COVID-19, 1918 Influenza Pandemic, and Racial Disparities

Abstract

The coronavirus disease 2019 (COVID-19) pandemic is exacting a disproportionate toll on ethnic minority communities and magnifying existing disparities in health care access and treatment. To understand this crisis, physicians and public health researchers have searched history for insights, especially from a great outbreak approximately a century ago: the 1918 influenza pandemic. However, of the accounts examining the 1918 influenza pandemic and COVID-19, only a notable few discuss race. Yet, a rich, broader scholarship on race and epidemic disease as a “sampling device for social analysis” exists. This commentary examines the historical arc of the 1918 influenza pandemic, focusing on black Americans and showing the complex and sometimes surprising ways it operated, triggering particular responses both within a minority community and in wider racial, sociopolitical, and public health structures. This analysis reveals that critical structural inequities and health care gaps have historically contributed to and continue to compound disparate health outcomes among communities of color. Shifting from this context to the present, this article frames a discussion of racial health disparities through a resilience approach rather than a deficit approach and offers a blueprint for approaching the COVID-19 crisis and its afterlives through the lens of health equity.

The coronavirus disease 2019 (COVID-19) pandemic has killed more than 100 000 persons in the United States (1). Nationwide data indicate that ethnic minority communities, particularly black, Latinx, and Native or indigenous communities, suffer disproportionately (2–7). This has significant historical antecedents; as Evelynn Hammonds recently argued, epidemic diseases “lay bare and make visible inequalities in a society” (8). Yet, at the onset of the crisis, few reported its effect on minorities (9). Even now, we may not know the full scope and details. Many states have published limited statistics, and race-stratified data, once fully released, will need to be carefully interpreted to address the causes of inequity rather than to perpetuate stigma and discrimination (10).
Unfortunately, this comes as no surprise to health equity researchers and historians of medicine and public health. The United States has a long history of racial and socioeconomic disparities, with the current pandemic further revealing the rifts created by historical injustice, structural racism, and interpersonal bias (11–13). Although some have touted COVID-19 as a “great equalizer” that strikes across age, sex, race/ethnicity, and geography, we contend that it has magnified the many “unequalizers” in our society (14, 15).
To understand the current crisis, physicians and public health researchers have mined history for insights (16). Most have focused on a century-old outbreak, the 1918 influenza pandemic (misleadingly called the “Spanish flu”), because COVID-19 most closely approximates it in scope and effect (17–19). Of the accounts comparing the 1918 influenza pandemic and COVID-19, only a notable few discuss race (8, 20, 21). Yet, a rich, broader scholarship on race and epidemic disease as a “sampling device for social analysis” exists (22–27). Given the excessive mortality due to COVID-19 in minority communities, reexamination of such historical antecedents is fruitful. Although this scholarship hesitates to offer predictions, this kind of analysis can provide orienting frameworks, reveal nuance, and modulate our approach to the current crisis—which has been called “unprecedented,” reflecting a lack of historical context.
We examine the historical arc of the 1918 influenza pandemic, focusing on black Americans and showing the complex, sometimes surprising ways it triggered particular responses both within a minority community and in wider racial, sociopolitical, and public health structures. Shifting to the present, we frame a discussion of racial health disparities through a resilience approach versus a deficit approach and offer a blueprint (Table) for approaching the COVID-19 crisis and its afterlives through the lens of health equity.

Table. The 1918 Influenza Pandemic, COVID-19, and Racial Disparities: Historical Context and Present and Future Opportunities* https://www.acpjournals.org/doi/10.7326/M20-2223