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COVID-19 (and HIV) Disparities Are About Racism, Not Race

two medical professionals checking patients vitals.The 23rd International AIDS Conference (AIDS 2020) was held virtually for the very first time and featured plenty of discussion about the current direction and future prospects for HIV prevention, diagnosis, and treatment. The conference was followed by a virtual COVID-19 summit. During the summit, a plenary session entitled, “Impact of COVID-19 in the Health Sector,” was held on July 10.

LaRon Nelson, Ph.D., RN, FNP, FNAP, FAAN, was one of the presenters at this plenary and gave a presentation entitled, “Anti-Black Racism and COVID-19 Inequities: Explaining the System, Exposing the Setup, and Exploring the Solutions.” Nelson is associate dean for Global Health and Equity and the Independence Foundation associate professor at the Yale School of Nursing. He also is the Ontario HIV Treatment Network research chair in Implementation Science with Black Communities, which is based in the MAP Centre for Urban Health Solutions at St. Michael’s Hospital of Unity Health Toronto in Canada.

Nelson’s research investigates the use of multilevel interventions to optimize HIV prevention and treatment outcomes in African and African diaspora communities. Nelson’s research has been supported by the National Institutes of Health, the Centers for Disease Control and Prevention, Ontario HIV Treatment Network, Grand Challenges Canada, and the Canadian Institutes of Health Research.

Terri Wilder: Dr. Nelson, your presentation explained what this system of racism is and how it sets up the production of health inequities that we are witnessing in the COVID-19 pandemic. You provided your thoughts about what can be done to stop it. So, can you begin by stating what race is as a social concept? You began your presentation with this, and I think it was important to lay that out at the beginning of your talk.

LaRon Nelson: Yes. Thank you, Terri. I often start with a definition of race so that we have a common understanding of exactly what we’re talking about. Because the popular understanding of what race is, is that it is a biological identification of human groups. If we start with that definition, it means that there are differences that are innate, that are meaningfully innate, and that there’s nothing we can do about them; and that those differences also represent a hierarchy within the human species. And then that becomes a basis for how society is structured—which has whiteness at the top and everything else at some gradient beneath that, with Blackness being at the bottom.

And so, the idea that there are these deep, significant biological differences between groups of people—if that is where we start, then everything else about racists, this racist system, makes sense, as that is out of our control. That’s how nature designed us. That’s how nature designed it.

And so, that is not the case. And so, that is the reason why I said, “Let’s understand what race is.” And I did that by pulling on some work that is this amazing work from the University of Pennsylvania, Sarah Tishkoff, who does a lot of work and study in genetic variance within the African continent among multiple different tribes and ethnicities.

What it lays out is that first of all, everybody’s from the same point of origin. And we’re talking about the scope of thousands of years. Right? So, what she’s saying is that the way that humans—if we look at race, right? Blacks, whites, browns, all the ones that are coming up—if we draw a circle around all these people that we say are black or white, it doesn’t make sense, from a biological standpoint, because all those people are not the same. The one thing they may have in common is the color of skin, perhaps; and maybe some anatomical features, perhaps.

But from a genetic standpoint, those are not homogenous groups of people. What is making them homogenous is the circle we draw around them, and then we call them a group of people. But otherwise, there is no natural, biological indication that these groups of folks are identical.

For example, I had a conversation recently with some folks about, really, why wouldn’t race be a predictor of clinical outcomes? Why couldn’t you use that? Obviously, the question was posed about, well, what about African-American women, who have higher risk of breast cancer mortality, compared to, you know, some other group of women, white women?

So I say, well, first of all, African American is not a race. African American is an ethnic group within the American society. So that’s the first thing. But to say that race is a predictor, that being a black-skinned person is a predictor, would mean that this person—who is African American, who may be a descendant of people who were brought to America, say, 400 years ago, is under very serious conditions of duress and ongoing trauma—is the same as a woman who came from Kenya whose ancestors had been there, have never left there, who got to America this morning; they both are women, they both are black-skinned, so we would say they’re both the same race. Are they genetically the same people? Would those same factors apply?

