This is part of Six Months In, a Slate series reflecting on half a year of coronavirus lockdown in America.
Since January, the coronavirus pandemic has killed more than 190,000 Americans, and it has left an especially brutal impact on Black people and people of color. The racist systems that keep many communities of color in a state of perpetual disadvantage—from housing to education to, yes, medicine—have made them uniquely vulnerable to this plague. I’ve been writing about COVID-19’s decimation of Black communities since the pandemic reached the U.S., and I’ve been speaking with fellow journalists and health professionals for my series Conversations on Moving Forward to get a sense of why Black people have been disproportionately dying of COVID, and what we can do about it. For the latest installment, marking about six months since the pandemic became real for Americans, I spoke with Dr. Uché Blackstock, founder and CEO of Advancing Health Equity and an emergency medical physician, about how the coronavirus pandemic intersects with racism, and what needs to change to ensure this won’t happen at the same scale again. Our conversation has been edited and condensed for clarity.
Julia Craven: You left academic medicine to come back into direct patient care.
Uché Blackstock: I’m a second-generation physician, which is something I need to mention because only about 2.6 percent of physicians are Black women.* My mother was the original Dr. Blackstock. All the work that I do, especially around health equity, is in her memory.
I left academic medicine because I wanted to do health equity work. I wanted to explicitly address racism in health care. As you may know, sometimes these organizations, even health care orgs, are not always the most hospitable to Black faculty and students and trainees. And I couldn’t really work in the authentic way that I wanted to. So I left and started my own organization to work with health institutions regarding racism in medicine and racial health inequities.
I spoke with you earlier this year about the pandemic and how it was going to have a really hard effect on Black communities and other communities of color. Give us an overview of what we have seen so far.
It’s been horrible. When we look at the COVID-19 mortality rates, Black Americans have died at the highest rates. The virus has been allowed to essentially run throughout our communities because of lack of any federal leadership around the pandemic.
What does this say about the way racism works in our country, particularly how it intersects with our medical and public health systems?
For a long time—and this is true for myself and other clinicians I know—we’ve always thought about health as being just related to the care that’s available. If you have access to health care, then you’re healthy, right? But I think what this moment has brought into clarity is the fact that we know structural racism is a key driving force of the social determinants of health. If you have jobs that are putting you on the front lines, you’re going to be exposed to the coronavirus. If you are living in overcrowded housing, which is more likely to occur in our communities because of lack of affordable housing and lack of opportunities for homeownership, then you’re going to be in environments where you’re more likely to be infected. Even thinking about who is using public transportation and who is less likely to be able to afford a car, we’re looking at our communities.
What systemic racism has done is limit the opportunities Black Americans have, to the effect that it’s placed us in a situation where we are most vulnerable to this virus. Add onto that the fact that our communities carry the highest burden of chronic disease—which, again, is a result of racism, lack of access to care, lack of quality care, lack of investment in our communities, lack of opportunities for finding healthy food options in our neighborhoods. All of what we’re seeing right now just shows how deeply embedded racism is in this country, in every aspect of the lives that we lead.
What happens when you compound that with the stress everyone’s feeling?
We also know that the chronic stress of living in areas where there has been this disinvestment, that increases your stress response, increases cortisol levels, influences gene expression. Some of the high rates of diabetes and autoimmune diseases that we see among Black Americans are due to this idea of epigenetics: the fact that the stress of racism can change which genes are turned on and off. All of those factors combined have left Black communities essentially sick.
Why is an anti-racist framework important in medicine, whether it be structurally or in your interpersonal interactions?
We actually have been having a discussion among physicians about whether social justice and systemic racism are things we should learn within our education and training. How can you adequately care for your patient on an interpersonal level, and how can institutions adequately and equitably care for communities, if we don’t understand the broader structural forces that are influencing people’s health? If there are underlying socioeconomic factors like poverty, inequality, lack of education, whatever I do is not going to make a difference, right? That’s why I think this is a call to action for health care institutions to be thoughtful and more transformative in thinking about how are we educating and training anyone interacting with patients. How do we give them a framework for understanding what especially Black patients and communities have gone through in this country for centuries?
That has my gears turning about how Black medical schools, historically Black medical schools, have closed. If they were still here, how do you think this would have abated the difference that we’re seeing with the coronavirus?
In the early 1900s, there was an educational specialist named [Abraham] Flexner who was commissioned by the Carnegie Mellon Foundation and the American Medical Association to look at medical education. He came up with these rigorous medical standards that didn’t necessarily correlate with better education or training, but did lead to the closing of a number of the majority of Black medical schools. A study showed that between 20,000 and 30,000 physicians, mostly Black physicians, would have been trained or in the workforce if those schools had remained open.
Another study came out last week on infant mortality. The Black babies who were more likely to be cared for by Black physicians at birth, their infant mortality rate was significantly lesser compared with the Black babies cared for by white doctors. We know that having more Black physicians is not going to end health care inequities, but it is one significant factor to addressing them. When we talk about reparations and talk about what needs to be done now, to have Black medical schools where we are focusing on educating Black health care professionals would be key.
I think about how vital it is to have Black doctors in place, because I know from my own experience, if it weren’t for Black doctors—
I had a patient, a young Black woman, who came in and said, “I want to make sure you’re Black because I want to make sure that I feel listened to.” And I said, “Yes, I am here. I will listen to you.” I realized that it’s so important for patients to feel seen, heard, and valued by the person caring for you.
