Shortly after midnight on Sept. 29, Felisha Walter assumed an identity very much at odds with the fullness of her life: statistic.
Walter was a devoted mother, a chef and caterer; gracious, giving and forgiving; spiritual and kind. And when she passed away, just after her 62nd birthday, at UAB Hospital in Birmingham, she was one more African American life lost to COVID-19 – a virus that has brought suffering and death to a disproportionate number of people of color in Appalachia and across the country.
A study released in September by the Kaiser Family Foundation and Epic Health Research Network found that Black people are infected with COVID-19 at a rate double that of white people, are three times as likely to be hospitalized with the virus and are more than twice as likely to die from it.
Social-justice advocates across the country assert that racism is at the core of these racial health disparities. City and county governments have passed resolutions declaring racism a public health crisis and the American Public Health Association has likewise called racism a crisis. Camara Jones, a past president of the APHA, has been among those most vocal in underscoring the urgency for action.
Jones, a family physician and epidemiologist, often shares an allegory she calls “The Gardener’s Tale,” in which a gardener has two flower boxes, one with rich soil, the other with poor soil, and two packages of seeds, one that will bear red blossoms, the other pink. The gardener prefers red blossoms, and plants those seeds in the rich-soil bed. As expected, the red blossoms flourish, the pink blossoms struggle.
In time, the flowers go to seed and drop their progeny into the soil, and the pattern is repeated, time and again. Some years later, the gardener studies her flowers and declares, “I was so right to prefer red over pink! Look at how vibrant and beautiful the red flowers are, and how pitiful and scrawny are the pink ones.”
Jones defines racism as “a system of structuring opportunity and assigning value based on the social interpretation of how one looks (which is what we call ‘race’) that unfairly disadvantages some individuals and communities, unfairly advantages other individuals and communities and saps the strength of the whole society through the waste of human resources.”
She identifies three types of racism: institutional (structures, policies and practices that result in differential access to services and opportunities); personally mediated (assumptions about the abilities, motives and intentions of others); and internalized (acceptance of the messages about our own abilities and intrinsic worth).
The representations of institutional racism in “The Gardener’s Tale,” Jones explains, are separating the seeds into different types of soil, structuring the flower boxes to keep the soils separate and never addressing the differences between the soils.
For Black social-justice activist Ash-Lee Woodard Henderson, racism as a public health crisis “is just a fundamental truth, not an opinion.”
“I think we can see both with the intersecting crises between white supremacy and this global pandemic – and its disproportionate impact on Black folks and Black communities – the evidence,” Woodard Henderson says, that it’s true.
Even if there wasn’t a global pandemic, “if me being Black puts me in an increased likelihood of being murdered by police officers with impunity, that’s a crisis.”
“If my children are at a greater likelihood of being incarcerated, expended, suspended from school,” Woodard Henderson says, if they’re more likely to have a jail cell built for them than to attend a university, “then that is a public health crisis.”
True and lasting change will never be effected, Jones insists, until we address institutional racism. A pandemic underscores the peril.
In Birmingham and Chattanooga – two of the largest cities in Appalachia, each with a significant Black population – people of all colors have turned out in the streets in the wake of the murder of George Floyd, demanding attention to racial injustice. And in these cities, as across the country, people have been compelled to contemplate the intersection of racism as manifested by police brutality and the quieter, equally lethal forms – the structural strains of racism that plague our institutions – most acutely experienced today within our health care system.
In Alabama, one of the two southernmost states in Appalachia, Blacks comprise 27 percent of the population but have suffered 40 percent of COVID-19 deaths. Likewise in Tennessee, on Alabama’s northern border, deaths have been racially disproportionate.
Selwyn Vickers, dean of the UAB School of Medicine, characterizes chronic racial health disparities as “smoldering embers,” with COVID-19 having now created “a firestorm.”
“It has linked lethality to one long-term problem like we’ve never seen before,” Vickers says.
Like countless members of Black communities, Felisha Walter was at high risk of dying in a pandemic. Many of those risks were upon her at birth.
