key: cord-295693-45etqt72
authors: McClure, Elizabeth S; Vasudevan, Pavithra; Bailey, Zinzi; Patel, Snehal; Robinson, Whitney R
title: Racial Capitalism within Public Health: How Occupational Settings Drive COVID-19 Disparities
date: 2020-07-03
journal: Am J Epidemiol
DOI: 10.1093/aje/kwaa126
sha: 
doc_id: 295693
cord_uid: 45etqt72

Epidemiology of the U.S. COVID-19 outbreak focuses on individuals’ biology and behaviors, despite centrality of occupational environments in the viral spread. This demonstrates collusion between epidemiology and racial capitalism because it obscures structural influences, absolving industries of responsibility for worker safety. In an empirical example, we analyze economic implications of race-based metrics widely used in occupational epidemiology. In the U.S., White adults have better average lung function and worse hearing than Black adults. Both impaired lung function and hearing are criteria for Worker’s compensation, which is ultimately paid by industry. Compensation for respiratory injury is determined using a race-specific algorithm. For hearing, there is no race adjustment. Selective use of race-specific algorithms for workers’ compensation reduces industries’ liability for worker health, illustrating racial capitalism operating within public health. Widespread and unexamined belief in inherent physiological inferiority of Black Americans perpetuates systems that limit industry payouts for workplace injuries. We see a parallel in the epidemiology of COVID-19 disparities. We tell stories of industries implicated in the outbreak and review how they exemplify racial capitalism. We call on public health professionals to: critically evaluate who is served and neglected by data analysis; and center structural determinants of health in etiological evaluation.

"Mr. Floyd is over six feet tall and weighs more than 200 pounds... Floyd had underlying health conditions including coronary heart disease and hypertensive heart disease. The combined effects of Mr. Floyd being restrained by police, his underlying health conditions and any potential intoxicants in his system likely contributed to his death." --criminal complaint against Derek Chauvin by the State of Minnesota, Hennepin County, May 29, 2020 (1) "… [T]he manner of Mr. Floyd's death was caused by asphyxia due to neck and back compression…. Sustained pressure on the right side of Mr. Floyd's carotid artery impeded blood flow to the brain, and weight on his back impeded his ability to breathe… '[H]e would be alive today if not from the pressure applied to his neck by fired officer Derek Chauvin and the strain on his body from two additional officers kneeling on him'." --Benjamin Crump, Esq. "Independent medical examiners determined #GeorgeFloyd's death was due to asphyxia from sustained forceful pressure. Full statement:" Jun 1, 2020 (2) The racialized use of individual-level risk factors is starkly evident in the aftermath of George Floyd's recent murder. We see how scientific evidence is used to attribute risk to Floyd's individual biology, in the form of the now familiar racial refrain of "underlying health conditions," as well as risky behavior on the part of the deceased whose physiological response to physical violence is presumed to have involved "potential intoxicants," shifting the cause of death away from police violence. The same racialized narrative is prominent in the medical literature on COVID-19. The attribution of increased acquisition risk to individual-level etiologiesincluding higher rates of comorbidities and socio-cultural differences such as health-seeking behavior and intergenerational cohabitation (3)overshadow differential transmission related to structural factors (4), in particular, work environments. In this commentary, we tell stories about illness and work. We argue that the most salient commonality among exacerbates COVID-19 risk for these worker populations, through replication of historical inequities and state-supported corporate neglect of worker protection (5, 6) . Moreover, we argue that epidemiology as a discipline has selectively produced and promoted quantitative findings to justify and further this system of racial capitalism. The inequities evident in the ongoing COVID-19 pandemic offer an opportunity to redress our role in producing racially disparate health outcomes. How does epidemiology support the interests of racial capitalism? In her scholarship on the history of race and medicine, Dr. Dorothy Roberts describes how focusing on "underlying" health conditions and behavioral risk factors allows society "[a] to ignore how disease is caused by political inequality and [b] to justify an unequal system by pointing to the inherent racial difference that disease supposedly reveals" (20) . Under racial capitalism, attention is drawn away from workplace hazards by arguing that workers are inherently at high risk of ill health due to their own racial and behavioral susceptibilities, masking and justifying how labor is structured to concentrate risky, lowwage work among non-White or otherwise marginalized workforces. Contemporary, "mainstream" epidemiology's technocratic focus on individual-level biological and behavioral risk factors (21) (22) (23) readily supplies data used to justify high levels of ill health observed among of low-wage workers. In particular, "mainstream" epidemiology colludes with racial capitalism by producing disproportionately more work documenting individual-level susceptibility than it does investigating more plausible alternative workplace-level explanations for workforce disparities (22) . Moreover, as we demonstrate in the empirical case study below, much of "mainstream" work in

epidemiology is structurally racist in that it serves to reinforce and, post hoc, justify pervasive narratives of biological and cultural inferiority of Black and Brown people (24) .

