said. “They may have to have people who look like her.”
The pandemic has exposed the bitter terms of our racial contract, which deems certain lives of greater value than others.
Six weeks ago, Ahmaud Arbery went out and never came home. Gregory and Travis McMichael, who saw Arbery running through their neighborhood just outside of Brunswick, Georgia, and who told authorities they thought he was a burglary suspect, armed themselves, pursued Arbery, and then shot him dead.
The local prosecutor, George E. Barnhill, concluded that no crime had been committed. Arbery had tried to wrest a shotgun from Travis McMichael before being shot, Barnhill wrote in a letter to the police chief. The two men who had seen a stranger running, and decided to pick up their firearms and chase him, had therefore acted in self-defense when they confronted and shot him, Barnhill concluded. On Tuesday, as video of the shooting emerged on social media, a different Georgia prosecutor announced that the case would be put to a grand jury; the two men were arrested and charged with murder yesterday evening after video of the incident sparked national outrage across the political spectrum.
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To see the sequence of events that led to Arbery’s death as benign requires a cascade of assumptions. One must assume that two men arming themselves and chasing down a stranger running through their neighborhood is a normal occurrence. One must assume that the two armed white men had a right to self-defense, and that the black man suddenly confronted by armed strangers did not. One must assume that state laws are meant to justify an encounter in which two people can decide of their own volition to chase, confront, and kill a person they’ve never met.
The underlying assumptions of white innocence and black guilt are all part of what the philosopher Charles Mills calls the “racial contract.” If the social contract is the implicit agreement among members of a society to follow the rules—for example, acting lawfully, adhering to the results of elections, and contesting the agreed-upon rules by nonviolent means—then the racial contract is a codicil rendered in invisible ink, one stating that the rules as written do not apply to nonwhite people in the same way. The Declaration of Independence states that all men are created equal; the racial contract limits this to white men with property. The law says murder is illegal; the racial contract says it’s fine for white people to chase and murder black people if they have decided that those black people scare them. “The terms of the Racial Contract,” Mills wrote, “mean that nonwhite subpersonhood is enshrined simultaneously with white personhood.”
The racial contract is not partisan—it guides staunch conservatives and sensitive liberals alike—but it works most effectively when it remains imperceptible to its beneficiaries. As long as it is invisible, members of society can proceed as though the provisions of the social contract apply equally to everyone. But when an injustice pushes the racial contract into the open, it forces people to choose whether to embrace, contest, or deny its existence. Video evidence of unjustified shootings of black people is so jarring in part because it exposes the terms of the racial contract so vividly. But as the process in the Arbery case shows, the racial contract most often operates unnoticed, relying on Americans to have an implicit understanding of who is bound by the rules, and who is exempt from them.
The implied terms of the racial contract are visible everywhere for those willing to see them. A 12-year-old with a toy gun is a dangerous threat who must be met with lethal force; armed militias drawing beads on federal agents are heroes of liberty. Struggling white farmers in Iowa taking billions in federal assistance are hardworking Americans down on their luck; struggling single parents in cities using food stamps are welfare queens. Black Americans struggling in the cocaine epidemic are a “bio-underclass” created by a pathological culture; white Americans struggling with opioid addiction are a national tragedy. Poor European immigrants who flocked to an America with virtually no immigration restrictions came “the right way”; poor Central American immigrants evading a baroque and unforgiving system are gang members and terrorists.
Donald Trump’s 2016 election campaign, with its vows to enforce state violence against Mexican immigrants, Muslims, and black Americans, was built on a promise to enforce terms of the racial contract that Barack Obama had ostensibly neglected, or violated by his presence. Trump’s administration, in carrying out an explicitly discriminatory agenda that valorizes cruelty, war crimes, and the entrenchment of white political power, represents a revitalized commitment to the racial contract.
But the pandemic has introduced a new clause to the racial contract. The lives of disproportionately black and brown workers are being sacrificed to fuel the engine of a faltering economy, by a president who disdains them. This is the COVID contract.
As the first cases of the coronavirus were diagnosed in the United States, in late January and early February, the Trump administration and Fox News were eager to play down the risk it posed. But those early cases, tied to international travel, ensnared many members of the global elite: American celebrities, world leaders, and those with close ties to Trump himself. By March 16, the president had reversed course, declaring a national emergency and asking Americans to avoid social gatherings.
