According to preliminary data about the coronavirus pandemic, African-Americans are bearing a strikingly disproportionate share of the suffering in the United States. In Illinois, where fourteen per cent of the population is African-American, black Americans represent more than forty per cent of the state’s confirmed coronavirus deaths. Coronavirus fatalities have a similar breakdown in Michigan, and several Southern states show even greater disparities. The possible reasons for these inequities are myriad: African-Americans are less likely than white Americans to have the option of working from home and to receive high-quality medical care, and more likely to have preëxisting medical conditions that lead to worse outcomes from the novel coronavirus. New research links coronavirus deaths to air quality, which is often worse in poor communities and communities of color.

Nancy Krieger is a professor of social epidemiology at the Harvard T. H. Chan School of Public Health. Her work focusses on health disparities between demographic groups and the social structures that help determine those disparities. We recently spoke by phone about how American health inequities are playing out during the pandemic. During our conversation, which has been edited for length and clarity, we discussed why the field of social epidemiology is crucial to understanding inequality, the causes of racial disparity in health outcomes, and what can be done to ameliorate the suffering of the most vulnerable Americans during this crisis.

Is the spread of the coronavirus, and especially its disproportionate impact on the African-American community, teaching us new things about racial disparities in health care and health outcomes or confirming things we have long known?

More the latter. What the virus is doing is pulling a thread that is showing how many things are actually connected, and how deeply people are actually connected. But it’s also revealing the very different conditions in which we live because of social structures that are inequitable, both within the United States and between countries. By pulling the thread, it’s revealing patterns that have been long known in public health.

So, when you think about something like this coronavirus, you have to think about who’s exposed in the first place and where they are exposed—at work, at home, and what are the conditions? You have to think about, if they’re exposed, do they get infected? You have to think about, if they get infected, do they get ill? And you have to think about, if they’re ill, do they actually die?

And you take each of those steps, which are all different steps in this process, and turn to what are the preliminary—and, I emphasize, preliminary—data on the excessive death rates. My state, Massachusetts, just released the first reports that have any racial or ethnic data. The amount of missing data is horrific. Fifty-three per cent of confirmed cases and deaths have no race or ethnicity recorded. So this is really stunning. Thank goodness for what the journalists are doing compared with what the actual health agencies are doing. And I could trace that back to issues like funding cuts in public health that have been pronounced over the past two decades, if not more.

But what you can do is use this to look at what the coronavirus is exposing. So let’s start with who’s being exposed. Well, if you are living in crowding households—and household crowding is intimately related to lack of living wage and unaffordable housing—what do you have when people are living in crowded spaces? An increased risk of exposure and transmission. If you work in certain kinds of service jobs, which require you to be in close proximity to all kinds of people without sufficient barriers, you’re going to be more likely to be exposed. Who is able to stay at home to do their work and who is not? Who is being given protective gear?

Just think about the amount of work that has been done to organize among, for example, people in grocery stores to make sure that they’re provided with protective gear. They’re considered essential workers now, many of them. Are they essential enough to give protective gear? And then think about the steps that people are being asked to take to protect themselves, including not only physical distancing, while keeping social connections, but also washing your hands. So it’s important to note that there have been calls, for example, for not letting utilities cut people’s water off. In Detroit, that’s been particularly pronounced, because if people don’t have running water how can they wash their hands?

I was just looking at the C.D.C. guidelines on masks, which say that the way to clean masks is with a washer. That is the only thing they listed, and a lot of people don’t even have washers, and certainly not in their homes or apartment units.

I don’t know if you saw the postcard that was sent out to all residents, all people that are domiciled and have a mailing address in the United States, from the Trump Administration about COVID-19. Have you seen that?

I haven’t.

Oh, well, you should’ve got it in your mail. It’s called “The President’s Coronavirus Guidelines for America.” And it says things like, if you feel sick, stay at home—do not go to work. Who can afford to do that? What is this showing about sick leave, and family leave? It says that, if your children are sick, keep them at home and contact your medical provider. Who can watch them at home? Do you have a medical provider? Do you have health insurance? It says that, if someone in your household has tested positive, keep the entire household at home. Again, what are the social conditions that allow people to do that? What are the social policies and what are the glaring gaps that do not allow people to do that equitably in our society? And washing your hands—again, who has access to running water?

So the thing is you can go through each step of what happens with this virus—and we haven’t even got to whether you get ill—and, at each step in this process, you can say, “How is this showing what the threads are that connect us, and who’s not equitably treated?”

It’s interesting that you keep talking about this thread, because I had been thinking that maybe it would be helpful to disaggregate some of these things, even if they have some of the same root causes. So, on the one hand, you have things like people of color being more likely to live in conditions that make preventing exposure difficult. And then you have specific ways in which people of color may not be treated equally once they get sick, or once they’re in a hospital.

Yes. The way that I frame things is what is called the eco-social theory of disease distribution, which asks the question “How do we embody our societal and ecological context?” And the thing about that is that our bodies could give a fig about how people want to parse things out and call this transportation-related, that related to housing, that related to the conditions in the schools, et cetera. Our thinking needs to be integrated, as we are living organisms who are biological and social, constantly interacting with the environs in which we live, which are both biophysical and also social. And it’s never an either/or. It’s always a both/and.