Emergency physician Uché Blackstock on why the virus has been a perfect storm in Black communities.
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.
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.
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 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.
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.
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.
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?
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.
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’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.
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.