Over the weeks that followed the declaration of an emergency, the pandemic worsened and the death toll mounted. Yet by mid-April, conservative broadcasters were decrying the restrictions, small bands of armed protesters were descending on state capitols, and the president was pressing to lift the constraints.
In the interim, data about the demographics of COVID-19 victims began to trickle out. On April 7, major outlets began reporting that preliminary data showed that black and Latino Americans were being disproportionately felled by the coronavirus. That afternoon, Rush Limbaugh complained, “If you dare criticize the mobilization to deal with this, you’re going to be immediately tagged as a racist.” That night, the Fox News host Tucker Carlson announced, “It hasn’t been the disaster that we feared.” His colleague Brit Hume mused that “the disease turned out not to be quite as dangerous as we thought.” The nationwide death toll that day was just 13,000 people; it now stands above 70,000, a mere month later.
As Matt Gertz writes, some of these premature celebrations may have been an overreaction to the changes in the prominent coronavirus model designed by the Institute for Health Metrics and Evaluation at the University of Washington, which had recently revised its estimates down to about 60,000 deaths by August. But even as the mounting death toll proved that estimate wildly optimistic, the chorus of right-wing elites demanding that the economy reopen grew louder. By April 16, the day the first anti-lockdown protests began, deaths had more than doubled, to more than 30,000.
That more and more Americans were dying was less important than who was dying.
The disease is now “infecting people who cannot afford to miss work or telecommute—grocery store employees, delivery drivers and construction workers,” The Washington Post reported. Air travel has largely shut down, and many of the new clusters are in nursing homes, jails and prisons, and factories tied to essential industries. Containing the outbreak was no longer a question of social responsibility, but of personal responsibility. From the White House podium, Surgeon General Jerome Adams told “communities of color” that “we need you to step up and help stop the spread.”
Public-health restrictions designed to contain the outbreak were deemed absurd. They seemed, in Carlson’s words, “mindless and authoritarian,” a “weird kind of arbitrary fascism.” To restrict the freedom of white Americans, just because nonwhite Americans are dying, is an egregious violation of the racial contract. The wealthy luminaries of conservative media have sought to couch their opposition to restrictions as advocacy on behalf of workers, but polling shows that those most vulnerable to both the disease and economic catastrophe want the outbreak contained before they return to work.
This is a very old and recognizable story—political and financial elites displaying a callous disregard for the workers of any race who make their lives of comfort possible. But in America, where labor and race are so often intertwined, the racial contract has enabled the wealthy to dismiss workers as both undeserving and expendable. White Americans are also suffering, but the perception that the coronavirus is largely a black and brown problem licenses elites to dismiss its impact. In America, the racial contract has shaped the terms of class war for centuries; the COVID contract shapes it here.
This tangled dynamic played out on Tuesday, during oral arguments over Wisconsin Governor Tony Evers’s statewide stay-at-home order before the state Supreme Court, held remotely. Chief Justice Patience Roggensack was listening to Wisconsin Assistant Attorney General Colin Roth defend the order.
“When you see a virus like this one that does not respect county boundaries, this started out predominantly in Madison and Milwaukee; then we just had this outbreak in Brown County very recently in the meatpacking plants,” Roth explained. “The cases in Brown County in a span of two weeks surged over tenfold, from 60 to almost 800—”
“Due to the meatpacking, though, that’s where Brown County got the flare,” Roggensack interrupted to clarify. “It wasn’t just the regular folks in Brown County.”
Perhaps Roggensack did not mean that the largely Latino workers in Brown County’s meatpacking plants—who have told reporters that they have been forced to work in proximity with one another, often without masks or hand sanitizer, and without being notified that their colleagues are infected—are not “regular folks” like the other residents of the state. Perhaps she merely meant that their line of work puts them at greater risk, and so the outbreaks in the meatpacking plants, seen as essential to the nation’s food supply, are not rationally related to the governor’s stay-at-home order, from which they would be exempt.
Yet either way, Roggensack was drawing a line between “regular folks” and the workers who keep them fed, mobile, safe, and connected. And America’s leaders have treated those workers as largely expendable, praising their valor while disregarding their safety.
