Seven weeks out from what would have been graduation, leaving St. Louis more abruptly than I ever envisioned, I’m reminded in a nightmarish way of why I chose public health and social work. The distribution of power and resources in society shapes our individual and collective health, and these connections hold our reality in dynamic balance. I am afraid for what is to come, I still have faith in humanity, I am concerned it will never be enough, and I know we cannot give up.
I am heartbroken at what the most vulnerable among us are enduring. The people who provide and enable the essential services whose capacity is already being strained. The people whose health status or access to care place them at higher risk for adverse outcomes. The people for whom there is no safety net when critically important but economically painful mitigation strategies are enacted. The people who are sick and who have died. Their families and communities. I am infuriated that system failures continue to manifest, and you are suffering as a consequence. Your life matters. The roots of this crisis run deep. None of this is random. None of this is okay.
It has to be emphasized that structural forces shape the distribution of vulnerability. When we look at who are considered the essential workers, who are those most affected by chronic diseases or lack of health care access, who are those excluded from access to public benefits and the tools of financial security, we see the population-level result of systems that disadvantage certain people while privileging others. People of color will be disproportionately likely to bear the health and economic burdens of COVID-19, not because of inherent risks associated with racial or ethnic identity, but because structural racism embedded in our institutions, policies, and practices fundamentally restricts the opportunities that people of color have to secure the social, economic, environmental, and political conditions that enable human beings to thrive. Women and non-binary folks will be disproportionately likely to bear these burdens, not because sex or gender itself is a risk factor, but because sexism and gender discrimination restrict opportunity to thrive. People who face poverty will be disproportionately likely to bear these burdens, not because there is anything inherently different about people who are poor – again, because poverty restricts opportunity to thrive. This difference between person-level characteristic and structural force is critical, and applies as well to considering differential outcomes based on immigration status, disability, incarceration history, or any number of socially-mediated characteristics.
The danger of stratifying bluntly by such characteristics, however, is that we miss important differences in the ways structural forces manifest. Racism operates through different institutional and policy pathways to shape the experiences of Black people than for Native American people, and further along lines of gender; the unique experiences of Asian people or Latino people of different ethnicities or immigration histories are obscured through monolithic labels. And, these forces are historical, intergenerational in nature, and operate throughout an individual’s life-course. The intersectional nature of oppression will compound the effects of COVID-19 for people whose identities and social positions are disadvantaged through multiple causal paths, and ease the effects for people who benefit from aspects of their identities that carry privilege.
This is not to say that white people, men, and rich people will not suffer. They will, and their suffering should be mourned as well. It is to say that structural racism, sexism, or classism will not have been a fundamental cause of their vulnerability.
Perhaps, then, the distribution of suffering is not a system failure. It is evidence of a system designed to produce inequity. The pattern already exists. This will play out in foreseeable ways.
None of this has to be this way, however. I am encouraged and grateful to see how many people are doing their part to respond — to lead ethically, to provide care with an equity lens, to support preferentially the needs of people most excluded by structural forces, to step out of the way and invest in the response efforts of existing community networks and leaders, to sacrifice plans and goals in the interest of the common good, to pause. Our individual and collective actions could not be more important. Our lives are intertwined and interdependent, and always have been.
Laura McNulty, MPH, MSW 