In the final months of the First World War, after the initial wave of the influenza pandemic had waned and as the United States and its allies were mounting the Hundred Days Offensive, the city of Philadelphia planned a parade. The U.S. had only recently introduced a federal income tax and was struggling to raise revenue; local officials were under pressure to sell war bonds, known as Liberty Loans. Around the country, parades would be venues for both patriotism and fund-raising. Philadelphia doctors, alarmed by the prospect of a large gathering during the pandemic, beseeched the city’s health commissioner, Wilmer Krusen, to cancel its parade. But city officials, although they distributed flyers urging people to cover their mouths when sneezing or coughing, allowed it to proceed.
On September 28, 1918, two hundred thousand people watched and cheered as a miles-long procession of troops, Boy Scouts, and women’s auxiliaries made its way down Broad Street. Warplanes were displayed on floats, and John Philip Sousa led an impressive group of marching bands, while bond salesmen worked the crowd. The parade raised hundreds of millions of dollars. But, within seventy-two hours, not a single hospital bed in Philadelphia remained unoccupied. In the coming weeks, nearly fifty thousand residents would become infected with influenza; in the month after the parade, ten thousand died of it. In St. Louis, which had cancelled its parade, fewer than seven hundred people died of influenza during the same period.
The killing of George Floyd is not the hawking of government bonds, and the coronavirus is not influenza. But parallels remain: mass gatherings, even those held outdoors, even with precautions, are potential super-spreader events—opportunities for a virus to explode through a population. In the past week, tens of thousands of Americans have taken to the streets in scores of cities to protest racial injustice and police brutality; by Wednesday, more than nine thousand had been arrested. Many of the cautious, phased reopening plans state governments had put in place have been upended. As a matter of racial justice, the case for protest is unequivocal: Floyd’s killing was grotesque, and the latest in a series. From a public-health perspective, however, the situation is more complex. Fragile progress toward containing the coronavirus has been threatened. Last month, we debated how far the virus could travel when we speak loudly, and how close together tables at restaurants should be; this month, we may learn how much virus is expelled from the nose and mouth when pepper spray irritates the lungs.
Even before the protests, confirmed coronavirus cases were holding steady or increasing in many parts of the country—including in cities such as Minneapolis, Los Angeles, and Atlanta, which saw some of the largest protests. Last week, Minnesota recorded its highest single-day COVID-19 death toll to date. The state’s health commissioner, Jan Malcolm, warned that the protests would “very predictably accelerate the spread” of the coronavirus; the mayor of Atlanta, Keisha Lance Bottoms, advised demonstrators that they “probably need to go get a COVID test this week.” Howard Markel, a physician and medical historian at the University of Michigan, told me that he is sympathetic to the demands of the protesters but deeply concerned about viral risk. “As a historian, I’m uncomfortable predicting the future,” he said. “But, as a doctor, I believe these protests will lead to a spike in cases. The only question is how large the spike will be.”
The close proximity of protesters creates obvious concerns, but, from an infectious-disease standpoint, that’s just the beginning. What starts as a socially distanced endeavor may quickly devolve as events unfold. Demonstrators exert themselves as they march, shout, and push against barricades. “You watch these protests and often people are being corralled together with sawhorses,” Markel said. “They’re yelling, screaming, and, of course, droplets are flying everywhere.” Though most protests have been peaceful, some have entailed violent encounters with law enforcement. “Now consider the dispersal tactics used by police: tear gas and pepper spray,” Markel continued. “They make you cry, they cause your nose and mouth to secrete mucus—all of which exacerbates spread of the virus.” Tear gas can collect on masks, making them unbearable to wear. Some protesters are arrested and taken to jail, where rates of viral transmission are astronomical. Others wait at crowded bus stops or take the subway home, where the virus spreads to friends, neighbors, and family members.
When I spoke with Ashish Jha, the director of the Harvard Global Health Institute, he told me that he hopes that, because the protests are outside, their impact on coronavirus transmission will be limited. But he also warned that cases could surge, particularly if people don’t have the opportunity to engage in safe practices. “I support the protesters and what they’re protesting for,” Jha said. “But obviously we’re in the middle of a pandemic. We have to walk a fine line. I care deeply about issues of justice, but I also care deeply about people not getting sick.” Meanwhile, Jha said, too much focus on the protests as a source of infection could itself be dangerous. “If we do see cases spike, people are going to say it’s all the protesters,” he said. “I can see those headlines already.” The protests coincide with many other factors—restaurant and workplace reopenings, elective surgeries, barbecues and pool parties. It will be hard to disentangle the effects of the demonstrations from the effects of planned reopening. Still, Jha said, “Even if it’s not clear exactly what causes a surge, it may become politically convenient to blame it on the protests.”
