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The federal government has failed its populace in many ways since the COVID-19 pandemic reached American soil. It began early on with an inadequate supply of test kits being provided to clinicians, compounded when the Centers for Disease Control and Prevention enacted strict criteria for which patients could even receive one.

Dr. Uché Blackstock notes that discriminatory effects were embedded into those criteria. The initial CDC recommendations discouraged doctors from testing every patient who came in with a fever, coughing, and difficult breathing. A test, they said, should only be performed if those symptoms presented in someone who had recently traveled to an area where COVID-19 cases were prevalent, or if they had come into close contact with someone who had already been diagnosed with the coronavirus.

In the Brooklyn urgent care center where Blackstock does part-time clinical work, she says, she noticed early on that most of the patients who answered “yes” to those two questions were affluent and white. The majority of her Black patients said “no.”

“We got all of these patients who would come in and had flulike symptoms but didn’t have the flu, and they probably had COVID-19,” she told Slate. “But we weren’t able to identify them because the criteria is already biased.”

Blackstock is an emergency medicine physician by training. She was in academic medicine for 10 years until she left in December to focus on her company, Advancing Health Equity, which partners with health care organizations to make sure that they have the tools needed to provide equitable care.

Her academic and clinical experience have led her to conclude that not only will testing patterns fall along racial and socioeconomic lines, but Black people are going to be disparately affected by COVID-19. Black Americans experience profound racialized health disparities, including higher rates of diabetes, hypertension, asthma, and diabetes—chronic illnesses that heighten the chance of adverse outcomes should one contract the coronavirus. She also discussed environmental and structural factors that contribute to the gap in health between Black and white people.

The interview has been edited and condensed for clarity.

Julia Craven: What role has privilege and affluence played in testing? I keep thinking about the celebrities who have been tested, and I don’t know if you’ve seen this, but there’s a map of Dallas County where there are more confirmed cases in George W. Bush and Mark Cuban’s neighborhood than there are in other areas.

Uché Blackstock: I have no idea where these people are going to get these tests. Even myself, as a health care worker, if I was exposed to COVID-19 and I didn’t have symptoms, I wouldn’t even be tested. I would be told to go home and quarantine for 14 days.

It shows the peak of our systemic inequities that certain people can be tested so easily—and not just easily, but the tests that they’re getting seem to be from companies that have very quick turnarounds. My patients are waiting five to seven days to find out. So for five to seven days you’re asking someone to self-quarantine at home. Don’t go out. Minimize your exposure to other people.

And these people have jobs. One thing I have noticed is that a lot of my Black patients work for the city. They are essential employees. They’re bus drivers. They work for transit. They can’t really afford to be out of work anyway, and they still have to work. They don’t have the luxury of working remotely.

When I tell them it’s five to seven days, they’re like, “What am I supposed to be doing in those five to seven days?” And I’m like, “I’m sorry. You’re going to have to stay at home.”

That map of Dallas County is very enraging because it’s not that white, rich people are getting COVID-19 more. It’s that they’re more capable of being tested for it.

I was worried that people would say, “Oh, no. But, look! There are Black celebrities who have gotten tested.” And we know there are a few basketball teams where the entire team got tested and they weren’t even symptomatic. But that represents a very minuscule percentage of Black folks. The fact is that most Black people will not have access to that sort of ease in testing.

One thing that scares me about this whole thing—especially with limited testing and just people getting really, really sick—is that doctors don’t always take Black patients seriously and they don’t always listen to us. What do you think is about to happen in hospitals if doctors have to start triaging resources?

There’s so many things that we already know. We already know that clinicians don’t really listen to Black patients and that, even on the implicit association test, clinicians have a preference for white patients over people of color. And we know, even aside from the interpersonal dynamics, the way that systems work. There’s an algorithm that is supposed to allot a certain amount of resources to critically ill patients, but it underestimated how much resources critically ill Black patients use.

When it’s time for clinicians to ration resources, I think we can already assume that Black patients are going to be disadvantaged because they’re not going to be listened to. They’re going to be disadvantaged because even if you say we’re going to use a certain protocol, which we’re saying is objective, it’s not really objective. It has bias embedded in it. And I think it’s just going to compound the inequities.

I think most people would say, “This thing is going to affect everybody.” Yeah, but Black folks are also going to be the most significantly affected. I have no doubt about this.

When I heard about doctors in Italy having to ration ventilators and then the incredibly likely possibility that that is going to happen here, my first thought was so many Black people are going to die.

When I talk about implicit bias, I link it very strongly to structural racism because it has the same effects. Even looking at maternal mortality, we know that bias is implicated in the high mortality rates. So when we’re thinking about rationing ventilators, the fact is that, because we live in a racist society, that clinicians will have a stronger affinity for certain patients over others. They’ll have a stronger affinity for white patients versus Black patients.