And what I’ll argue is that it does not. The thing that connects them is that we have socially grouped people with the same skin color together, regardless of everything else. I think it’s easier when we even use examples of white people. If you just went across the globe and just plucked white-skinned people from wherever you found them—South Africa, Iceland, United States, Australia, Russia, wherever they might be—and you said, “So these are all people who have white skin,” would they have the same sort of clinical profile because of their white skin?

They wouldn’t. You wouldn’t even presume that they would. Because you would understand that the one commonality—not culture, not language, not tradition, not ritual, and not even genetic profile, which is what Tishkoff’s work is saying—that the thing that unites them in whiteness is just the classification of them based on the color of their skin. Nothing else holds. The only thing that holds is the social grouping.

So, the reason why that’s important to start with is that I don’t think most people understand race as that thing. What they understand as race is just how people are naturally developed across the Earth; and it is what it is. And that’s not what it is.

In order to have a serious conversation about racism—which, again, is grounded in the idea that race is biological and that these differences are natural and nonmodifiable and not about control—[how] that justifies the way that the world has developed with white supremacy has to be the starting point.

TW: You later spoke in your presentation about the fact that racism is a social system. And then you had this nice graphic outlining that racism has four dimensions: There’s institutional racism, structural racism, interpersonal racism, and internalized racism. One of the most important points that you made is that this social system of racism is continuously operating and actually doesn’t even require conscious participation.

Can you talk more about what you mean by, “It doesn’t even require conscious participation”?

LN: That’s a good question. I spend a lot of time trying to think about how to explain this to students, mostly, and then trying to understand why we see some of the patterns we’re seeing in research. And so, I use it to say that everything is structured around this. We’re all already operating within it. We don’t even have to know it.

I’ll give an example. It’s an analogy, but I think it’s helpful that no one would necessarily need to spend time understanding whether or not anything Terri or LaRon did was capitalist. Like, “Is Terri being a capitalist?” “Well, I don’t know.”

It doesn’t even matter if you were or not; we live in a capitalist system. Everything we do is supported by the—we support this system. Whether we’re a boss, whether we’re a worker, whether we’re negotiating salary to get more for our labor, or whether the employer is trying to get as much labor as he can to maximize their profit; we are all participating in it. Even if one of us ever thinks, “How am I going to be the best capitalist I could be today?” Or, “How am I going to be less capitalist today than I was yesterday?”

We don’t need to think about it, because it doesn’t matter to that degree. Because everything is already structured in that way. You are a cog in the wheel.

It is the same thing with racism, right? It’s already in operation. The thing that you can do is actively try to work against it and obstruct it. Because otherwise, all you’ve got to do is wake up and it’s already there. And you just move through it.

So, I explain it that way because I think people focus on the interpersonal domain, and often say, “Well, I’m not doing that, so how can I be a participant in racism?” Right? And nobody would say—well, maybe somebody would say it, but some of the things that you hear when people try to justify why they can’t be racists; like, nobody would say, “Well, I can’t be capitalist, because I have friends who are poor. How can that be capitalist?”

Of course you can have friends who are poor and still be a participant in the system! Of course you can have friends who are white, or not white, and still be a participant in the system—even though the system is structured that it will produce (as in capitalism) profit; and it will also produce poverty. Racism also produces this same type of advantage for whiteness in all its manifestations, even in people, and disadvantage for other folks, particularly Black and indigenous and other people of color.

So that’s what I mean by, “It’s continuously operating.” Because I think the out, the easy out, for people is to go directly to the interpersonal and say, “But I don’t think I do that,” and to say you don’t have to be doing that to still be participating in the system; it’s already happening.

So, what has to happen is, you have to find ways to not be participating in the system. And that’s hard, because everything is organized around this white supremacist framework in this country. Even how we’re educated. So, you don’t have to be white to even think that way. You can be any color and social category to think that way. So, that’s what I meant by “It’s continuously operating.”

