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Does Covid Discriminate?

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from the magazine

Does Covid Discriminate?

The virus has had disproportionate effects on certain demographic groups, even in countries with the most generous welfare provisions. Summer 2020
Covid-19

One evening in early March, Razzak Khalad, a 49-year-old taxi driver, picked up his final fare of the day at the airport. The passengers, a couple in their fifties, were arriving from a ski trip in the Italian Alps. They loaded their baggage and settled themselves inside for the ride home. As Khalad drove and for most of the ride, the couple coughed.

You probably can guess what happened next. Four days later, Khalad came down with Covid-19. Over the following days, as he quarantined at home, his health deteriorated. Only when he finally felt that he could no longer breathe did he go to the hospital. There he waited, was examined, and waited some more; finally, after six hours, the hospital staff sent him home, with assurances that he would “fight it off.” And it’s true: he didn’t suffer the ultimate fate. But he remained sick enough to be unable to work when the Associated Press interviewed him in early May, a full two months after that ride from the airport.

As the coronavirus swept the United States, the outline of Khalad’s story became worryingly familiar: conference-hopping and ski-tripping cosmopolitans transporting the virus into the vulnerable respiratory systems of low-income, usually dark-skinned, service providers, who, when sickened, usually had recourse only to under-resourced, unresponsive urban hospitals. In the virus red zone of New York City, this scenario became as familiar a part of Covid-19 news as the presence of Anthony Fauci on television. The largely white residents of the luxury zip codes of Manhattan fled to their summer homes in the Hamptons or Westport. Meantime, the black and immigrant denizens of the poorer neighborhoods of Queens, Brooklyn, and the Bronx rode the subway to their jobs stocking shelves at Whole Foods, mopping hospital floors, or delivering FedEx packages to Zoom-conferencing, homebound shoppers before returning home to coronavirus-haunted neighborhoods. No surprise, then, that Manhattan’s richer neighborhoods had the lowest per-capita rates of infection in the city, while gritty outer-borough areas suffered the highest rate. And no surprise, either, that the shelf-stockers, floor-moppers, and delivery drivers turned out to be disproportionately nonwhite.

Of course, New York was not the only place in the U.S. where Covid numbers were a distressing reflection of the nation’s racial inequalities. Such disparities were the rule in Michigan, too, where blacks make up 15 percent of the overall population but 31 percent of the cases—and 41 percent of the deaths. As of early May, African-Americans were half of Chicago’s Covid deaths while making up only 30 percent of the population. Nationally, black Americans died of the virus at two times the rate predicted by their portion of the population. In parts of the country with fewer blacks, Latinos generally took first place among the victims. In Rhode Island, Latinos, mostly working class, are 16 percent of the population but make up 45 percent of the confirmed cases. Latinos were infected at higher rates in a number of states, including Illinois, where they make up 17 percent of the population but account for 43 percent of cases.

At times, the virus seemed to be conspiring with the creators of the New York Times’s 1619 Project to advance the image of America as a land of entrenched and systemic racism, and of a heartless economic regime that privileges profits over the well-being of nonwhite people. The Covid gap “is not about race; it’s about racism,” said Alexis Madrigal, an editor at The Atlantic and leader of the COVID Tracking Project, on NPR. New York Times columnist Charles Blow added: “The crisis is exposing the class savagery of American democracy.”

Here’s a truth inconvenient to this line of thinking: Covid-19 racial disparities were the rule everywhere in the Western world. Remember Khalad, the taxi driver who picked up the ailing ski vacationers? He wasn’t looking for fares at JFK. Nor did he have to wait long hours at an underfunded hospital in the Bronx. Khalad is an Iraqi immigrant living in and driving his taxi through Stockholm, Sweden. As it turns out, the plague that attacked the United States in the early spring exposed inequality in wealthy countries that run the gamut from cowboy capitalist to socialist-adjacent. Sometimes the inequalities looked racial; sometimes they didn’t. Some of those countries have welcomed new foreign populations, giving them all the expansive services of their welfare states; sometimes they’ve been more restrictive. Yet in each, the disadvantaged suffered more than the middle class and well-to-do. Covid-19 didn’t expose America’s “class savagery” so much as reveal inequality as a stubborn fact of human social arrangements that even the most generous welfare state cannot resolve.

