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.
“Strengthening vaccine access and confidence today is more important than ever because … all across the globe we are dealing with the [COVID-19] pandemic,” Nancy Messonnier, MD, director for the CDC’s National Center for Immunization and Respiratory Diseases, said at last week’s event.
The pandemic has interrupted and delayed routine vaccinations for many people, including children, Messonnier noted.
Robin Nandy, MPH, principal adviser and chief of immunizations for UNICEF, added that a “substantial setback” in immunizations is expected. He highlighted a study from UNICEF, the World Health Organization, and others estimating that 80 million children across 68 countries were at risk for preventable diseases due to disruptions in care resulting from the pandemic.
Discussing the prospect of a COVID-19 vaccine, Messonnier said she hopes some will be available this fall, with more arriving in the winter, but expressed concern that a large number of Americans won’t be willing to be immunized.
One in four U.S. adults said they were not interested in getting a coronavirus vaccine, a recent Reuters/Ipsos poll found. Ongoing research suggests that, at a minimum, 70% of the U.S. population would need vaccine-based immunization, or infection with the virus itself, to achieve herd immunity.
In addition, vaccine confidence levels vary across different ethnic and socioeconomic groups, Messonnier noted.
“It’s very concerning to us that overall confidence in vaccines is lower in Hispanic and black communities, lower in those [of] lower income, and lower in those with lower education,” she said, citing research from the Pew Research Center.
Messonnier noted that even parents who report that they are less confident in vaccines are more likely to get their children vaccinated when they have “easy access.”
To that end, the CDC and other public health experts are working on plans for the distribution of a coronavirus vaccine, to monitor the impact of such a vaccine, and on gaining a better understanding of public perceptions of the coronavirus vaccine in order to develop effective messaging.
However, experts know that the impact of fear as a motivator “doesn’t last very long,” Messonnier said.
As a result, the CDC is pivoting toward a strategy of “vaccinating with confidence,” which involves identifying pockets of low vaccination, working to improve vaccine access, and taking steps to try to stop misinformation.
A child’s doctor is still the “most trusted source of information” for most parents, Messonnier said, adding that, in some cases, the reassurance of those doctors has been enough to get vaccine-hesitant parents to change their minds. Strengthening the conversation between parents and providers will be a critical part of the plan to increase vaccine uptake.
Vaccine Uptake and Access
Immunization rates among U.S. children are strong overall, with more than 90% of those under 2 years of age having received their “primary series,” Messonnier said. High rates are due in part to the Vaccines for Children (VFC) program, which has also reduced disparities in coverage and reduced incidence of vaccine-preventable diseases.
The program provides vaccines for more than half of the children in the U.S., many of whom are uninsured or underinsured, she noted, adding that despite the availability of the VFC program, children without access to health insurance are nine times more likely not to have received a vaccine by the time they’re 2 years of age.
Vaccine uptake among adolescents is a “mixed picture,” said Messonnier, with 86% receiving their Tdap (tetanus, diphtheria, and pertussis) immunization, but only 52% receiving a flu shot, and only 68% receiving one or more doses of the HPV vaccine.
Only about 60-64% of adults receive their routinely recommended vaccines, and somewhere between 35-68% of adults receive the annual flu vaccine.
There are also vaccination disparities related to race, ethnicity, and location. American Indian and Alaska Native children have the lowest MMR (measles, mumps, and rubella) vaccination rates for children under 2 years. Urban-dwelling children are more likely to receive one or more MMR doses versus those in rural areas, according to a 2019 Morbidity and Mortality Weekly Report.
While school vaccination requirements have helped to protect students from vaccine-preventable illnesses, “grace periods” that allow parents to enroll their children in school, with a pledge to visit the doctor for an immunization at a later date, have proven challenging.
The number of kids who fall into these grace periods across different states is anywhere from 0.2-6.7%. Some of these children do eventually get vaccinated, while others may be children of vaccine-hesitant parents who are taking advantage of this loophole in schools’ policies. Most counties and schools lack the staff and resources to follow up with families and determine which children ultimately did receive a vaccine.
If all non-exempt children who fell into these grace periods went on to be vaccinated, most states would see a 95% MMR coverage rate, Messonnier said.
Vax “Drop Off“
Messonnier said she’s worried about the “dramatic drop off” seen in rates of healthcare providers ordering routine vaccinations after March 13, when the White House declared the novel coronavirus pandemic a national emergency. This was particularly true for routine measles vaccination across all ages, with kids under age 2 faring slightly better than other groups, she added.
Parents are worried about exposing their children to COVID-19, and haven’t been going to the doctor, which is an “appropriate concern,” Messonnier stated.
But the CDC and the American Academy of Pediatrics want parents to know that it’s safe to go back to the pediatrician’s office, and are urging healthcare providers to encourage “catch-up vaccinations” through outreach to parents.
Many practices are implementing special preventive measures to help reduce the risk of viral spread. For instance, some are having “well child” visits in the mornings and seeing sick children in the afternoon.
The CDC is also urging public health officials and clinicians to disseminate information regarding the VFC program as there may be more families who are eligible for the program given the increasing unemployment rates, Messonnier said.
Over the past month, a growing number of nursing associations have been calling upon members of the profession to take action against racism.
The first official remarks appeared the day after George Floyd’s death. On May 31, the Minnesota Nurses Association issued a press release stating that “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.”
The Board of Directors of the New York State Nurses Association declared, “As nurses, we mourn for the hundreds of Black men and women killed by the police every year, like Breonna Taylor, an EMT studying to be a nurse in Louisville, Kentucky.” The NYSNA called upon nurses to “fight against the bigotry, intolerance, and hate fueling current politics and feeding an armed white supremacist movement that threatens our democracy.”
This is “a pivotal moment,” according to ANA President Ernest J. Grant. In a June 1 statement, he urged US nurses “to use our voices to call for change. To remain silent is to be complicit.”
Calling racism “a public health crisis,” the Washington State Nurses Association said, “Racism has a 400 year history in America – and the hand of racism rests heavily on the health care system and public health. We know that people of color face systemic barriers to accessing health care and being listened to or heard. It is the reason African American women face higher rates of maternal death and why the burden of the coronavirus pandemic is falling more heavily on people of color. It is why African Americans have the highest death rate and shortest survival of any racial and ethnic group in the US for most cancers. It is why African Americans are almost twice as likely to die from a firearm than their white counterparts. And, it is why we as nurses must look racism in the face and call it what it is.”
The Oregon Nurses Association commented, “As nurses, it is our duty and our calling to protect and serve the health and well-being of the entire community. That duty extends particularly to people of color who are especially vulnerable in this healthcare system.” In an interview with Austin station KXAN, Dr. Cindy Zolnierek, CEO of the Texas Nurses Association, echoed Grant’s statement, saying, “This is core to our ethics. It’s human rights so we cannot stand on the sidelines. To be silent is to be complicit. So, we have a role in this. We have a role to play in advancing human rights – in advancing health care.”
The Kentucky Nurses Association released a seven-point action plan to combat racism both in the profession and in the culture at large. The plan includes goals such as “training for nurses regarding racial disparities,” promoting the “recruitment of African American nurses and other nurses of color to serve on boards and commissions and leadership positions within our organization as well as others that focus on health,” and the addition of “cultural competency training, bias training and disparity education in every Kentucky nursing school curriculum.”
The Massachusetts Nurses Association also spoke out: “As nurses and healing professionals… we recognize institutional racism and the systematic oppression of communities of color as both a crisis in public health and a pervasive obstacle to achieving the goals of our work in both nursing practice and in the labor movement.”
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.”