The Hidden Structural Racism in the American Response to Public Health Emergencies

by R. Drew Smith, July 23, 2020 (Public Seminar)

In recent decades, in reacting to threats to public health, the U.S. government has often resisted mobilizing a robust response until the dangers were perceived as hitting “close-to-home.” A closer look at what counts as “home” suggests that experts often assumed the term meant the white homeland understood in terms of evangelical Christian values.

When faced with emerging epidemics related to HIV/AIDS in the 1970s, to crack cocaine in the 1980s, to Ebola in 2014 and 2018, the U.S. government was slow to intervene on behalf of homosexual populations, or urban poor populations, or African populations, who respectively were most-affected by those public health emergencies.

Currently, there is a striking statistical association between HIV/AIDS and Black people, with Black people accounting for 42 percent of persons in the United States living with HIV and 44 percent of deaths, and with HIV deaths in sub-Saharan Africa roughly 10 to 20 times the rates in most of the rest of the world. The Ebola and crack cocaine epidemics were also strongly associated with Black people.

When COVID-19 first appeared as a health threat earlier this year, it was initially dismissed by President Donald Trump and other administration officials as a problem for China — not America. Today, as COVID-19 cases continue to soar across the United States, disproportionately impacting Black and brown Americans, Trump has continued to downplay the threat. Of the almost 140,000 American COVID-19 deaths so far, 40 percent have been of Black or Hispanic persons.

In confronting previous health crises, the U.S. government has tended to behave as if safeguarding Black lives mattered less than protecting white lives. The political, public health, and moral imperatives of mounting the fullest possible response to COVID-19 seem self-evident. And yet the U.S. government has yet to rise to this challenge.


Racial bias looms large as an explanation — and all Americans will pay a high price if the implicit racist calculus in the government response is not acknowledged and systematically addressed.

Racial aspects of recent epidemics and responses

When HIV/AIDS began sweeping across the United States in the 1980s, the government and media response was initially a mixture of silence about the disease’s increasingly tragic dimensions and stigmatization of AIDS as a disease trending among persons whose lifestyles or demographics marked them as “social others.” The federal government’s response at first was mostly one of neglect, with the U.S. Congress making its first allocation toward AIDS research and treatment in 1986 in the amount of $12 million, even though 1,450 HIV infections and 558 deaths had been reported by that time.

Even in the 1980s, Black people comprised a disproportionate number of U.S. infections. Now, in 2020, the number of persons in the U.S. living with the disease has grown to 1.1 million, with Black people comprising roughly 45 percent of HIV cases.

Given government neglect, it has been left to Black organizations, following in the footsteps of the white gay institutions that mobilized to fight AIDS in the 1980s, to do similar outreach within at-risk Black communities.

In the meantime, sub-Saharan Africa has become the global epicenter for HIV/AIDS cases. Of the 38 million persons worldwide living with HIV/AIDS, 26 million currently reside in Africa. Ironically (and for religious reasons we will explore in what follows), the U.S. government — initially under the leadership of George W. Bush — was at the forefront of responding to the HIV/AIDS epidemic in Africa, having committed almost $90 billion since 2003 to the global fight against HIV/AIDS through its Presidential Emergency Plan for AIDS Relief (PEPFAR).

Sub-Saharan Africa is also associated with major outbreaks of the Ebola virus, including the largest Ebola outbreak in history which occurred 2014­–2016 in West Africa and resulted in more than 28,600 cases and 11,325 deaths. The second largest outbreak of the disease, which occurred 2018–2020 in the Democratic Republic of Congo (DRC), involved more than 3,400 cases and 2,200 deaths.

Although the West African outbreak of 2014 was acknowledged internationally in March of that year, it was six months before significant U.S. governmental resources were deployed. Unfortunately, even during the Obama presidency, African affairs received limited U.S. government priority. What belatedly provoked U.S. involvement was the arrival of several travelers infected with Ebola on our shores that fall. This inspired a full-blown panic, fanned by the American media.

In response, the United States committed $350 million in aid and a potential allocation of $1 billion more through Pentagon channels. This included a deployment to West Africa of several thousand military personnel tasked with enhancing medical response capacities through logistical support and construction of treatment and training facilities.

By the time these U.S. government mobilizations occurred, the number of persons infected with the virus had grown dramatically, more than doubling from 3,500 cases in early-September to 7,500 cases in early-October. According to a 2015 U.S. Presidential Commission, the delay by global powers such as the United States in responding to the virus was cited as a critical factor in the spread of the disease. Accusing the government of a “fumbled” response, the Commission’s report pointed to the United States’s scientific unpreparedness in combatting epidemics and its political unwillingness to act. The lesson for the future, the Commission warned, is that a “failure to prepare and a failure to follow good science . . . will lead to needless deaths.”

