Well-mixed models do not protect the vulnerable in segregated societies.
Read the Reflection, written 21 August 2021, below the following original Transmission.
African Americans are dying from COVID-19 at a rate two to four times higher than white Americans.2,3 Per capita cases are higher on the Navajo reservation than in every U.S. state.4 What are the causes of this disparate impact of COVID-19, why did epidemic models not predict it, and what can be done to address it?
Myriad explanations for racial differences in COVID-19 exposure and mortality have been proposed, particularly focused on the work circumstances, living conditions, health status, and healthcare access among African Americans. African Americans tend to live in denser urban areas and multi-generational households, and to be essential employees who cannot work from home. They are likely to have less paid sick leave and health insurance, but more underlying medical conditions such as diabetes, cardiovascular disease, sickle cell disease, asthma, and exposure to environmental pollutants that elevate COVID-19 mortality risk. African Americans are often turned away or have the severity of their condition underestimated when they seek medical care. The history of unethical medical experimentation and exploitation (e.g., the Tuskegee syphilis experiment and Henrietta Lacks’s cancer cells) has led to community-level distrust of the medical system. When the novel coronavirus initially spread among international travelers centered in China and Europe, myths gained traction on social media that people of African descent could not contract COVID-19.
Higher COVID-19 mortality, particularly at younger ages, is consistent with other health disparities in African Americans: a fourfold greater probability of dying from complications during childbirth, 20 times greater chance of heart failure before age 50, and a four-year-shorter lifespan.5 The stress of living under the threat of racism appears to age black bodies faster than white ones. The multiplication of many inequities over time results in greater disparity; black income is 60 percent of white income, but black wealth is only 10 percent that of whites.
Native American COVID-19 risk is also influenced by extreme inequity in health and economic circumstances, including lack of services as basic as running water and inadequate federal funding of health care.6 The Native population is a staggering 17 times more likely to be diagnosed and over 10 times more likely to die from COVID-19 than the white population in New Mexico7 (one of the few states reporting sufficient data to make such comparisons). Previously isolated Native populations were decimated by diseases upon European contact and were also four times more likely than others to die in the 1918 flu pandemic.8 COVID-19 threatens the very survival of small Pueblos like the Zia with fewer than 1,000 members. The proximate socioeconomic factors correlated with COVID vulnerabilities are themselves the manifestation of hundreds of years of structural racism that has left formerly enslaved and colonized populations with poor physical and economic health and often in spatially segregated places.
How do epidemic models incorporate these racial and socioeconomic realities? Thus far, they don’t. Initial epidemic models, and most that still influence pandemic policies, assume “well-mixed” populations. More sophisticated network models consider different categories of people and their risk of infection and mortality,9 but far more work is needed to incorporate systematic correlations among epidemic factors within particular groups in particular places. More often, people are modelled like identical balls bouncing randomly in a lottery machine, equally likely to contact infection, become sick, infect others, or have their number drawn as the unlucky one to die. However, people are not equally vulnerable, and America is not well mixed.
One of the greatest determinants of physical and economic health is the zip code in which you were born. Zip code is a powerful predictor of the chance that you will go to college or prison, that you will have heart disease or asthma, whether you will drive a bus or work safely at home and order your groceries online. Like wildfires that burn where the winds blow and the grass is driest, the spread of disease is determined by a template of risk and vulnerability laid out in physical space. In America, that space is largely determined by race.
Zip code has long been used as a proxy for race. Redlining was the deliberate practice of denying Black Americans access to safe neighborhoods with high property values and good schools. Now zip code is used in algorithms that determine where predictive policing is concentrated and eligibility for loans and higher credit.10 The spatial segregation of Native and African Americans have different historical causes, but similar consequences are clearly visible (fig. 1). The zip codes, counties, and territories where African and Native Americans are concentrated are the deadliest places in America.
Figure 1. Per capita positive cases (higher values in darker colors) in the four states with the highest percentages of African Americans, and in Arizona and New Mexico with large Native American populations.
