Racism’s Hidden Toll

By Gus WezerekAug. 11, 2020

As hospital beds filled up this spring, health departments in cities like Milwaukee and Charlotte, N.C., began to report an alarming trend: A disproportionate number of their patients were Black.

Data eventually revealed that the pattern was nationwide. Black people were three times more likely than white people to contract the coronavirus, six times more likely to be hospitalized as a result and twice as likely to die of Covid-19.

The gap in Black and white infections has become part of a conversation this year about how deeply racism is embedded in the day-to-day lives of Black people.

“An epidemic shows in a short period of time what’s been going on for hundreds of years,” said David Ansell, who directs community health equity at Rush University Medical Center in Chicago.

What’s been going on for hundreds of years is the systematic neglect of Black Americans’ health. In 2018, Black people died at higher age-adjusted rates than white people from nine of the top 15 causes of death.

Gaps between Black and white mortality rates for the top 15 causes of death

+15 white

deaths per 100k

+15

+30 Black

deaths

Higher Black death rate

Heart disease

Seventh-largest

cause of all deaths

149 per 100k

Seventh-largest

cause of all deaths

21 per 100k

Diabetes

Second-largest

149 per 100k

Cancer

Second-largest

164 per 100k

Homicide

Stroke

Kidney disease

Hypertension

Liver disease

Septicemia

Flu and

pneumonia

Flu and

pneumonia

Parkinson’s

Alzheimer’s

Accidents

Suicide

Lung

disease

Lung

disease

Higher white

death rate

Higher white

death rate

+10 white deaths

per 100k

+10

+20

+30

+40 Black

deaths

Higher Black death rate

Heart disease

Seventh-largest

cause of all deaths

21 per 100k

Seventh-largest

cause of all deaths

149 per 100k

Diabetes

Black people are more likely

to die by homicide.

Black people are more likely

to die by homicide.

Second-largest

149 per 100k

Second-largest

164 per 100k

Cancer

But homicides are so rare that the difference barely contributes to the overall mortality gap.

Homicide

Stroke

Kidney disease

Hypertension

Liver disease

Septicemia

Flu and

pneumonia

Flu and

pneumonia

Parkinson’s

Alzheimer’s

Accidents

Suicide

Lung disease

Higher white death rate

Note: For non-Hispanic Black and white people in 2018. Rates have been adjusted for age and sex. Source: Centers for Disease Control and Prevention

“Health inequities have literally killed thousands and thousands of Black people who would not have died if they had the death rates of white people,” said Dorothy Roberts, a professor of Africana studies, law and sociology at the University of Pennsylvania.

If Black people had died at the same age-adjusted rate as white people in 2018, they would have avoided 65,000 premature, excess deaths — the equivalent of three coach buses filled with Black people crashing and killing them all every day of the year.

Note: Estimates based on age- and sex-specific mortality rates for ages 0-79.·Source: Mary R. Jackman and Kimberlee A. Shauman, “The Toll of Inequality: Excess African American Deaths in the United States over the Twentieth Century.”

Perceptions of health in America depend on who you are. A 2011 survey found that only 55 percent of white people knew about inequalities in Black and white health, compared with 89 percent of Black people.

When confronted with disparities in Black health, Americans have been slow to acknowledge that those inequalities are “not a Negro affair, but an index of social condition,” as W.E.B. Du Bois, a pioneering sociologist, wrote in 1906.

“Usually what people will say is, ‘Oh, clearly it’s genetics, clearly it’s socioeconomics, clearly it’s individual behavior,’” said Jay Pearson, an assistant professor of public policy at Duke University.

“Well, it’s not genetics at all,” Dr. Pearson said. As for income, education and behavior, “those explain away some of the difference but not all of it. What we’re really talking about is structural racism.”

Tracing the origins of Black health disparities, you can go all the way back to the slave traders’ barracoons. Historians estimate that at least half of the Africans who were captured and brought to America died before they could be sold as slaves.

But the modern history of the segregation that is keeping the Black death rate separate and unequal begins during Du Bois’s era, at the turn of the 20th century.

More than a million Black people migrated from the South to Northern cities throughout the early decades of the 20th century. Short on money and job opportunities, new arrivals were forced to rent third-rate housing that lacked clean water and sewer lines.

The unsanitary living conditions caused Black city dwellers to die from tuberculosis and the flu at about twice the rates of white people between 1910 and 1935.

Stories today of entire familie s dying of Covid-19 correlate with similar accounts of Black “house infection” a hundred years before.

“Tuberculosis is the family skeleton, the ever haunting dread,” Charles Frederick Weller wrote in 1909 about the Black families who lived in the alleys behind rowhouses in Washington, D.C.

So bleak were Black peoples’ death rates that Frederick Hoffman, a statistician at the Prudential Life Insurance Company, published a 329-page report in 1896 arguing that if trends held, the “gradual extinction” of Black people was “only a question of time.”