“There were no masks. There was no distancing inside the plant, only [in the] break room. We worked really close to each other,” Raquel Sanchez Alvarado, a worker with American Foods, a Wisconsin meatpacking company, told local reporters in mid-April. “People are scared that they will be fired and that they will not find a job at another company if they express their concerns.”
Although, by the official tally, more than 70,000 Americans have died from the coronavirus, many governors are rushing to reopen their states without sufficient testing to contain their outbreaks. (Statistical analyses of excess deaths in comparison with years past suggest that COVID-19 casualties are approaching and may soon exceed 100,000.) Yet the Trump administration is poised to declare “mission accomplished,” engaging in the doublespeak of treating the pandemic as though the major risks have passed, while rhetorically preparing the country for thousands more deaths. The worst-case scenarios may not come to pass. But federal policy reflects the president’s belief that he has little to lose by gambling with the lives of those Americans most likely to be affected.
“We can’t keep our country closed down for years,” Trump said Wednesday. But that was no one’s plan. The plan was to buy time to take the necessary steps to open the country safely. But the Trump administration did not do that, because it did not consider the lives of the people dying worth the effort or money required to save them.
The economic devastation wrought by the pandemic, and the Trump administration’s failure to prepare for it even as it crippled the world’s richest nations, cannot be overstated. Tens of millions of Americans are unemployed. Tens of thousands line up outside food banks and food pantries each week to obtain sustenance they cannot pay for. Businesses across the country are struggling and failing. The economy cannot be held in stasis indefinitely—the longer it is, the more people will suffer.
Yet the only tension between stopping the virus and reviving the economy is one the Trump administration and its propaganda apparatus have invented. Economists are in near-unanimous agreement that the safest path requires building the capacity to contain the virus before reopening the economy—precisely because new waves of deaths will drive Americans back into self-imposed isolation, destroying the consumer spending that powers economic growth. The federal government can afford the necessary health infrastructure and financial aid; it already shelled out hundreds of billions of dollars in tax cuts to wealthy Americans. But the people in charge do not consider doing so to be worthwhile—Republicans have already dismissed aid to struggling state governments that laid off a million workers this month alone as a “blue-state bailout,” while pushing for more tax cuts for the rich.
“The people of our country are warriors,” Trump told reporters Tuesday. “I’m not saying anything is perfect, and will some people be affected? Yes. Will some people be affected badly? Yes. But we have to get our country open and we have to get it open soon.”
The frame of war allows the president to call for the collective sacrifice of laborers without taking the measures necessary to ensure their safety, while the upper classes remain secure at home. But the workers who signed up to harvest food, deliver packages, stack groceries, drive trains and buses, and care for the sick did not sign up for war, and the unwillingness of America’s political leadership to protect them is a policy decision, not an inevitability. Trump is acting in accordance with the terms of the racial contract, which values the lives of those most likely to be affected less than the inconveniences necessary to preserve them. The president’s language of wartime unity is a veil draped over a federal response that offers little more than contempt for those whose lives are at risk. To this administration, they are simply fuel to keep the glorious Trump economy burning.
Collective solidarity in response to the coronavirus remains largely intact—most Americans support the restrictions and are not eager to sacrifice their lives or those of their loved ones for a few points of gross domestic product. The consistency across incomes and backgrounds is striking in an era of severe partisan polarization. But solidarity with the rest of the nation among elite Republicans—those whose lives and self-conceptions are intertwined with the success of the Trump presidency—began eroding as soon as the disproportionate impact of the outbreak started to emerge.
The president’s cavalier attitude is at least in part a reflection of his fear that the economic downturn caused by the coronavirus will doom his political fortunes in November. But what connects the rise of the anti-lockdown protests, the president’s dismissal of the carnage predicted by his own administration, and the eagerness of governors all over the country to reopen the economy before developing the capacity to do so safely is the sense that those they consider “regular folks” will be fine.
Many of them will be. People like Ahmaud Arbery, whose lives are depreciated by the terms of the racial contract, will not.
Following several nationally publicized police killings of unarmed Black Americans in the United States, Eva L., a fitness instructor who identifies as Black, started to experience what she describes as “immense paranoia.” She would often call in sick, because she feared risking an encounter with police upon leaving her house. She also started to second-guess her and her husband’s decision to have children. “Seeing Black bodies murdered and physical/emotional violence online and on the news” was a trauma she could no longer bear, Eva says. “I was terrified of bringing a child into the world we live in and experience as Black people. I thought not having kids was a truer sign of love than risk them being harmed by this world.”