And it’s hard for me to explain it, other than when I talk about other systems that people can understand. Like, “Oh, OK. I can see how I can just be doing what’s normal, my normal, regular routine, and still be contributing to the system.”

I hope you understand what I’m saying.

TW: Yes. That’s a great analogy. The other day I was on Twitter or Facebook, and somebody was having a conversation with other folks about what puts people at risk for disease, disability, or death. And somebody was saying, “Well, you know, people who are this race are more at risk for a disease, disability, or death.” And in terms of Black or Brown people, it was really the context. The person who was kind of leading the conversation said, “No. It’s not race; it’s racism that puts people at risk.”

One of your slides had the following sentence in big, bold, red letters—and I’m going to quote the sentence that was on it—“Racism is a form of structural violence, because it produces socially unjust conditions that predispose Black communities to disability and death.” I’m wondering if you can talk about how racism produces these conditions, particularly in terms of what the conference was focusing on, which is the COVID-19 pandemic.

LN: So, if we think about racism as a system with multiple dimensions, including multiple institutions that all work together to uphold white supremacy; the upholding of white supremacy and white advantage is dependent on producing and distributing disadvantage to a different group or class of people.

If we look historically at the ways in which Black folks have been disenfranchised from where they could live and how they could build wealth, right? That has structured the ways in which communities look, in terms of how—in close proximity to which they can live to or away from each other, and how they may have necessarily been warehoused in particular housing complexes because of the limitations of how they could distribute developed wealth and use that to build more space between each other. Not that having more space is a particular advantage. But the option to do it, as we can see in COVID, has made some folks less likely to be exposed and other folks more likely. So, things like historically how they’ve been able to sort of build wealth and determine where they can live, and how close proximity they can live to other people.

The histories of criminalization of, let’s say, drug laws that disproportionately impacted Black folks—that led to arrests, that led to incarcerations, which led to very different opportunities for income generation and employment once people come back home (if they come back home), that led to different opportunities for housing that people can get if they have criminal records; even being able to vote.

If we just think about these policies that have impacted Black people—that are racist—they’re racist because they have been designed and implemented in a way that disproportionately applies to Black people, and a way that does not apply to all people, and particularly white people; and that has, what I say later on, funneled disadvantage in a particular way. So, that has led to conditions about where people work, the type of industries that they’re in, necessarily. Some people like the work that they do. Not everybody likes their job. There are people who work at my university who probably don’t like their job.

But there are many people who are in jobs because they don’t have other choices, because they have been put into conditions that have forced them into living in particular places, living under particular conditions. They have uncertain access to resources, or restrictions to resources, that when this pandemic hit, there are things that are already structured that will protect people—like being able to work from home, being able to social distance, being able to afford a mask, being able to have some sort of health insurance that allows you to access things like good health care.

So, in the context where all those things are already happening, that all that is already in place because of racist policies, when the pandemic hit, those people in those conditions who happen to be—it’s not even that they happen to be—Black; I think that because the policies are potentially anti-Black, that those are the folks who are going to suffer the worst outcomes. They’re going to get it more because they’re in jobs that are then deemed essential; they have incomes that may be primarily precarious, which means they can’t just say, “Well, I’m just going to stop working for a little while until this all blows over.”

All those conditions have predisposed Black communities to this pandemic, and to the likelihood that they’re going to get sick, that they will be—when they become sick—that they will more likely be severely ill, and as they are severely ill, they’re more likely to die.

Those conditions have already set up a situation where it didn’t have to be COVID-19; it could have been anything like this. Like, this is what was going to happen. And so, that is the violence of it—that it’s not random; that this is—and I hate to even admit that it is, in some ways, predictable and avoidable, but it is. And it was. That’s what I meant by racism is structurally violent: The structure sets up people for the types of injuries that we’re seeing, that didn’t have to be this way if our system didn’t set it up this way.

