Akilah Johnson and Dan Keating, Washington Post, October 19, 2022
Skill Wilson had amassed more than three decades of knowledge as a paramedic, first in Memphis and then in Fayette County. Two places that felt like night and day.
With only five ambulances in the county and the nearest hospital as much as 45 minutes away, Skill relished the clinical know-how necessary to work in a rural setting. Doing things like sedating patients to insert tubes into their airways.
But when it came to covid-19, despite more than 1 million deaths nationwide, Skill and his family felt their small town on the central-eastern side of Fayette County, with its fields of grazing cattle and rows of cotton and fewer than 200 covid deaths since the start of the pandemic, was a cocoon against the raging health emergency.
“It was a lot easier to stay away from others,” his widow, Hollie Wilson, said of the largely White and predominantly conservative county of about 42,000 residents. “Less people. Less chance of exposure.”
Covid seemed like other people’s problem — until it wasn’t.
The imbalance in death rates among the nation’s racial and ethnic groups has been a defining part of the pandemic since the start. To see the pattern, The Washington Post analyzed every death during more than two years of the pandemic. Early in the crisis, the differing covid threat was evident in places such as Memphis and Fayette County. Deaths were concentrated in dense urban areas, where Black people died at several times the rate of White people.
Over time, the gap in deaths widened and narrowed but never disappeared — until mid-October 2021, when the nation’s pattern of covid mortality changed, with the rate of death among White Americans sometimes eclipsing other groups.
A Post analysis of covid death data from the Centers for Disease Control and Prevention from April 2020 through this summer found the racial disparity vanished at the end of last year, becoming roughly equal. And at times during that same period, the overall age-adjusted death rate for White people slightly surpassed that of Black and Latino people.
The nature of the virus makes the elderly and people with underlying health conditions — including hypertension, diabetes and obesity, all of which beset Black people at higher rates and earlier in life than White people — particularly vulnerable to severe illness and death.
That wasn’t Skill.
The virus also attacks unvaccinated adults — who polls show are more likely to be Republicans — with a ferocity that puts them at a much higher risk of infection and death.
That was Skill.
He joined the choir of critics opposing vaccination requirements, his rants in front of the television eventually wearing on Hollie, who, even if she agreed, grew tired of listening and declared their home “covid-talk free.”
So, she said, Skill commiserated with like-minded people in Facebook groups and on Parler and Rumble, the largely unmoderated social networking platforms popular with conservatives.
“We’re Republicans, and 100 percent believe that it’s each individual’s choice, their freedom,” when it comes to getting a coronavirus shot, Hollie said in January. “We decided to err on the side of not doing it and accept the consequences. And now, here we are in the middle of planning the funeral.”
Capt. Julian Greaves Wilson Jr., known to everybody as Skill, died of covid Jan. 23, a month after becoming infected with the coronavirus. He fell ill not long after transporting a covid patient to the hospital. At the time he died, infection rates in Fayette County had soared to 40.5 percent among people taking coronavirus tests.
‘A different calculus’
When the coronavirus appeared in the United States, it did what airborne viruses do — latched onto cells in people’s respiratory tract, evaded innate immune responses and multiplied. The pathogen, free of politics or ideology, had a diverse reservoir of hosts and found fertile pathways for growth in the inequalities born from centuries of racial animus and class resentments.
Unequal exposure, unequal spread, unequal vulnerability and unequal treatment concentrated harm in communities that needed protection the most yet had the least. Cumulatively, Black, Latino and Native American people are 60 percent more likely to die of covid.
But as the pandemic progressed, the damage done by the virus broadened, and the toxicity of modern-day politics came to the fore.
The Post analysis revealed the changing pattern in covid deaths. At the start of the pandemic, Black people were more than three times as likely to die of covid as their White peers. But as 2020 progressed, the death rates narrowed — but not because fewer Black people were dying. White people began dying at increasingly unimaginable numbers, too, the Post analysis found.
In summer 2021, the nation saw some of the pandemic’s lowest death rates, as vaccines, shoring up the body’s immune response, became widely available.
Then came the delta variant. The virus mutated, able to spread among the vaccinated. As it did, an erosion of trust in government and in medicine — in any institution, really — slowed vaccination rates, stymieing the protection afforded by vaccines against severe illness and death.
After delta’s peak in September 2021, the racial differences in covid deaths started eroding. The Post analysis found that Black deaths declined, while White deaths never eased, increasing slowly but steadily, until the mortality gap flipped. From the end of October through the end of December, White people died at a higher rate than Black people did, The Post found.
That remained true except for a stretch in winter 2021-2022, when the omicron variant rampaged. The Black death rate jumped above White people’s when the spike in cases and deaths overwhelmed providers in the Northeast, resulting in a bottleneck of testing and treatment.
When the surge subsided, the Black death rate once again dropped below the White rate.
“Usually, when we say a health disparity is disappearing, what we mean is that … the worse-off group is getting better,” said Tasleem Padamsee, an assistant professor at Ohio State University who researched vaccine use and was a member of the Ohio Department of Health’s work group on health equity. “We don’t usually mean that the group that had a systematic advantage got worse.”