A recent study sponsored by the University of Pennsylvania—released just before the anniversaries of the deaths of Eric Garner (2014), Michael Brown (2014), John Crawford (2014), and Philando Castile (2016)—found that there could be millions like Eva, for whom these killings have been a mental health trigger. Research included data from the Mapping Police Violence Project database for police killings between 2013 and 2016 and information from the Behavioral Risk Factor Surveillance System of over 103,000 Black Americans. The results indicate that police killings of unarmed Black Americans are having a population-level impact on the mental health of Black Americans.
According to researchers, the incidents may contribute to 1.7 additional poor mental health days per person every year, or 55 million more poor mental health days every year among Black Americans across the United States. That means the mental health burden for African Americans caused by police killings of unarmed Black victims is nearly as great as the mental health burden associated with diabetes. African Americans have some of the highest rates of the disease, which contributes annually to 75 million days of poor mental health among them.
African Americans make up 13 percent of the U.S. population but they accounted for 26 percent of people fatally shot by police in 2015 and 2016. While the death of a loved one can be tragic for the family and community of any police-shooting victim regardless of race, the study reveals that there is a deeper trauma for African Americans, related to the victim or not. Eva started seeing a therapist who diagnosed her as having generalized anxiety and post-traumatic stress disorder. It’s been two years now, and she admits that her progress toward healing has been slow, yet steady. Jacob Bor, co-author of the study and assistant professor at the Boston University School of Public Health, says the responses in his social circle to police killings of unarmed Black victims is what interested him in conducting this study. Bor noticed that White people were able to comprehend “the injustice on an intellectual level but did not experience the same level of trauma.”
The study findings confirmed Bor’s personal observations. The research team did not observe spillover mental health effects in White respondents from police killings. It should also be noted that among respondents of either race, there were no spillover effects for police killings of unarmed White people or killings of armed Black people. The research is essential in considering our own personal experiences, says Bor, adding that the findings speak to the overall “value of different people’s lives.” This society “has a long history of state-sanctioned violence” toward racially marginalized groups, he says. The mental health sector is only now researching the impact of police brutality, a concern that has affected African Americans for decades. “Clinicians can go through medical school without [gaining] any experience in treating the effects of racism,” Bor says. Studies like his, he adds, can help to create long overdue critical mainstream discussions about the effects of racism on mental health, such as, “How do we in public health, society, and among the clinical and mental health services support people when these incidents occur?” and “Can a profession dominated by White providers effectively treat the emotional struggles of ‘living while Black’ in this country?” According to Bor, these discussions are needed to implement change. “Among many White Americans, there is an empathy gap … and a failure to believe when people of color say ‘this hurts me,’” he says.
“Mental health is the ultimate intersectional concern.”
Adding to the deficiency of culturally competent therapists, poverty and other formidable socio-economic challenges—also stemming from structural racism—remain steadfast barriers to African Americans accessing mental health care, according to the American Psychological Association. New York City’s first lady, Chirlane McCray, has also become a passionate advocate for what she describes as a movement for “culturally competent mental health care.” “When you talk about people of color, who are obviously facing discrimination and legacy of racism and poverty in huge numbers, you are talking about something that is really tough to overcome,” McCray says. Inadequate care undermines benefits from policies and resources designed to mitigate the burdens of systemic oppression. “Mental illness along with substance abuse disorders are hardship multipliers,” she says. Struggling unsupported with “mental illness can make everything that much harder.” For example, holding on to affordable housing, staying enrolled in college, and even surviving encounters with law enforcement can be extremely more difficult for those suffering from mental illness or trauma, McCray says. In fact, the most recent annual numbers from the Washington Post’s database of fatal police-shooting victims indicate that “nearly 1 in 4 of those shot was described as experiencing some form of mental distress at the time of the encounter with police.” “Mental health is the ultimate intersectional concern,” McCray says. “It is reflected in all of our policies … education, housing, school, relationships.” In 2015, she and her spouse, Mayor Bill de Blasio, launched Thrive NYC, a $850 million mental health program that incorporates 54 initiatives. Among the program’s several core objectives is the aim to address the stigma around mental illness and increase access to treatment across the city. McCray believes that ThriveNYC’s community focused approach is one of several necessary steps toward reaching historically underserved groups. “Culturally competent care to me is all about trust,” McCray says. “It improves early identification, accessibility, and outcomes.” Also, she says, “People have to be seen.” From her advocacy experience she has observed that “people have to feel that they can turn to someone that they trust.” Connecting people with the appropriate resources, however, means surmounting many challenges. “There is great deal of work to be done to eliminate the stigma,” McCray says. There is also the matter of affordability and infrastructure. “We’ve never had a well-coordinated mental health system in our country—ever. People who have the money find ways to manage.” She says she wants to fight for everyone to get the resources they need to cope. Eva recognizes that her path to healing has taken a significant amount of work and support beyond the means of many African Americans. “Access to therapy is a privilege,” she says. “I know that most people can’t afford weekly sessions at $150-plus.” Yet, she adds, “[going through therapy] is the only reason why I’m OK planning for kids at 32.”
