Masks Are the New Condoms: Health Communication, Intersectionality and Racial Equity in COVID-Times

Racism is a most persistent, pervasive and pernicious driver of health disparities in the U.S. (Institute of Medicine Committee on Capitalizing on Social Science and Behavioral Research to Improve the Public’s Health, Division of Health Promotion and Disease Prevention, 2001) and is a fundamental cause of inequitable COVID outcomes (Pirtle, 2020). Inequities in COVID-related morbidity and mortality will continue to widen as the epidemic rages on, without a systematic and collective focus on racism, specifically. Indigenous, Latinx and Black communities bear an exceedingly high burden of COVID-related morbidity. By current estimates, Black Americans, who account for 13% of the U.S. population experienced 31% of COVID deaths. Hispanic/Latinx people account for 13% but bore an even higher mortality rate, with 44% of COVID deaths. Indigenous communities account for less than 1% of the U.S. population and experienced a staggering 22% of COVID deaths. It is likely that COVID-related morbidities will follow similar racial and ethnic lines.

Health communication scientists and practitioners increasingly acknowledge that health disparities are driven by social and structural factors. These fundamental causes lie largely outside of the control of those experiencing inequities. Contrary to these stipulations, health communication scholarship and practice has focused disproportionately on reducing individual risk by seeking to change individual behaviors (Dutta, 2008; Viswanath, 2006). This approach presumes that by focusing on “personal responsibility,” individuals will be able to mitigate the structural impact of being Black in the U.S. In doing so, communication scholars fail to generate solutions needed to address racism as a cause of health disparities. The COVID crisis demands new directions; communication scholars must resist staid interventions that focus on victims of racism in the health system and instead broaden our efforts to address racism at the interpersonal, social, and structural levels.

Intersectionality (Crenshew, 1989) is an essential framework for understanding and reducing health disparities. Intersectionality attends to the ways institutional and social forces (e.g., racism, sexism, classism) interact with individual identity dimensions (e.g., race, gender, class) to afford privilege and disadvantage differently for people at different social locations. Intersectionality centers the experiences of Black women in particular, and summarily, historically marginalized groups, focusing scholarly attention on the multiple vectors that impinge upon individuals and shape socio-political realities. Intersectionality reveals how social-structural forces shape and constrain individual health (Parker & Aggleton, 2003), shaping for example, HIV risk, prevention, and treatment for Black women (Bowleg, 2012). This attentional focus shifts the onus of responsibility to change from the individual whose opportunities are constrained, to the system that constrains opportunities and magnifies risk (i.e. healthcare quality, labor practices, gendered relationship norms, mass incarceration of Black people, lack of employment options). Thus, intersectionality prescribes a means for thinking through the ways that disparate COVID outcomes are magnified by social-structural discrimination.

There are many parallels between the domestic COVID and HIV epidemics, where responses targeting individual behavior, even when effective have not proven transformative. A long history of systemic racism has created circumstances in which Black people experience disproportionately high HIV incidence and mortality, yet as new treatment and prevention tools emerge, the patterns of uptake do not mirror the demonstrable need (Siegler et al., 2018). Racial and gender disparities in awareness, access, and uptake of HIV pre-exposure prophylaxis (i.e. prevention) as well as antiretroviral use (i.e. treatment, viral suppression) are evidence of this (Adams & Balderson, 2016; Levine et al., 2007). The decades-long racial disparities in HIV are evidence that addressing individual level factors is insufficient for eliminating inequities or ending an infectious disease epidemic. Although behavior change interventions have led to successful uptake of prevention behaviors among individuals, with racial, ethnic and sexual minorities exhibiting the highest levels of adoption of those behaviors, members of those communities continue to bear a disproportionate burden of HIV/AIDS. This seemingly paradoxical reality is evidence that the same or even higher rates of protective behavior (i.e. condom use) do not confer equal protection across racial groups, due to social-structural (i.e., segregation, poverty) and contextual factors (i.e. community prevalence). Similarly, facial masks and social distancing will not be effective for ameliorating racial disparities in COVID outcomes because the same health behaviors confer different levels of protection due to the context of exposure and social-structural inequities that impact risk and recovery. Although individual behaviors confer protection, there will continue to be disproportionately high transmission in communities with high COVID prevalence (Flagg et al., 2020), unless we target the social systems and institutions that drive the disparities.

