As the novel coronavirus pandemic takes an ever-increasing toll on the United States, it’s now widely publicized that COVID-19 deaths haven’t been experienced evenly across all segments of the population. Across the country, Black people are dying from the disease at disproportionately high rates. One of the first researchers to identify the severity of this trend was Dr. Clyde W. Yancy, chief of cardiology at Northwestern University’s Feinberg School of Medicine. Yancy has studied cardiovascular health disparities for decades and hopes the current crisis will be a catalyst for major public policy and values shifts in our society.
Maya Dukmasova: How did you get to looking at the disparate impact of COVID-19 on African Americans?
Clyde W. Yancy: In my 30-year career as an academic cardiologist, part of my research focus has been evaluating the dissimilarity in cardiovascular diseases and cardiovascular health as a function of race. Over the years we’ve identified a greater burden of cardiovascular risk factors in persons who are African American: hypertension, obesity, and diabetes. These health disparities exist independent of access to health care. The reasons this focus on the presence of risk and disease beyond access to care is so important is because there’s nothing about biology per se that describes this disproportionate vulnerability to risk and the attendant disproportionate consequence of disease. Therefore what we’ve been studying is how the life and living circumstances of different groups will lead to greater exposure to risk, greater manifestations of disease.
The COVID-19 experience is just another example of these evident health disparities, but it may be the most glaring example. At this point it’s appropriate for me to interject that my heritage and my race is as a Black American. So a big part of these discoveries and these conversations is actually personal.
In Chicago, where only about a third of the population is Black, more than half of the people who’ve died of COVID are Black. Has anything caught your eye about how these disparities are playing out here?
It was the recognition of data from the Illinois Department of Public Health that incited the deeper dive that revealed the extent to which these disparities are present. When I first became aware of the data, I paused because it could have been spurious, it could have been unique to Chicago or explained by other variables. But as we studied the data more we recognized that it wasn’t spurious, that it was validated in Detroit and New Orleans and New York. We began to realize that it was indicative of a very painful aspect of this overall crisis.
In your Journal of the American Medical Association article you write that Black people in America experience a “higher burden of at-risk comorbidities.” What does that mean?
In many communities, Chicago included, race defines where home is. That’s important because home determines your life circumstances: what’s the housing density, what’s the access to high-quality education, what are the crime rates, what’s the prevailing socioeconomic status, and in particular what is the access to healthy foods, particularly fruits and vegetables. The aggregate of the things that I just described generates additional risk for the development of cardiovascular disease. I am a lifelong volunteer with the American Heart Association and we have a practice now of reminding people that zip code may be your greatest risk factor for cardiovascular disease and stroke.
Do you think that seeing this disparity in the context of COVID data is going to make it more likely that some kind of racial justice remedies are enacted? Why would it be this crisis that would make us more likely to act?
First, this crisis has dramatically highlighted not just the presence of another disparity but the extent of this disparity. COVID-19 has removed the Band-Aid from our health disparities environment and demonstrated how deep the wound is. [The] second thing is that the loss of life, the human toll involved here, is compelling. I believe that in a civil society there’s a pain point beyond which we are uncomfortable tolerating such disproportionate suffering.
In the JAMA piece you bring up this point about this not being tolerable. What are examples of other major diseases where civil society stood up and did something in the face of disproportionate suffering?
Think about other infectious diseases. We don’t see polio happening anymore because not only did we see scientific discovery [to cure it] but as a society we said we cannot have maimed and injured young adults going into their most productive years. There was a time when we had hospitals just for tuberculosis. We got to a pain point when we said we can’t allow this to be and with scientific discovery and also with public health we did things differently. We got beyond just observing that people have an illness to finally getting to a point where it exited public health and entered public policy. Someone had to initiate an effort and say it is our will that we won’t live like this. I think there’s now a sufficient rationale to execute the same distaste for disproportionate suffering.
The point of my reference in the JAMA article is to say that I am not targeting a utopian environment. I am suggesting that in times past we have hit thresholds that have incited change. And I think that very quickly we’ve gotten to the same place with COVID-19. The change that it’s incited is to really look at why do we have these disproportionate exposures to risk and in turn these painful and disproportionate burdens of disease? If it does track to this phenomenon of disparate determinants of health, which are largely driven by where and how people live, that’s where opportunity for change happens at the public policy level. Persons like me and my colleagues who are deeply involved in scientific discovery will continue to look for unique therapies, but to get to where I’d like for us to be, where health equity is a goal, we need the entirety of the population to value health as a primary objective in our society going forward.
The only way we can successfully recover is to have broad subscription to new economic initiatives. We would have to be much more inclusive than ever before by race, by ethnicity, by age, by gender, sex, every categorization you can imagine. If it’s taken all hands on deck to respond to the urgency of the COVID-19 crisis, it will take all hands on deck to restore our economic enterprises. That necessarily means we need to be healthy enough to do so.