I also think that, being a patient, that’s the most vulnerable you can be as a human being, to put your care, your health, into the hands of this complete stranger. And we have a lot of data and literature that shows that most clinicians, regardless of their race, have a preference for white patients over Black patients. We’ve seen that manifest in terms of who gets pain medication and who doesn’t. We’ve seen that implicated as a factor in the Black maternal mortality crisis. We see it with infant mortality data. We have to think about training a workforce that is competent in providing care to Black patients. Part of that is having more Black physicians, but part of it is training other health care professionals who may not be Black in taking care of Black patients—which is crazy, but that just shows you how deeply embedded racism is, right?
Another thing I wanted to get into is the mental health effects of the pandemic on communities of color. I saw a study from the CDC saying that there is an increased rate of respondents saying they were suffering from depression and anxiety and having suicidal ideation. And that increase was higher among people of color. When we start talking about a community that already has limited access to mental health care options, what are we looking at here?
That shows how racism is not just affecting physical health, right? Black people have to deal with our fellow Black citizens being killed by the police. That’s the stress of everyday racism. Our communities have suffered the more significant economic losses, in terms of small businesses, in terms of jobs. All of those factors are making this crisis even more of a crisis for us in particular. Add that onto the fact that in our communities, we’re under- and uninsured and don’t have access to mental health professionals. I think we’re going to see this second wave of mental health issues. We’re thinking of physical issues in terms of the virus, but also thinking about the long-term effects of what this will do in terms of the mental health of our communities.
Any local and state efforts that are going to address racial health inequities, it’s not just going to be about increasing testing availability, it’s not going to just be about making sure that the health care institutions in our communities are more well resourced, but it’s going to be about making sure people have housing and financial assistance and that they have access to mental health services. It’s going to have to be a multipronged approach.
It’s frustrating that people don’t have access to these very basic needs.
That’s why, however horrible and depressing this moment is, I also think it’s a moment to think about transformative structural change and about how, just from a health care perspective, we can provide better care to people. I’m all for universal health coverage, single-payer. That’s something we’ve seen across the world: Countries have done better when people have health insurance. But we need to also be thinking about how our health care institutions function and ensure they’re engaged with the communities they’re serving, that they’re working with community-based organizations on the ground who already have trusted leaders in the community. How can we liaise with these organizations to make sure the COVID patients we’re discharging have somewhere to stay, have financial assistance, have health insurance? These are ways that health care institutions can start thinking a little bit more progressively and competently about how you care for patients in these communities. It needs to be what we call structurally competent care.
There was a piece about pulse oximeters and how they don’t give accurate reads on melanated skin. I was wondering if that’s something people should be concerned about, considering that pulse oximeters and blood oxygen levels play such a big role in coronavirus treatment.
Absolutely. I saw that piece and obviously was very disturbed by it, but it made sense to me that that would happen, because often we are not enrolled in clinical trials or in testing of medical devices, right? There is that whole other issue with recruiting us—you have bias in and bias out. So I would say to be extra vigilant if you’re having any symptoms. I tell my patients to come back even if it’s just to get your oxygen checked, because we can also do other testing for you to see how you’re doing. What we see with the pulse ox is that this is also a way that technology itself can be embedded with bias that could be harmful to our patients.
I wanted to ask you about the election and the coronavirus. One narrative we’ve seen popping up is that an administration change could dramatically shift the response that we’re seeing.
I’m trying to be realistic because the fact is we had racial health inequities during prior administrations. We had the killing of Black Americans during prior administrations. So I don’t know if we’re going to see radical enough change on that level. I do think that if we have a change in administration, there will be improved testing availability, an emphasis on preventative measures, and more effective leadership, hopefully. But I think it’s going to take a while for us to see any real improvement.
What about sending kids back to school? For Black and Latino Americans, for people who have essential jobs, this is a big issue, and day care is very expensive.
The fact is, schools have essentially become a safety net for our children. I’m in NYC, which has 1.1 million children in the public school system, including my own children, and most of them are Black and Latino. The kids don’t just go to school for education but for health care: We have hundreds of clinics in schools. They go for special education services.
Our children not being in school is going to have profound effects, worse than educational gaps. But we also know that our communities are also the ones that have been most disproportionately affected by the coronavirus, and the schools may not have the resources to bring people back safely. So, it’s almost a false choice, right? I think for many families, it will be deeply personal depending on what their priorities and needs are.
I remember seeing early on how a lot of folks were concerned about kids being able to eat, because school is often the only place some kids can get food. I know that in D.C., at least a couple of the schools said, Kids can come here and get their food. It’s been interesting to see how our social systems have shifted to meet this moment, because some of them weren’t meeting the moment before. Same with evictions: It was very clear, once the pandemic kicked in, that we don’t have to evict people.
Yeah, I think this is opportunity for us to think about transformational change in all aspects of how we do things. So, as I mentioned, even with how we take care of patients—thinking about it as beyond the interpersonal and more structural. So even though this is an unprecedented time, and there’s been a significant amount of human suffering, this is an opportunity for us to move forward in thinking about how can we create structural and sustainable change that will help support our communities.
Watch the full conversation here:
Correction, Sept. 14, 2020: Uché Blackstock originally misstated that 2.6 percent of Black women are doctors. That percentage of physicians are Black women. Her quote has been edited.