The United States has been hit particularly hard by the COVID-19 pandemic. According to the Centers for Disease Control and Prevention (CDC) website, with cases last updated on May 20, the U.S. has had a little over 1.5 million cases and almost 100,000 deaths.
COVID-19 is highlighting health disparities that have long existed. To learn more about how the COVID-19 pandemic has impacted the most vulnerable in our society, Terri Wilder, M.S.W., spoke with Natalia Linos, Sc.D., M.Sc., executive director at the FXB Center for Health and Human Rights at Harvard University. She’s a social epidemiologist with a wealth of global health experience.
Prior to joining the FXB Center, Linos led the United Nations Development Programme’s work on addressing complex challenges at the nexus of health and environment, looking especially at the vulnerability of poor and marginalized communities to climate change.
Linos is a three-time Harvard University graduate, earning her Bachelor of Arts in anthropology; Master of Science in social epidemiology; and a Doctor of Science in social epidemiology. She also holds a Certificate in Forced Migration from Oxford University’s Refugee Studies Centre.
Terri Wilder: First of all, thanks for speaking with me. I know it’s a very busy time, so I really appreciate you making time today. To get started, can you tell me more about your work and the mission of FXB Center for Health and Human Rights at Harvard University?
Natalia Linos: Of course. And thank you so much for having me, interviewing me on this important topic. The FXB Center for Health and Human Rights at Harvard is an interdisciplinary center that brings together researchers and advocates from different disciplines, including law, medicine, public health. And the point of the center is to conduct rigorous investigation on the most serious threats to health globally, including issues around injustice and inequalities posed by discrimination, poverty, conflict, and disaster.
It was set up in 1993 with a vision to link two different agendas: the health agenda and the human rights agenda. And it was because of the HIV/AIDS epidemic, to focus on the social reasons—the marginalization, discrimination, and stigma—that were the root causes of the epidemic then, and are still the root causes of many epidemics, including COVID. So, the center has been in existence for a long time, over 25 years. And the theme is to do research and work to show that health is not simply about the absence of illness, and it’s not just about health care. It’s really about how we as societies organize ourselves. How do we treat and care for and create a social system that enables people to achieve wellbeing? It’s really around health as a human right.
TW: On March 2, the Washington Post published an article that you and Dr. Mary Bassett wrote, entitled, “The Coronavirus Could Hit the U.S. Harder than Other Wealthy Countries.” In the article, the two of you write, “Epidemics emerge along the fissures of our society, reflecting not only the biology of the infectious agent, but patterns of marginalization, exclusion, and discrimination. The United States has many open wounds, rooted in decades of racist policies and the criminalization of poverty. The coronavirus is likely to reveal deep failures and reinforce existing health inequities.”
Can you talk about what you meant by this when you wrote this?
NL: Sure. And it’s unfortunate that our prediction came true. When we wrote that piece on March 2, there had only been one death in the United States. And what we were talking about in terms of epidemics emerging along the fissures of society is basically what social epidemiologists like myself have known to be true for a lot of different disease outcomes.
First, epidemiologists talk about social gradients: basically, that if you are poor, if you are in conditions of—you know, if you face discrimination or exclusion, you are more likely to die younger, and at higher rates, as compared to others. So, what we warned then is that we thought that COVID would not take a different track, and that our hope in warning in March that this could happen was that there could have been an explicit health equity agenda and targeted approach to COVID—meaning, really making sure that those who are the poorest, or those who are most marginalized, whether because of their background or are low-wage workers, could have been given the extra support. Because what we foresaw, or what we were hoping would not come true, was that we would see what we see today, which is significant patterning of COVID deaths among the poorest, and among people of color.
So, when we say that the United States has many open wounds, rooted in decades of racist policies, we were referring to things like redlining, or the fact that in the Navajo Nation lands, access to running water was not available. Issues around the criminal justice system and those sort of problems—that Black and Brown communities [are disproportionately] in prisons and jails, and these would become hotspots for COVID.
Our hope was to draw attention to the fact that we can’t just think about COVID-19 as biology—you know, how do you transmit the disease? Or how does it biologically work? But also thinking about social dynamics, how we may expect different people to be exposed to the virus and then to die from the virus because of social dynamics. So, for example, low-wage workers—if you think about whether they are able to take the same precautions. Or the poorest Americans: Can they really stock up to have three weeks of food in their pantry? Or are they going to be possibly exposed because they’re able to only buy food every other day, because they don’t have wealth, or income, to do this advance planning?
These were the issues that we were trying to alert the public to. And, unfortunately, there wasn’t a health equity response or plan put in place early enough.
TW: I want to piggyback on something that you just said, in terms of folks who have been incarcerated. Many activists around the country are very worried about people who are incarcerated. Since the United States has a long history of specifically incarcerating Black and Brown people, what is the risk to this particular population in terms of COVID-19?
NL: The risk is huge. And we’re glad to see activists raising the alarm on this issue. I mean, if you look at just in Massachusetts, where we are, the Bridgewater Massachusetts Treatment Center—or New York City, Rikers Island, Cook County Jail in Illinois—you have had huge rates of COVID-19. And it’s not surprising. You know, COVID-19 spreads in close proximity. That’s why we are asking everyone to stay home. But when you are in a prison setting, or in a jail, you are not able to self-isolate.
