We’re better off with health equity

This spring, public health officials have been laser-focused on getting more Americans vaccinated against COVID-19. So why do racial disparities persist around vaccination? And once more Americans are vaccinated, how do we ensure that Black and Latino families aren’t left vulnerable to future public health crises? In the latest episode of Better Off, Mary Bassett talks about the historical roots of health inequities, and the big changes needed to close those gaps.

Guest: Mary T. Bassett, director of the François Xavier Bagnoud Center for Health and Human Rights at Harvard University.

Episode transcript


Anna Fisher-Pinkert: From the Harvard T.H. Chan School of Public Health, this is Better Off. A podcast about the biggest public health problems we face today . . .

Mary Bassett: We have to remember the kinds of vulnerabilities that made the US have a disproportionate share of the world’s deaths, as compared to our population, despite our vast resources.

Anna Fisher-Pinkert: . . . and the people innovating to create public health solutions.

Mary Bassett: And those won’t be fixed with a vaccine.

Anna Fisher-Pinkert: I’m your host, Anna Fisher-Pinkert.

Anna Fisher-Pinkert: I got my COVID-19 vaccine in a busy clinic in Boston. As soon as the nurse gave me the shot, she handed me a little timer set for 15 minutes, the length of time they ask you to hang around to make sure you don’t have any adverse effects. I sat in the waiting room, surrounded by masked people sort of squirming impatiently in their seats. And one by one, the timers went off [beeping sound]. There’s one [beeping sound], there’s another one. . . each little beep inching us closer to the end of the pandemic. The people walking out of the clinic looked lighter, happier, than the people walking in.

But the vaccines aren’t reaching everyone. The vaccination rate for Black and Latino Americans is lower than for white Americans. And the death and hospitalization rates are higher. The pandemic has revealed how our health care system repeatedly fails people of color. And even if we get everyone vaccinated – that’s just one virus. How do we avoid going down the exact same path again? How do we address the entrenched health disparities in this country?

So, in this episode we’re going to dive into all those big questions – because this week, we’re better off with Mary Bassett, health and human rights expert.

Mary Bassett: My name is Mary Bassett and I am the director of the François Xavier Bagnoud Center for Health and Human rights at Harvard University.

Anna Fisher-Pinkert: As of mid-April, the Kaiser Family Foundation reported that the vaccination rate in the U.S. for white people was 1.8 times higher than the rate for Latino people, and 1.6 times higher than the rate for Black people. So I asked Mary Bassett to talk about why this gap exists.

Mary Bassett:  It has simply has to do with access. Where you get a vaccine, where this vaccination sites are located, what it takes to get an appointment, whether people have access and capacity to use the internet. . . Whether they have the time to take an appointment at any time it’s offered to them, and that kind of flexibility in their lives, whether they have transport. It’s all getting better. That’s for sure. And more and more people of all groups are getting vaccinated.

But the racial, ethnic disparities that we’ve witnessed throughout this pandemic have been replicated in terms of the ability to administer vaccinations to the people who arguably most need that protection.

Anna Fisher-Pinkert: But this winter, a lot of media sources were more focused on vaccine hesitancy among Black Americans. Like this story from CNN in February:

News anchor: Health officials worry misinformation could complicate the process of getting shots in the arms of Black and Brown communities. New CDC data from the first month of vaccination shows Black and Latino people lagging way behind in the states reporting racial breakdowns. So far, 60%. . .

Anna Fisher-Pinkert: So, is hesitancy a part of the picture?

Mary Bassett: Of course it is. I mean, Anna, I would argue that everyone has the right to get their questions answered, and their reasonable concerns addressed. Education, it should be part of any vaccine campaign, and telling people to line up and do as they’re told is not ever a good public health strategy – or ever a good strategy at all.

As people know, there’s a very troubled history. And even more than that, there’s people’s day-to-day experience with health care systems in which they don’t experience dignity and respect, which everyone is entitled to expect when they seek health care, that makes people of African descent in particular very wary.

Anna Fisher-Pinkert: But if you want to look at the numbers, a March 2021 poll, for example, from NPR, PBS News Hour, and Marist shows that, actually, 73% of Black people and 70% of white people plan to get the shot. So, in other words, hesitancy isn’t limited to people of color.

Mary Bassett: I’m just perplexed as to why people, when people talk about vaccine hesitancy, they’re not worrying about white Republicans who have, you know, by far the highest proportion of people who are declaring that they’ll never get right vaccinated. And I worry, about why people keep coming back to certain cultural tropes, this notion that Black people are defiant, resistant.


