In the early days of COVID-19, I was a bioethics fellow at Johns Hopkins, and I became involved with several efforts to evaluate the ethics of the pandemic response.
One thing that immediately stood out was that Black, Hispanic, and Native Americans were experiencing significant disparities in hospitalizations and deaths due to COVID-19 compared to white and Asian Americans, notwithstanding much greater parity in the reported cases across these groups.
A pathogen that didn’t seem to care about skin color or social status when it infected people, nevertheless caused much greater sickness and death for black and brown Americans than for white Americans. Why?
It didn’t take very long to figure out that the disproportionate rates of morbidity and mortality were due, in large part, to preexisting disparities in comorbidities (such as hypertension, diabetes, and obesity), plus unequal access to high quality diagnostic and treatment resources. Zooming out a bit, the COVID health disparities could also be explained by significant racial and ethnic inequalities with respect to the “social determinants of health” (SDOH). The SDOH are standardly defined to include access to quality healthcare and education; income, wealth, and stable employment; and safe and clean residential areas with reliable access to fresh air, clean water, and utilities. Racial and ethnic disparities concerning all of these SDOH persist despite decades of public health efforts to address them.
Pointing to preexisting disparities of disease, healthcare access, and the other SDOH, is a helpful explanation of the COVID disparities—but only up to a point. This purely descriptive explanation leaves open several critical normative questions—like are these disparities wrong or unjust? If so, why? And who is to blame for them? What should be done to address them and who is responsible? As a bioethicist and a political philosopher, these sorts of normative questions are the focus of my work.
Normative questions in bioethics are not just academic. It is crucial for members of a political community to be able to accurately and coherently identify and describe injustices that plague the community, and to propose appropriate and workable remedies. Moreover, as Merlin Chowkwanyun and Adolph Reed argued during COVID-19, the failure to provide a normative explanation for racial health disparities can lead to misunderstanding, stigma, victim-blaming, and specious biologization of race.
Ruqaiijah Yearby argues that we should recognize structural racism (and more generally structural discrimination) as the “root cause” of racial and ethnic health disparities. Yearby’s root cause explanation is helpful, in part, because linking health disparities to an underlying injustice, namely structural racism, offers not only the outlines of a causal backstory, but also a normative explanation of why these disparities are unjust. And a normative explanation of why health disparities are unjust structural forestalls misattribution of health disparities while also forcing us as a society to confront health disparities as a matter of injustice in need of remedy.
We might read Yearby as providing a structural explanation in the sense described by Sally Haslanger (and more recently by Lauren Ross). If we want an explanation for why a particular patient, who happens to be Black or Hispanic, developed an acute case of COVID-19, then it might be both sufficient and medically expedient to point to the patient’s underlying comorbidities or to their lack of health insurance, which prevented their timely access to care. But, drawing on Haslanger’s work, if we want to explain why there is a disproportionate pattern of acute COVID-19 cases affecting Black and Hispanic patients nationwide, then we need to focus on the structural relations, practices, and constraints that, taken together, force us into durable, mutually reinforcing patterns of action and behavior, which in turn add up to large-scale social effects.
I agree with Yearby’s structural explanation of the COVID racial and ethnic health disparities, but there is more work to be done. Yearby’s structural explanation answers some of our normative questions—especially by clarifying that racial and ethnic health disparities are unjust and demand societal attention and redress. But that’s just the first step. A structural explanation, on its own, lacks the specificity and direct tie to specific historical or political events, which may be needed to assign individual or institutional responsibility and design effective remedies. We need to dive deeper into the structural relations, practices, and constraints that, taken together, add up to structural racism.
My work picks up the story here, trying to unravel one thread from the tangled web of relations, practices, and constraints that contribute to racial and ethnic health disparities. Drawing on the work of two historians, David Barton Smith and George Aumoithe, I describe the pattern of hospital “white flight” that mimicked residential white flight from cities to suburbs in the late 1970s and early 80s. Responding to a mixture of economic and political incentives, many hospitals that served diverse, lower-income urban populations closed or relocated to the suburbs, leaving behind the communities they had served. This pattern of relocations reshaped urban healthcare access and in some ways recreated the system of racially segregated healthcare before the civil rights era.
My recent article “Indirect Discrimination and the Hospital Relocation Cases” argues that many examples of hospital white flight are instances of indirect or disparate impact discrimination in violation of federal law, which courts at the time should have prevented. In contrast to direct or disparate treatment discrimination, indirect or disparate impact discrimination is neither explicit nor intentional. Nevertheless, I argue that legal protections against discrimination could and should have been used to prevent these hospital relocations or to craft other appropriate remedies. The courts’ failure to utilize existing law—and our ongoing conceptual or semantic failure to recognize the importance of indirect discrimination—represent one thread among many in the social structural web that contributes to racial and ethnic health disparities. When we see disparities like those during COVID, we should start by recognizing that racial and ethnic health disparities are a product of structural racism and other forms of structural injustice. This is an important starting point, but as philosophers we should not stop there. Next, we need to identify the specific relations, practices, and constraints that make up the web of structural injustice. The historic pattern of white flight hospital relocations, plus the legal and conceptual failure to prevent this form of indirect discrimination, is one thread that makes up this web.
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