TW: In your presentation, you had several maps of the United States to make a point of where COVID-19 was most pronounced. Can you talk about, a little bit more, in what very specific ways has COVID-19 impacted the Black community?

LN: Those slides were amazing. They were from a presentation that Greg Millett from amfAR gave early on in the AIDS 2020 conference. He let me use those.

The stark thing about it is, there is almost no place in the U.S.—particularly in the South, but no place in the U.S.—where the rate of COVID-19 cases among Black people were proportionate to the percentage of Black people in those counties. There was almost no place in the U.S. where COVID-19 deaths among Blacks were proportionate to the percentage of Blacks who lived in those counties. In almost every place where there was data, except maybe, I think, Rhode Island and Washington or California, that was the pattern.

And so, Black people were more likely to get COVID-19, probably because they’re more likely to be exposed to the coronavirus. And if they got it and got sicker, they were more likely to die.

But this is not unlike other illnesses that we talk about. I think what COVID-19 has shown in a very short period of time is what we had come to understand about the AIDS epidemic over decades, where we were kind of like, “Wait. This is …”—and I think we realized it a long time ago. But this isn’t necessarily about that Black people—Black gay men, in particular, aren’t doing particular things [to predispose them to HIV]. There are other things going on that are driving this; stigma and policies that undermine people’s ability to get access to care and housing. But I think it took a while to get there. This is the same phenomenon that is happening [with COVID-19]. And it’s the same phenomenon because the structure is the same; it’s a racist structure.

But because COVID is spread so quickly and because the effects are so rapid, I think you can see very clearly, almost immediately, what the impacts have been. So, it’s undeniable (although people will still try to deny it). It is undeniable.

I don’t know if I could tell you that I know somebody who’s Black who does not know somebody who died from COVID-19. Like, I don’t think there’s even one person I can think of right now in the U.S. And even thinking about what that will mean for people who are trying to still stay focused amid this, who are trying to go to work, as many folks are essential workers who can’t afford not to be at work, where it’s mandated that they have to come and provide these services; in the context where death is happening at an accelerated pace around them, and places where local and state governments are not moving to ensure that there are protections for them.

Because I just mentioned that the workforce that are essential workers are overrepresented by Black people. Right? They’re going to be more likely to be exposed. And that’s deliberate. It has to be deliberate to say people in this community don’t have to wear masks. That will mean that these folks who are on the front lines doing this work will necessarily be exposed, because policies are driving that. Policies are not protecting them.

It’s more than that policies are not protecting them. By refraining to enact public safety, public health safety policies, it is actually increasing the risks to people who are working—not just in medical facilities, but just trying to help everybody sort of stay alive by providing goods and services.

TW: You gave your thoughts on how to fight this, fight these systems, how to fight COVID-19. You talked about the need to fight on two intersecting fronts. Can you talk about what are those two fronts?

LN: I’m a nurse. One front is—the clinical public health front is really trying to do what we can to reduce the spread of the virus and control people’s exposure to it, one. And then, for people who get ill, to just try to make sure that they can recover quickly and reduce the number of deaths that we’re seeing. There’s been some progress in some places, but that was very short-lived.

And so, I wanted to make the point that, while the presentation was really focused a lot on anti-Blackness and the system of racism, that there is still a very real clinical public health front that we need to give attention to.

At the same time, there has to be attention to racism and the system of it that is also contributing to the patterns of disease and death that we see. So we can’t stop one to focus on the other. We have to be focusing on both at the same time. That was the point I was trying to make.

I was also trying to make a point about the work that people are doing. Because I don’t know if people appreciate that activists and advocates and folks who are in the streets and making noise; they’re working! They’re working. They are trying to stop this system, racism, that is not just having an impact on COVID-19, but it’s been having an impact on death and life for centuries.

