From Boston to San Bernardino, California, communities across the U.S. are declaring racism a public health crisis.
Fueled by the COVID-19 pandemic’s disproportionate impact on communities of color, as well as the killing of George Floyd in the custody of Minneapolis police, cities and counties are calling for more funding for health care and other public services, sometimes at the expense of the police budget.
It’s unclear whether the public health crisis declarations, which are mostly symbolic, will result in more money for programs that address health disparities rooted in racism. But officials in a few communities that made the declaration last year say it helped them anticipate the COVID-19 pandemic. Some say the new perspective could expand the role of public health officials in local government, especially when it comes to reducing police brutality against Black and Latino residents.
The declarations provide officials a chance to decide “whether they are or are not going to be the chief health strategists in their community,” said Dr. Georges Benjamin, executive director of the American Public Health Association.
“I’ve had a firm view [that] what hurts people or kills people is mine,” said Benjamin, a former state health officer in Maryland. “I may not have the authority to change it all by myself, but by being proactive, I can do something about that.”
While public health officials have long recognized the impact of racial disparities on health, the surge of public support for the Black Lives Matter movement is spurring calls to move from talk to financial action.
In Boston, Mayor Martin J. Walsh declared racism a public health crisis on June 12 and a few days later submitted a budget that transferred 20% of the Boston Police Department’s overtime budget — $12 million — to services like public and mental health, housing and homelessness programs. The budget must be approved by the City Council.
In California, the San Bernardino County board on Tuesday unanimously adopted a resolution declaring racism a public health crisis. The board was spurred by a community coalition that is pushing mental health and substance abuse treatment as alternatives to incarceration. The coalition wants to remove police from schools and reduce the use of a gang database they say is flawed and unfairly affects the Black community.
Those localities follow in the footsteps of Milwaukee County, Wisconsin, which last year became the first jurisdiction in the country to declare racism a public health crisis, citing infant and maternal mortality rates among Blacks. The county’s focus on the issue primed officials to look for racial disparities in COVID-19, said Nicole Brookshire, executive director of the county’s Office on African American Affairs.
Milwaukee County was training employees in racial equity and had launched a long-term plan to reduce disparities in health when the pandemic hit. “It was right on our radar to know that having critical pieces of data would help shape what the story was,” said Brookshire.
She credits this focus for the county’s speedy publication of information showing that Black residents were becoming infected with and dying of COVID-19 at disproportionate rates.
Using data to tell the story of racial disparities “was ingrained” in staff, she said.
On March 27, the county launched an online dashboard containing race and ethnicity data for COVID-19 cases and began to reach out to minority communities with culturally relevant messaging about stay-at-home and social distancing measures. Los Angeles County and New York City did not publish their first racial disparity data until nearly two weeks later.
Declaring racism a public health crisis could motivate health officials to demand a seat at the table when municipalities make policing decisions, and eventually lead to greater spending on services for minorities, some public health experts say.
The public is pressuring officials to acknowledge that racism shortens lives, said Natalia Linos, executive director of Harvard’s Center for Health and Human Rights. Police are 2½ times as likely to kill a Black man as a white man, and research has shown that such deaths have ripple effects on mental health in the wider Black community, she said.
“Police brutality is racism and it kills immediately,” Linos said. “But racism also kills quietly and insidiously in terms of the higher rates of infant mortality, maternal mortality and higher rates of chronic diseases.”
The public health declarations, while symbolic, could help governments see policing in a new light, Linos said. If they treated police-involved killings the way they did COVID-19, health departments would get an automatic notification every time someone died in custody, she said. Currently, no official database tracks these deaths, although news outlets like The Washington Post and The Guardian do.
Reliable data would allow local governments to examine how many homeless or mentally ill people would be better served by social or public health workers than armed police, said Linos.
“Even symbolic declarations are important, especially if they’re accurately capturing public opinion,” said Linos, who is running to represent the 4th Congressional District of Massachusetts on a platform of health and equity. “They’re important for communities to feel like they’re being listened to, and they’re important as a way to begin conversations around budgeting and concrete steps.”
