Universal Health – United States

For decades, Black Americans have been living through a public health crisis

Menka Sandrasagren

Long before the outbreak of COVID-19, a significant portion of the US population were already suffering from profound health inequalities. These disparities have been made worse by the effects of the virus and are particularly pronounced along ethnic lines, with Black Americans more at risk than any other group due to their limited access to testing and treatment.

Furthermore, without substantive change to the country’s social and health systems, these inequalities are likely to continue once the pandemic is over. This is reflected in the fact that time and again, across a range of public health challenges from lead poisoning to tuberculosis, Black communities have been significantly worse affected than the white population.

One long-standing problem is the disproportionate number of Black Americans without health insurance: in 2019, on the eve of the pandemic, 11.4 per cent of Black people were uninsured, compared to 7.8 per cent of the white population, a rate close to 50 per cent higher. As insurance plays a major determining role in the ability of citizens to access health care, the large coverage gap is a significant factor in their poorer health outcomes. For example, Black Americans have the highest mortality rate for all cancers combined and almost twice the national average of infant deaths, at 11 infant deaths per 1,000 live births.

The devastating impact of inequalities on Black Americans has meant that, even in the supposed normality before the pandemic, they were living through a public health crisis. For example, a study by the academic Elizabeth Wrigley-Field, published in September 2020, estimated that pandemic-related mortality levels among the white population would need to rise by a factor of almost six to attain the same levels as those experienced by Black people outside the pandemic, leading to the startling conclusion that ‘even amid COVID-19, US White mortality is likely to be less than what US Blacks have experienced every year’. 

In 2019, on the eve of the pandemic, 11.4 per cent of Black people were uninsured, compared to 7.8 per cent of the white population, a rate close to 50 per cent higher.

The biggest misconception early on in the pandemic was the myth that COVID-19 was the ‘Great Equalizer’, namely that the impacts of the virus would be felt equally among all demographics. The reality on the ground has been that the poor, the elderly and ethnic minorities have been disproportionately impacted by the virus. This is illustrated by the fact that the mortality rate up to 21 July 2020 from COVID-19 for Black Americans was 97.9 per 100,000, roughly double the rate of 46.6 per 100,000 for white Americans. One contributing factor in this is job precarity: for example, almost 40 per cent of Black workers are engaged in low-wage employment without paid sick leave. Other factors that have contributed to higher infection levels include the concentration of Black community members in segregated housing, often in unhealthy environments with limited access to health facilities.

All these determinants are closely associated with the Black American experience in the US and are determined by existing social systems that enable or prevent groups’ and individuals’ full enjoyment of the right to health. Without significant changes to the social and health systems of the country, there is a risk that the inequalities already exacerbated by COVID-19 will increase significantly. These changes need to have at their core the protection of human rights and human dignity, by ensuring that policies aimed at addressing the pandemic do so in a equitable and targeted manner. Instructions to self-isolate need to be met with actual financial support for workers and families if they are to be able to live without fear of dismissal. Access to broadband needs to be mainstreamed for children and workers working from home, to enable them to keep working and to prevent children from missing out on essential learning.

Whilst some changes are more intuitive, such as universal health coverage, paid family leave and paid sick leave, more ambitious policies also need to be put forward. Reducing food insecurity, ensuring adequate housing and strengthening mental health services are all necessary steps in mitigating the historical inequalities that Black Americans have faced. Only a complete transformation of the country’s inequitable social and health systems can prevent COVID-19 – and a host of other conditions, illnesses and hazards – from continuing to exacerbate the health inequalities that have so long existed between Black Americans and the white majority.


Photo: Health workers hold up Black Lives Matter signs as they demonstrate outside the a hospital in New York City to mark Juneteenth, commemorating the ending of slavery in the United States in 1865. Credit: Enrique Shore/Alamy Live News.