In March of 1820, the Missouri Compromise was signed and the state of Missouri was born out of an insistence to continue systematically subjugating, devaluing black lives. The “compromise” in the name refers to the unwillingness of those in the Missouri Territory to give up slavery. To maintain the fractious balance of the young nation, Congress admitted Missouri to the union as a slave state and Maine as a free state.
In Spring of 2020 – 200 years later – COVID-19 is revealing that we are still very much grappling with that original sin. The pandemic and its disproportionate effect on black St. Louisans is pulling back the veil on our broken and inequitable systems, underscoring the ways we continue to compromise on our shared values and how we can use this crisis as an opportunity to catalyze racial equity. Unique local data analyses in the #StillCompromising series by Forward Through Ferguson and the Prevention Research Center have identified stark local and statewide inequities in testing and, once people are infected, who is getting sickest and dying.
While egregious state test rationing has made it hard for many to be tested, barriers to access – including sometimes requiring a referring physician, public transportation difficulties, uncertain costs, and unclear information – can be challenging for black residents because of structural inequities. These barriers have contributed to disproportionate infection and death rates.
As of May 20, 68 of the 109 victims of the pandemic and 1,091 of the 1,717 cases in the city were black. That means 62.3% of the victims and 63.5% of the cases were black people, though blacks make up 45.95% of the city’s population.
Another contributor to disproportionate infection and death lies in who is literally closest to the disease. Frontline workers in the St. Louis region (e.g., those working in healthcare, transit, building cleaning and other “essential” spaces) are 68% more likely to be black, 32% more likely to fall below the poverty line, and 12% more likely to be uninsured than non-frontline workers.
From descriptions of patients in New York City, Seattle, Louisiana, Italy, and Wuhan, we know that people who are older or have medical conditions like diabetes, high blood pressure, and obesity get more sick from COVID-19 and die at a higher rate. We also know that the same systems that determine how resources and influence are distributed in a society determine who has a better shot at being healthy.
During the pandemic, a person who has an underlying condition can have a harder time seeing their doctor and managing their illness. If they get a severe COVID-19 illness, they require more treatment. Patients with obesity are routinely dismissed and undertreated by their healthcare providers, which for black patients comes on top of widespread race-based discrimination in healthcare.
In St. Louis city, neighborhoods with the highest rates of COVID-19 risk factors are located north of the Delmar Divide. Place, marginalization, and access to opportunity meaningfully shape a person's health, so it’s no surprise that COVID-19 underlying conditions cluster within certain neighborhoods. The same neighborhoods where many black St. Louis families live, love, work, and create are the neighborhoods where over 100 years of policies and practices of segregation by St. Louis and Missouri decision-makers have created a disturbing pattern. This disinvestment results in higher poverty and lower economic opportunity, food access, access to insurance, mobility, and air quality.
Black Americans die from COVID-19 at higher rates in St. Louis and other cities and counties across the nation. These disparities, while tragic are unsurprising and far from accidental – rather they reflect the health, social, and economic inequities present in our society.
In the short term, the just answer to the injustice of a higher burden of underlying COVID-19 risk factors in black communities is to allocate a higher amount of resources to these communities. This means putting in place sufficient testing, surveillance, mitigation strategies, and economic and healthcare safety nets in these communities. It also means that any plans for rationing care or public health resources must not be colorblind and must explicitly incorporate a racial equity lens.
In the long term, the pandemic presents an opportunity to dismantle the systems and structures that create health inequities in black communities. We must put in place and then go beyond actions that compensate for the current systems. It is transformative solutions like living-wage policies, universal early childhood education, decarceration, and affordable housing that will address the cycle of disadvantage and thus the root causes of disease. St. Louis has no shortage of bold, community-based policy reports on how to create a region where all have the opportunity to thrive. We know what needs to be done.
As the pandemic continues to unfold, our region’s best hope for fighting back is information paired with a strong commitment to racial equity. Forward Through Ferguson will continue to point a spotlight on the disparate impact of COVID-19 on “essential” workers, the economy, and education through the #StillCompromising series. We must support community demands for more equitable treatment and investment, like the Ready by Five coalitions push for fair resources and support for early childhood educators.
Almost six years after the Ferguson unrest, it is long overdue for our decision-makers to not only apply a racial equity lens in word, but to actively demonstrate their commitment to equity with resources and action.
Karishma Furtado, PhD, MPH, is the data and research catalyst for Forward Through Ferguson. Alexandra Morshed, PhD, MS, is a postdoctoral research associate at the Prevention Research Center in St. Louis at the Brown School at Washington University in St. Louis.