‘Underlying Fundamental Injustices’
Black adults experience hypertension, diabetes and obesity at higher rates than white adults, conditions that render COVID-19 more lethal. But many in public health argue that social determinants of health – where we live and work, the quality of our education system, access to well-paying jobs and other economic opportunities – are at least as critical.
Black people are at greater risk for contracting and experiencing more severe symptoms from the virus for a number of reasons. They’re more likely than white people to be front-line workers. They’re more likely to live in overcrowded, often multigenerational, and substandard housing. They’re twice as likely to be uninsured.
Felisha Walter and Valerie Jones became friends – sisters, really, Jones says – 35 years ago. “I was blessed to meet her,” Jones says.
Jones believes that when Walter began having trouble breathing about 15 years ago and sought medical help, she was assessed – Black, low-income, overweight – and dismissed. Whether consciously or unconsciously, Jones says, those viewed as lesser are treated accordingly.
Jones worked for 14 years as an emergency room nurse and three as a nurse manager at Cooper Green Mercy Hospital in Birmingham. She currently works at the UAB School of Medicine in utilization management. She helped guide Walter to specialists, through treatments, eventually finding a pulmonologist who took the time and care to properly diagnose her with sarcoidosis, an inflammatory disease that most commonly affects the lungs and lymph nodes.
By that point, though, the disease was advanced. An aggressive steroid treatment was required and, as a result, Walter had contracted diabetes. When COVID-19 hit, Jones says, her friend was clearly at high risk.
In addition to her preexisting conditions, Walter’s age was a factor. But Black people’s vulnerability to the virus spans the age spectrum. A Kaiser Health News analysis of Centers for Disease Control and Prevention data found that Blacks between the ages of 65 and 74 are five times more likely than whites to die from COVID-19. And a CDC study released in mid-September reported that of the 121 Americans below the age of 21 known to have been killed by the virus, nearly two-thirds were Black or Hispanic.
Walter lived in Birmingham; the majority of deaths in the U.S. have occurred in urban areas. But Black people have been dying disproportionately in rural communities as well. Rural counties with the highest percentage of Black residents have had a 70 percent higher average daily increase in their COVID-19 mortality rate.
Jay Pearson, an assistant professor at Duke University’s Sanford School of Public Policy who specializes in race, says that racial health disparities aren’t about genetics; the primary source is structural racism.
The fundamental drivers of these differences were established early on in the history of this country, Pearson says, “and what we see in contemporary society, including differences in COVID-19, are simply the latest manifestations of these underlying fundamental injustices.”
The race construct as we know it in this country today, he says, was conceived by European immigrants to the emerging U.S. to justify the exploitation of Native Americans in the form of appropriation of their land and the economic exploitation of Black Africans in the form of stolen labor.
Pearson stresses that the injustice is also about stolen narrative. Who gets to tell the story and how they’ve chosen to tell it has deep implications for our understanding and acknowledgment of structural racism and how it manifests in people’s lives. It results, he says, in a failure to acknowledge that not everyone in this country has equal opportunities.
COVID-19 is “accelerating, exacerbating and revealing this long-underlying phenomenon” of structural racism, Pearson says.
In our health care system, as throughout society, systemic racism comes at great cost.
In her book “Just Medicine: A Cure for Racial Inequality in American Health Care,” Dayna Bowen Matthew cites a 2011 study that estimated more than 30 percent of the direct medical costs that African Americans, Hispanics and Asian Americans incur are excess costs due to health disparities – nearly $230 billion over a three year period.
Matthew notes that David Satcher, founder of the Satcher Health Leadership Institute, estimated 83,570 lives are lost each year as a result of racial and ethnic health disparities.
She quotes Martin Luther King Jr.: “Of all the forms of inequality, injustice in healthcare is the most shocking and inhumane.”
Criminalization of Mental Illness
Say “Appalachia” and most people are likely to think: eastern Kentucky, West Virginia, coal country; white and working class. The national media poured into Appalachia during the 2016 presidential election, christening it “Trump Country.”