Urban tenements and alley houses often lacked ventilation and waste disposal. Runoff from shared privies would stream down streets and into basement apartments.From “Housing Conditions in Baltimore,” by Janet Kemp, 1907

The state of Black health was cause for much hand-wringing by white writers and medical professionals. Often, their concerns were founded in a fear that the Black maids and cooks they employed would bring disease into their homes.

“The fact is not pleasant to contemplate, but is nevertheless true, that there are colored persons afflicted with gonorrhea, syphilis, and tuberculosis employed as servants in many of the best homes in the South today,” a physician said in a speech in 1914 about “the Negro health problem” to the American Public Health Association.

In pamphlets and editorials, white people repeatedly linked Black people to disease and danger. “Lung block” maps, which overlaid city grids with dots representing tuberculosis cases, were used by city health departments to establish authority over Black neighborhoods and justify the surveillance of residents and demolition of buildings.

Baltimore’s Lower Druid Hill neighborhood on a tuberculosis map created by the city’s health department in 1902. Blue dots represent Black deaths; red dots represent white deaths.The Sheridan Libraries, Johns Hopkins University

Caricatures of Black people as physically and morally degenerate contributed to white people’s fear of integration. In large Northern cities in the 1920s, for every Black person who arrived in a neighborhood, three white people left.

Black people, meanwhile, were often prevented from leaving increasingly overcrowded neighborhoods. A 1911 law in Baltimore was the first of many across the country to make it illegal for Black people to relocate to blocks where more than half the residents were white.

The Baltimore journalist H.L. Mencken described how the ordinance kept Black people sick, writing that when a Black person “tries to move out of his sty and into human habitation a policeman now stops him. The law practically insists that he keep on incubating typhoid and tuberculosis.”

In cities where residential segregation wasn’t perpetuated by the government, white people found other ways to keep Black people at a distance. In Chicago, a Black home was bombed every month between 1917 and 1921. White property owners also used tactics like restrictive covenants, which prevented future deed holders from selling neighborhood homes to Black people.

From “Neglected Neighbors,” by Charles Frederick Weller and Eugenia Winston Weller, photograph by Lewis Hine, 1909, via Widener Library, Harvard University

Inextricable from the story of Black health in America, residential segregation may have also been behind one of its more surprising footnotes.

At the peak of the 1918 pandemic, Black people were less likely to catch the flu than white people. Historians have speculated that a milder version of the disease may have spread throughout Black neighborhoods in the spring and given residents partial immunity to the more deadly flu strain that arrived in the fall.

Nevertheless, the white death rate during 1918 was still lower than Black mortality had ever been. The same is likely to be true for the white death rate during the current pandemic.

On the opening track of her recent visual album, "Black Is King," Beyoncé sings, "Life is your birthright / they hid that in the fine print / take the pen and rewrite it."

Black people in the early 20th century embodied the spirit of that charge, defying the predictions of people like Mr. Hoffman and surviving.

Barred from white-only hospitals and medical schools, Black people started their own. They fought for sanitation systems and organized health education weeks. Antibiotics curbed tuberculosis infections, though the drugs arrived in Black communities years after white patients got them.

A nurse and a medical intern at Provident Hospital in Chicago, which was founded in 1890 by Daniel Hale Williams, a renowned Black surgeon.Jack Delano, Library of Congress

The Black-white death gap has narrowed to an all-time low in recent years, thanks to legislation like the Social Security Act, the Civil Rights Act and the Affordable Care Act.

Residential segregation and wealth inequality persist, however, and have forced Black people to relive health inequities that their ancestors faced a century ago. Today, Black people continue to:

Work jobs that limit their ability to quarantine. Black people account for 12 percent of workers overall, but 17 percent of front-line workers.

Live in overcrowded housing. Black renters are twice as likely as white renters to live in a household with more than two people per bedroom.

Live closer to environmental hazards. Black people are exposed to almost twice as much air pollution as white people.

Have limited access to health care. Black people are twice as likely to be uninsured as white people.

Interact with a largely white medical establishment. Black people make up 13 percent of the country’s population but only 5 percent of physicians.

Marching alongside Black protesters this year, white people finally started to hear what Black people have been saying for years: “Stop killing us.”

It remains to be seen whether white people will continue to address the racial prejudice inherent in America’s law enforcement, politics and health care. When the pandemic ends and the media moves on to the next story, it will be tempting to remember this year as a tragic “episode” in America’s history.

But if nothing changes, Black men will still lose their lives to AIDS at six times the rate of white men. Black women will still be three times as likely to die from childbirth. And Black infants will still be expected to live three fewer years than white babies.

“We have to tell the truth. This country isn’t fair and it never has been,” Dr. Pearson at Duke said. “And unless we make major, wholesale changes, it won’t be in the future.”