When it comes to the color and socioeconomic status of Covid-19 victims, the United States is but one in the crowd. In the United Kingdom, well-to-do Londoners hunkered down in quaint country towns; one wealthy family earned a few minutes of fame for buying out entire hotels in the Irish countryside. By contrast, the BAME populations (the abbreviation officials use for black, Asian, and minority ethnic people) succumbed like frontline infantry at Verdun. Death rates were almost six times higher for black Africans than for whites, four times higher for Pakistanis and Bangladeshis, 2.6 times higher for Indians, and 3.7 times higher for Caribbean blacks.

The race story was similar elsewhere in the Anglosphere. The Maori in New Zealand died at a far higher rate than their white fellow citizens did. Canada also had large Covid disparities. According to the Toronto Public Health Department, recent immigrants and low-income “visible minorities” had 113 cases of the virus per 100,000 people, compared with 73 cases per 100,000 people in the highest income group. In Montreal, which had more deaths per capita than Los Angeles and Chicago, numbers from “health regions” suggest that a disproportionate number of those fatalities were in the black and immigrant Montréal-Nord district.

Hard data on these sorts of disparities are difficult to come by in many countries; most, including Canada, France, and Germany, don’t collect information on ethnic or racial background. Still, it’s possible to draw some conclusions from census-type data like those from Canada’s health regions. In Paris, as in New York and London, the moneyed fled to Saint-Tropez villas or family country homes. Yet the banlieues outside the city confirm that country’s BAME reality. In Seine-Saint-Denis, home to large populations of poor Arabs and Africans, the death rate was up a full 62 percent over the previous year.

Postcolonialists might say: of course, England and France are hostile to minorities. The problem with that explanation is that these discrepancies extend to their most admired nations, too. In Finland’s capital city of Helsinki, for example, Somalis accounted for 17 percent of positive cases for the disease—ten times their share of the city’s population, according to Reuters. In Norway, too, Somalian refugees had infection rates more than ten times the national average. (The Norwegian health minister did, however, ban the well-to-do from fleeing to their vacation cabins—“no exceptions.”)

Sweden’s racial Covid gap was a silent rebuttal to the country’s proudly egalitarian self-image. As in France, the foreign-born in Sweden tend to live in segregated suburbs, where incomes are half those of wealthier areas. One of the hardest-hit, the Rinkeby-Kista district in the north of Stockholm, is home to Somalis, Iraqis, Syrians, and Turks. It had 238 confirmed cases as of April 6—the equivalent of 47 cases per 10,000 residents, more than three times higher than the regional average of 13 cases per 10,000.

So why the apparent Covid racial animus in countries with no history of Jim Crow or redlining, countries committed to multiculturalism and generous safety nets? Experts in every country, including the U.S., point to the same factors. First: density. The biggest outbreaks have all been in metro areas with populations over 10 million: Wuhan, Milan, Madrid, Paris, London, and New York. Minorities are more likely to live in urban areas. Overall, urban counties in the U.S. are 54 percent nonwhite. During the 1918 pandemic, when the black population was largely rural, it was whites who swamped the hospitals and morgues. It’s true that rural areas have not been safe from Covid-19, but demographer Joel Kolko found that density on the county level was significantly associated with Covid-19 deaths in the United States. As of May 18, more than 2,000 U.S. counties still had zero cases; they were all rural areas.

Still, a number of analysts have noted that Seoul, Tokyo, Taiwan, and Hong Kong have more people per square kilometer than New York, the densest city in the U.S., yet those city governments contained the virus. (As of July 1, Hong Kong has reported only seven Covid-19 fatalities in a population of 7.5 million.) Manhattan, with its high-rise apartment buildings, is the densest borough in New York. Yet Covid took a lighter swipe there compared with, say, Queens, with its five- and six-story apartment buildings and small semi-attached houses. It turns out that the strongest predictor of Covid-19 rates in New York City was the average number of people living together. Crowded homes help explain why Navaho Indians, who live on isolated reservations, had some of the nation’s most alarming per-capita Covid numbers. The Wall Street Journal explains: some 18 percent of Navaho homes have five or more people, and 14 percent are classified as crowded, among the highest rates nationwide. The problem is not population density but the density of living quarters.