So, to me, those are both critical workers. Those are people who are fighting to save American lives. I do think that we position folks who are fighting against racism as, you know, risky and not responsible. Well, they are taking risks; they’re taking risks the same way nurses are taking risks when they go into those hospitals, knowing what could happen to them when they go. But they have a duty. They know this is a problem. They know that if they don’t fight on this front line, more people will die. And they put themselves and their bodies at risk to help save all of us.

I think people who are fighting racism are doing very similar work, in that people understand that this is happening in the context of a pandemic. And yet, it still has to happen. And there has to be some people willing to do that very difficult, very dangerous work. It’s not even just dangerous because of the coronavirus; but it’s dangerous because of the type of violence that folks who do this are often met with in a way to sort of shut it down.

I thought it very important to say that. And I hope people got that message. It’s that we need to be supporting both at the same time.

TW: How do we support those risking their lives to fight on both of these front lines?

LN: Yes. I have to think about this one. I think that there’s a lot of power and capital, social capital—maybe even money, but—that scientists and journalists, very influential people, health care providers, others, have. And I think that we have to use it to sort of push this, to push it into the, I don’t know, mainstream. This is our issue. This is the issue. This is something that we have to get rid of. I think everyone has to mobilize around it. Folks can’t be silent about it.

I think there are ways. And this isn’t even a new fight. The folks who are doing this have been doing this for years. They’ve just been ignored. They’ve just been sort of pushed off as fringe voices. And so, I think what we have to do is make sure that it’s clear that this issue is not a fringe issue, that it’s not an issue that just impacts a small group of people, that it impacts all of us. And there are spaces where we are where I think we have to—there are boardrooms that we sit in. There are places where decisions are made. But I think we have to identify where racism is playing a role in here. And we have to stop it. Everybody has to take a wrench and somehow break the system.

You will have to break the structure. And it will be painful. And we have to be willing to do things when we realize that the structure—if the structure does not allow us to achieve the goals we want, then it has to be broken. We have to. And I think as Americans, maybe in general across the globe, but I think in American society, we are very concerned with order, and wanting to figure out how to do things within the parameters that allow things to be sort of orderly and peaceful.

Except—going back to our initial discussion about racism being a system that is ubiquitous and that we are ordered within that system—that it means that there is something, that you’re going to have to go into a conference room or to a board meeting and say, “Nope. This is not reformable. We have to change this. This has to stop.” At the risk of people calling you out and saying, “Oh, you’re being extra. …” Or at the risk of you not getting that promotion that you want.

So, there’s a lot tied up into us just behaving, and letting this thing go the way it wants to go, versus speaking up in ways that some of us can be targeted and casualties to a system that really wants to protect itself because of the benefits that people get. I think we’d have to commit to doing what we can in our own sectors to uproot this.

And I encourage people to think, seriously, about what that means. What they’ll have to give up; what power that it means they’ll have to share. Right? When they go to the ballot box, right? So, nurses who have patients who, they’re so upset because this patient can’t be adherent to their medication because they don’t have stable housing, and it’s terrible, and if they had stable, affordable housing they could really get ahold of their, whatever it might be—their viral load, or their blood glucose levels. Right?

And then, you know, once you leave work and you go to the ballot box, there’s a referendum about whether or not they can change zoning laws and a particular zoning requirement in a certain place that might allow it to construct affordable housing. But it’s too close to your neighborhood. Like, “Oh, I want them to have housing, but I don’t want them in housing next door to me.” This is what it is. Like, OK, you really want social change. This is what it means. And I think people have to think really seriously hard about what they want to give up.

But I guess, to answer that question, Terri, is they have to be willing to give something up. Because the system perpetuates itself by having us really get wrapped up in our own self-interests in a way that depends on the exploitation and disadvantage of others. I don’t think we see it that way. But that is the way.

And, again, it’s not unlike capitalism. Whether we like it or not—and some of us don’t like it—but the system is set up for some people to get more. And you can only get more by making sure other people get less.