Even when it comes down to assessing pain—I mean, it’s so well-documented that it’s scary—that clinicians of all races, and mostly white clinicians, will underestimate Black patients’ pain and will undertreat Black patients. So when you think of someone who’s dying and gasping for air and you have a Black patient and a white patient, we almost know what’s going to happen just based on the data that we already have.

Which is terrifying. Black people are also at a higher risk of developing serious complications from COVID-19 because we have higher rates of hypertension, asthma, and diabetes, and are more likely to have comorbidities compared with other racial groups. So what does that look like when we’re having this conversation?

The reason why we have such high levels of diabetes, hypertension, and asthma is directly linked to structural racism. The weathering effect, which is when everyday racism causes a stress response that ages our bodies, and epigenetics, which is how structural racism and that chronic stress affects gene expression. We’re already very vulnerable. When you add this pandemic on top of us, we’re more likely to be sicker when we present. And then we have to worry about whether or not we’re going to receive unbiased care. It’s just layers and layers and layers.

When it hits the fan, we’re the ones that are going to suffer the most. We’re even more likely to be uninsured. Now people are supposedly able to get the test for free, but that’s a nonissue because the testing is not even widely available. This is not going to end well for us.

What environmental factors make someone more susceptible to respiratory illnesses? Like you said, outside of just the physical disadvantage that we have, there’s the fact that we are more likely to live in substandard housing, less likely to have insurance, etc.

Some of the high asthma rates are related to the cockroach feces that actually can exacerbate those factors. Also we’re more likely to live in neighborhoods where there’s toxic dumping, where there’s environmental racism happening. In medical school, we’re not taught any of this. We’re not taught from a public health perspective in most medical schools. We’re not taught about how practices and policies, historically and even in current day, have perpetuated health inequities. There are a lot of physicians, clinicians, nurses, and physician assistants out there who have no foundation in how structural factors influence health or structural racism influences health.

Right. Are you afraid that some Black people won’t seek health care just because of our community’s strained relation with the medical system?

Definitely, that can happen, and I wouldn’t be surprised if that did happen. History is very rich in terms of how the health care system has exploited and abused Black communities and Black people. And I definitely know that, when my patients see me, there’s almost sometimes a look of relief on their face.

I can relate to being grateful to see a Black doctor.

What I often tell my patients is “Please, if your symptoms worsen, anything changes, please come back,” because I also know that they probably are used to clinicians not taking their concerns very seriously.

And how can the people involved here—clinicians, government officials, and others—address the structural factors that contribute to racism in health care?

It has to be top of mind when you’re thinking about testing criteria, about practices and policies that are put into place, and even thinking about which hospitals Black patients are more likely to go to. Making sure that those hospitals have the resources to adequately care for critically ill patients is key so they don’t have to transfer a patient out. Being proactive and thinking about which communities are going to need more and thinking about how you provide equitable care and resources to different communities.

You had some patients who came in, and they tested negative for the flu and other things. And you kind of had to deduce that they had COVID-19. What were those conversations like, and how did you feel having to tell these patients, “Hey, I can’t test you for this?”

It’s the worst feeling ever because I felt like the weight was on my shoulders. Telling patients, “I know you deserve this test, and we should’ve had this test for you.” Obviously, I can’t say all of that, but it’s the most horrible feeling.

I’m trying to figure out how do I have that conversation with each patient in order to explain to them that, yeah, “There’s a test that you should be having and that you deserve to have, but we don’t have enough resources for it. I have a limited number and I have to be really thoughtful about who I give this test to, but I know that what’s going on with you is important and I know it’s worrisome to you. That’s why you came here today.”

It’s hard. They come to us because they need reassurance. So how do I tell them in a way that, when they walk away, they feel reassured?

Have there been any other circumstances where you’ve had to deny a patient a medical test as frequently as you’re having to do it now?

No. Never. Never.

We’ve obviously talked about this a lot through our conversation, but why should we be especially concerned about COVID-19’s effect on Black Americans?

Because if you don’t protect the most vulnerable people of your society, then everyone will be negatively affected by COVID-19. The consequences will be even more profound. I feel like, if you address education, health care, mass incarceration with us, if you address all those issues, you bring all of society up.

What’s at stake here?

Humanity. If we don’t think about the most vulnerable members of our society, what kind of society are we? We talk about all the values of living in this country, but if we don’t take care of each other, we don’t take care of the people that really have the least, then we are on a, really, a very dangerous, dangerous course—especially with this pandemic.

I’m scared to see what’s going to happen.