I’m from a neighborhood in Manhattan called Washington Heights. Most of my family still lives there. And my sister accompanied my mother, who was 92 and fully eligible, to get vaccinated. And when she got there, it was the vaccination site in Washington Heights, but she said, when she pulled up, it looked like people were coming from the opera.

They were from Westchester, New Jersey, and they had figured out that they could get vaccinated at this site. When she went in there, there was nobody around who spoke Spanish. The neighborhood, you know, has a very large Spanish speaking population.

So there were lots of signals that you’re actually not welcome here. Whether they were intended or not.

Anna Fisher-Pinkert: From Dr. Bassett’s vantage point, access to vaccines is just one of many areas of the pandemic response where people of color have been left out. Black and Latino people are overrepresented in the essential workforce, and in the prison system – which means there are a lot of people of color who could not stay home and could not stay socially distant.

Mary Bassett:  I would have thought that there would be recognition that certain occupations create high-risk situations.

Anna Fisher-Pinkert: We know that age is a huge risk factor for COVID-19 – but Mary Bassett argues we need to look at racial disparities more closely. While the majority of Americans who have died of COVID-19 were over the age of 65, younger Black and Latino people have died at much higher rates than their white peers.

Mary Bassett: Even though the risk of death is much higher in somebody who’s 90 years old, the fact that we were seeing, relative to whites, Blacks and Latinos, having five- to ninefold the risk of dying when they were young to middle-aged adults is simply wrong. Not only because it’s terrible to die before you’ve had a chance to have, you know, a full arc of life, but because these are people who have families who are breadwinners, who have children who are dependent on them. And the knock-on effects are very large.

Anna Fisher-Pinkert: But the roots of these racial and ethnic disparities are far older than the COVID-19 pandemic.

Mary Bassett: I think as we think about the vaccine, we have to remember the kinds of vulnerabilities that made the U.S. have a disproportionate share of the world’s deaths, as compared to our population, despite our vast resources, both material and human.

And those won’t be fixed with a vaccine.

Anna Fisher-Pinkert: Even if we manage to vaccinate our way to herd immunity, which some scientists are skeptical about, the COVID-19 vaccines only protect against one virus. In public health, that’s called a “downstream” solution. It doesn’t fix whatever issue is “upstream.”

Mary Bassett:  I think that there’s a tendency that we all have to, you know, look forward to a biomedical fix. And certainly, these vaccines are triumph of science. I don’t mean to say that science hasn’t vastly increased our ability to protect health, but it doesn’t solve the problem of people who are working in low-wage jobs without protections at their work site, who are working multiple jobs because they can’t afford to live on what they earn at their job. It doesn’t fix the fact that there were all these people who went to work without personal protective equipment.

Anna Fisher-Pinkert: In the U.S., where you work, what you earn, and your health outcomes are all intertwined. And so I asked Dr. Bassett, how do we begin to address those issues? And her answer was. . . pretty big!

Mary Bassett: I think we also have to talk about capitalism. Capitalism has been, joined at the hip or as Ibrahim Kendi says, are “conjoined twins” with the phenomenon of racism, which is based on the idea of the superiority of whites to people of color, particularly people of African descent. And that ideology was what permitted nearly 250 years of exploitation of enslaved labor, which was not just a quaint system that let America have a sort of slightly sordid start. It was enormously profitable. And it profited the North and the South.

Anna Fisher-Pinkert: The legacy of slavery still has an impact on the health and well-being of Black Americans.

Mary Bassett: The legacy has meant that people of African descent in this country have never in a single year that we’ve had statistics had life expectancies that were equal to the life expectancies of people descended from Europeans.

We have narrowed the gaps. We’ve never eliminated them. In some cases, the relative gaps have actually risen. In New York City, where I was the health commissioner, the infant mortality relative gap went up to three to one.

Despite the fact that this is not natural, it’s been so prolonged in our country that people start to think that, you know, nobody’s surprised when Black people have higher mortality rates, it’s just always like that. Well, it’s not natural or inevitable. So I’ve lately been thinking about the idea that’s been floating around for a long time. . . And it’s the idea of reparations for the transatlantic slave trade, for the 250 years, nearly, of enslaved labor and the terror that followed.