In fact, Appalachia, as defined by the Appalachian Regional Commission, sprawls from Schoharie County in central New York to Kemper County in deep Mississippi. Quite a number of Appalachians voted for Donald Trump in both 2016 and 2020; quite a number didn’t.
And, yes, there is diversity in Appalachia, economic, racial and otherwise. The southern region has the highest percentage of Blacks, including seven in 10 Birmingham residents.
Woodard Henderson considers herself Affrilachian. She’s co-executive director of the Highlander Research and Education Center in New Market, Tennessee, just outside of Knoxville, which for nearly a century has been on the front lines of the struggle for social justice and workers’ rights.
Woodard Henderson is the first Black woman to serve in that role. Being Affrilachian, she says, is a particular way to be a Black Southerner.
“I think that everything I know about how to be good in this world, how to be in right relationship with the land, how to fight for what is right, is influenced by being from east Tennessee.”
“I believe the reason that I fight the way I do is because it’s my inheritance, because Black people in Appalachia have been fighting for social justice, economic justice, education justice and all of the forms of liberation and justice for as long as our people have been living in this part of the world,” she says.
Among those Henderson cites as Black freedom fighters in the South is Maxine Cousin, who, along with Annie Thomas, founded Concerned Citizens for Justice in Chattanooga in 1984, after Wadie Suttles, a Black man, died in police custody.
Chen Schobert, a CCJ member today, describes what he calls that city’s valley syndrome: isolation, both physical – the mountains that surround it – and cultural – at least partially attributable to those mountains. It’s generally difficult to organize people in the city, Schobert says. But not in response to the murder of George Floyd. A collective voice sounded for racial justice.
“It was a beautiful thing,” he says. “I don’t think I’d ever seen Chattanooga rise like that.” He was struck by the number of people who came out “who had been traumatized and brutalized” by law-enforcement officers.
Demonstrators in front of the Hamilton County courthouse were told by law enforcement that they were on private property, Schobert says; tear gas was then deployed to disperse them.
The demonstration organized on the Friday after Floyd’s death was held in the name of Javario Eagle, a 24-year-old Black man killed following a standoff with Chattanooga police officers in December 2015, moments after having called 911 for assistance, sounding, according to the dispatcher, irrational. Eagle was shot 19 times. The officers were investigated and cleared. Protests followed, with assertions that his killing was unjustified.
Schobert speaks of the criminalization of mental illness, most particularly for Black people, when he describes Eagle’s death and that of another Black man, Leslie Prater, in 2004, who died of suffocation after four police officers pinned him to the ground with his wrists handcuffed behind his back.
These were two young Black men in mental health crisis, Schobert says, both desperately in need of help. “If there was any empathy, any ability to properly see us as human beings,” these deaths would have been prevented, he says.
The 2019 Hamilton County Community Health Profile reveals that Blacks in the county, of which Chattanooga is the seat, are four times more likely than whites to die of hypertension, two and a half times more likely to die of diabetes and twice as likely to die of prostate cancer. The study also reports that Black men were the victims of 60 percent of fatal assaults in the county.
LaDarius Price is a 40-year-old Black man running for election in March to Chattanooga’s city council on a platform to improve public health and invest in youth development. Price is community outreach manager for Cempa Community Care, which provides health care and support services.
Price sees a lot of young Black men struggling in Chattanooga; addressing their anxieties in this charged moment is very much a part of his job. “People might say, ‘What does health care have to do with social injustice?’ Well, it’s got a lot to do with it. It’s affecting these young men and how they’re able to move forward.”
Cempa Community Care offers trauma-informed care. “I’m not going to be sitting in a classroom focused on what a teacher is telling me about three times five when I’ve seen my uncle or somebody from my neighborhood get killed last night,” Price says.
David R. Williams, a professor of public health and chair of the department of social and behavioral sciences at Harvard’s T.H. Chan School of Public Health, has written of his concern for a “pandemic of stress” experienced by communities of color.
