For the first weeks of the pandemic in St Louis, Missouri, the only ones to die from the virus were black.
By 8 April the coronavirus had killed 12 people. Each and every one was African American.
In this midwestern city that six years ago became the focal point for a national debate on race and policing after an unarmed African American teenager, Michael Brown, was killed by police in the suburb of Ferguson, the racial disparity attached to the Covid-19 death toll held a particular resonance.
“It’s an education system issue, it’s a health and resources system issue and it’s a public transportation issue,” said Cedric “C-sharp” Redmon, a local rap artist and youth ambassador for the city of St Louis who is part of the city’s outreach efforts, as he attempted to pinpoint the root causes of the disproportionate death toll. “There’s a lot of stuff that would need to be rectified in order to stop something like this again.”
The death toll in St Louis now stands at 21, with 64% of all Covid-19 cases in the city being African American. They make up only 45% of the population.
Although a nationwide statistical picture is nowhere near complete, St Louis is far from an anecdotal outlier. Major US cities including Chicago, New York and New Orleans report similar racial disparities in the thousands of lives now claimed by Covid-19. In 2014, Brown’s death split the United States between those ready to recognise the entrenched racism that underpinned the black community’s experience with law enforcement, and those unwilling to do so.
In 2020, Covid-19 has begun to divide the country between those ready to explore the structural racism ingrained in America’s public health outcomes, and those who are not.
Earlier in the month, Donald Trump described evidence of the disproportionate effect of Covid-19 on black communities as “terrible” and a “tremendous challenge”, but the president has done little to respond to it since.
The Centers for Disease Control and Prevention (CDC), the administration’s leading public health agency, has begun to publish more detailed data on the racial breakdown of confirmed coronavirus cases. But of the 828,441 confirmed cases documented, only 36% are broken down by race, largely due to many states and municipalities not recording racial data on those who test positive. According to the Associated Press, the CDC has offered little pathway to assist local governments to better record this information.
In a marker of the pressing need to address this glaring hole in the national picture, Democrats in Congress introduced legislation last week to compel US government health officials to publish daily data on the number of Covid-19 cases and deaths broken down by race.
“Because of government-sponsored discrimination and systemic racism, communities of color are on the frontlines of this pandemic,” Senator Elizabeth Warren, one of the bill’s backers, said in a statement. “To effectively slow the spread of the virus and ensure our response is robust and equitable, we need comprehensive national data on who is getting infected, who is getting treatment, and who is dying.”
Key aspects of the bill were passed as part of the latest coronavirus relief package on Friday. There are currently no Republican co-sponsors of the full legislation in the house.
As with much of the scattergun approach to the pandemic in the US, the Trump administration has largely left the states to administer their own responses to racial disparities.
In Michigan, one of the first states to create a racial disparity Covid-19 taskforce, the lieutenant governor, Garlin Gilchrist, told the Guardian that Trump “is simply not taking strong enough action” to address the disparities.
The state began monitoring racial outcomes early in the pandemic. Over 2,900 people have now died in Michigan, with African Americans constituting 40% of the death toll, but only 14% of the population. Gilchrist, a Democrat, personally knows 15 people who have died from Covid-19 – all but two are black.
“This is something that’s very real for communities. I live in Detroit and part of the reason that communities of color are so anxious is because typically, when something so frightening is happening we come together to cope with it as a community. And this virus has made the act of coming together, dangerous and deadly.”
The taskforce will involve public health experts, labor organizers and politicians to examine a suite of issues believed to contribute to the disparity, from air pollution in minority neighbourhoods, less availability of testing, and the root causes of other underlying health issues, with an aim to push both real time solutions as well as longer-term legislative action.
Numerous experts have pointed out how longstanding health and socio-economic disparities have made minorities more vulnerable to the worst consequences of infection along almost every point of the microbe’s path.
“If you look at the health conditions that we know dramatically increase the risk of death if you’re infected with Sars Covid-2, African Americans have much higher prevalence of every one of those conditions. Diabetes, hypertension, heart disease, you name it, African Americans have a higher prevalence,” explained Thomas LaVeist, dean and professor at Tulane’s school of public health and tropical medicine.
“Whenever there’s a tragedy like this, or some sort of a major disaster occurs, it’s going to be the least advantaged people who are going to be most harmed by it,” he said.
African Americans and Latinos are less likely to be able to work from home and more likely to be forced to take public transportation, increasing their risk of exposure to coronavirus. Minority and low-income communities are more likely to experience food insecurity, which is linked to higher rates of obesity and diabetes, and less able to stockpile supplies.
Decades of segregation, discriminatory housing policies and poor environmental protections have left many African Americans living in substandard and high-density housing (where social distancing is that much harder) or areas of higher air pollution, leading to higher rates of asthma and other diseases.
Racial and ethnic minorities of all education levels report they are typically less able than whites to handle financial setbacks. Black- and Hispanic-owned small businesses have less access to traditional financial lenders, making it more difficult or impossible to access coronavirus relief programs like the now drained $350bn paycheck protection program.
“We need to understand that people’s health is not a direct result of their behaviors and actions,” said Dr Lisa Cooper, a Bloomberg distinguished professor and director of the center for health equity at Johns Hopkins University. “People’s individual actions and behaviors do play a role in health. But the environments in which they exist and the policies that we put in place that shape people’s opportunities actually determine what choices they have to make.”
Only two states – Kansas and Illinois – are tracking racial and ethnic information on coronavirus testing, according to Johns Hopkins University. But city-level data has begun to reveal disparities in testing.
An analysis last week by the New York Post found that 22 of the 30 most-tested zip codes in New York City, the center of the national outbreak, are whiter or wealthier (or both) than the city’s average demographic profile.
In Philadelphia, those living in higher-income zip codes have been tested at a rate six times greater than those in poor areas, according to an analysis by the Drexel University epidemiologist Usama Bilal.
Rubix Life Sciences, a Massachusetts-based biotech company, recently released a report that found African Americans who reported common coronavirus symptoms were less likely to get a test. The study used patient survey and hospital billing data from seven states in February and March.
Reginald Swift, CEO of the company, also said he expects to see racial disparities in access to clinical trials for experimental Covid-19 drugs.
He claims trials in some cases have limited the drugs to patients without underlying illnesses, leaving out a large proportion of Covid-struck African Americans. There are also health insurance issues, where many low-cost insurance plans refuse to cover costly experimental trials.
“Everybody knows it’s the elephant in the room,” he said.
Research from the last decade has also shown minorities are more likely to live in “healthcare deserts”. One study found black Americans were on average nearly 70% more likely to live in a zip code with a shortage of primary care physicians. African Americans in some major US cities are also more likely to live in an area with no hospital trauma center within five miles.
Racial discrimination in the world of medicine has a particularly gruesome history in America, stretching back to the gynecological experiments of J Marion Sims on enslaved women in the 1840s, to the infamous Tuskegee experiment and the case of Henrietta Lacks.
Cooper worried that the unprecedented stress on the healthcare system during the coronavirus crisis could exacerbate existing biases among already overloaded hospital staff.
“We know that those biases tend to be increased at a time when there’s a lot of stress on people,” she said.
Ultimately, Cooper said, the actions we take today will leave a lasting legacy in the future.
“What will people say about us?” she asked. “Did we think about everyone when we were trying to address this problem? Did we want to make a better life or a better country for everyone? Or do we just decide that certain groups of people didn’t matter as much?”
Sophie Kasakove and Lauren Gambino contributed reporting