The old African-American aphorism “When white America catches a cold, black America gets pneumonia” has a new, morbid twist: when white America catches the novel coronavirus, black Americans die.
Thousands of white Americans have also died from the virus, but the pace at which African-Americans are dying has transformed this public-health crisis into an object lesson in racial and class inequality. According to a Reuters report, African-Americans are more likely to die of covid-19 than any other group in the U.S. It is still early in the course of the pandemic, and the demographic data is incomplete, but the partial view is enough to prompt a sober reflection on this bitter harvest of American racism.
Louisiana, with more than twenty-one thousand reported infections, has the largest number of coronavirus cases outside of the Northeast and the Midwest. When the state’s governor, John Bel Edwards, announced recently that it would begin to provide data about the racial and ethnic breakdowns of those who have died, he included the grim acknowledgement that African-Americans, thirty-three per cent of Louisiana’s population, comprise seventy per cent of the dead.
The small city of Albany, Georgia, two hundred miles south of Atlanta, was the site of a heroic civil-rights standoff between the city’s black residents and its white police chief in the early nineteen-sixties. Today, more than twelve hundred people in the county have confirmedcovid-19 cases, and at least seventy-eight people have died. According to earlier reports, eighty-one per cent of the dead are African-American.
In Michigan, African-Americans make up fourteen per cent of the state’s population, but, currently, they account for thirty-three per cent of its reported infections and forty per cent of its deaths. Twenty-six per cent of the state’s infections and twenty-five per cent of deaths are in Detroit, a city that is seventy-nine per cent African-American. covid-19 is also ravaging the city’s suburbs that have large black populations.
The virus has shaken African-Americans in Chicago, who account for fifty-two per cent of the city’s confirmed cases and a startling seventy-two per cent of deaths—far outpacing their proportion of the city’s population.
As many have already noted, this macabre roll call reflects the fact that African-Americans are more likely to have preëxisting health conditions that make the coronavirus particularly deadly. This is certainly true. These conditions—diabetes, asthma, heart disease, and obesity—are critical factors, and they point to the persistence of racial discrimination, which has long heightened black vulnerability to premature death, as the scholar Ruthie Wilson Gilmore has said for years. Racism in the shadow of American slavery has diminished almost all of the life chances of African-Americans. Black people are poorer, more likely to be underemployed, condemned to substandard housing, and given inferior health care because of their race. These factors explain why African-Americans are sixty per cent more likely to have been diagnosed with diabetes than white Americans, and why black women are sixty per cent more likely to have high blood pressure than white women. Such health disparities are as much markers of racial inequality as mass incarceration or housing discrimination.
It is easy to simply point to the prevalence of these health conditions among African-Americans as the most important explanation for their rising death rates. But it is also important to acknowledge that black vulnerability is especially heightened by the continued ineptitude of the federal government in response to the coronavirus. The mounting carnage in Trump’s America did not have to happen to the extent that it has. covid-19 testing remains maddeningly inconsistent and unavailable, with access breaking down along the predictable lines. In Philadelphia, a scientist at Drexel University found that, in Zip Codes with a “lower proportion of minorities and higher incomes,” a higher number of tests were administered. In Zip Codes with a higher number of unemployed and uninsured residents, there were fewer tests. Taken together, testing in higher-income neighborhoods is six times greater than it is in poorer neighborhoods.