That’s consistent with other known Covid-19 hot spots in Western countries: prisons, nursing homes, cruise liners, navy boats, and migrant-worker dorms. Outbreaks among prisoners and prison staff were reported in Italy, France, Spain, Belgium, Germany, Portugal, and the United Kingdom. Nursing homes, unknown in countries not wealthy enough to support workforces dedicated to care of the elderly, were swamped with sick and dying residents. As it happens, minorities in Europe, as in the United States, more commonly live in multigenerational households. In the U.K., whether for economic or cultural reasons, extended families are far more common among BAME populations. In 2019, only 2 percent of whites described their household type as “other, with dependent children,” compared with 11 percent of Asians and 7 percent of blacks. In France, Arab and African households tend to include extended family members; that tradition made Seine-Saint-Denis one of the country’s most densely populated departments. Sweden has the highest rate of single-person households in Europe—except in its low-income areas. A 2017 OECD report calculated that 31.5 percent of the country’s housing arrangements for the lowest 20 percent of earners were overcrowded.

Low-skilled service jobs, many deemed essential and requiring face-to-face contact, also help explain why Covid seemed to target racial minorities. The best study illustrating the minority / service job / Covid nexus in the U.S. comes from San Francisco’s Mission District, one of the most densely concentrated Hispanic neighborhoods in the city; a full 58 percent of its residents are Hispanic, and 34 percent are white. When researchers tested more than half of the residents in the area, an unusually high share for such a study, a modest 2 percent came back positive, but the racial breakdown was startling. Ninety-five percent of the positives were Hispanic; not one was white. More to the immediate point, 90 percent of Mission Hispanics worked in jobs like food delivery and cleaning. They generally lived with more than three people and often had to travel to work via poorly ventilated and crowded mass transit. A report from New York City comptroller Scott Stringer confirmed this close tie between race and service work in that city. A disproportionate share of “janitors, home health aides, delivery people, grocery and farm workers and sanitation workers [and] much of the municipal work force is black or Hispanic,” the report indicates, and more than 50 percent were foreign-born.

The results recall the nostrum that the U.S. depends on immigrants to “do jobs Americans won’t do.” As other Western nations have become more diverse, they appear to have followed America’s lead in this area. Indeed, café-lingering Westerners increasingly rely on minorities, many foreign-born, to do their dirty work. In Canada, up to a third of the hard-hit “key workers”—cleaners and delivery people and kitchen help—are foreign-born; one study found that 42 percent of personal-care workers in Ontario identified as a “visible minority,” close to double their share of Canada’s population. In Europe, Covid set its sights on exactly the same immigrant-dense service occupations. European professionals and administrators depend on migrant workers to clean, take care of the elderly, drive cabs, and the like. Twenty percent of key workers in Italy, Belgium, Germany, Sweden, and Austria are non-EU immigrants. In early May, French doctors reported that they had found Paris’s “patient zero,” a man infected with the virus as early as December. He was an Algerian-born fishmonger.

Workers in low-skilled service jobs, which have significant contact with the public, were more likely to contract the virus. (SAMUEL RIGELHAUPT/SIPA USA/ALAMY STOCK PHOTO)

This divide is less about race than it is about cheap labor. Especially since the expansion of the EU, Western Europeans have also been relying on white low-wage workers from Eastern Europe to do the Covid-spreading jobs that they don’t want to do. In the U.K., tens of thousands of Poles, Romanians, and Hungarians drive trucks, take care of the elderly, and stock warehouses. (At least they did before Brexit. Since then, many have moved to Germany to find work.) Every spring, workers from Central and Eastern Europe—almost always white—crisscross the farms and vineyards of wealthier countries to their west to plant and pick grapes and vegetables. This year, in an effort to keep the virus at bay, Germany chartered planes to avoid the long bus rides usually taken by the expected 80,000 migrants. Maybe authorities were right that planes were safer than buses, though the same could not be said of the packed dormitories where migrants would rest after their days in the fields.

Still, the pickers were probably better-off than the migrants working the line at meatpacking facilities, where cold temperatures and close working conditions encouraged viral spread. In the U.S., these factories turned rural counties in Nebraska and Texas into Covid-19 hot spots. Of the 25 rural counties with the highest per-capita case rates, 20 contain a meatpacking plant or prison where Covid could hitch a ride into workers’ homes. Meatpacking factories manned by immigrants were the site of bad Covid outbreaks in Brazil, Australia, Spain, Ireland, Portugal, Germany, and Canada. In the United States, Poles worked the slaughterhouses back in the day. Today, such workers are often Mexican or Central American; in Canada, they’re Filipinos; in Germany, Romanians.

