Soon there will be more than 700,000 white flags dotting the lawn of the National Mall in Washington, D.C.—one for each life lost to COVID-19, all part of an art installation dedicated to capturing the nation’s immense losses during the pandemic. (See the epic COVID-19 memorial on the National Mall, in one stunning photo.)
In more than a year and a half since the first case was detected in Seattle, America’s death toll has climbed steadily. And those deaths continue to climb steadily even as more than half of the country has already been immunized with highly effective vaccines. (COVID-19 surpasses 1918 flu as deadliest pandemic in U.S. history.)
“We have to remember that each of those people represent a life: It’s someone’s mother, brother, father, best friend,” says Crystal Wiley Cené, executive director for health equity at the University of North Carolina Health System. “The toll is much greater than 700,000 deaths.”
And tragedy has hit some communities harder than others. Throughout the pandemic, marginalized racial and ethnic groups have borne a disproportionate share of U.S. COVID-19 deaths. The Centers for Disease Control and Prevention reports that Hispanic, Indigenous, and Black people are all at least twice as likely to die of COVID-19 than white people—even though the latter do account for most of the overall deaths as the country’s largest demographic group.
Although the coronavirus ripped through cities like New York and San Francisco during the earliest months of the pandemic, the rural areas of the country have ultimately seen the most devastation. The Rural Policy Research Institute at the University of Iowa recently published data showing that 1 in 434 rural Americans have died from COVID-19 since the beginning of the pandemic compared to about 1 in 513 people who live in metropolitan areas.
Experts say these disparities aren’t surprising—nor are they unique to COVID-19. Cené recalls how many people claimed early in the pandemic that the virus wouldn’t discriminate between the privileged and the socioeconomically disadvantaged.
“The reality is it was not a great equalizer,” she says. “We were not all equally at risk.”
Instead, she says, the same groups that have always been marginalized are the ones at highest risk of dying from COVID-19. These disparities reveal larger truths about the structural inequities of the health care system—and the need to reckon with them before the next pandemic.
Historic discrimination and distrust
America’s long history of racial discrimination and segregation has shaped the inequities that persist in the healthcare system. Cené says an accumulation of laws and policy have made certain socioeconomic groups more likely to live in disadvantaged areas with fewer healthcare facilities, higher exposure to pollution and other environmental harms, and patchy access to resources to learn about good health care practices. The resources these communities do have are often underfunded.
Take the country’s historic practice of redlining, refusing bank loans to racial and ethnic minorities to keep them out of white neighborhoods. In June, a study published in JAMA Network Open linked the legacy of these practices directly to deaths in the COVID-19 pandemic.
In this study of more than 44,000 adults admitted to hospitals across the U.S. with COVID-19, researchers found that Black patients were 11 percent more likely to die or be transferred to hospice care—but that discrepancy narrowed when researchers adjusted for the hospital in which care was received. These findings suggest that the difference in surviving COVID-19 may come down to the hospitals that are available to Black and white patients.
“Hospitals that tend to care for a disproportionate burden of racial and ethnic minorities are themselves under resourced,” Cené says, pointing out that many of these hospitals have struggled in the pandemic to access life-saving equipment like PPE and ventilators. “That certainly is going to affect the quality of the care that they’re able to provide.”
Indigenous populations—which are at the highest risk of dying from COVID-19 than any other racial or ethnic group—and Hispanic people also face similar structural barriers that put them at risk of severe disease. Racial and ethnic minorities are at higher risk for the underlying conditions that make COVID-19 especially dangerous and are also more likely to be the so-called essential workers—food workers, nursing assistants, and manual laborers who aren’t able to work from home. Meanwhile, the federal clinics charged with meeting the healthcare needs of Indigenous communities are chronically underfunded.
Rural areas, too, have barriers to access adequate healthcare. Keith Mueller, director of the RUPRI Center for Rural Health Policy Analysis, says that cases and deaths began to spike after last year’s winter surge—and continues to climb with the spread of the Delta variant. He attributes the rise in cases to a confluence of factors.
“The factors that we know work in mitigation—like distancing, masking, vaccination—all are affected by a lot of the other conditions of living that differentiate metropolitan and non-metropolitan life,” he says.
Much as with marginalized communities, people who live in rural areas are less likely to have access to health insurance or to live near healthcare facilities that are capable of not just treating COVID-19. They also often work in low-paying high-risk jobs—such as the meatpacking plants that were coronavirus hotspots early in the pandemic—with little sick leave.
Mueller says that the pandemic is also causing new challenges for healthcare facilities in rural communities. While hospitals across the country face staffing shortages as health-care workers abandon their jobs in droves, rural communities are suffering the most. Mueller says it’s always been a challenge to recruit people to work in rural health-care facilities—and now they have to compete with hospitals in metropolitan centers that can offer much more money.
“What we’ve learned coming through the pandemic is the importance of a public health infrastructure that includes all of America, including rural America,” Mueller says. “Coming out of the pandemic we need to focus on maintaining that structure.”
Experts also point out that COVID-19 is now primarily a disease of the unvaccinated—which is certainly a factor in the high death rates among rural populations as well as racial and ethnic minority groups. Not only have these groups been bombarded with disinformation about the safety of the vaccines, but the American medical community’s history of experimentation on people of color has made many people understandably wary.
“There are many reasons that these communities do not trust us and that’s because we have not been trustworthy,” Cené says.
In the journal Health Equity, Spero Manson and Dedra Buchwald outlined the centuries of pandemics in which Indigenous people have suffered in larger proportions than the white European settlers who brought those diseases to America.
“This unfortunate history deeply colors American Indian and Alaska Native views of the SARS-CoV-2 crisis,” write Manson and Buchwald. “Seldom the masters of their own fate, often subject to external forces imposed upon them by the federal government, Native people are suspicious of promises of aid that have often proved to be hollow offerings.”
Cené says that public health professionals need to get better at building trust and at communicating with marginalized communities—meeting them in a language and a format that they will understand. But while the pandemic has underscored the vast inequities in the healthcare system, Cené says it has also opened up conversations about those inequities.
“The thing that we have to be careful of is that this doesn’t just remain at the level of a conversation,” she says. We need to move toward realizing equity and we have to be held accountable to that.”