Focusing Upstream

African Americans die from COVID-19 at more than two and one-half times the rate of whites. We must bring more attention and effort towards reducing the number of deaths from COVID-19 in general and the significant disparity among African Americans in particular.

Our heroes in the medical community are telling us what to do. First, they say we should wear masks and practice social distancing when among others. They also suggest we should have more testing and more contact tracing.

We should push ourselves to have the appropriate individual behavior. However, we must also push officials to do more testing and contact tracing.

The Coronavirus Urban Report, which we launched on Facebook Live last Saturday evening, is an effort to help address some of these issues, primarily as they affect African Americans. This show can be seen at https://www.youtube.com/watch?v=0wD17XxFGmM

As we busy ourselves in these essential tasks, however, we must be mindful of the need to focus upstream and address the causes of these health disparities among African Americans. We can frame our work in the public health model of prevention. The public health approach considers prevention in three steps or phases: primary, secondary, and tertiary prevention.

Primary prevention helps individuals avoid disease before signs or symptoms of the disease. Secondary intervention is essentially the early detection of disease, followed by an appropriate response, such as health promotion or treatment. Tertiary prevention aims to reduce the impact of the disease and promote rehabilitation of persons with the disease. This is typically referred to as treatment.  

Physicians and nurses are working overtime and at high unnecessary personal risks to provide tertiary treatment of COVID-19 infected people. Other medical personnel are fighting hard in secondary intervention—to get more testing, more contact tracing, wearing masks, and more social distancing.

This pandemic clearly shows the need for primary prevention, such as being prepared, heeding the calls for producing tests, and personal protective equipment. Preventing the racial disparities in COVID-19 causes us to look more particularly at the causes of that disparity. A story might help to illustrate it.

A parable often told in public health circles illustrates key dimensions of prevention: Two physicians are standing beside a river when they hear a cry for help from someone in the water, holding on to a floating log.  One of the physicians runs, gets a rope, and throws the end of it to the man, who was obviously in dire straits. As soon as they brought the person ashore and began applying artificial respiration, another person yelled for help from the middle of the river. The second physician throws the rope to save this fellow, just in time to hear a third person in the river crying for help. One of the physicians says to the other, “You stay here and rescue the next one. I’m going upstream to see who is pushing these fellows into the river. 

We must pay attention to persons in immediate need of assistance. In the vernacular of public health, this is tertiary prevention. However, it should be just as apparent that tending to such persons does not entirely solve the problem. Attention must be focused upstream as well. Social justice in general and good public health in particular require primary prevention—stopping these men from falling–or being pushed–into the river.

What causes African Americans to get COVID-19 is undoubtedly the same thing that causes whites to get it. However, what causes blacks to get this virus and to die more readily than whites is something else–racism.

It is understood and accepted in public health that racism is a primary cause of racial health disparities. Scholars agree that racial inequalities in health occur primarily because racism is a fundamental cause of racial differences in socioeconomic status (SES), and because SES is an underlying cause of health inequalities. Further, there is a racism effect beyond the effect of SES.

We must focus upstream and address this racism. I will have more to say about what and how in the coming weeks.