I lay in bed, exhausted after a long day of seeing patients, helping convert our federally qualified health center to telemedicine, and trying to make sense of seemingly conflicting information communicated by the CDC and other government agencies. It was early April, and the frightening preliminary numbers illustrating the disproportionate effect of COVID-19 on black and brown communities weighed heavily on my heart. As a family physician serving an ethnically diverse community in a predominantly white state, I worried about how this virus would affect my patients in the coming weeks and months, and whether their experiences would be documented equitably.
Would they be able to survive infection if it occurred?
How would the seemingly invisible essential workers -- like housekeepers and factory workers -- reconcile the stress and economic necessity of working while keeping their families safe?
How could someone conceivably practice self-isolation while living in a two-bedroom apartment with multiple generations under one roof?
Would my symptomatic minority patients be offered appropriate care as readily as their white counterparts if they required COVID-19 screening or hospitalization?
My undocumented patients had even fewer options because most of them are essential workers or live with someone who is.
Undoubtedly, after witnessing the growing chasm of disparities in deaths in New York City and observing the lack of testing in communities of color, my anxiety about the downstream consequences of this virus began to heighten.
Working under the stress of tragedy is part of my training. However, I was not prepared for the jarring emotions that stirred my heart. For the first time, I felt caught between two distinctively not ideal circumstances. Do I put myself in the line of danger and work on the front lines with the knowledge that I lacked necessary personal protective equipment, or do I protect myself and my loved ones in a crisis situation that appears to disproportionately kill people who look like me?
Whether implicitly or explicitly, these choices echoed throughout social media, in government communications and within my professional circles. Imagery and rhetoric evoking the notions of battle, war and command emerged at a whirlwind pace. Yet, while doctors, nurses and other essential workers were hurried into saving lives, administrative bureaucrats calculated the cost-benefit analysis of risking the very people it needed to respond to an astronomical threat to the lives of thousands of Americans. When my colleagues spoke out about the conditions they faced, they risked losing their jobs.
Once again, as a healer working in a system seemingly based more on economics than wellness, I felt forced to make an impossible ethical decision. Then, I realized that the underlying question for me to answer was not whether I would treat individuals at the risk of my own self. Rather, I needed to pan out my scope of view and ask, "How can I help rebalance the scales of justice to reflect the inherent worth of the black and brown lives that I both serve and represent?"
A May 6 article in The Washington Post reported that although public health officials and politicians have attributed the high rate of serious illness and death among blacks to underlying health conditions, a recent study led by researchers from the Rollins School of Public Health at Emory University and Amfar, the Foundation for AIDS Research, found that those factors were not the main cause of the disparities. Instead, the newspaper wrote, "other social determinants, including employment, access to health insurance and medical care, and poor air and water quality, were more predictive of infection and death from covid-19."
The fact is that over the years, academicians have quite eloquently documented the obtrusive denigration of black and brown communities throughout U.S. history through the use of racist structures and appropriations. This pandemic is amplifying these trends to a degree that we, as a society, can no longer ignore. However, if our country's leaders speak of this health inequity as bullet points during press conferences yet remain indolent in enforcing policy changes that will correct it, then our country will understand who is implicitly most valued under our system of care.
This is why I dedicate myself to advocating for the unseen, the unheard and undervalued.
After receiving news that a dear friend of mine, a middle-aged black man, was intubated due to COVID-19, my grief could no longer be contained. As I walked away from my workstation to compose myself, I received a different notification on social media. The image of a 21-year-old black woman who died from complications of HELLP syndrome after weeks of delayed care in the Bronx was branded into my growing mental catalogue of lives lost too soon due to structures and systems only privilege can allow to swipe by.
I held my breath. What I was experiencing, in multiples of thousands, was repeated trauma from mourning the deaths of those whose lives could have been saved if measures had been taken sooner and the system was more balanced. This moment of clarity sobered me. As a black woman physician, the sheer numbers of the afflicted in an unfairly allocated health care delivery system struck at my humanity. Not only were my friends and colleagues contracting this illness, but I worried that the small representation of ethnically diverse communities in my state would be seen, but not heard.
What makes this situation so different for me is the dissonance between my position as a healer and the very system in which I work. After all, whereas equitable structures and best practices should be in place to protect those who have been historically excluded, instead they repeatedly deny the value and humanity of minority communities. Before readers counter by noting the high incidence of white people who have died from the virus, justifying reopening with "balancing the health of the people with the health of the economy," or saying that the conversation "doesn't always have to be about race," let's put our privilege aside and honestly observe the trends and behaviors for what they are -- biased. Let's discuss and enforce policy that reflects the most important of American principles: the value of human capital in the form of wellness for all.
As much as we would like to ignore the cancer of racism in our history, our nation still reaps its ramifications. Only now, it seems that the community's proverbial reserves to tolerate injustice have run dry. I am not surprised that in the midst of a global pandemic, black and brown communities mourn not only deaths from COVID-19, but also the recurring murders of unarmed black men and women. Racism and its effects never sleep.
Most recently, the killing of George Floyd has ignited an outcry of righteous indignation around the world. Protests, unrest and demands for change ripple across the nation, not only for the one life taken, but for the thousands that have gone unseen, unheard. We have to remember that witnessing and experiencing racism and its effects are trauma-equivalents for blacks in the United States. These experiences have direct impact on health outcomes. In fact, the AAFP recently released a statement saying that it "considers racism a public health crisis" and that it will "continue to use our organization's platform and voice to advance the conversation and take action against racial injustice."
Perhaps the graphic image of a knee pressing the freedom of breath out of another human was the personification of what many black and brown Americans experience on a daily basis.
"I can't breathe."
Being unable to afford living without the next paycheck.
"I can't breathe."
Generations living without adequate education.
"I can't breathe."
Premature deliveries and black mothers dying.
"I can't breathe."
Unaffordable nutrition options.
"I can't breathe."
Never getting an interview because your name is "too ethnic."
"I can't breathe."
Being told your cough is allergies, no COVID-19 testing needed.
I. Can't. Breathe.
It is too easy to dismiss the recent protests as civil disobedience and neglect to acknowledge the connection between today's protests and yesterday's COVID-19 statistics. I submit that we must instead recognize that our country's greatness comes from its diversity. However, we cannot claim diversity without first setting all people on an equal footing.
These days, I choose to harness courage by encouraging those around me to practice racial justice. Whether they see color or not, we all should respect, validate and support the experiences of our colleagues and patients during these unsettling times.
Marie-Elizabeth Ramas, M.D., is a family physician activist with a full-scope practice in Nashua, N.H. She is the convener of the AAFP's National Conference of Constituency Leaders and a Board member of the New Hampshire AFP. She also focuses her passion on promoting health equity through state initiatives and is a guest health expert on local radio stations. You can follow her on Twitter @docramas.