We’ve heard stories of incarcerated people not having access to water and soap; not being able to take the precautions the rest of us take for granted. So the alarm and the worry that activists have around these populations is true. And we, at the FXB Center, have been supportive of efforts to call for a quick response that involves decarceration; taking out people who are there because they can’t pay bail. They should not be put at risk. Their lives should not be put at risk because they don’t have the finances for bail.
Or the elderly. Prisons have populations above the age of 50 who are at heightened risk for dying from this disease. So, really, the call from activists to do something quickly and urgently, which some governors did respond to, and to make sure that we’re removing numbers of people in prison. The reality is a disease like COVID spreads because of close proximity. So, you have to change that. The risk is still there, and it’s still huge. And it is unjust, especially because so many Black and Brown people are in prison for reasons including drug use, or things that do not pose any threat to people outside. So, you need to—you know, taking their health seriously is important.
The other point on incarceration and prisons is that you’re not only putting the people who are incarcerated at risk. Those who work in those settings, you know, whether they are correctional officers; they often come from poor communities. They often come from the same communities. And they are going in and out and bringing that risk back home to their families. So, even if you weren’t framing it through a human rights lens of protecting the health of those who are incarcerated, you could also have the same call for action, thinking about the correctional officers themselves.
TW: Let’s talk about the role that anti-immigrant policies have played in influencing and informing the United States COVID-19 response. You know, there’s been certainly lots of reports of Asian communities being attacked and blamed. But that comes from a long line of anti-immigrant policies, particularly that have come out of this particular White House.
NL: Yeah. It is very, very troubling to see the rise and spike in violence against—and, you know, harassment that immigrants, especially Asian Americans, are facing today. It’s important to think about it. The relationship is complex.
For example, anti-immigrant policies and maybe racist ideas around who was at risk could be to blame, to some extent, for why the U.S. did not take the threat or the risk of COVID-19 seriously enough in the early days. Many have written about the fact that by calling it a Chinese virus or, you know, othering it was seen as: We are not at risk, because we do not behave—we do not eat the same way. You know, these sort of underlying biases probably led to the United States not taking action early enough. So that’s one. And it’s not only anti-immigrant; it’s also just racist.
In terms of specifically anti-immigrant policies, I think a key concern has been around whether people from communities that either they themselves may be undocumented or have a family member who’s undocumented—whether they would actually seek care. In epidemics and in infectious disease, one of the key tools that public health has is contact tracing. But that involves a lot of trust. If you identify someone who has COVID-19, you need to then identify everybody they have been in touch with in the past X number of days and encourage them to self-isolate or put them in quarantine. But that involves that the person who has been identified as safe by the health department is able to name those individuals.
Anti-immigrant policies have led to fear. So, if you have fear in a community that, because of your citizenship status, you may be deported, clearly, you’re not going to give the name of someone in your neighborhood or in your family and put them at risk. So, it backfires. You cannot do contact tracing in an environment of fear. That’s one very specific way that anti-immigrant policies have influenced the COVID-19 response.
As we see in Queens, New York, immigrant communities have been hit the hardest. And there, it’s difficult to disentangle what is the anti-immigrant policy and what is just poor support for immigrants. Is it that immigrant families are living in more crowded, more poor settings, more multigenerational, and therefore there is a higher impact on them? Or is it specific anti-immigration policies?
In any case, thinking specifically about the needs of immigrant communities is essential moving forward.
TW: I want to talk about the broad health care infrastructure in the United States. And I’m curious about your thoughts on, how has the fact that Americans have inadequate health care access, often due to lack of health insurance, impacted the COVID-19 pandemic in the United States?
NL: Yeah. I think that’s a very important point to raise. You know, despite the fact that the U.S. is one of the wealthiest countries—and actually spends a lot more per capita on health care—the inadequate access, in terms of both people who are uninsured and underinsured, definitely creates a vulnerability to the COVID pandemic. Some states and some local authorities try to overcome that by saying that, “Your COVID-19 test and any treatment will be free,” so, removing the financial barrier.
But health care access, and lack of health care access, over the years has also led to the fact that Americans, on average, are in poorer health than, say, Europeans. This is a reality, a sad reality—that there is great inequity in health status in the U.S. right now, with high rates of diabetes and some of these, you know, what is known as preconditions that lead to worse COVID-19 outcomes. So, it’s a complex relationship. It’s clearly a huge risk factor for why COVID-19 has taken such a huge toll here: the health care access. But it’s important to not only focus on that. Because health is not shaped only by your access to health care. It’s an important part, but it’s not the only.
There has been a disinvestment in the U.S. in public health, in general, too, and promoting the public health data and research. There’s also been a disinvestment in preparedness, pandemic preparedness. Those are also important issues to raise.
And of concern now, with unemployment rates soaring to unprecedented numbers, is what is happening to people who have newly lost their insurance coverage. So, we worried quite significantly about this, this cyclical cycle of, not only did we originally have higher rates of people not having access to health insurance. But now there’s the new group of individuals who have lost their insurance.
