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 Abstract

Excerpted From: Charlene Galarneau and Ruqaiijah Yearby, Racism, Health Equity, and Crisis Standards of Care in the Covid-19 Pandemic, 14 Saint Louis University Journal of Health Law & Policy 211 (2021) (238 Footnotes) (Full Document)

In late July 2020, in the midst of the COVID-19 pandemic, Trinity Health announced its plans to close Mercy Hospital, located in a predominantly Black neighborhood on the south side of Chicago. The city's oldest hospital, Mercy is a “safety net hospital” serving as “an oasis in the medical desert of the predominately Black and [B]rown South Side.” According to Mercy's 2019 community health needs assessment, sixty-two percent of Black Chicagoans live within Mercy's service area. Low health care access has been associated with high COVID-19 mortality in Chicago, a city where Black residents are at greatest risk of COVID-19 death. Community activists, residents, elected officials, and clinicians argued that Mercy's closing would limit access to health care and worsen health inequities in their community. In mid-December, a state review board unanimously rejected the closure plan, yet since then Trinity Health has reaffirmed its intention to close the hospital.

“This is what institutional racism looks like,” observes Chicago Sun-Times columnist Mary Mitchell, “the health care system is structured in such a way that Black and Brown people do not receive the same quality care as [W]hite people do.” The closure of Mercy hospital will disproportionately limit access to health care for Black residents and communities and ultimately impair their health status. This Article centers its analysis of racism and health inequities in the COVID-19 pandemic on Black persons and Black communities throughout the United States; an analysis that may also be relevant to Latino, Indigenous, and Asian people who experience racism and health inequities.

Nearly one in every seven persons in the United States (13.4%) identify as Black or African American, which the U.S. Census defines as, “[a] person having origins in any of the Black racial groups of Africa.” Black people were enslaved for 250 years, separate and unequal for 100 years, and disproportionately harmed by the 2008 to 2012 Great Recession, thus entrenching the racism that has heightened the devastating harm of the COVID-19 pandemic.

Racism is a complex array of social structures, institutional practices, interpersonal interactions, and beliefs used by the dominant racial group to create a hierarchy that categorizes people into “races,” and which is the basis for disempowering, devaluing, and differentially allocating societal resources to other racial groups. Racism in health care is often portrayed as interpersonal, that is, individual racism that harms individuals, but racism also takes institutional forms that harm whole communities and groups.

Institutional racism “refers to the processes of racism that are embedded in laws (local, state, and federal), policies, and practices of society and its institutions that provide advantages to racial groups deemed as superior,” while limiting the power and “differentially oppressing, disadvantaging, or otherwise neglecting racial groups viewed as inferior.” One example of institutional racism is racial residential segregation. As a result of racist mortgage lending and other practices, Blacks have been relegated to racially segregated neighborhoods that lack access to healthy food, clean air, and safe places to exercise. This has been associated with Black people's higher rates of chronic diseases such as blood disorders (sickle cell and diabetes), kidney disease, obesity, and heart disease. These chronic diseases not only decrease Black people's life expectancy compared to Whites, but also it makes them more susceptible to viruses, such as COVID-19.

In a 2012 report regarding health equity and pandemics, the U.S. Department of Health and Human Services (HHS) acknowledged that inequities in infections and deaths during pandemics were due to racism that increased Black people's susceptibility to infections and decreased Black people's access to health care. However, HHS's proposed solutions for this issue did not address eliminating racism. Even though the recommendations discussed establishing partnerships between community representatives and the public health preparedness system, they did not empower communities to take the lead in developing strategies to address to pandemics. This has been replicated during the COVID-19 pandemic, as officials work to develop partnerships to educate communities about the virus, but fail to empower communities to develop strategies to fight the spread of COVID-19. Making matters worse, some federal public health officials and state government officials have begun to blame racial and ethnic minorities for inequities related to COVID-19.