Inconsistent testing, in combination with steadfast denials from the White House about the threat of the virus, exacerbated the appalling lack of preparation for this catastrophe. With more early coördination, hospitals might have procured the necessary equipment and staffed up properly, potentially avoiding the onslaught that has occurred. The consequences are devastating. In the Detroit area, where the disease is surging, about fifteen hundred hospital workers, including five hundred nurses at Beaumont Health, Michigan’s largest hospital system, are off of the job with symptoms of covid-19. Early in the crisis, at New York City’s Mount Sinai Hospital, nurses were reduced to wearing garbage bags for their protection. Across the country, health-care providers are being asked to ration face masks and shields, dramatically raising the potential of their own infection, and thereby increasing the strain on the already overextended hospitals.
The early wave of disproportionate black deaths was hastened by Trumpian malfeasance, but the deaths to come are the predictable outcome of decades of disinvestment and institutional neglect. In mid-March, Toni Preckwinkle, the president of the Cook County Board in Illinois, which encompasses Chicago, lamented the covid-19 crisis and proclaimed that “we are all in this together,” but, weeks later, she closed the emergency room of the public Provident Hospital in the predominantly black South Side. Preckwinkle claimed that the closure would last for a month and was a response to a single health-care worker becoming infected with the virus. Leave aside the fact that nurses, doctors, and other health-care workers have been testing positive for covid-19 across the country, and their facilities have not been shuttered. It is a decision that simply could not have been made, in the midst of a historic pandemic, in any of the city’s wealthy, white neighborhoods on the North Side.
Meanwhile, in Cook County Jail, three hundred and twenty-three inmates and a hundred and ninety-six correctional officers have tested positive for covid-19. Not only have officials not closed the county jail as a result but they also have yet to release a significant number of jailed people, even though the facility has the highest density of covid-19 cases in Chicago. These are the kinds of decisions that explain why there is a thirty-year difference in life expectancy—in the same city—between the black neighborhood of Englewood and the white neighborhood of Streeterville. They are also just the latest examples of the ways that racism is the ultimate result of the decisions that government officials make, regardless of their intentions. Preckwinkle is African-American, and the chairperson of the Cook County Democratic Party, but her decisions regarding Provident Hospital and Cook County Jail will still deeply wound African-Americans across Chicago.
The rapidity with which the pandemic has consumed black communities is shocking, but it also provides an unvarnished look into the dynamics of race and class that existed long before it emerged. The most futile conversation in the U.S. is the argument about whether race or class is the main impediment to African-American social mobility. In reality, they cannot be separated from each other. African-Americans are suffering through this crisis not only because of racism but also because of how racial discrimination has tied them to the bottom of the U.S. class hierarchy . . .
No insurance. 64 years old. Alone, along with all the other black people at the bottom of the pandemic.
By LeRhonda S. Manigault-Bryant
Dr. Manigault-Bryant is an associate professor of Africana studies at Williams College.
My mother is dying a painful death, and it has everything and nothing to do with Covid-19.
In a piece for The Atlantic detailing the ways in which the coronavirus seems to be hitting black people the hardest, Ibram X. Kendi wrote: “Sometimes racial data tell us something we don’t know. Other times we need racial data to confirm something we already seem to know.” My mother is a living example of what we already know about race, class and suffering.
She is not in an elder-care facility, nor a hospital. She has not been, and most likely will not be, tested for the virus or receive a diagnosis of having it.
Still, hers is the body of all the black people at the bottom of the pandemic. No insurance, though not for lack of trying. Medicaid applications denied for reasons we don’t understand. Inconsistent care at a local public clinic meant hard-to-come-by appointments and checkups only at moments deemed most critical. It wasn’t enough.
Now, she’s dying from end-stage liver disease and kidney failure, diagnosed too late to save her. This has nothing to do with Covid-19.
She is not even that old (64, and thus Medicare ineligible), but FaceTime tells no lies, and she is wasting away before us. What’s worse, even as I’m exactly four hours and three minutes away — geographically closer than I’ve been in over a decade — I can’t be near her, touch her, cook for her, kiss her or tell her all of the things that I don’t yet know I need to say. This has everything to do with Covid-19.