People in underserved communities were “already struggling to support their families in low-wage jobs, living in substandard housing they could barely afford and beset by violence and pollution in their neighborhoods,” Williams writes. “They experienced multiple, chronic stresses.”
In the pandemic, children of color may be exposed to traumas with “lifelong implications” – the loss of loved ones, economic distress and food insecurity – which can increase the risk in adulthood of heart disease, stroke, cancer, diabetes, chronic lung disease, Alzheimer’s and suicide.
“For these kids,” he writes, “the crisis isn’t a matter of 12 or 18 months. Its impacts will shape an entire generation.”
‘Walk with Confidence’
On a Saturday morning in September, Price has convened a gathering at Brainerd High School of young Black men, most in their teens, some younger, to talk about charting their own path, mindful of perceptions commonly held of who they are and of how to counter those perceptions. The forum is titled “Against All Odds.”
A therapist and a police sergeant are among those who sit on the panel. A businessman who’s also a DJ moderates, maintaining a spirited pace. Incrementally, the young men gather the confidence to stand up and share what’s on their mind – issues they’re facing at home, their defense mechanisms, ambitions.
Price urges them to stay alert to their surroundings. “Because of the skin that you’re in,” he says, society views you differently. “And that’s just me keepin’ it real for you; being totally transparent. You need to understand that.”
Price tells them he had to learn that it was okay to express himself. “Society wants us to think we’re supposed to internalize everything,” that showing emotion is a sign of weakness. “And it’s not.”
“Walk with confidence in who you are,” Price says, “and be proud of who you are.” And find someone you can trust. “You need somebody to check on you. When they say, ‘check on your people,’ that’s real.”
Dylan Bryant, who was called from the audience to speak, served 14 and a half years in prison, where he earned his GED, took college courses, reoriented himself; he now wants to share what he’s learned.
You must tune into the person you are to get what you want out of life, Bryant tells the young men. Be who you are mentally, spiritually. Be careful who you surround yourself with.
“My message to them was, first and foremost, find out who you are as a person in order to become a better person,” Bryant says in a conversation the next day. “You can be anyone you want to be.” It’s okay to be angry now and then; transform it into something positive. Be patient. “Know who you love and where you want to be.”
Chris Ramsey attended the forum. He worked at Blue Cross for 25 years and now serves on an advisory committee for the Hamilton County Health Department. The messages conveyed resonate with him. He wants to see these young men empowered to express themselves.
“Mental health, especially in the African American community, is kind of taboo,” Ramsey says. “Growing up, we had a mental health hospital, Moccasin Bend. It sits on a little island. It was the crazy place. ‘If you go to Moccasin Bend, you’re crazy.’”
Ramsey believes the stigma around mental health isn’t what it once was but recognizes that the hard work ahead to address it has been compounded by a virus. COVID-19, Ramsey says, has laid bare the disparity in Chattanooga. “It’s exposed what we already knew.”
‘Go Right Now to See Her’
As a former emergency room nurse, Valerie Jones has witnessed a lot of dying; she wasn’t sure she wanted to see her friend Felisha Walter in her final days. She’d visited with her on Walter’s birthday. She thought, perhaps, that was the image she should carry.
But on the last Monday of September, she was working from home and, she says, “The Holy Spirit said, ‘Get up. Go right now to see her.’”
It was impossible for Walter to recognize her behind all the protective gear. But when she heard Jones’ voice, Walter grasped her hand. “I told her, ‘I just wanted you to know that I’m here. Your girls are going to be okay. I’m going to be with them always.”
As of Dec. 8, 49,994 Black Americans were known to have lost their lives to COVID-19.
Walter loved butterflies. At her funeral, a kaleidoscope of them was set loose. “I’m going to miss her terribly,” says Jones.
This is part one of a two-part series exploring racism as a public health crisis in Appalachia and its compounding due to COVID-19. Read part two here.
This article was co-published with Tarbell.org, an online non-profit investigative news publication founded by health care reform advocate and health insurance industry whistleblower, Wendell Potter.