‘The Father of Environmental Justice’ Isn’t Surprised by COVID-19 Health Disparities – Texas Monthly

As the coronavirus keeps large swaths of Texas shut down, from the economy to the education system and social life, it has become common to note that the disease “doesn’t discriminate.” But Robert Bullard, a professor and former dean at Texas Southern University’s Barbara Jordan–Mickey Leland School of Public Affairs, has spent the past four decades researching the opposite: how natural disasters and crises wreak havoc on society unequally. Low-income communities of color often have far fewer resources to address disaster and, as a result, face far greater risks than whiter, wealthier neighborhoods in times of crisis.

Indeed, across the nation, evidence suggests that people of color are dying at higher rates from COVID-19 than are white people. Though Texas’s Department of State Health Services has so far reported incomplete racial data, some counties are following the national trend. In Harris County, for example, 40 percent of those who died from COVID-19 were black, though black people account for only 20 percent of the county’s population.

A number of factors could be responsible for the disparity. In Texas, black and Latino communities have higher rates of preexisting conditions that make the coronavirus deadly, like asthma and high blood pressure. When it comes to health care, black, Hispanic, and Native Americans in the state are more likely to be uninsured than white residents, according to data from the Kaiser Family Foundation. Testing for COVID-19 is also far from equally accessible: in the city of Dallas, testing is concentrated in high-income areas. And people of color might also be more likely to be employed in sectors that preclude social distancing: black and Latino workers are the least likely to report being able to work from home, according to the U.S. Bureau of Labor Statistics.

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While COVID-19 is a new phenomenon, racial disparities in health outcomes are not. In the seventies, Bullard’s research in Houston demonstrated that toxin-releasing facilities like waste and sewage plants were disproportionately placed in the city’s black neighborhoods, leading to a higher concentration of health problems. To this day, the pattern holds true.

Bullard’s work catalyzed the American environmental justice movement, which argues that environmental problems disproportionately affect communities of color and the poor, and that race and class should be accounted for in their potential solutions. Texas Monthly spoke with Bullard about how the pandemic intersects with environmental issues and why people of color are more vulnerable to the disease.

[This interview has been lightly edited for length and clarity.]

Texas Monthly: In your book The Wrong Complexion for Protection you write, “When societal resources are distributed unequally by class and race, it should be no surprise that population health is distributed along those lines as well.” Were you at all surprised by the racial disparities many counties are reporting with COVID-19?

Robert Bullard: No. When it comes to who gets in line first, and who has priority [for resources like health care], a lot of that is predetermined by the power structures, politically and economic. Oftentimes privilege aligns with race, with white people getting the first and the best protection. And so it’s not surprising when you look at how structural and institutional racism has given privileges for some and disadvantaged others. And when you have poverty, lack of access to health care, [high rates of] uninsured, many who have no private automobiles and are dependent on the buses and public transportation, and neighborhoods in pollution sacrifice zones—and then you pile on top of that the stress of racism—you’re going to get people who are vulnerable. It’s not rocket science. These social determinants of health have been known for many years.

And so the coronavirus is basically taking advantage of those vulnerabilities, and you’re seeing it play out in the deaths. And that’s more than sad. It’s unacceptable.

TM: The coronavirus seems to be a public health disaster that’s layering on top of existing disparities in environmental and social determinants of health. How do you see these things as interconnected, and how are environmental vulnerabilities making the coronavirus worse in certain communities?

RB: We know that if communities are saturated with all kinds of polluting facilities—landfills, incinerators, petrochemical plants and refineries, and coal power plants—and the air quality is bad, you’ll find high rates of ill health: asthma, respiratory illnesses, and other kinds of diseases that are elevated among people of color and poor people, like diabetes and hypertension.

We’re not even dealing with the coronavirus yet: we’re talking about studies that have shown that areas that have high concentration of polluting facilities also have high concentration of health disparities.

So when you apply that to this virus that appears to be attacking the respiratory system … and the cardiovascular system, it’s already hard to breathe in some of these neighborhoods. The coronavirus will make it even harder. It will kill you.

The idea is that if a community is located physically on the wrong side of the levee, the wrong side of the river, on the wrong side of the tracks, it receives less protection than those who are on the right side. Communities of color are disproportionately more vulnerable.

You tell me your zip code, and I can tell you how healthy you are. And so when you talk about trying to map out those social, economic, and racial vulnerabilities, and then overlay health, you can see that there’s a big disparity. You can go from one census tract or one zip code to another, and life expectancy changes by more than fifteen or twenty years by just crossing that line.

TM: Has Texas’s response failed to acknowledge preexisting health disparities?

RB: Texas has the second lowest percentage of testing but that doesn’t surprise me. What surprises me is that it doesn’t have the worst.

