IDWeek 2020: A look at HIV, COVID-19 in America highlights the role of racism as a vector of infectious diseases

The 2020 Edward H. Kass Lecture: "All policy is health policy"

When the disparate and damaging impacts of HIV and AIDS on Black Americans across the United States finally began to draw notice in the late 1980s and early '90s, the recognition came with an assumption. Those most affected by the epidemic, common wisdom had it, were those whose behaviors put them at the greatest risk.

That didn't explain what Dr. Adaora Adimora was seeing among the patients she served, however. Yes, some of her patients used drugs, had sex with multiple partners, but some did not. What her patients did have in common was poverty, resulting from intersecting policies that institutionalize inequities, including through mass incarceration and barriers to health service access.

The interplay of these policies and how they have exacerbated the impacts of  America's deadliest two epidemics -- COVID-19 as well as HIV -- was the topic Dr. Adimora's IDWeek 2020 Edward H. Kass Lecture: "All Policy is Health Policy" Thursday. The lecture, named for a founding leader of the Infectious Diseases and past president of the Infectious Diseases Society of America examines societal influences in medicine. Dr. Adimora is a past chair of IDSA's HIV Medicine Association, which, with IDSA, produces this blog.

The mass incarceration that sprang from America's "War on Drugs," and grew through the 1980s, disproportionately affecting Black Americans through policies that included disparate charging and sentencing guidelines, in turn, drove factors influencing health that include poverty, destabilized relationships, reduced numbers of available partners, and restricted employment opportunities, Dr. Adimora showed. 

"It's impossible to overstate the damage mass incarceration does to individuals and communities," she said.

Among the results of limited employment opportunities, she noted, is limited access to health care. With Black Americans living with HIV less likely to be in care, data, in turn indicate that most HIV transmissions in the United States come from individuals who are not in care.

With 2018 data showing 29% of White Americans working from home, and just 19% of Black Americans working from home, limited employment opportunities also have driven disparate impacts of COVID-19, she said. As the pandemic puts frontline workers at greatest risk of exposure to the novel coronavirus, less than one in five Black workers has the option of working from home.

Voting for leaders, policies and policy makers to tackle fundamental barriers to justice and health access could address these inequities, but those most affected are also most disenfranchised from weighing in at election time, Dr. Adimora showed. Home to a million people barred from voting by felon disenfranchisement laws in 1976, by 2016 the U.S. had laws across the nation barring six million people from the polls, with Black Americans, again, disproportionately affected. These numbers, she showed have affected Presidential and Senate elections, including the outcome of Bush v. Gore in 2000.

"Racism and domestic terrorism have defined the lives of many Black Americans for centuries," she said. That could change, she added, "if the American public is serious that Black lives matter."

Holding police accountable and demilitarizing their forces, eliminating minimum sentences for nonviolent crimes, and reallocating funding now supporting over-policing and mass incarceration to the expansion of social safety nets, eliminating unreasonable collateral damage from criminal convictions, as well as health policies that provide all Americans with access to high quality care are critical first steps, she said.

"All policy is health policy," Dr. Adimora concluded. "U.S. racial inequities in HIV and COVID are not inevitable."