Racism, not race, is a risk factor for infectious diseases

As the COVID-19 pandemic circles the world, every country that confronts it has unique challenges when it comes to their pandemic responses. The United States has some of the greatest structural challenges, and they run deep.

America is combatting a pandemic -- COVID-19 -- in the context of a more than 400-year history of ongoing endemic and systemic racism. Members of Black, Indigenous and Latinx communities are dying at three-to-four times higher rates due to COVID-19 than white communities (age-adjusted mortality). While this disproportionate impact on marginalized communities of color is jarring, it is certainly not unforeseen.

We are all too familiar with all infectious diseases carrying the heaviest burden on Black, Indigenous, and other people of color in America and on countries that in the aftermath of 20^th century colonialism are considered now to be “developing,” globally. Infectious outbreaks exacerbate pre-existing social inequities and expose the ugliest systemic injustices.

During the ignition of global awareness of the brutality of systemic racism in the aftermath of the extra-judicial police killings of Breonna Taylor, George Floyd and countless other Black people, the community of infectious diseases specialists, microbiologists and responders is uniquely equipped to bridge racial justice and science. Racial disparities in COVID-19 illnesses and deaths are attributed to higher rates of comorbidities that include diabetes and hypertension, often with no mention of the root cause -- racism. This has serious consequences.

America was built on racism -- as a settler colonial nation established on the genocide of Indigenous people and expanded via the enslavement and exploitation of Black people. While the manifestations of racism evolve over time, it remains a structural system of injustice that advantages white people and disadvantages marginalized people of color. Like COVID-19, racism is a brutal public health crisis. Like COVID-19, racism kills. Whether through police brutality, violent discrimination, deprivation, or intergenerational trauma, racism is a fundamental cause of bad health that those of us in the infectious diseases  community must fight to dismantle.

The justification for slavery and modern racism comes from flawed historical and modern research claiming intrinsic biological differences between races; including, Black people having thicker skin, smaller skulls, larger sex organs, genetics-based immunity to certain illnesses and susceptibility to others. These fallacies, presented as scientific fact and consensus in medical journals, remain rooted in medical practice today and are used to justify or perpetuate mistreatment and mismanagement of Black patients.

The phenotype of a microbe is a product of its genotype and external environment. Similarly, COVID-19 infection and mortality rates are higher in marginalized communities because they are more exposed to COVID-19, and face a greater burden of chronic diseases, both of which are manifestations of systemic racism. Communities of color face exceedingly high rates of systemic discrimination, poverty, police violence, mass incarceration, exposure to toxic pollutants in their air or water, homelessness, and unemployment while lacking accessible healthcare, public housing, equitable education, transportation and healthy food (food deserts). This is compounded by the mental stress and physical manifestations of constantly surviving anti-blackness, institutional racism, discrimination and intergenerational trauma. A culmination of all such factors leads to chronic diseases, for example, Black people are 60% more likely to be diabetic and 40% more likely to be hypertensive. Black, Indigenous and other people of color are also more exposed to COVID-19 since they are overrepresented in essential jobs (called “unskilled” jobs) like sanitation, postal or warehouse workers, meat packers, domestic workers, hospital orderlies, etc. This is an outcome of poverty and segregation where people of color are often second-class citizens living in poor, densely populated, over-crowded, over-policed, urban neighborhoods or reservations with underfunded schools leading to scarce employment options besides “unskilled” work. In these high-risk occupations, Black and Brown lives are undervalued and hence, they are not given adequate protection against infection.

The United States has the highest global incarceration rate with 2.3 million inmates (more than 23% over age of 50) in overcrowded detention facilities -- including jails and immigrant detention centers, lacking basic sanitation. Black and Latinx people compromise 56% of the prison population. The largest COVID-19 clusters have been in correctional facilities -- from Marion Correctional Institution in Ohio (80% of inmates had COVID-19) to San Quentin State Prison in California (1/3^rd of inmates had COVID-19). Mass incarceration and the school-to-prison pipeline also deprive Black and Brown families of income earners and economic mobility. These socioeconomic inequities and systemic hurdles make it unbearably expensive for these communities to seek medical care. They literally cannot afford to get sick.

From the Tuskegee Syphilis study to the mismanagement of HIV epidemic, the medical community has contributed to the poor health outcomes of Black and Indigenous people and other people of color. In 2018, Black people made up 13% of the population, but comprised 42% of new HIV diagnoses. Despite innovation and translational discoveries in infectious diseases skyrocketing, we have yet to see an equitable translation of the positive impact of those to marginalized communities.

As an immigrant, Muslim and  infectious diseases scientist of color, I have pursued research in my field while combating daily structural racism and discrimination in academia, as have my colleagues of color. Besides our science and clinical work, we bear the constant burden of advocating for our communities. We pay the academic “minority tax” by spearheading diversity and inclusion initiatives which seldom help us but shine a positive light on our institutions. Women of color in the infectious diseases field battle the intersectional fight, confronting racism and sexism, having to reduce ourselves to survive the culture of respectability politics and tone policing in academia. We are burnt out.

It cannot be up to infectious diseases scientists and physicians of color to take the racial justice mantle of change. We need our white colleagues to recognize that racism, and not race, is a risk factor for infectious diseases. The legitimization and perpetuation of systemic racism through power structures like academia and medicine has advantaged white people and directly created adverse outcomes for Black, Indigenous Americans and other people of color. Thus, the training of scientists and clinicians must include mandatory longitudinal anti-racism curricula. This education includes a global and intersectional understanding of racism, sexism, homophobia and other forms of discrimination that addresses the ID scientist or clinician’s role in confronting racial health disparities. Academic journals need to set higher standards for publishing on racial health inequities to ensure egregious race-based claims are avoided and so all research is contextualized in the critical race theory framework to discuss the impact of racism on a study’s findings. Lastly, academic institutions including microbiology and infectious diseases training programs not only need to ramp up recruitment of underrepresented minorities but develop sustainable racial justice policies that redirect funding and resources to support our retention, upliftment, promotion and long-term career development.

COVID-19 has exposed America’s ugly truths and exposed the racism in science and medicine that continues to threaten Black lives. Transformative success in combatting infectious diseases will only come if we dedicate ourselves to identify, confront and abolish racism, a root cause of health inequity, that should, at least now, finally, be impossible to ignore.