The end system of racism means that people, regardless of whatever group you’re assigned to, whatever color of your skin, that folks who have gotten more in an unfair way, and folks who have gotten less in an unfair way; that would be where we would commit that we don’t want that system and ask to redistribute it. And some of us will not be willing, easily, to give that up.

TW: One of your last slides, I loved what you put on it: We need less theorizing, less apologizing, and more mobilizing. And clearly, there’s been mobilizing in lots of different ways: Black Lives Matter; there’s COVID-19 groups that have stigma and racism subcommittees looking at these issues. But how do we get the people who have never been involved in any kind of social justice work before to get mobilized? How do you reach those people and say, “The time is now”?

LN: I think that the people who have really been taking a lead in raising this issue and saying that we can’t go back, we have to stop this system now—that they have to push hard and continuously. Because I just don’t believe, I don’t think it’s an issue of education. I don’t think people just don’t know that this should be different.

I think people are faced with the fact that there are consequences if you continue to subject people to this system, that it’s also in our interests to change it. Because I think the writing is on the wall in many ways. I mean, we saw buildings being burned and cars being turned over.

Somebody asked me—a nurse, of all people—“What if they come and turn over your car?” And I was like, “Folks have been saying this for a long time, and nobody’s paid any attention. Nobody’s going to pay any attention until it looks like this is consequential. This will not stand.”

I think that has to happen. And I think that people who lead organizations have to commit—more than commit, they have to restructure. I think that there will be some backlash. There will be some resistance to people who want to continue to have a racist system that benefits them. But I think as structures change, I think—and as accountability is enforced—that we’ll also see how these functions change, in particular institutions.

So, I guess I’ll back up a little bit to say my discussion on racism as a system—the system is built by multiple components, mostly institutions. And so institutions, by themselves, may not be able to take down the system. But the constellation of institutions who are doing things—if everybody, and all these institutions, are restructuring, putting your policies and enforcing the policies in ways that are antiracist, I think it can get us there. But that’s the mobilization that needs to be happening.

I think it will not happen—I don’t think people will just decide, “Oh, I’m just going to do this.” Because I think they would have done it. And I think that’s why the protests and the riots, the rebellion, is so necessary. Because without it, I don’t think anybody would have done anything differently.

And I don’t buy this idea that people have all of a sudden sort of awakened. Like, they were slumbering and then the sun is out, and they’ve kind of like [just] woken up. No. Somebody shook the bed, right? There is an awakening, but it’s an awakening because it’s an enforced awakening that said that this has to stop.

So, I think there are two things. I think the mobilization: I think there are folks who need to join it, who need to find ways to figure out what people are asking for, to unlearn some of their practices and some of the beliefs that they have that are definitely racist, and then figure out ways to sort of dismantle and disrupt racist policies and practices within their own institutions, within their own practices—if they’re practicing science or medicine or nursing or journalism, or whatever it might be—and then commit to restructuring how these institutions operate. And then find ways to hold folks accountable.

In a way, it is sort of a moral—I don’t know the words. I guess I’ll say what I said before. I don’t think it’s about a lack of education.

You know what? I read this book called Race and Epistemologies of Ignorance. It is fabulous. It’s the book. But it helped me—because I struggle with this, talking to mostly nurses who are, like, “If only I’d known.” Or, even when I tell them, there’s this, like, but: “But what about this? But what about that?”

So I’m like, “Well, so, listen. I just presented you with tons of evidence. Literature reviews. Systematic reviews. So this is not about you not knowing. This is about your resistance to knowing. Because knowing changes a lot for you.”

I think that’s the work that folks have to do. And it’s hard. But that’s why I think both have to be happening. We have to find allies within these institutions who are willing to connect with the movement that’s happening in the streets. The movement that’s happening has to continue—because otherwise I think people will go back to status quo very quickly, very easily. And folks who have the moral conscience that the way we’re doing this is wrong and are willing to accept it, and then also be willing to do something about it within our own institutions.

That will mean disrupting. That will mean being labeled. But it will mean you have to do it, because otherwise the system will stay in place.


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