This virus does not does not look at your race, or your color. It looks at vulnerability. You can try and look at geographic areas the virus is hitting and not look at race. But then if you put race back in, you will see that there is a discernible pattern. Oftentimes, lax enforcement of environmental law means that communities on the frontline suffer. And that goes hand in hand with lax civil rights enforcement. Texas has the highest rates of uninsurance in the nation, and it has resisted expanding Medicaid, for example. So these policies have created vulnerabilities and it disadvantages communities.

If you talk to people in those neighborhoods on the streets, they can tell you without mapping that they’re most likely to get flooded. Most likely to get polluted. Most likely to suffer from extended unemployment. Or they don’t have the benefit of working from home or a safety net for sick days and paid leave. The medical folks call it comorbidity. Folks on the frontline have always known that’s how things are connected. It’s the cumulative impact of all these things coming at you at one time.

TM: What sort of public policies do you think that Texas, or the United States more generally, should implement to close these racial disparities?

RB: There are some obvious things that need to happen like strengthening people’s access to health care and health insurance. In the last few weeks, we’ve seen attempts to weaken both access to health care and environmental standards with federal rollbacks of specific provisions of the Clean Air Act and tailpipe pollution, and even today with mercury emissions.

So for many of us who have been advocates of environmental justice and health equity, that’s the wrong direction. Other states have taken the high road, and expanded Medicare and access to health insurance. And we should also acknowledge that climate change will make it even more difficult in the future for Texans with hotter days and more bad air-quality days. There will be more outbreaks [because of climate change], as health professionals and scientists have said. We can’t wait to address these issues. We need a real emergency plan for disasters, especially as our population is growing in Texas, to make our cities and rural areas more resilient.

TM: Low income communities are also more likely to live in environmentally vulnerable areas, particularly those at risk of flooding. Do you have concerns about hurricane season coming up and how that might put a double strain on some communities?

RB: The communities that are hit hardest and take the longest to recover, those are the same communities that I’m worried about. On June 1, if we have an active hurricane season in communities that are already suffering from COVID-19, how can you shelter in place when you have to evacuate? Where do people go? If you go to a shelter, it’s going to be hard to social distance. So you’re talking about disasters compounding. That should be worrisome for FEMA and the state government. I’m hoping there is planning for that, so that we don’t get caught flat-footed. I would hope that the smartest people in government are working on the areas that have historically had these severe weather events.

People are stressed about the virus, and people who live on the Gulf Coast, April and May is when they start getting stressed about hurricane season. How are we going to respond to another Harvey or Imelda? In many cases, community groups are the first line of defense. People aren’t going to wait on the government for [immediate aid], because if we do, it will be too late. It’s important to lift up organizations and institutions that have built up that trust in communities. We have to make sure that these organizations are funded and positioned in a way that can address what’s happening.

Why African-Americans may be especially vulnerable to COVID-19

African-Americans are more likely to die from the disease than white Americans

two people wearing masks
African-Americans have increased exposure to COVID-19, in part, because they disproportionately have jobs in the service sector. Here, a man is shown with his ride share driver at a train station in Joliet, Ill., on April 6.CHARLES REX ARBOGAST/AP PHOTO

COVID-19 was called the great equalizer. Nobody was immune; anybody could succumb. But the virus’ spread across the United States is exposing racial fault lines, with early data showing that African-Americans are more likely to die from the disease than white Americans.

The data are still piecemeal, with only some states and counties breaking down COVID-19 cases and outcomes by race. But even without nationwide data, the numbers are stark. Where race data are known — for only 3,300 of 13,000 COVID-19 deaths — African-Americans account for 42 percent of the deaths, the Associated Press reported April 9. Those data also suggest the disparity could be highest in the South. For instance, in both Louisiana and Mississippi, African-Americans account for over 65 percent of known COVID-19 deaths.

Other regions are seeing disparities as well. For instance, in Illinois, where the bulk of infections are in the Chicago area, 28 percent of the 16,422 confirmed cases as of April 9 were African-Americans, but African-Americans accounted for nearly 43 percent of the state’s 528 deaths.

Other data find similar trends. A study published online April 8 in the U.S. Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report looked at hospitalizations for COVID-19 across 14 states from March 1 to 30. Race data, which were available for 580 of 1,482 patients, revealed that African-Americans accounted for 33 percent of the hospitalizations, but only 18 percent of the total population surveyed.

Here are three reasons why African-Americans may be especially vulnerable to the new coronavirus.

1. African-Americans are more likely to be exposed to COVID-19.

SARS-CoV-2, the coronavirus that causes COVID-19, is highly contagious, even before symptoms appear (SN: 3/13/20). So to curb the virus’ spread and limit person-to-person transmission, states have been issuing stay-at-home orders. But many individuals are considered part of the critical workforce by the U.S. Department of Homeland Security and must continue to work. That includes caregivers, cashiers, sanitation workers, farm workers and public transit employees, jobs often filled by African-Americans.

