Covid-19 is an inverse equity story, not a racial equity success story

As MacArthur Foundation fellow Jennifer Richeson noted in The Atlantic in 2020, Americans love to perpetuate narratives of racial progress, regardless of whether that narrative is aligned with reality.

We saw this in a recent New York Times essay that claimed the change in Covid-19 death rates is a laudable example of the U.S. overcoming racial injustice. Pointing to improvements in vaccination rates in Black and Hispanic communities, Times senior writer David Leonhardt wrote that the racial gap in death rates has also disappeared. “In a country with deep racial inequities, where Covid was initially another tragic example,” he went on to say, “the virus is no longer disproportionately harming Black and Hispanic Americans.”

And once again we are implored to use the story of redemption to whitewash the story of racial injustice.

Covid-19 laid bare inequities that reflected poorly on what is supposed to be one of the most advanced nations in the world. Narratives like Leonhardt’s allow Americans to feel better about the mistakes we collectively made; they assuage the consciences of those who made decisions that created and perpetuated those disparities in the first place. It’s no surprise, then, that White House Chief of Staff and Covid advisor Ron Klain retweeted it, posting “Progress on racial equity in battling COVID.”

But to understand what’s really going on requires paying attention to the many things omitted from the narrative. It is true that vaccinations have improved now, and that the racial gap in death rates have narrowed now, but to call that a “public health success story” is a failure to “acknowledge the full picture,” as Leonhardt’s essay implores us to do.

Here is a fuller picture: According to the Centers for Disease Control and Prevention, increases in excess deaths led to a decline in life expectancy of 6.6 years for American Indian or Alaska Native populations, 4.2 years for Hispanic populations, and 4 years for non-Hispanic Black populations. Overall, American life expectancy declined by 2.7 years — the biggest decline in almost 100 years. The Covid-19 pandemic reversed more than 10 years of progress made in closing the gap in life expectancy between Black and white Americans and reduced the previous Hispanic mortality advantage by over 70%. Moreover, more than 200,000 American children lost their caregivers due to Covid-19, losses that were concentrated among children of color.

These losses, and the disparities in these losses, which will have ripple effects for decades and generations to come, were preventable.

Early in 2020, health equity experts noted that Covid-19 would lead to racial disparities unless intentional action was taken. They laid out what ethical and equitable allocation of resources, including the scarcest medical resources, could look like. Actionable data were available using the CDC’s own previously developed metric of social disadvantage, the Social Vulnerability Index (SVI), which identifies communities with higher rates of poverty, crowded housing, racial/ethnic minorities, and lack of access to transportation compared to communities with a low index. The CDC’s own data showed early in the pandemic that areas with a high SVI were at increased risk for Covid-19 outbreaks. Those areas have since experienced increased in-hospital deaths and major cardiovascular events, lower vaccination rates, and lower uptake of antiviral treatments.

The U.S. had clear warning signs — and ignored them. After health care workers and those in congregate care settings were prioritized for vaccines, in most areas of the country agencies determined vaccine priority simply on the basis of age, instead of using the data available to prevent the inequities that were sure to emerge. A series of vaccination rollout decisions exacerbated preventable disparities by incentivizing health care systems, pharmacies, and providers to find the easiest arms to reach first. As a result, the first arms to get the jab were predominantly wealthy and white.

In the Yale Law Journal Forum, Kristen Underhill and Olatunde C.A. Johnson referred to Covid-19 vaccine distribution as a case study of the inverse equity hypothesis, the theory that “when health innovations emerge, they are initially adopted by wealthy and connected segments of the population, thereby amplifying rather than reducing inequality.” The theory explains precisely why racial gaps were widest at the beginning of the pandemic, and with each surge.

The inverse equity hypothesis is predictable, but not inevitable. It depends on the extent of government action to make effective use of available tools and to design delivery systems that mitigate its effects. And yet it held up consistently across Covid-19 innovations: medication allocation and utilization, testing, clinical trials, and clinical algorithms. The SVI metric was not incorporated into CDC decision-making or guidance around lifting masking in May 2021, in defining “community levels” of Covid in February 2022, or in source control in health care settings in September 2022.

By January 2021 the CDC had issued reports detailing that age-adjusted Covid-19—associated mortality among American Indian or Alaskan Native populations was 1.8 times higher than among non-Hispanic whites, that Hispanic and non-Hispanic Black individuals were disproportionately represented among Covid-19-associated deaths, and that, in some parts of the country, the majority of adult Covid-19 cases, hospitalizations, and deaths were among Hispanic adults. Covid-19 is an ongoing reminder of the magnitude of loss we are willing to tolerate when it comes to the lives and welfare of people who are Black, Hispanic, Indigenous, and Pacific Islander.

Tragically, early failures led to predictable — remember, not inevitable — losses.

A full picture of the pandemic’s inequities should also acknowledge multiple other outcomes that directly affect survival and well-being. Job losses were most severe, and job recovery the slowest, among Black, Hispanic, and Asian women. In salary projections, Black women are now in a downturn that suggests they will never close the wage gap. Food insecurity, inequities in health insurance coverage, delays in routine medical care, and delays in seeking and receiving care for acute life-threatening emergencies have all been exacerbated by the ongoing pandemic.

The mental health of Black, Hispanic, and Asian people also worsened relative to white people during the pandemic, with significant increases in depression and anxiety among racialized minorities. While data on long Covid are only slowly emerging, the incidence and impact of the disease is certain to be more profound among those in racial and ethnic minority groups.

Almost three years after the warning signs started flashing, the U.S. is now at a place where gaps in current death rates have narrowed. It is worth celebrating the tenacity of community champions in their relentless fight for equitable access to vaccines and the subsequent reduction in mortality among Black and Hispanic people. But fixing injustice requires fundamental changes in systems and structures. True success means a public health infrastructure that doesn’t have to claim success from recovering from predictable tragedy. It would mean that the country felt secure that subsequent surges from new variants will not further exacerbate disparities.

Reading Leonhardt’s column reminded us of something the late public health champion Dr. Paul Farmer once wrote: “Those whose lives are rarely touched by structural violence are uniquely prone to recommend resignation as a response to it.”

Declaring a public health success in the face of such profound disparities feels dismissive of the scope of the losses and the entrenched underpinnings of such disparities. Decision-makers need to understand that the choices they made during the pandemic set people from racial and ethnic minority groups on fundamentally different life trajectories, a story of inequities that will be with the nation for decades and generations to come. While that may make many people (including opinion writers and policymakers) uncomfortable, it is the story of injustice that must be told in order to learn from our nation’s collective mistakes and prevent them from happening again.

Marina Del Rios is an emergency medicine physician and an associate professor of emergency medicine in the Department of Emergency Medicine at the University of Iowa. Nathan Chomilo is a pediatrician and internist, an adjunct assistant professor of pediatrics at the University of Minnesota Medical School, and the former director of Covid-19 vaccine equity for the Minnesota Department of Health. Neil A. Lewis, Jr., is an assistant professor of communication and social behavior in the Department of Communication at Cornell University and the Division of General Internal Medicine at Weill Cornell Medicine.