Derrell Slaughter, a district commissioner in Ingham County, Michigan, said he hopes his county’s declaration will lead to more funding for social and mental health as opposed to additional policing. Slaughter and his colleagues are attempting to create an advisory committee, with community participation, to make budget and policy recommendations to that end, he said.
Columbus City Council members coincidentally declared racism a public health crisis on May 25, the day Floyd died in Minneapolis. Four months earlier, the mayor had asked health commissioner Dr. Mysheika Roberts for recommendations to address health issues that stem from racism.
The recent protests against police brutality have made Roberts realize that public health officials need to take part in discussions about crowd control tactics like tear gas, pepper spray and wooden bullets, she said. However, she has reservations about giving the appearance that her office sanctions their use.
“That definitely is one of the cons,” she said, “but I think it’s better than not being there at all.”
Published courtesy ofKHN (Kaiser Health News) is a nonprofit news service covering health issues. It is an editorially independent program of KFF (Kaiser Family Foundation), which is not affiliated with Kaiser Permanente.
As nationwide protests sparked by the death of George Floyd enter their fourth week, the American Thoracic Society is calling for a moratorium on the use of tear gas and other chemical agents to control demonstrators.
On Thursday, ATS officials issued a statement asking law enforcement groups to stop using tear gas agents such as 2-chlorobenzalmalononitrile (CS) and highly concentrated oleoresin capsicum (OC) pepper oil due to concerns about long-term lung injury.
Concerns about the use of tear gas and other agents on the spread and severity of COVID-19 were a factor in the move, said ATS President Juan Celedon, MD, in the statement.
“The use of chemical crowd control agents is outlawed in the time of war. They cause significant short-term and long-term respiratory health injury and likely propagate the spread of viral illnesses, including COVID-19,” Celedon said.
“Based on the lack of crucial research, the escalation of tear gas use by law enforcement, and the likelihood of compromising lung health and promoting the spread of COVID-19, the American Thoracic Society calls for a moratorium of CS tear gas and OC pepper weapons use,” he added.
The statement was issued on the same day President Trump — speaking at a roundtable discussion on policing and race — praised the use of tear gas and other aggressive tactics against demonstrators in Minneapolis early in the protests, calling it a “beautiful scene.”
Sven-Eric Jordt, PhD, of Duke University School of Medicine, Durham, North Carolina, has spent years researching the impact of chemical exposures — including tear gas — on the lungs.
He told MedPage Today that a study in military recruits linked tear gas exposure to chronic bronchitis, viral respiratory illness, compromised lung function and other acute and possibly chronic lung injuries.
The study, published in the journal Military Medicine in 2014, showed that recruits intentionally exposed to CS during basic training had more than twice the risk for an acute respiratory disease diagnosis after exposure compared to before exposure.
Jordt said recent technical advances in tear gas deployment allow the gas to be dispersed over much greater areas, and the clinical impact of this wider exposure has not been studied.
Likewise, in the U.S. protests and in other parts of the world where tear gas has been widely used to disperse crowds, police tactics have changed in ways that can make exposure more problematic, he added.
“What we are seeing and what we have seen is that police are using massive amounts of these agents,” he said. “In the recent protests in Hong Kong there were days when several thousands of cartridges were used.”
He added that in many recent protests within and outside the United States, tear gas and pepper spray were deployed as a first line measure, rather than a measure of last resort.
“In U.S. cities we have seen episodes where police are boxing in protesters and then using tear gas or pepper spray when the protesters have no way out,” Jordt said.
While there are, as yet, no studies directly examining the impact of tear gas exposure on COVID-19, Jordt and Celedon both said there is cause for concern that exposure may promote SARS-CoV-2 transmission.
Someone exposed to tear gas would be likely to quickly take off protective masks due to contamination, and maintaining a safe distance from other people would probably not be their main concern, Jordt told MedPage Today.
COVID-19 patients also often report loss of sense of smell, which could increase their risk of unknowingly inhaling dangerous levels of tear gas. And tear gas makes people cough, enhancing the virus’s spread if those individuals are currently infected.