For instance, almost 30 percent of employed African-Americans work in the education and health services industry and 10 percent in retail, according to 2019 data from the U.S. Bureau of Labor Statistics. African-Americans are less likely than employed people in general to work in professional and business services — the sorts of jobs more amenable to telecommuting.

Additionally, a disproportionately high percentage of African-Americans may live in places that could increase their risk of exposure. Census data from January 2020 show that only 44 percent of African-Americans own their own home compared with almost 74 percent of white people. Consider a family living in a crowded inner-city apartment, says epidemiologist Martina Anto-Ocrah of the University of Rochester Medical Center in New York. “Can you possibly take an elevator alone? No.”

African-Americans’ risk of higher exposure to COVID-19 has historical roots — including legal segregation in schools and housing, discrimination in the labor market and redlining, the practice of denying home loans to those living in predominantly African-American neighborhoods. Those forces have contributed to a persistent racial wealth gap, with African-Americans continuing to struggle to move into neighborhoods with the sorts of socioeconomic opportunities that allow white families to better avoid exposure to COVID-19.

“All the ingredients are in place for there to be a sharp racial and class inequality to this [pandemic],” says Robert Sampson, a sociologist at Harvard University.

2. African-Americans have a higher incidence of underlying health conditions.

Among those at highest risk of getting severely ill with COVID-19 are patients with other serious health problems, such as hypertension, diabetes and heart disease (SN: 3/20/20). Over 40 percent of African-Americans have high blood pressure, among the highest rates in the world, according to the American Heart Association. By comparison, about a third of white Americans have high blood pressure. Similarly, African-Americans tend to have higher rates of diabetes.

Part of that heightened risk has to do with African-Americans’ disproportionate exposure to air pollution. Such pollution has been linked to chronic health problems, including asthma, obesity and cardiovascular disease (SN: 9/19/17). In an April 2019 study in the Proceedings of the National Academy of Sciences, Sampson and fellow Harvard sociologist Robert Manduca showed that poor African-American neighborhoods have higher levels of lead, air pollution and violence than poor white neighborhoods (SN: 4/12/19).

 

 

 

Researchers are still sorting out how neighborhood stressors contribute to poor health. But even if the causes aren’t always clear, research suggests that helping people move to better neighborhoods can improve health. For instance, a 2017 study in JAMA Internal Medicine showed that for African-American adults, moving out of racially segregated neighborhoods was linked to a drop in blood pressure (SN: 5/15/17).

3. African-Americans have less access to medical care and often distrust caregivers.

Inequities in access to health care, including inadequate health insurance, discrimination fears and distance from clinics and hospitals, make it harder for many African-Americans to access the sort of preventive care that keeps chronic diseases in check.

According to a December 2019 report from The Century Foundation, a nonpartisan think tank based in New York City and Washington, D.C., African-Americans are still more likely to be uninsured than white Americans. And African-Americans who are insured spend a greater fraction of their income on premiums and out-of-pocket costs, about 20 percent, than the average American, who spends about 11 percent.

Census data show that about 20 percent of African-Americans live in poverty compared with 10 percent of white Americans. As a result, African-Americans have been disproportionately hurt by some states’ decisions not to expand Medicaid as part of the Affordable Care Act. Expanded Medicaid has been linked to a reduced likelihood of deaths from cardiovascular disease (SN: 6/7/19) and a reduction in the racial health gap between white and black babies (SN: 4/23/19).

Lack of preventive care means that African-Americans are more likely than other racial groups in the United States to be hospitalized or rehospitalized for asthma, diabetes, heart failure and postsurgery complications, researchers reported in 2016 in the Annual Review of Public Health.

African-Americans can also face hidden biases to care. For instance, an algorithm used to determine which patients should receive access to certain health care programs inadvertently prioritized white patients over African-American patients (SN: 10/24/19), researchers reported in October 2019 in Science. That disparity arose because the algorithm used health care spending as a proxy for need, but African-Americans often spend less on health care because they are less likely to go to a doctor. In part that may be because African-Americans have a long-standing distrust of the medical establishment due to events such as the Tuskegee experiment (SN: 3/1/75), in which hundreds of African-American men with syphilis were denied treatment for decades.

“These long-standing structural forms of discrimination that African-Americans have faced in the [United States] are manifesting in what we’re seeing with COVID right now,” says epidemiologist Kiarri Kershaw of the Northwestern University Feinberg School of Medicine in Chicago.

Even so, more can be done to identify communities that might be especially vulnerable to COVID-19 and improve their odds of coping with the pandemic, Sampson says. For example, “look at a map of incarceration, lead risk and violence in Chicago [and] you’ll basically see a map of COVID deaths,” he says. Those kinds of proxies could provide a road map to identifying at-risk communities and targeting resources to them, such as greater access to COVID-19 testing, distribution of masks and mobile clinics to provide care.

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