Ohio State Senator and physician, Stephen A. Huffman, charged with enacting laws to protect citizens from the spread of COVID-19 and treating COVID-19 patients, speculated “could it just be that African-Americans or the colored population do not wash their hands as well as other groups or wear a mask or do not socially distance themselves?” When asked about the inequities in COVID-19 infections and deaths during a White House COVID-19 briefing, Surgeon General Jerome Adams, a Black physician, noted that the inequities were not biological or genetic, but stated that people of color should “avoid alcohol, tobacco and drugs” to prevent the spread of COVID-19. We need you to step up and stop the spread so that we can protect those who are most vulnerable.” By blaming Black persons for health inequities in COVID-19 infections and deaths, these government officials reinforced the notion that Black people behave in unhealthy ways, thus making Black persons responsible not only for their own COVID-19 infections but for the infections of others. Additionally, these officials ignored their duties to create policies that not only substantially engage these communities, which help assure that all persons are equitably cared for, but also disregarded their duty to effectively address racism. An example of these failures is Crisis Standards of Care (CSC).

CSC are ethical and clinical guidelines created to achieve the fair allocation of scarce critical care resources to seriously ill patients during public health emergencies. The COVID-19 pandemic has prompted the creation or revision of CSC by many state health departments and health care institutions. Although racial and ethnic minority communities have been disproportionately impacted by COVID-19, they have been marginalized in the processes of CSC creation. Furthermore, the ostensibly objective triage protocols of most CSC, in effect, prioritize White people's lives above those of Black people.

Ibram Kendi's work on antiracism is helpful for envisioning antiracism as health equity wherein “everyone has the opportunity to attain full health potential and no one is disadvantaged from achieving this potential because of social position or any other socially defined circumstance.” Antiracism “is a powerful collection of antiracist policies that lead to racial equity and are substantiated by antiracist ideas.” The powerful multi-sector resistance to the attempted closure of Chicago's Mercy Hospital reflects an antiracist commitment to equitable health for Black and other local communities. We assert that the state-level governments and health care institutions drafting and implementing CSC should adopt an antiracist approach with the aim of achieving health equity. This approach would, among other things, require health leaders to partner with Black communities in drafting the CSC and to prioritize health equity when determining how care will be allocated. Here, we focus on the racism within CSC, fully cognizant that achieving health equity will require addressing the many and broader manifestations of racism in the U.S. health care and public health systems. This particular policy analysis may well be relevant for analyzing racism in other health policies, including, most immediately, vaccine allocation, and in the longer term, policies in non-pandemic contexts.

This Article proceeds as follows: Part II discusses how racism has caused health inequities before and during the COVID-19 era. Part III examines how racism in CSC reinforces racial hierarchy through “objectivity” and “race irrelevant” practices, which, if implemented, will result in reduced critical care resources and harms to the health of Black people. Part IV suggests the integration of antiracist ideas and practices into CSC to achieve health equity.

[. . .]

COVID-19 has laid bare the racial inequalities in access to resources, which have resulted in health and health care inequities for Black people. Black communities, and other marginalized communities, must be given the power and ability to address inequities during the COVID-19 pandemic. Specifically, Black communities, in partnerships with the federal government, state health departments, and health care systems/institutions, should make decisions regarding access to health care and the contents of CSC. These partnerships could ensure that CSC reflect the Black communities' needs and values including redressing the past harms of institutional racism. For these partnerships to work, all involved must adopt an antiracist, pro-health equity approach. While it has become commonplace in this COVID-19 era post George Floyd's murder to assert that racism is a public health crisis, racism has been a chronic health crisis in the United States for centuries. We have no “standards of care” for this crisis. Health equity, with its commitment to create the conditions for everyone to reach their best health, is the standard of care we need. Only then can we truly begin to work towards improving the health and well-being of Black communities and all racial and ethnic minorities.

Charlene Galarneau, Faculty Member, Center for Bioethics and Senior Lecturer, Department of Global Health and Social Medicine, Harvard Medical School; Associate Professor Emerita of Women's and Gender Studies, Wellesley College; B.S. University of Massachusetts; M.A.R. in theology and ethics; Iliff School of Theology; A.M. and Ph.D. in the Study of Religion - in social ethics and health policy, Harvard University.

Ruqaiijah Yearby, Professor of Law and Member of the Center for Health Law Studies, Saint Louis University, School of Law; Co-Founder and Executive Director, Institute for Healing Justice, Saint Louis University; B.S. (Honors Biology), University of Michigan; J.D., Georgetown University Law Center; M.P.H. in Health Policy and Management, Johns Hopkins School of Public Health.

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