In Mississippi, Holmes County has the highest per capita death rate. It is 83 percent African American, the third highest proportion of the 82 counties in the state. Four counties in Georgia have among the highest COVID-19 mortality in the nation (1 death per 250–290 people). They are ranked 1st, 5th, 7th, and 20th in proportion of African Americans (49–73 percent) of 159 counties. In South Carolina’s 46 counties, the highest mortality is in Lee and Clarendon counties, ranked 11th and 3rd (49 percent and 64 percent black). St. John the Baptist is the highest mortality parish in Louisiana, the 5th most African American (54 percent) of 64 Parishes. The highest mortality counties in adjacent regions of northern New Mexico and Arizona have the highest Native American populations (27 to 73 percent).
Data and images from The New York Times, May 26, 2020.
Complex systems thinking developed powerful and mathematically tractable epidemic modelling approaches that mitigated unfettered exponential growth of COVID-19 in the general population. Yet, as many authors in the Transmission series have pointed out, the simplifying assumptions that allow for powerful broad scale predictions are only a starting point. Models need to incorporate the systematic and structural features of societies that determine how both policies and physical space mediate disease spread.
Complex-systems thinking should emphasize that viral spread is not an idealized mathematical process taking place in a vacuum. Disease is an emergent phenomenon whose spread and severity is a consequence of the properties of the SARS-CoV-2 virus, the age, health, occupation, and socioeconomic status of individuals, and societal structures which cause disease to spread differently among different people in different places for different reasons.
Disease spread is an inherently multi-scale spatial process. It is caused by the entry of a nanometer-sized virus into a cell, where the probability of that infection is influenced by the space in a crowded factory, nursing home, or prison, by the availability of healthy food or prevalence of air pollution in a neighborhood, and by a nation’s social structure, which determines the level of stress, inflammation, and cardiovascular health of the body that cell inhabits. COVID-19 also disproportionally impacts ethnic minorities across the globe.11 It will grow where the most vulnerable are concentrated in refugee camps, favelas, and war-ravaged cities.
How do we find a path forward? Disparate impact matters not just for predicting who is at risk, but also for prioritizing who is tested, isolated, economically supported, treated, and vaccinated. As in civil rights law, mitigating disparate impact does not require ascribing intent or completely disentangling causal factors. How can our response to this disease increase how resilient the most vulnerable populations are to the next pandemic, the next economic shock, and the looming climate crisis?
COVID-19 racial and ethnic health disparities are the new frontier of human rights in the United States and globally. The international efforts in reparations for human rights violations provide a framework not just for redress of past injustices that have led to increased community risk from COVID-19, but also for forward-looking provision of free access to community health initiatives located specifically in the places where the most vulnerable populations live. COVID-19 maps show us where those places are (fig. 1).
A complex-systems approach to addressing past inequities would consider the historical, layered, and interacting factors that may be impossible to disentangle, but which collectively put certain populations at highest risk. The goal is not just to repair harm, but also a concerted effort to make people and places less vulnerable to the next pandemic: lowering rates of diabetes, increasing access to healthy food and caring doctors, and reducing air pollution. Such systemic changes support resiliency to survive the next outbreak in the places we already know are most vulnerable. These investments are far less expensive than blindly shutting down an entire economy. We will know we have succeeded if the next map looks different — if the location of the biggest outbreak is due to the random draw of a lottery, and not the inevitable consequence of generations of inequity.
Melanie Moses
University of New Mexico
Santa Fe Institute
Kathy Powers
University of New Mexico
ENDNOTES
1 Both authors are members of the SFI/UNM project on Algorithmic Justice.
2 Yancy, C. W., “COVID-19 and African Americans.” Journal of the American Medical Association. 2020.
3 Price-Haywood, E. G., et. al. “Hospitalization and Mortality among Black Patients and White Patients with COVID-19.” The New England Journal of Medicine. 2020.
4 https://www.ndoh.navajo-nsn.gov/COVID-19
5 Williams, D. R., “Miles to Go Before We Sleep: Racial Inequities in Health.” Journal of Health and Social Behavior. 2012.