On the occasion she’s strong enough to answer the phone, holding the phone for FaceTime proves too much. Calls come too late, even as time is too short. The grandchildren who live close by cannot get close to her — the idea of transmitting anything to her, as she’s so obviously immune-compromised, is terrifying. The underlying conditions would amplify an already-certain death. This has everything to do with Covid-19.
My brother, who lives exactly six minutes and 24 seconds away from Mommy, risks seeing her because someone needs to make sure she’s still breathing. That check-in is thus essential. He scrubs himself clean after work with all manner of chemicals — he’s a waste management truck driver, an essential employee. This is an effort to protect her. He’s close to her. This is an effort to protect us. This has everything to do with Covid-19.
He tries to get her to eat something other than her single meal of applesauce and Vienna sausages. This has nothing to do with Covid-19.
It’s officially power-of-attorney and health-proxy time. Getting my mother to the lawyer — a four-minute drive — is a thing. My brother and I spend hours strategizing transportation. The errand feels like it takes an eternity. This has everything to do with Covid-19.
My mother is going to die soon, and my process isn’t pretty. I laugh and remember, rage and weep, and I lament time lost, never to be regained. When she has enough energy to speak, she rushes me off the phone, invoking busyness. She’s busy getting ready to die, and it doesn’t seem like it’s on her own terms. Is it ever? I want more time. This has nothing to do with Covid-19.
Like so many, countless others, my family and I are going to be left with the unsettling weight of her death. My mother is going to die soon, and it will most likely be alone. I am afraid. I am one of many grieving, forever-changed faces. No repast. No low-country songs sung graveside. No sending up our timber for her. We cannot grieve properly. Lots of regret. This has everything to do with Covid-19.
As many college students as well as others have moved back home during the current pandemic people’s houses are feeling more cramped than ever. The conditions of small living spaces feel even more confining as communities are tasked with staying inside as much as possible with orders to shelter in place still intact in some locations. These conditions have left many feeling restless, bored, agitated and sad as they try to carve out private space and a sense of normalcy in such an uncertain time. The feelings of confinement ordinary people are facing contrasts starkly with the views of celebrity housing available through live streams, photos, and videos on social media. Gal Gadot and several other celebrities, for example, released a video of them singing John Lennon’s “Imagine.” The video was posted to Gadot’s Instagram with the caption “We are in this together, we will get through it together. Let’s imagine together. Sing with us. All love to you, from me and my dear friends.” Immediately, people on Instagram and Twitter noted the emptiness of these gestures coming from wealthy celebrities without the addition of material action.
The pandemic has drawn to a head the inequalities in housing and wealth defining the contemporary US. The nation’s majority have been left scrambling to make rent for their tiny apartments while watching the wealthy squirrel away in large open concept mansions with lush lawns and huge pools.
For Black communities, these contradictions are nothing new, as forced immobility and confinement have defined their historical and contemporary experiences with regard to the matters of space. As West Africans were rendered slaves, one of their primary spatial experiences was confinement, first in slave castles like El Mina in modern Ghana and then aboard the thousands of slave ships that traversed the Atlantic across five centuries. Africans crossed the ocean packed in and chained together with little room to move.
The carceral space aboard the slave ship put captives in a position of increased vulnerability to diseases and illness. Despite slave trader’s efforts to bring only “healthy” Africans across the sea many ships suffered numerous casualties due to yellow fever, smallpox, scurvy, malaria, flux, and several other diseases. Sowande’ Mustakeem has noted that the isolation caused by the sea voyage along with the cramped and unsanitary conditions captives were held in created unique and devastating encounters with disease. The spread of disease was further aggravated by the violent treatment of captives aboard these ships as well as poor nutrition. As people’s bodies attempted to heal from physical and psychological injuries as well as illness, they faced an environment that only further deteriorated their capacities to fight infection.