The collusion of epidemiology with racial capitalism is particularly insidious because racial capitalism can leverage statistical methodology that is perceived as objective to hide even obviously racist distributions of health (25, 26) . Below we present an example from occupational health that demonstrates how epidemiologic data is strategically used to downplay the effects of occupational exposures on poor health and thus minimize financial exposure of the corresponding industries.

Lung function and hearing loss are metrics commonly monitored in manufacturing industries due to Occupational Safety and Health Administration (OSHA) regulations (27, 28) . These metrics are proxies of health impacts of hazardous work environments in manufacturing settings (29) . Moreover, lung impairment and hearing loss are frequent grounds for workers' compensation claims (30) . Workers' compensation is a legal process in which workers file claims in relation to illness and injury resulting from job tasks and exposures. Compensation is paid by industry when the court rules in favor of the worker (30) . Therefore, strategies that minimize identification of worker injuries directly benefit the owners of and investors in the businesses employing those workers.

In the United States, on average, Black adults tend to have worse lung function but better hearing than White adults (31, 32) . Seminal epidemiologic analyses of the National Health and Nutrition Examination Survey (NHANES) III (1988-1994) concluded that lung function among "African-Americans" is 12-15% lower than among "Caucasians" (31) . The epidemiologic data indicate the opposite for hearing. Numerous U.S. cohort studies, have concluded that Black adults tend to have better hearing than

White adults (and females tend to have better hearing than males) (32) (33) (34) (35) .

Epidemiologic studies suggest that the minimum noise levels must be 25 to 45 percent louder to be detected by White Americans compared to Black Americans (34, 36) .

Workers qualify for compensation only when they reach a set level of impairment. For lung function, workers are typically eligible for compensation when their lung capacity performance is lower than 90% of their predicted lung capacity. 

a similar time period to the NIOSH data. We restricted the sample to respondents aged 20 to 65 years who reported "ever having job exposure to loud noise" (40) . We estimated the percent of workers who meet the respective thresholds for a disability claim under two conditions: (1) the current standard and (2) a counterfactual scenario in which race adjustments were (hearing) or were not (lung function) used. For the counterfactual hearing loss condition, we applied a conservative 25% decrement to White workers, based on age-adjusted population estimates (34, 36) . For the counterfactual lung function condition, we eliminated the race correction from the predicted lung function equation. Using the current algorithms for predicted lung function, 60% of White workers and 81%

of Black workers' qualify for compensation. When applying an algorithm to Black workers that is not race corrected, 94% of the Black workers would qualify for compensation. Using the current, non-race corrected algorithm for predicted hearing, 43% of white workers and 70% of Black workers would qualify for compensation. When imposing a race-specific adjustment for White workers, only 38% of White workers would qualify.

In all four scenarios in Figure 1 Our analysis of workers' compensation claims makes explicit one mechanism by which racial capitalism enriches industries. In the counterfactual scenario of no Black lung function correction but a White hearing correction, industry would owe 31% more in worker's compensation payouts (this calculation is based on applying the average payout associated with each workers' compensation award in a typical state (30)). Of course, applying a Black race correction to lung function and a White race correction to hearing would theoretically reduce industry payouts even more. So why are race corrections for lung function uncontested, standard practice in occupational regulations and occupational epidemiology research (37, 41) , while race corrections for hearing are not? First, as shown by the 31% statistic above, the Black race correction is more profitable to industry than a White race correction. Under racial capitalism, Black workers experience more work-related health damage because they are concentrated in riskier, less protected jobs. Therefore, "corrections" that understate the extent of their damaged health will be disproportionately more valuable to industry than corrections that understate workplace impacts on less exposed populations. Second, consistent applications of race corrections would undermine the narrative of inherent Black biological inferiority that helps make racial capitalism so profitable. Exposing the fact that Black workers in high-noise jobs experience more hearing impairment even though a race correction is applied to account for the typically worse hearing of White adults makes more obvious the likelihood that the greater hearing damage observed among Black workers is actually because of the workplace setting. That logical connection in turn suggests that other health harms disproportionately experienced by Black workers are also because of the organization of work.