That lesson, alas, would subsequently go unheeded. When Ebola flared up again in the Congo in the spring of 2018, the American Centers for Disease Control immediately dispatched agents to Africa, but the Trump administration just as immediately withdrew the CDC from the field, with the result that far fewer Americans were enlisted in the global fight against the second Ebola outbreak than in the first.

The reaction of the Trump administration to COVID-19 has followed a similar pattern of a sluggish response to a large-scale health emergency disproportionately impacting persons of color. President Trump has been dismissive of the COVID-19 crisis throughout, ignoring for months reports of an emerging outbreak, then deriding it as a “China virus” or “Kung Flu,” and consistently resisting and actively disputing protocols and prescriptions from medical and scientific experts on how to respond to the outbreak.

Racial disparities in COVID-19 infection rates had become clear by the end March, with figures showing Black people (who are 13 percent of the U.S. general population) making up 33 percent of those hospitalized due to COVID-19.

By June, COVID-related hospitalizations of Black people numbered 221 per 100,000 population and Hispanics 178 per 100,000 population. By contrast, white hospitalizations were 40 per 100,000 population. With respect to COVID-related deaths, both Black people and Native Americans died from the disease at rates disproportionate to their percentage within the U.S. general population, with Black people comprising 21 percent of COVID-19 deaths and Native Americans comprising 4 percent (though making up only 1.6 percent of the U.S. general population).

Racial and Religious Dimensions in Designating Public Imperatives

At the same time, the Trump administration has demonstrated that when it is white Americans bearing the brunt of a public health emergency, a systematic and sympathetic response can be marshalled. This was made plain during the first years of his presidency, when Trump in 2017 officially declared the opioid epidemic a public health emergency necessitating treatment programs. In addition, Trump threatened targeted law enforcement actions against opioid supply chains — including the pharmaceutical corporations flooding communities with these drugs and the medical professionals over-subscribing these drugs to patients. Building upon $181 million authorized during the Obama presidency for substance and opioid abuse, the Republican-controlled Congress in the first year of Trump’s presidency authorized an additional $6 billion to “triage opioid emergencies.”

As welcome and long-overdue as this governmental response has been, the recent government mobilization to attack opioid abuse among America’s “forgotten men” makes obvious the many decades of public health inaction when it seemed that mainly Black and brown people were using heroin and crack cocaine. Instead of funding treatment programs and helping cities and states cope with overdoses, the government ratcheted up its incarceration of poor people of color arrested by the police with even minimal quantities of drugs.

In 1974, the number of Black males who had ever served time in prison within the United States was 595,000. By 1991, that number had grown to 1,181,000, and by 2001 to 1,936,000. The cumulative number of incarcerated Hispanic males also grew exponentially during that period, increasing from 94,000 in 1974, to 392,000 in 1991, to 911,000 in 2001. In 2018, one-fifth of the roughly two million persons incarcerated in the United States were serving time for drug charges, and almost 80 percent of the persons serving time in federal prisons on drug-related charges were Black or Hispanic.

Privileging of white life is likely one factor that accounts for differential U.S. government responses to various health emergencies during the last fifty years. But another key factor is the extent to which a health emergency registers as a “moral imperative.”

Take what seems like the anomalous proactive response of the George W. Bush administration to AIDS in Africa. American evangelicals were influential advocates for American intervention in this case, because they could tie this aid to their own missionary outreach. With significant input from evangelical leaders, Bush Administration officials and Congressional allies built into PEPFAR’s design an emphasis on abstinence before marriage, faithfulness within marriage, and discouragement of condom use. Organizations receiving PEPFAR monies were also required to sign a pledge renouncing prostitution.

In the process, what was also made clear was the power of conservative sexual doctrines in converting a tepid U.S. governmental response to HIV/AIDS within its own homeland to one driven by moral urgency in a foreign context where Christian missionaries were actively recruiting new followers.

This sheds light on our current moment in another way. As long as the flourishing of people of color remains less a moral imperative than the flourishing of white lives, or of less moral priority than the kind of socially self-interested religious parochialism advanced in the PEPFAR case, “Black Lives Matter” declarations and activism serve as essential reminders of the ways in which the status quo has in fact discounted the value of Black lives, and brown lives, and the lives of Indigenous Americans.

Meanwhile, President Trump continues resisting calls for rooting-out the systemic racism that disproportionately places people of color in harm’s way.

As the Black and brown death toll climbs from COVID-19, President Trump has made clear his top priority is reopening American society, no matter what: “There’ll be more deaths,” he’s remarked with a rhetorical shrug: “Will some people be affected? Yes. Will some people be badly affected? Yes. But we have to get our country opened and we have to get it open soon.”

Indeed, people need to work. Students need to learn. But how important will those things be if a large and growing number of Black Americans literally “can’t breathe”?