Anna Fisher-Pinkert: Reparations are a controversial idea in the United States. A 2020 Reuters/Ipsos poll found that only 1 in 10 white Americans supported reparations, and only about half of Black Americans support the idea. But in 2021, the city of Evanston, IL became the first U.S. city to offer reparations. In this case, specifically for the descendants of Black residents who were excluded from home ownership by racist housing policies in the 20th century, including redlining. Qualifying households are set to receive $25,000 for home repairs or down payments on property.

Mary Bassett: So what they’re planning in Evanston is a good start and it’s an honest. Uh, effort, I think by a local jurisdiction, but this is not a problem to be solved by local jurisdictions. This requires the federal government, because all that happened was entirely legal and not only, permitted, but often endorsed and led by the federal government. Redlining, for example, wasn’t just related to the private prejudices of developers. It was, put in place and championed, in fact, by the rating system that was developed by the Home Owners’ Loan Corporation in the 1930s, a government entity, a federal government entity.

Anna Fisher-Pinkert: What has been happening more frequently at a local, state, and national level is a new interest in discussing racism as a public health crisis.

Louisville Mayor Greg Fischer: I’m announcing today that I’m signing an executive order declaring racism a public health crisis in Louisville.

Mary Bassett:  There’ve been lots of them declarations, that racism is a public health crisis. I think they’re close to 180 of them by various jurisdictions.

Boston Mayor Marty Walsh: But first I want to declare racism to be a public health crisis in the city of Boston.

Michigan Mayor Gretchen Whitmer: Today I also signed an executive directive declaring racism as a public health crisis in Michigan.

Anna Fisher-Pinkert: Most recently, Rochelle Walensky, director of the Centers for Disease Control, also issued a statement on racism and health.

Mary Bassett: Well, it really, it’s important that the federal public health agency is acknowledging this, right? I took a look at the CDC website. And the, the only time they use “racism” was to say something like “discrimination, including racism.” The acknowledgement of, of the impact of racism on our bodies and our health is important in and of itself.

So declarations matter. Words matter. But additionally, they did say more things than that. They talked about how they’re gonna look at how they’re allocating their budget. They talked about taking a look at themselves. “They” meaning the CDC. They need to have an agency that looks like our country. That’s what Bill de Blasio wanted in New York City. And we were able to do that. The health department, when I joined it as commissioner, had not a single Black or Latino in its leadership. And when I left, the over half of the agency leadership was non-white.

Anna Fisher-Pinkert: From Mary Bassett’s perspective as a former New York City health commissioner under Mayor Bill de Blasio, it’s important that everyone who works in public health wrestle with the issue of racial equity.

Mary Bassett: One person isn’t going to figure this all out. What I did, as health commissioner was, I said to the entire agency leadership, whether they worked in finance or in human resources, or ran the lab. . . no matter what their area I wanted them to apply a racial equity lens, their work and it was extraordinary what people came up with.

It’s really important that there be leadership and I’m really grateful to Dr. Walensky for taking that step, but it still takes courage, I would say.

Anna Fisher-Pinkert: In the summer of 2020, at the peak of the protests over George Floyd’s murder, a colleague of mine interviewed Mary Bassett and asked her if she felt hopeful that real change could happen toward dealing with structural racism. And she answered, “I’m more hopeful than I’ve been in a long time.” When I spoke to Dr. Bassett, there was no verdict yet in the case against Derek Chauvin, the police officer who killed Floyd. I asked her if she still felt hopeful.

Mary Bassett: I do. I do. Because my whole working life really has been a pushback. I’ve witnessed a pushback against the great society legislation of the 1960s. Remember that the last time the majority of white voters voted for a Democrat was in 1964.

This past summer I witnessed an outpouring that I just haven’t seen in well over a generation. In 50 years, really. And it was a multi-racial outpouring. And I think that there is a growing willingness to embrace the reality that racism hurts all of us. The United States has departed from its peer nations in terms of our life expectancy, despite spending more on health than any other nation. Our life expectancy is declining, and the pandemic is going to push it down further and make it even more unequal. So, I think there’s a good reason for everyone to feel that we have a stake in this. And clearly many, many people did who, who took to the streets to say that this lethal racial hierarchy is not something that we are willing to endure any longer ­– Black and white.

So that makes me hopeful.

Anna Fisher-Pinkert: Hope is something we all need in 2021. And I think everyone is finding it in different places. You can choose to find it in a protest, a declaration, or in a little vial of vaccine.

That’s all for this week. Thanks for listening.

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I’m Anna Fisher-Pinkert, host and producer of Better Off a podcast of the Harvard T.H. Chan School of Public Health.