That’s exactly what happened as the White death rate surpassed that for Black people, even though Black Americans routinely confront stress so corrosive it causes them to age quicker, become sicker and die younger.
The shift in covid death rates “has vastly different implications for public health interventions,” said Nancy Krieger, professor of social epidemiology at Harvard University’s T.H. Chan School of Public Health. Officials must figure out how to connect with “communities who are ideologically opposed to the vaccine” while contending with “the cumulative impact of injustice” on communities of color.
“Think about the fact that everyone who is age 57 and older in this country was born when Jim Crow was legal,” she said. “What that did was intersect with covid-19, meaning that embodied history is part of this pandemic, too.”
So what contributed to the recent variation in death rates? And why?
The easy explanation is that it reflects the choices of Republicans not to be vaccinated, but the reasons go deeper. The Post interviewed historians and researchers who study the effects of White racial politics and social inequality on health, spoke with relatives and friends of those lost to covid, and compiled data from federal databases and academic studies.
What emerged is a story about how long-standing issues of race and class interacted with the physical and psychological toll of mass illness and death, unprecedented social upheaval, public policies — and public opinion.
Resilience gave way to fatigue. Holes left by rural hospital closures deepened. Medical mistrust and misinformation raged. Skeptics touted debunked alternatives over proven treatments and prevention. Mask use became a victim of social stigma.
Many Republicans decided they would rather roll the dice with their health than follow public health guidance — even when provided by President Donald Trump, who was booed after saying he had been vaccinated and boosted.
Researchers at Ohio State found Black and White people were about equally reluctant to receive a coronavirus vaccine when they first became available, but Black people overcame that hesitancy faster. They came to the realization sooner that vaccines were necessary to protect themselves and their communities, Padamsee said.
After it became clear that communities of color were being disproportionately affected, racial equity started to become the parlance of the pandemic, in words and deeds. As it did, vaccine access and acceptance within communities of color grew — and so did the belief among some White conservatives, who form the core of the Republican base, that vaccine requirements and mask mandates infringe on personal liberties.
It’s a calculation informed by the lore around self-sufficiency, she said, a fatalistic acceptance that hardships happen in life and a sense of defiance that has come to define the modern conservative movement’s antipathy toward bureaucrats and technocrats.
Researchers at the University of Georgia found that White people who assumed the pandemic had a disparate effect on communities of color — or were told that it did — had less fear of being infected with the coronavirus, were less likely to express empathy toward vulnerable populations and were less supportive of safety measures, according to an article in Social Science & Medicine.
Questions about the government’s role in ensuring the public’s health and well-being hang heavy with historical inflections in states such as Tennessee, once home to the president who argued that Reconstruction-era legislation to help and protect newly freed enslaved people violated states’ rights.
And so in many ways, the roots of the consternation over recent pandemic-control measures began sprouting a century and a half earlier.
But that hasn’t stopped people such as Civil Miller-Watkins from wondering why those roots are choking so many now.
“We put it on Republicans and politics,” she said, “but I think we should dig deeper.”
That’s what Jonathan M. Metzl, director of Vanderbilt University’s Department of Medicine, Health, and Society, did for six years while researching his book “Dying of Whiteness: How the Politics of Racial Resentment is Killing America’s Heartland.”
Published in 2019, it is a book about the politicization of public health and mistrust of medical institutions. It is a story about how communal values take a back seat to individuality. It’s an exploration of disinformation and how the fear of improving the lives of some means worsening the lives of others.
“I didn’t know it at the time, but I was writing a prehistory of the pandemic,” Metzl said in an interview. “You’re seeing a kind of dying-of-Whiteness phenomenon in the covid data that’s very similar to what I saw in my data.”
Metzl and Griffith, a Vanderbilt professor at the time, conducted focus groups on the Affordable Care Act throughout Middle Tennessee that included White and Black men who were 20 to 60 years old. Some were small-business owners or security guards. Others were factory workers or retirees.
The divergent medical experiences of Black and White patients permeated Metzl’s focus groups, particularly when the conversation veered toward the politics of health and government’s role in promoting well-being.
“Black men described precisely the same medical and economic stressors as did White men and detailed the same struggles to stay healthy,” Metzl wrote. “But Black men consistently differed from White men in how they conceived of government intervention and group identity. Whereas White men jumped unthinkingly to assumptions about ‘them,’ Black men frequently answered questions about health and health systems through the language of ‘us.’ ”
As Metzl conducted research for his book in 2016, a 41-year-old uninsured Tennessean named Trevor who was jaundiced and in liver failure told him “I would rather die” than sign up for the ACA. When asked why, Trevor, who was identified by first name only, said: “We don’t need any more government in our lives. And in any case, no way I want my tax dollars paying for Mexicans or welfare queens.”
Much like protests to “repeal and replace” the ACA, Metzl said rejecting public health measures is about dogma more so than a mistrust of the science of vaccines or masks.
“We’ve oversimplified this with morality tales about the vaccine is good, and anti-vaxxers are bad, and they’re automatically racist,” Metzl said. “Being anti-vaccine or anti-mask is part of an ideology. When people get more desperate, they get more ideological.”