So, you know, there are some radical calls for just rethinking our health care system. And I think COVID-19 should be seen as a wake-up call to the fact that we are a wealthy country and yet we do not have—we do not guarantee the rights of people to be able to reach their health, or their wellbeing, and have access to health like other countries where there are much poorer guarantees.
This is definitely a call for rethinking and putting our values first, that people should not be dying because they cannot afford health care. And people should not be dying because the quality of care is worse in their community, or because there are biases that are ingrained, that put, especially, patients of color at excess risk.
TW: You know, as I’m listening to you talk about this issue, it kind of occurred to me that if you don’t have access to health care because you don’t have insurance, or you may have just recently lost your job because of all the closings around COVID-19, in a sense, people may be getting their health care through public health messaging. And that’s what is directing them to kind of individually make decisions about health.
But a lot of the information that is coming out of the White House Task Force has been very confusing. In the very beginning: “Don’t wear a mask.” Now: “Wear a mask.” You know, lots of misinformation; lots of disinformation. Very confusing messages. And so, for the person who doesn’t have insurance, doesn’t have a way to get health care, if their only way of making decisions about how to protect themselves is through these press conferences and news, how do you think that is contributing to health inequity?
NL: I think the problem of misinformation/disinformation is huge. I also recognize that COVID-19, that what we know and don’t know about it has been evolving. So, to some extent, we would expect that there would be changing messaging. But that doesn’t mean that consistency in messaging—the White House has failed in many ways to convey both the urgency, as well as what needs to be done.
Now, from a health equity perspective, it’s also important to think about whether the measures that we are proposing, whether everybody has the means to implement them. For example, social isolation: stay home. That’s a clear message. And for the majority of wealthy Americans, it’s one that they can follow, especially if their job is flexible and they are allowed to stay home and work remotely. But that isn’t a message that the essential workers—and many of them essential workers who are receiving very low wages, as well as having no access to PPE [personal protective equipment]. They do not have access to masks.
So, in many ways, the messaging has to take into account whether people have the means to do it. So, staying home requires that you have a home. So, for homeless populations, that is not the right message. Or for victims of, or survivors of violence, that may not be the safest place.
Similarly, washing hands presumes that you have access to running water. And we know that that is not the case for every American. And, sadly, even just that sort of guidance has been difficult. In terms of whether to wear a mask or not wear a mask, there’s also been some concern around, what does it mean to wear a mask if you’re a Black man who is worried about being perceived as a threat or a risk?
You know, we heard from New York City that the vast majority of people who have been arrested for not following the guidance are people of color. So there’s something very important to be said around, not only whether the information and the guidance is accessible; but, also, how do we enforce it? How do we enforce it in a way that is humane, in a way that doesn’t exacerbate the inequities?
One idea that we have been having is, what is the role of police versus a civilian workforce? And, in many ways, the framing around what has to be done around COVID-19 has been around punishing those who deviate from these guidelines. But, in fact, punishment is not how you solve an epidemic. You really need to be building trust and giving people the means to follow the guidance. So, distributing masks, for example, is a good way to encourage people to wear masks. Fining people for not wearing masks is a bad way to do that.
So, the conversation has to shift from [just] making sure people have the right information; but also, having the means and the ability to follow that information. Both have to happen if we are to reduce health inequities.
TW: In your opinion, what are some very specific human rights–based responses that need to be put in place? Maybe speak to things that haven’t been done yet; things that need to be done urgently.
NL: The call from the FXB Center is that we need to center our analysis and our planning around health equity and a justice lens; that it is not enough to make decisions based on, say, biology or trends—not thinking about who is most impacted, and why. So, for example, a human rights–based response would take into account the fact that a large majority of people [at risk] are those who are low-income workers, who are deemed essential but who do not have access to PPE.
While we fully agree with the push to make sure that our hospitals, our nurses, and our doctors have access to masks and personal protective equipment, it is wrong to forget about those who are doing other essential services—delivering your mail, at the grocery store, the front line in other ways—and forget that they, too, have that same need for personal protection because they are enabling the rest of us to stay home. So, a human rights–based response to COVID means thinking about those who have the least power and the least financial means and negotiations to protect themselves.
The conversation right now that is kind of the whole conversation is: When do we reopen? And, yes; there’s a lot of pressure that economies need to reopen. But if we do that in a way that does not take specific needs of the most vulnerable into consideration, we will see, again, deaths mounting among the poorest Americans and those who are least able to protect themselves. So, a human rights–based response is not only needed in terms of the health care access; but also in terms of how we plan for reopening.
Another very clear example is around incarceration and, similarly, ICE detention centers and other forms of detention. You know, a human rights–based response is, we should not be putting individuals at risk for their life by holding them in detention centers that don’t provide for—do not enable them to socially isolate.
So, I think the key point to say here is that epidemics always show the worst in us. Because those who have the means, and those who have the privilege, are able to benefit—to stay home to protect themselves—and those who don’t, don’t. So, a human rights–based response means that the governments, local authorities, need to take into account those needs first.