6 Warren, E. and Haaland, D. “The federal government fiddles as COVID-19 ravages Native Americans.” Washington Post. May 26, 2020.
7 https://cv.nmhealth.org/ calculated from the 10 percent Native population accounting for 58 percent of cases and the 37 percent white population accounting for 12 percent of cases.
8 Kakol, M., et. al. “Susceptibility of Southwestern American Indian Tribes to Coronavirus Disease 2019 (COVID-19).” Journal of Rural Health. 2020.
9 Scarpino, V. S., et. al., “The effect of a prudent adaptive behaviour on disease transmission.” Nature Physics 2016.
10 Lepri, B. et. al. “Fair, Transparent, and Accountable Algorithmic Decision-making Processes.” Philosophy and Technology. 2018
11 Kirby, T., “Evidence mounts on the disproportionate effect of COVID-19 on ethnic minorities.” The Lancet. 2020.
This piece was the springboard for an article which appeared in Nautilus in November 2020.
Read more posts in the Transmission series, dedicated to sharing SFI insights on the coronavirus pandemic.
Listen to SFI President David Krakauer discuss this Transmission in episode 34 of our Complexity Podcast.
Reflection
August 21, 2021
LEGACIES OF HARM, SOCIAL MISTRUST & POLITICAL BLAME IMPEDE A ROBUST SOCIETAL RESPONSE TO THE EVOLVING COVID-19 PANDEMIC
In our Transmission of June 2020 we wrote that our scientific models and our COVID-19 mitigation strategies did not protect the most vulnerable members of society as African-American, Native American and Latinx/Hispanic Americans died at rates up to four times that of White Americans. In November 2020 we wrote that “the complexity of harms that lead to disproportionate exposure rates, infection rates, and death also limit social trust in new vaccines that might mitigate these risks in the future,”1 and then in January 2021 that “an untrustworthy system has created many who are understandably vaccine hesitant” and lamented online disinformation campaigns that are fueled by baseless conspiracies and prey on distrust.2
Now, we are again facing nearly 10,000 global deaths per day as the reality sinks in that the vaccines, despite extraordinary success in protecting individuals from hospitalization and death, may not sufficiently block transmission to provide societal-level “herd immunity” from the hyper-transmissible Delta variant. Even if vaccines alone will not completely stop the virus from circulating, they are the best tool we have to protect ourselves individually from severe disease and death and to reduce transmission to others. In combination with masks, social distancing, testing, and antibody therapies, vaccines can dramatically reduce suffering from COVID-19 in the US and worldwide. Yet, less than 2% of people on the African continent are vaccinated. That the successful, urgent production of vaccines for the US and other wealthy nations has done so little for the global poor may ultimately be considered the greatest moral failure of this pandemic, a failure that may contribute to the evolution of more dangerous variants.
In addition to the unequal global distribution of the vaccine—with most of the doses administered in just ten countries—we must also address the question of why so many refuse to accept the vaccines that are available to them and could save them from suffering and death. Scientific tools like vaccines are produced by and embedded in complex social systems. Our socio-economic, political, and biomedical systems have often engendered mistrust. Governments that have sanctioned unethical medical experimentation in the past are now devising strategies to incentivize or compel their citizens to be vaccinated today. But memories are long with respect to human-rights violations, especially when they have been repeated over time. In the Democratic Republic of the Congo and West Africa, refusal of Ebola vaccination was explained as disbelief that the virus was real, but it may instead have reflected an understandably deep distrust of external forces that brought colonialism and slavery and contemporary exploitation.3 Memory of past atrocities can stifle vaccination rates as is seen in communities of color in the US and in other populations around the world.
Restoring trust requires reckoning with contemporary inequities as well as past harms. Why should the global poor trust pharmaceutical companies and international health organizations who have provided so little access to vaccines? Why should a young Black American who is threatened by his government’s criminal justice system trust his government’s public health system? The ability to trust is itself a privilege. Trust can act as a ratchet that exacerbates inequity when those with more privilege have greater trust in solutions to problems that cause greater harm for the less privileged who are then blamed for their individual choices. The contribution of societal factors to those choices are not sufficiently examined.