The final consensus reason for Covid’s unnerving mirroring of ethnic inequalities is that lower-income populations tend to be in poorer health. Low-income Americans, especially blacks, have high rates of obesity, hypertension, and diabetes; all these infirmities appear to increase the risk of death among Covid patients. Pro Publica studied the first 100 victims in Chicago, a city with the largest life-expectancy gap between black and white in the country. Most of the subjects lived in majority black neighborhoods. Only five of the 100 had no comorbidities; and 78 had hypertension and diabetes.

Is America’s notoriously unaffordable and byzantine health-insurance system to blame? “This is what happens when you don’t recognize the right of access to health care as a basic human right when you have large parts of the population suffering from nutritional deficiencies and so forth,” economist Joseph Stiglitz told an interviewer about the country’s Covid-19 performance. A closer look at the global picture might have made the Nobel Prize winner hesitate. The virus didn’t reveal the flaws in our system as much as it highlighted how tricky it is to resolve inequality, especially in matters of health.

Hierarchies have been a rule of human groups since the Anthropocene. Writing about the plague that brought ancient Athens to its knees, Thucydides observed that crowding and poor sanitation and housing conditions among the plebs helped spread the disease. Medical anthropologists have discovered that at the time of the Black Death, the poor were younger when they died than were landowners. In the fifteenth and sixteenth centuries, the rich fled cities in England, France, and Italy, and quarantined in their country estates, while the lower classes died in their hovels and on the fetid streets. Italian doctors took to calling plague “a disease of the poor.” In eighteenth- and early-nineteenth-century America, poor immigrants frequently dwelled near harbors and swamps, where yellow fever and cholera menaced them. In the early twentieth century, bubonic plague gripped San Francisco’s Chinatown, the city’s poorest, most congested district, while the immigrant tenement districts of Gotham seethed with cholera, TB, and diphtheria.

In fact, for much of history, cities were “demographic sinks,” where the population died off faster than it reproduced; cities grew only because people arriving from the countryside replaced the dead. Over the centuries, as scientists learned more about the causes and progression of disease, city planners designed infrastructure to limit infection and contagion. The discovery of polluted water as the source of cholera and dysentery led to the marvel of sewer systems and modern plumbing in London, Paris, and other cities. (See “Germs and the City,” Spring 2007.) As overcrowded and garbage-strewn slums with outhouses and shared bathrooms became culprits in the spread of typhus, cholera, and respiratory infections, officials tore down tenements and built public housing with private bathrooms, ventilation, and light. In 1934, New York City mayor Fiorello La Guardia celebrated the destruction of the Lower East Side’s notorious “Lung Blocks,” where his wife had become infected by the tuberculosis that eventually killed her. “Down with hovels, down with disease, down with firetraps, let in the sun, let in the sky!” he preached at the opening of the first public-housing buildings in the city. That some of those public-housing projects were built by the now-maligned Robert Moses, and that those very projects designed with the health and safety of the poor in mind were many decades later targeted by Covid-19, are the sorts of ironies that history never tires of.

Inevitable policy missteps aside, the modern city reveals the possibilities of medical knowledge when tethered to competent governance. American cities and parts of Europe saw a stunning decline in mortality in the late nineteenth and early twentieth centuries. By 1940, city dwellers in the U.S. could expect to live as long as country folks. And it wasn’t the Astors and Rockefellers weighting the numbers; working-class people were also better-off. As the twentieth century began, Americans lived, on average, 47 years. As of 2017, life expectancy in the U.S. was closing in on 79 years. In Western Europe, Canada, Australia, South Korea, and Japan, people can look forward to living well over 80 years.

During the twentieth century in the West, medical progress brought longer, healthier lives to rich and poor, whites and nonwhites; what it didn’t bring was equality. In the U.S., disease and mortality rates among blacks remain higher than those of whites, as they have been since records have been kept. More recently, working-class whites have begun to die younger than their parents did, the first such decline in history. This inequality will surprise no one even vaguely familiar with recent American politics.

More unexpected are the large differences between low- and high-income populations in countries with the most admired universal systems. Consider that black Canadians—who, like all their compatriots, enjoy one of the best-funded, universal single-payer health systems—suffer disproportionately from high levels of the same comorbidities, such as hypertension and diabetes, as American blacks do. France prides itself on having one of the world’s best health systems; maybe, but the system was not good enough to prevent many people in places like Seine-Saint-Denis from becoming obese, diabetic, and asthmatic, or from facing a scarcity of doctors. “Many [patients] arrive at hospital already in a critical condition because they tend not to have regular care or contact with the health system,” an activist told the Guardian. In the U.K.’s National Health Service, an institution that inspires more British pride than Magna Carta, Afro-Caribbeans are more likely than whites to develop high blood pressure and, along with South Asians, are more prone to Type-2 diabetes. For reasons that remain elusive, nonwhite Britons were substantially overrepresented among NHS doctors who died from Covid-19.