“We have seen a dramatic escalation of (tear gas) use that I fear may become normalized,” Jordt said. “We have to reassess the safety of these agents with state-of-the-art toxicological techniques.”
Nursing organizations have joined individual nurses in speaking out. American Nurses Association President Ernest J. Grant, PhD, RN, FAAN issued a moving statement, in which he remarked, “As a black man and registered nurse, I am appalled by senseless acts of violence, injustice, and systemic racism and discrimination. Even I have not been exempt from negative experiences with racism and discrimination. The Code of Ethics obligates nurses to be allies and to advocate and speak up against racism, discrimination and injustice. This is non-negotiable…. At this critical time in our nation, nurses have a responsibility to use our voices to call for change. To remain silent is to be complicit.”
“You clapped for us. We kneel for you.”
A mingling of professional training and empathy moved nurses such as Miami RN Rochelle Bradley to take a knee in remembrance of Floyd’s death. Bradley told CNN that “Kneeling here today for nine minutes and knowing that that’s how long George Floyd was on the ground with his airway compromised really bothered me as a nurse.”
For healthcare workers, the protests also reinforced their sense of unity in the era of COVID-19. In Boston, nurses who gathered to kneel in front of Brigham and Women’s Hospital carried a sign reading, “You clapped for us. We kneel for you.” One nurse interviewed, Roberta Biens, said, “I just want everybody to know they’re not alone, we’re with them and we’ll stand in front of them or behind them, wherever we need to be to support them.”
Minneapolis nurses appeared in force at the protests. One local ER nurse told the Insider, “COVID is a temporary and critical health crisis. Racism, through violence and disease, has been killing our patients since the hospital was built and will continue killing them long after COVID is gone.” And in an official statement, the Minnesota Nurses Association said, “Nurses continue to see the devastating effects of systematic racism and oppression targeting people of color in our communities. We demand justice for George Floyd and a stop to the unnecessary death of black men at the hands of those who should protect them.”
Hospitals in New York City united to stand behind the protests. The Gothamist scanned official Twitter posts and noted, “The six major hospital systems in the city–NYU Langone Health, Mount Sinai Health System, New York-Presbyterian, NYC Health + Hospitals, Northwell Health, and Montefiore Health System–have all posted publicly in support of the demonstrations…”
Weighing the Call to Civic Action Against Public Health Concerns
Medical practitioners are understandably divided about engaging in public assemblies while the coronavirus is still at large, but many believe the risk is worth taking. On June 8, World Health Organization (WHO) director-general Tedros Adhanom Ghebreyesus said, “WHO fully supports equality and the global movement against racism,” but added, “As much as possible, keep at least 1 meter from others, clean your hands, cover your cough and wear a mask if you attend a protest.”
Asked by Health.com about the danger of public protests, Natalie DiCenzo, an Ob-Gyn resident in New Jersey, responded that “the risk of remaining silent and complacent in the face of racism and police violence is also deadly. I believe that with the proper precautions, these protests can be done relatively safely when it comes to COVID-19.”
Nearly 2,000 US “public health professionals, infectious diseases professionals, and community stakeholders” also expressed direct support for the national protests in a widely circulated June 4 letter (initiated by faculty from the University of Washington School of Medicine). Following a statement that “White supremacy is a lethal public health issue that predates and contributes to COVID-19,” the letter recommended a series of safety measures to protect protestors from the virus. Among other issues it urged “that protesters not be arrested or held in confined spaces, including jails or police vans, which are some of the highest-risk areas for COVID-19 transmission, “ and that no use be made of “tear gas, smoke, or other respiratory irritants, which could increase risk for COVID-19 by making the respiratory tract more susceptible to infection…”
On Twitter, nurses participating in the protests offered their own practical suggestions. A DC pediatric nurse told attendees to bring gloves, sunglasses or goggles for eye protection, and “an extra mask. Yours will get hot and sweaty so switching it out halfway through is smart. If you have a cloth mask throw a bandana on top too…” Following participation in protests, some nurses have also taken the step of self-quarantining for two weeks.