We end this section with a note about epidemiology's complicity with racial capitalism in regard to damage to hearing and lung function. As we've described above, the field of epidemiology has published and promoted the use of race-"corrected" equations for Whatever the intentions of these analytic and dissemination decisions, the overall impact of this body of epidemiologic research is to reinforce a narrative of Black workers' biological inferiority, increasing the financial gains that industries can reap by using racial capitalism as an organizational strategy.

Next we briefly discuss key industries implicated in the spread of the SARS-CoV-2 virus in the U.S. We group the work settings by the demographic compositions of the workers or the clientele served. Applying theories of racial capitalism and Inverse Hazard Law, we argue that the risks associated with these workplaces are highly patterned by race/ethnicity and immigrant status.

From farmworkers to meatpackers to supermarket chain employees and food delivery workers, the extreme vulnerability of labor forces across the food production system demonstrates that while industrial agriculture work is considered essential, the workers themselves are treated as expendable (14) . Moreover, the concentration of U.S. 

The construction industry employs nearly 7 million workers with an estimated 14% of construction workers being undocumented, though this is likely an underestimate.

Austin, Texas, is home to an estimated 50,000 construction workers, about 50% of whom are undocumented and more than 50% of whom make below poverty-level wages (46) (47) (48) . Despite early orders by local government declaring construction workers "non-essential" and subject to stay-at-home orders (49) , and despite an epidemiologic study identifying significant risk of hospitalization from COVID-19 if construction workers were to resume work (50) , under the influence of building and real estate industries the state governor quickly intervened with a statewide order deeming all construction work as "essential" (51) . By early April it was clear that construction workers, Latinx workers in particular, were falling sick and being hospitalized from COVID-19 at disproportionately higher rates than the general public (51) (52) (53) . The majority of cluster cases in Austin were linked to construction work sites and surveillance testing for coronavirus among construction workers yielded a positive rate of approximately 3.5 times the average rate at drive-through surveillance sites (54) .

The flawed dominant narrative blames workers in this industry by attributing high disease transmission to multigenerational households, inadequate personal hygiene and poor health literacy (55) . However, despite city-wide requirements for construction employers to support strict physical distancing guidelines and personal hygiene recommendations, no oversight mechanism exists and workers report ongoing lack of access to personal protective equipment (56) . 

Carceral facilities differ from the other workplaces described above in that a predominantly White workforce oversees a disproportionately Black and Latinx population (72) . We include these facilities here because jails, prisons, and ICE detention centers are major sites of SARS-CoV-2 transmission (73) (74) (75) . We recognize that the disparities in incidence and mortality related to COVID-19 stem from centuries of U.S. industrial development which depends on structural racism to thrive (7). Our analyses have salience beyond the scope of this outbreak. As with all diseases for which workplace environment is a root cause, the most marginalized workers with the least power and resources (e.g. undocumented residents, incarcerated individuals, people of color, women, LGBTQ individuals) are least likely to have access to testing for infectious diseases and most likely to be missed in cohort enumeration (17) . During the COVID-19 outbreak, public health institutions are not collecting and/or suppressing complete testing, workplace, and demographic information (12, 79) .

Despiteor perhaps because ofunderlying risks, decision-makers have been reluctant to release data regarding COVID-19 cases, deaths, and hospitalizations associated with nursing homes, with some going as far as insinuating it was "bad for business" (80, 81) . At minimum, all COVID-19 researchers in the U.S. should routinely collect data on occupation and stratify data summaries by race, ethnicity, and gender whenever possible. At the least, we must strive toward a field of inquiry in which political influence does not compromise public health practice. We urge COVID-19 researchers and public health professionals more broadly to engage with occupational hazards as root causes of diseases and disparities.

One of epidemiology's founding legends is John Snow's removal of the Broad Street

Pump (82) . Would we be talking reverentially about John Snow if he'd done a study of individual-level risk factors for cholera death among those admitted to the regional hospital? Ford and Airhihenbuwa's Public Health Critical Race praxis calls on public health professionals to question the ways in which we recreate racism through our study designs, information collection, research questions, and data analysis methods (83) . By ignoring and misrepresenting root causes of poor health among workers, we absolve industries and government leaders of their responsibility for equitable health protection.

In the midst of the COVID-19 crisis, we have an opportunity to critically evaluate our methods and take measurable steps toward promoting social justice and health equity. 

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