In clinical settings, Black people routinely experience racism that results in low quality clinical encounters (Stone, 2005), reduces healthcare quality (Cooper-Patrick et al., 1999), delays appropriate treatment (Penner et al., 2010), and cultivates distrust (Lee et al., 2009). Racially-biased clinical decision-making tools and corrections result in inequitable diffusion of care. In the context of HIV, ample evidence demonstrates gendered racial biases in clinical decision-making. When considering otherwise identical patients, medical students are more likely to prescribe PrEP to a White gay male patient, due to biased presumptions that Black patients will increase risky behaviors while on PrEP. When presented with otherwise identical patients, healthcare providers are disinclined to introduce and prescribe PrEP to Black women relative to White women due to racially biased expectations about the patient’s ability to adhere (Hull, unpublished data). COVID vaccines are likely to present similar opportunities for the introduction of racial and other bias into clinical decisions about who is a “good candidate” for treatment. How will race, ethnicity, insurance status or comorbidities determine vaccination priority? Will Black, Indigenous and Latinx people who experience long term COVID effects receive equitable diagnosis and care (CDC, 2020; Yong, 2020), particularly as interpretations of patient’s symptoms are often biased by racial stereotypes. Inequitable diffusion of accurate information about – and access to – innovations in COVID prevention, diagnosis and treatment will only magnify COVID disparities. Mitigating these effects requires a collective focus on eliminating racism in healthcare.

Healthcare providers are gatekeepers of information and access to innovations in prevention, detection, and treatment. There is a critical need for evidence-based interventions focused on mitigating racial bias among them (Craven, 2020). As racism and discrimination are social phenomena constructed and transmitted through communication, it is within the purview of communication scholarship and practice to inform efforts to mitigate racial bias broadly, and to aid the diffusion of innovations in COVID diagnosis, prevention, and treatment equitably.

Communication interventions that bring transparency to the distribution of resources may also serve to close information gaps, undermine misinformation, and cultivate trust. Data visualization tools, like the AIDSvu.org, shine a spotlight on the distribution of disease burden and the availability of resources. Tools such as this are necessary to ensure transparency about whether and how the distribution of COVID prevention, detection, and treatment resources maps onto the demonstrable need. Simultaneously, it is critical to grapple with misinformation in online networks, particularly around the vaccine evidence and development. Other apertures for strategic communication intervention include media advocacy in favor of policy and funding to support adequate protection for essential workers, particularly those in low-wage roles. Identifying and deploying effective framings of public health issues relevant to structural racism is also fertile ground for communication science. We have evidence that we can employ communication science to address fundamental drivers of disparities. For example, the Acceptance Journeys campaign had the goal of decreasing HIV disparities in a Black Community by successfully decreasing deeply entrenched social stigmas (Hull et al., 2017).

As we prioritize using our scholarship and practice to target fundamental drivers, we will require dedicated funding that allows for community-engaged research that informs the development of communication interventions designed to address racism. We must prioritize funding communication scholars of color, who disproportionately work in close collaboration with Black, Latinx and Indigenous communities using community-based participatory methods. We must prioritize the dissemination of the expertise of these scholars in our journals, professional meetings and convened talks, and move away from centering white communication scholarship (Chakravartty et al., 2018) and toward centering the experiences of those most impacted.

Racism is deeply woven into the social fabric. Our efforts to interrupt systemic racism must include strategic efforts (programs, campaigns, messages, advocacy), applied through an intersectional lens, employing social and structural interventions. By addressing racism as a fundamental cause of disparities, we will not only mitigate inequities in COVID outcomes, but will also make progress on eliminating seemingly intractable health disparities in numerous other domains. Are we ready to rise to the challenge?