It sounds like you’re optimistic about the possibility that this is one of those threshold moments. You don’t think that the fact that COVID victims are disproportionately Black will actually make it less likely that there would be this necessary response? There’s a history in this country of treating problems seen as Black people’s problems as not that urgent.
I’m an optimist. I believe in the resilience of the American spirit and we have a history of standing up and ultimately going in the right direction. This disproportionate suffering is not just experienced by African Americans. When this is all settled it will have touched every family in this country: urban, rural, Black, white. And it would have done so disproportionately, not just based on color, but based on economics, based on access to resources. No person in this country will be able to say they haven’t been impacted, influenced, touched by COVID-19. So I think there would be many more people collectively engaged in moving forward than those that would be resisting.
Are there some specific public health interventions locally that could help right the racial health disparities, both immediately in the context of the crisis and longer term?
I think that when one reduces an issue that is this complex and has these kinds of consequences to a bulleted list we run the risk of being shortsighted and trivial. I think the broad focus is the really right place to start, whether in Chicago or anywhere else. The very first thing that needs to be done is not just an acknowledgement but a commitment to health. Ultimately our health is the only real luxury any of us have and that luxury is shared by far too few people. What’s most important is the preservation of our health. The second big point here is recognizing that we don’t all share equitably in access to good health and that collectively we now have a commitment to change.
The reason I’m avoiding specific steps even here in Chicago is that health is a very local enterprise. In some communities it may truly be because they’re living in food deserts, in others it may be because there aren’t many opportunities to find gainful employment. It may be because of housing, it may be because of education. To try to deconstruct this to a list of items oversimplifies the issue. I think the first steps really have to do with the reality of what we’re facing and the importance of recalibrating what’s necessary here. Once upon a time we thought that freedom was the primary objective. I think right now we need to recalibrate and say health is the primary objective.
Do you think that discrimination against Black people in the medical establishment is becoming more visible as a result of this crisis?
The data tells us that the differences we see are explained by a variety of factors: factors that we’ve discussed already, like life and living circumstances, factors that go beyond access to care, that deal with how patients receive care. There are phenomena of implicit bias that have to be navigated. It goes to institutions where patients receive care, clinics where patients receive care. Many persons we’re talking about receive local care, and quality metrics in some of those hospitals and clinics are not ideal. It is important to recognize that there are multiple dimensions in these discussions, which do involve volition and how people process public health messages, how people make decisions about lifestyle and living circumstances. But their ability to make those decisions are greatly affected by their living environments.
Are you seeing anything specific about the way that medical care is administered to African Americans during this COVID crisis that’s troubling you?
What I’m seeing is the exact opposite. In our facilities and the facilities in which I have insight, the medical community has been heroic. They’ve stepped up, they’ve embraced all patients who have presented with COVID-19, they’ve cheered for every success and they’ve mourned over every loss. So I stand stridently on the side of our health-care workers, in particular our physicians and nurses who really have stepped up and provided color-blind, race- and ethnicity-blind, age-blind care to people facing the most desperate challenge to their health.
From a public policy position we do know that across the country there are certain communities where access to coronavirus testing has been limited and those communities disproportionately have aligned with concentrations of Black populations. That is something that when the smoke settles will need to be looked at very carefully as we do a thorough review of how we responded to this crisis. But we have to be careful. We don’t know all the mitigating reasons why testing was or was not available in certain communities.
In a recent New York Times Magazine article you noted how tragic it was that a traditional Mardi Gras gathering of Black men in New Orleans became a hot spot for the spread of the virus there. Do you have any thoughts about the way the public discussion has been happening around these house parties in Chicago that have been presented as gatherings of young Black people? Are they being depicted fairly?
It continues to pain me that a heritage that I know so well in the deep south, in the heart of Louisiana, was so disproportionately impacted, even destroyed by COVID-19. This exposure happened when there was very little clarity and uniformity in the public health messages. Where we’re at today is—regardless of the city, regardless of the participants, regardless of the community—the public health messaging is explicitly clear. We’re still being strongly advised to practice social distancing, we’re being strongly advised to wear masks. We’re being strongly advised to practice hand hygiene, clean surfaces, and to report at the first sign of any symptoms. There’s no one, no one in this country that should ignore these public health messages. The pain I expressed over the loss of these men who were simply exercising their right to congregate and to celebrate a tradition that was nearly 100 years old, that pain will be revisited if any group of people under any circumstances ignores today’s very strong public health messages. If I can end my comments with one thought it would be this: People, be safe, listen to the public health messages, and follow those messages accordingly. v