Stories on COVID-19 occasionally refer to the Spanish Flu, a devastating worldwide outbreak that came in three waves in 1918-1919 and took more lives than the notorious Bubonic Plague of 1347-1351. In an attempt to better understand the 2020 pandemic and reduce its impact, medical historians have been revisiting the events of what is known as the worst pandemic in world history.
The Spanish Flu (so-called owing to a mistaken belief that it originated in Spain) appeared just as World War I was winding down. Ironically, the age group that suffered most in the war, people between the ages of 20-40, were particularly vulnerable to the virus as well. When the flu struck, it hit hard, often progressing from an apparent bout of common influenza to a suffocating pneumonia in as little as 24 hours. In the end the cost in American lives was 10 times that of the war, with over 500,000 dying of the virus. The estimated worldwide death toll was a staggering 50 million.
Nations that were still absorbing the unprecedented death toll of the Great War scarcely noticed the arrival of the Spanish Flu. Spreading across the globe via trade routes and armed forces transport ships, in spring 1918 the virus reached the US. After first appearing at Fort Riley, Kansas, it proceeded to move through military installations and prisons. The country was preoccupied with ending the War, and as fatalities were low in the initial outbreak, few expressed alarm at this stage. As summer ended, though, the flu was on the move, latching onto troops as they moved through US towns and cities. Social distancing recommendations were still being neglected in November, when large-scale gatherings and close human contacts at Armistice Day celebrations acted as superspreader vehicles. As winter arrived, the nation was in the grip of a full-blown pandemic. A fierce third wave hit in 1919. Over 28% of the American population was infected and social systems were in crisis. Communities in hot spots wrestled with shortages of health care workers, medical supplies, coffins, funeral homes, and gravediggers.
How did the country respond to the pandemic? When the flu began raging through civilian populations, various localities made attempts to “flatten the curve,” as we now call it. The measures they took will seem familiar, as recounted by Molly Billings of Stanford University: “Public health departments distributed gauze masks to be worn in public. Stores could not hold sales, funerals were limited to 15 minutes. Some towns required a signed certificate to enter and railroads would not accept passengers without them. Those who ignored the flu ordinances had to pay steep fines.”
Knowing the history of the Spanish Flu pandemic can have a profound impact on what happens today. Enacting social distancing rules—and adhering to them—saved lives in 1918-19. A recent National Geographic article cited the findings of two 2007 studies of the flu pandemic: “Death rates were around 50 percent lower in cities that implemented preventative measures early on, versus those that did so late or not at all. The most effective efforts had simultaneously closed schools, churches, and theaters, and banned public gatherings.” The studies also offer a warning against prematurely lifting social distancing rules: “St. Louis, for example, was so emboldened by its low death rate that the city lifted restrictions on public gatherings less than two months after the outbreak began. A rash of new cases soon followed. Of the cities that kept interventions in place, none experienced a second wave of high death rates.”
With these lessons in mind, historians as well as nurses are encouraging people to heed the advice of public health specialists. In the meantime, we can only hope that future studies of 2020 won’t have a compelling reason to quote philosopher George Santayana’s truism “Those who cannot remember the past are condemned to repeat it.”
State child access prevention (CAP) laws were linked with a 13% relative
reduction in childhood firearm-related fatalities compared with states without
such laws in the years 1991-2017, according to an analysis of CDC data.
So-called “negligence laws,” in which caregivers are criminally
liable if a child accesses and uses a firearm, were associated with a 13%
reduction in all-intent firearm fatalities, a 15% reduction in firearm
homicides, a 12% reduction in firearm suicides, and a 13% reduction in
unintentional firearm fatalities among children ages 0 to 14 years, reported
Eric Fleegler, MD, MPH, of Boston Children’s Hospital, and colleagues.
The most stringent CAP laws, which hold parents responsible if a child has
the ability to access firearms (but does not access or use them), were
associated with a 28% relative reduction in all-intent firearm-related deaths,
they wrote in JAMA Pediatrics.
