The Mask of Unequal Health and Excess Death: A Reality

In Edgar Allan Poe’s 1842 gothic tale, “The Mask of the Red Death: A Fantasy,” a nobleman and his wealthy friends attempt to escape a horrific plague by hiding out in a castle-like abbey dancing the night away, until death in the form of a masked figure systematically stalks them all down. The reality in our current pandemic is quite different as many in the middle and upper classes have been able to flee COVID-19 by staying home to work, ordering necessities to be delivered, or retreating to their second rural or beach homes. Poe’s story demonstrated that a plague death was not escapable, but we know from other pandemics, not just this current one, that race, class, gender, and immigrant status always affect who survives or does not. ¹ What do we do about this?

We know that nonpharmaceutical interventions matter in saving lives and preventing illness on both the personal and collective level, as a 2007 historical analysis of the 1918–1919 flu pandemic showed. Officials used this report over and over again in the current pandemic to make the argument for all the school and commerce closings that led toward “flattening the curve” of rising infections. ² In the same year as the historical analysis appeared, a different report by bioethicists established a set of social justice principles that argued for identifying so-called disadvantaged groups who would be more harmed by a pandemic, engaging them in planning, and identifying their special needs. ³ The Trump administration barely took the lessons from the historical analysis and certainly ignored the concern with social justice.

Most of us in public health knew systemic racism and health disparities would make differential illness and death rates happen. At first it was hard to prove this because not all states were keeping statistical data by race. ⁴ Much of this could have been expected had we learned more from how to use the data from the 1918–1919 flu pandemic. ⁵ However, the data are not so clear from that experience, and many Southern states did not keep vital statistics on Black Americans until the 1920s. Historian Vanessa Northington Gamble argued that the 1918 flu pandemic caused fewer deaths than expected among Black Americans, at least in hard-hit Philadelphia, although she notes that conclusion is uncertain because of probable undercounting. The caring work by Black health care professionals and lay women, in particular, made a difference in outcomes, and segregation may have served as “de facto quarantine.” But none of this changed the racism that affected life chances after the pandemic. ⁶

As our modern-day lynching photos in the form of the endless videos of Black deaths at the hands of the police make clear, there is almost a pornographic expectation that people of color will continue to die in various ways out of proportion to their numbers in the population. In that sense, higher Black mortality has come be expected and, alas, accepted. If we take seriously the concept that racism is the number one public health problem, we have to do more than what happened after the other major pandemic. This is our time.

We have to follow the dictates of the 2007 bioethics report and consider what we do now. Pressure on legislatures, the federal government, the courts, and the giant health conglomerates to focus on population health and equity has to happen. If public health is not based on social justice, we will end up accepting that excess Black mortality is somehow “normal.” And if we do not do this in a way Poe will be right: we cannot all hide forever, and an unnecessary viral death will eventually stalk everyone.