Failure to address mistrust in vaccines is in part a failure to understand that people do not react to the vaccine in an isolated equation of risk and benefit. They also react to it as a reflection of the society that produced it and seeks to benefit from its adoption. One would logically answer yes to the question, “Would you take a vaccine that reduces your chance of death by over 95% if the risk of death from taking it is far less than a 1 in a million?” Yet the question some are actually answering is, “Do you trust a vaccine produced by a society that has experimented on your ancestors and will bankrupt you if you get cancer?”
Mistrust is amplified when public-health messaging changes (as it must do as the virus and our scientific understanding of it change) and by political structures that thrive on blame, scapegoating and, increasingly, disinformation, rather than cooperation. But mistrust can be overcome. Native Americans who suffered the most in the early days of the pandemic overcame mistrust of the vaccine to become the most vaccinated racial group in the US due in part to effective advocacy by trusted tribal leaders.4 The gap in vaccination rates between African-American and Latinx populations and White populations is narrowing, and vaccination rates have increased in the places hardest hit by the wave of Delta infections. SFI researchers found that in Austria, less than half of the surveyed population trusted their government to provide a safe vaccine,5,6 but over 60% have now gotten their first shot. An effective and equitable vaccine rollout can help to build the trust that is needed for future public-health efforts.
Complexity science suggests that we could make further progress if we transcend the reductionist approach that attempts to isolate vaccines and other scientific tools from the societies in which they are embedded. As beautifully stated by W. Brian Arthur, people in complex economies “explore, try to make sense, react and re-react to the outcomes they together create.” 7 Much of the reaction to vaccines reflects that they are seen as inseparable from unjust systems we have created. Developing a more equitable and trustworthy society is a crucial prerequisite to achieving trust in vaccines. Building that trust now will foster cooperation to address ongoing and future pandemics and the even greater challenges of climate change.
Understanding and confronting the causes of social mistrust is not a magic bullet. There will still be miscreants who peddle lies and exploit ignorance and grievance in opposition to common interests. A more trustworthy society may mitigate their influence, but not likely on the time scales to address this pandemic. Regardless, we must confront past harms and current societal inequities if we wish to have robust and adaptable collective responses to increasingly complex global problems in the future.
Read more thoughts on the COVID-19 pandemic from complex-systems researchers in The Complex Alternative, published by SFI Press.
Reflection Footnotes
1 M. Moses and K. Powers, “A Model for a just COVID-19 Vaccination Program,” Nautilus, November 25, 2020, http://nautil.us/issue/93/forerunners/a-model-for-a-just-covid_19-vaccination-program
2 M. Moses, “How to Fix the Vaccine Rollout,” Nautilus, January 20, 2021, https://nautil.us/issue/95/escape/how-to-fix-the-vaccine-rollout
3 E.T. Richardson, T. McGinnis, and R. Frankfurter, 2021, “Ebola and the Narrative of Mistrust,” BMJ Global Health: 4:e001932, doi: 10.1136/bmjgh-2019-001932
4 R. Read, “Despite Obstacles, Native Americans Have the Nation’s Highest COVID-19 Vaccination Rate,” Los Angeles Times, August 12, 2021, https://www.latimes.com/world-nation/story/2021-08-12/native-american-covid-19-vaccination
5 E. Schellhammer, J. Weitzer, et al., 2021 “Correlates of COVID-19 Vaccine Hesitancy in Austria: Trust and the Government,” Journal of Public Health: fdab122, doi: 10.1093/pubmed/fdab122
6 J. Weitzer, M.D. Laubichler, et al., 2021, “Comment on Alley, S.J., et al., ‘As the Pandemic Progresses, How Does Willingness to Vaccinate against COVID-19 Evolve?’” International Journal of Environmental Research and Public Health 18(6): 797, doi: 10.3390/ijerph18062809