Several studies even suggest that mortality differences widened during the 1970s and the 1980s, when social and health-care spending was rising to once-unimaginable levels. Yes, the working class became healthier and lived longer in ways that would have struck their hard-knocks grandparents as wondrous. But higher-income Europeans saw even greater gains, especially because of declining cardiovascular disease. Everyone’s health improved—but inequality grew.

Here’s the real shocker: the worst health inequalities are in Nordic countries. Nordic welfare regimes are explicitly aimed at reducing differences between social groups; researchers call their equality failure the “Nordic health paradox.” Norway provides universal health-care coverage, but its socioeconomic inequalities in mortality and self-reported health are among Europe’s largest. Though in the aggregate, Swedes are the healthiest of all Europeans, life expectancy is considerably higher for high-income than for low-income Swedes. Gaps in self-reported health between education and occupational groups widen from early to middle adulthood. A 2014 paper by researchers at Stockholm University and the Stockholm School of Economics found that men in the lowest quintile had twice the mortality risk as those in the highest.

How to explain the persistence—make that the growth—of life-shaping inequalities under what are arguably the most egalitarian social and economic conditions in the history of the planet? Scholars are coalescing around a theory that goes like this: before 1900, when malnutrition and poor sanitation and housing were the norm, it was spoiled food and waterborne and respiratory diseases that kept undertakers and grave-diggers busy. As material conditions improved, the threat of those diseases diminished. Since 1940, chronic conditions such as heart disease and cancer have taken their place as the leading causes of death. Luckily, medical science has more tools at its disposal to control and prevent cancer and early heart attacks than it did influenza epidemics. Statins, beta blockers, stents, bypasses, mammograms, and colonoscopies, to name a few, are all familiar to people past a certain age. Individuals also can improve their chance of living into their golden years by avoiding smoking, eating healthier, keeping BMI at reasonable levels, limiting alcohol, and exercising.

As human beings increase their ability to forestall disease and death, inequality grows for three reasons. First, people with money can avoid neighborhoods and occupations that might expose them to infectious diseases and environmental toxins. Second, most universal health-care systems allow supplemental private coverage as well. Even in the highest-quality national health care, the well-to-do may still get better, faster care than the poor and working class. And third, highly educated, affluent Europeans tend to follow health recommendations more carefully than their less educated peers. A 2019 paper from a consortium of the top Nordic and German research organizations found that “alcohol-related and smoking-related mortality” contributed between 30 percent and 50 percent to the income differences in life expectancy in Scandinavia.

American studies find similar class and education differences in smoking, binge drinking, obesity and responsiveness to antiobesity interventions, and awareness of and choices about nutrition. Anomalies exist: Hispanic-Americans live longer than whites, despite being poorer, working more physically taxing jobs, and having less health insurance. The trend in affluent countries nevertheless holds: the rich and educated got healthier; the poor and working class, not so much.

Saying that Covid-19 has illuminated inequalities in places where few expected to see them is not to deny that inequality is higher in the United States than in other comparably rich countries. It is not to ignore that black American disadvantage is in a class of its own, connected, as it is, to the country’s history of mistreatment. Nor is it to turn a blind eye to the ways that other countries make life easier for both the poor and lower middle class than we do. A taxi driver or hotel housekeeper would surely choose, if she could, the mandated 25 days’ paid vacation in Norway rather than the zero days federally legislated in the U.S., and universal health care instead of the costly mess that now burdens Americans.

Yet the difficult truth is that until the robots take over, advanced-economy countries will still need workers to pick the grapes, clean airport bathrooms, empty nursing-home bedpans, and drive trucks. In a globalized world, those workers are most likely to be migrants from poorer countries who have moved because they can earn more in a month in these places than they would in a year back home. Wherever they’re from and whatever their color, these workers deserve to be treated decently, to earn enough to support their families, to expect a good education for their children, and to be a part of a common life. For a host of reasons, however, they will likely continue to show health outcomes that lag those of the better-educated and better-off—and not just in pandemics.

Top Photo: Minorities are more likely to live in dense urban areas, where the biggest outbreaks have occurred. (ANTHONY BEHAR/SIPA USA/ALAMY STOCK PHOTO)

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