However, recklessness laws, which hold firearm owners liable for directly
providing guns to minors, were not associated with reductions in firearm
fatalities among children ages 0-14, they added.
“I would argue there is not much value to recklessness laws, and states
that pass them thinking they are making a difference in terms of protecting
children’s lives should think again,” Fleegler told MedPage Today.
“If you want to make the biggest difference … you should be aiming for
these laws that say, ‘If a child could access a gun, then that is a criminal
These findings would be even more meaningful if the authors measured how CAP
laws directly impact safe gun storage, particularly since prior research
suggested up to 70% of firearm-owning homes failed to store guns unloaded, with
a locking device, and separate from ammunition, wrote Megan Ranney, MD, MPH, of
Brown University in Providence, Rhode Island, and colleagues, in an accompanying editorial.
Notably, “confounding is likely at least partially responsible”
for the association, and the data may also be subject to selection bias since
states with stricter CAP laws are likely to have other strategies in place that
prevent pediatric injury and death, Ranney’s group noted.
“CAP laws may serve as a proxy for prioritization of a range of injury
prevention efforts and broader social determinants of health,” they wrote.
“This finding does not obviate the potential consequence of CAP laws, but
it highlights that laws do not exist in a cultural vacuum.”
Ranney and colleagues advocated for “coalition building” between
firearm owners and community groups to implement public health programs that
aim to promote safe gun storage and reduce youth access.
“While nationally representative scientific opinion polls have found
that most firearm-owning Americans support CAP laws, the passage of a law is
only one element in successful injury prevention,” they wrote.
“Firearm owners must be leading and trusted voices in all aspects of
firearm injury and mortality prevention, as illustrated in other studies.”
Although this was “methodologically appropriate,” future research
should focus on states where CAP laws cover older adolescents, because youth
from ages 15-19 are at the highest risk of firearm homicide and suicide, the
There were 13,697 firearm-related deaths to occur in the study period, of
which 56% were homicides, 22% were suicides, 19% were unintentional, and 3%
were related to legal intervention or undetermined intent. Trends in firearm
fatalities varied by states with a high of 7.1 per 100,000 children in Alaska
in 2015 to a low of zero deaths in Connecticut and Delaware across many years,
the authors reported.
If states without criminal liability for negligent gun storage were to apply
negligence laws, 1,230 pediatric deaths could have been prevented, the authors
calculated, adding that if these states were to apply the strictest negligence
“could access” laws, 3,929 deaths could have been prevented, they
The authors cautioned against assuming causality based on the ecologic nature of the study, which was a limitation. It remains unclear how aware constituents of these states are of the CAP laws as well, which could influence safe gun storage practices, they said. Finally, some mortality data may have been misclassified and data on the perpetrators of homicides and unintentional fatalities in children were not available, they noted.
the nation battles COVID-19, the health policy world is quietly
observing a milestone: the 10th anniversary of the Affordable Care
he was signing the bill into law on March 23, 2010, then-President
“The bill I’m signing will set in motion reforms that
generations of Americans have fought for and marched for and hungered
to see.” He listed some of the bill’s provisions, including a
ban on insurer discrimination against enrollees with preexisting
conditions, a mandate to cover children up to age 26 on their
parents’ policies, and a requirement that all health insurance
policies cover 10 categories of “essential health benefits.”
The law also strongly encouraged states to expand their Medicaid programs to include able-bodied adults making up to 138% of the federal poverty level — failure to do so would result in a state losing its federal Medicaid match — and created health insurance marketplaces in which individuals and small businesses could shop for health insurance plans. (The Medicaid expansion provision was later changed as a result of a Supreme Court case and is now completely optional for states.)