In the North American context, despite variation in housing circumstances across different regions and time, the enslaved were forced to live in confining spaces. Whether awaiting sale in a dingy and overcrowded slave pen in Richmond, living in overcrowded gender-segregated barracks in Charleston, or making lives in a drafty and inadequately sized cabin on a rural sugar plantation in New Orleans’ hinterland, slaves experienced the quotidian violence of tight living irrespective of other differences in their social conditions and labor. This contrasts sharply with white slave owners who demonstrated their power with sprawling homes on sprawling estates. Consider for example, Thomas Jefferson’s Albemarle County, Virginia mansion, Monticello in contrast to the small and poorly insulated log cabin structures in which the people he enslaved lived. The contrasts between Black and white space also had another dimension related to mobility. Especially in the wake of the Jacksonian era, white people moved freely, while enslaved people’s movements were legally regulated and violently circumscribed. Even free Black people, especially after Nat Turner’s bloody 1831 rebellion, were strictly delimited in their abilities to move freely. Confinement and immobility were twinned conditions for slaves. As Katherine McKittrick analyzes, Harriet Ann Jacobs, spent seven years in her grandmother’s garret or attic space, unable to fully stand upright in nine-foot-long, seven-foot-wide, three-foot-tall space. She hid in this space, carving it as a “loophole of retreat” in order to evade the violence of her master and eventually to escape. For Jacobs freedom required a subtle reworking of the confinement enforced on Black life and Black geographies.
This lack of mobility and confinement continued after slavery as part of its afterlives along with the related condition of predisposition to contagious disease and premature death. In Chicago between the World Wars, Black migrant communities were forced into the West and Southside by legally sanctioned segregation, policing, and vigilante violence. Black families rented small apartments called kitchenettes at exorbitant rates, and as St. Clair Drake and Horace Cayton characterized in their influential study, lived in cramped poorly heated and congested conditions. As Rashad Shabazz argues, in the spaces of kitchenettes, Black Chicagoans experienced an expression of carceral power in their ordinary lives, manifest in the arrangement of their housing. He writes “by creating close associations between people the kitchenette made privacy of any kind impossible, shaming its residents by putting all actions under the forced gaze of others in the room.”1 This kind of housing arrangement is psychologically wearing, as Richard Wright’s Native Son disturbingly and dramatically fictionalizes. Many Black Chicagoans, across generations, experienced life-long emotional states like the frustration, restlessness, and captivity some people stuck in their homes due to the pandemic currently are experiencing for the first time.
This confining geography extending out from kitchenette also had deadly effects. In 1918 and 1919 the Spanish Flu pandemic caused mass death and tremendous social upheaval that anticipated and rehearsed what Black communities are currently experiencing with COVID-19. Prisoners today are among the most vulnerable to COVID-19—the highest number of cases tied to a location is a prison in Ohio where 80% of the prisoners have tested positive. This resonates with the history of the Spanish Flu in Chicago. As one Chicago Defender writer noted, “Chicago police stations are doing more to breed disease than any other agency supposed to be working for the good of Chicago.”2 The journalist went on to note the way Chicago jails “huddle prisoners together” without medical examinations and how this led to the spread of the deadly flu.3 The carcerality of the kitchenette also made its residents vulnerable. Shabazz notes that Black Chicagoans had higher rates of mental illness, disease, and death all of which were influenced by their crowded and run-down living conditions. These kinds of vulnerabilities tied to spatial confinement are ongoing in Chicago where 50% of the deaths from COVID are Black, and where segregation and carcerality continue to define the landscape.”4
Blackness’s tie to tight spatial control and confinement,extending between living spaces and formal carceral institutions, and from slavery to the present, puts Black people at greater risk for disease and infection exacerbated by the mental health effects of confinement. This greater vulnerability tied to spatial confinement, overcrowding, and other effects of our nation’s anti-Black geography buttresses the spatial advantages white communities enjoyed historically and which they continue to enjoy. White slave owners profited from the confinement and forced vulnerability of their slaves. White landowners in Chicago profited from overcharging their Black tenants for poor quality housing. The risk of death, disease, and mental illbeing that Black people live with exists to produce white safety and comfort, guaranteed in exclusive geographies away from lead paint, rusty water, over-policing, and gratuitous violence. In order to mitigate the unequal deadly effects of COVID-19 and to prevent the future of devastating conditions disproportionately affecting Black people, we must reimagine the American landscape outside this history defined by the twinned and reinforcing structures of Black immobility and confinement.
Rashad Shabaz, Spacializing Blacknes: Architectures of Confinement and Black Masculinity in Chicago. (Chicago: University of Illinois Press, 2015), 50. ↩
“Spanish Plague Raging in Chicago: All Places of Public Assemblage Ordered Closed by Health Officials,” Chicago Defender (Chicago, IL), Oct. 19, 1918. ↩