One Thing’s for Sure…
looking back at the law all agree on one thing: it did increase the
insurance rolls — “primarily through Medicaid,” said Bob
Moffit, PhD, senior fellow in health policy studies at the Heritage
Foundation, a right-leaning think tank here. “Roughly 90% of new
coverage came out of Medicaid. And there’s no question it increased
access to healthcare, particular mental health benefits and services
for low-income people,” as well as reducing uncompensated care
the percentage of uninsured Americans stands at 9.1%, down from 16%
when the law was signed into effect, Rosemarie Day, CEO of Day Health
Strategies in Somerville, Massachusetts, and the author of Marching
Toward Coverage: How Women Can Lead the Fight for Universal Health
noted in a blog
post on Monday.
However, although the ACA made these gains possible, there are still
many uninsured and underinsured patients who likely would be afraid
to seek care if they thought they had COVID-19, because they might
not be able to pay for it, Day said in a phone interview.
don’t have a culture of universal healthcare; we have a culture of
‘Gotcha,'” she said. “You show up in the ER? Here’s a bill.
People are afraid of that if they don’t have the resources … Also
right now, immigrants are going to be very afraid because they’re
told they’re going to be deported if they use anything that’s
publicly funded,” such as Medicaid.
On the other hand, the ACA has done a lot to help people get care earlier for other types of illnesses, including preventive care, which is one of the ACA’s essential health benefit categories. “Many preventive services are free, so people are availing themselves and therefore getting tested earlier than they would, meaning that if perchance you have cancer, you’re getting screened earlier in the game,” Day said. “That whole flow prevents unnecessary deaths and it’s all about that access to healthcare.”
…But Problems Remain
the law still has a lot of problems, said Joe Antos, PhD, scholar in
healthcare and retirement policy at the American Enterprise
Institute, a right-leaning think tank here. “The most obvious
one is the Democrats’ overreach on Medicaid,” he said in a phone
interview. “They wanted to make it look like states would have a
choice about whether they expanded Medicaid or not. But the penalty
… goes beyond a simple penalty. They didn’t have to do that.”
the Obama administration “could have found some way to phase in
mandatory eligibility up to where they ended up,” said Antos.
“In retrospect, that was a really terrible mistake. What we have
now is 13 states — mostly Southern states — who did not expand
their Medicaid eligibility under the ACA and they’re in even greater
trouble now than they were before. So that’s a truly lost opportunity
with regard to this virus pandemic, because that would have been
resolved by now.”
Moffit sees a different flaw with the ACA. “The problem the ACA had is that the ACA did not control costs,” he said in a phone interview. “If you look back to 2010, and asked Americans what was the number one problem in the healthcare system, it was how to control healthcare costs. When President Obama was campaigning for the ACA, he made the argument that we’d see a $2,500 reduction in typical family health care costs” each year. But “that was total nonsense; it never happened,” Moffit said, adding that instead premiums jumped from an average of $244 per month in 2013 to $550 per month.
has his own solution to the ACA’s problems. “We ought to target
the funds a lot better than in the past,” he said. “I like
the idea of taking all the money we’re spending on the ACA — about
$1.6 trillion — and turning it into block grants for states, on two
conditions: that states offset the cost of health insurance for
people who are low-income; and that states offset the cost of
coverage for people with preexisting medical conditions.”
praised the ACA’s provision banning discrimination against patients
with preexisting conditions, adding that in order to improve the law,
the federal government could “allow states to address this in
different ways, whether through reinsurance pools, risk transfer
pools, or direct subsidies … there are a lot of different ways of
doing that.” Moffit’s home state of Maryland, where he is a
former member of the state’s Health Care Commission, is using a 1332
waiver to establish a reinsurance program for higher-cost patients.
The program “has been dramatically successful. There has been a
10% reduction in individual market premiums, so it’s working out
quite well,” he said.
Day prefers a different approach: universal coverage using a hybrid public/private system. One way to improve coverage would be to increase enrollment among people who are eligible for government health insurance — such as for the Children’s Health Insurance Program — but haven’t yet been enrolled. “We ought to have some form of auto-enrollment for kids,” she said. The federal government also should put more “guardrails” on the plans in the ACA’s health insurance exchanges, “regulating the plans to include essential health benefits and do the things the private market wouldn’t do on its own. That’s how other countries do it,” such as Germany, she said.