Miranda Yaver, a political scientist at the University of California, Los Angeles, who studies public health, decided to join the protests in her city, despite the personal and pandemic risks. Yaver has an endocrine disorder that requires regular treatment, which makes her more vulnerable to COVID-19. Still, she felt compelled to participate. “Silence is what allows for the perpetuation of these disparities,” she said. “I’m scared there will be terrible COVID outbreaks because of these protests, but I’m also scared of what happens when we allow racial injustice to go unchecked.”
A veteran demonstrator, Yaver has participated in dozens of protests, beginning with marches against the Iraq War and continuing through the deaths of Eric Garner and Michael Brown. She came across plans for the Los Angeles demonstrations on Twitter, drew up a sign (“White Silence = Violence”) and made her way to City Hall, where thousands had gathered. That was the first time she was tear-gassed. “My eyes were burning like crazy,” she said. “I couldn’t see. The next day, they started shooting rubber bullets at the crowd.” Yaver returned to protest for the next several days. In her experience, most demonstrators wore masks, but adequate social distancing was impossible. “Mass gatherings like this are a nightmare from a public-health perspective,” she said. “I carry real guilt about participating. But I’d feel more guilt about being a passive observer. There’s no win-win or easy answer.”
Taison Bell, who lives in Charlottesville, Virginia, is both an infectious-disease and a critical-care physician—exactly the sort of doctor one wants when contending with a hyper-contagious virus that sends people to the I.C.U. Since the start of the pandemic, he’s been caring for COVID-19 patients and helping to develop the response plan for his hospital, at the University of Virginia. Bell moved with his family to Charlottesville in 2017, a month before white supremacists and neo-Nazis descended on the city for the Unite the Right rally. He told me that, as a black man, he’s been disturbed but not surprised by both the most recent examples of police brutality and the disproportionate coronavirus death toll among African-Americans. (Nationally, the COVID-19 mortality rate for black Americans is two-point-four times higher than the rate for whites.)
Watching the current protests, Bell has wanted to join them; at the same time, he has worried about how they may worsen the pandemic. “The question is: How do you balance these competing needs to advocate for your life?” Bell said. “I’m a black man and a physician. I can’t choose one identity over the other, nor do I want to. Two competing factors, racism and COVID, are killing my community. It feels really unfair that I can’t fight both at the same time.” He and his wife have discussed this quandary many times without resolving it. I asked him what he says to patients or friends who tell him that they want to participate. “I tell them that, in addition to the long-standing threat of police brutality, there’s the added threat of COVID right now,” he said. “I tell them that, if you feel compelled to go, do the best you can: wear a mask, stay socially distanced, don’t share megaphones or water. Obviously, that’s all going to be very hard in this raw, emotional moment, but it may be the only choice you have if you want your voice heard.”
Bell has made a study of the trends that explain the disproportionate disease burden that black communities are bearing during the pandemic. In addition to working in jobs with greater exposure to the virus, African-Americans have higher rates of chronic disease; those rates, in turn, are attributable to poverty, unsafe neighborhoods, limited access to medical care, and persistent and pervasive prejudice. A growing body of research has suggested that chronic discrimination leaves its mark on the body by hardening arteries, disrupting sleep, raising blood pressure, propagating inflammation, and interfering with genetic machinery. “There’s a direct connection between the high COVID burden and structural racism,” Bell said. “That’s a powerful word, but it’s important to call it out.”
In recent days, as a way of participating in the protests while maintaining his distance, he’s started sharing his own experiences with his colleagues. “It’s a window into my world,” he said. Bell’s first child was stillborn; after his death, Bell couldn’t help but wonder about the social forces that may have contributed to that devastating outcome. (The black infant-mortality rate in the United States is twice the national average.) More recently, while at home one night, he received a page informing him that a patient of his in the I.C.U. had taken a turn for the worse. He quickly dressed and started driving to the hospital. When he realized that he was speeding, he felt a sudden terror. “I’m a black man speeding down the highway at 3 A.M.,” he said. “I started thinking, I’m a target. What’s this going to look like if I’m pulled over? What are the chances I could be harassed, shot? It’s not something a lot of my white colleagues have to think about.”
Two weeks ago, the global coronavirus pandemic and America’s struggle with racist policing looked like separate crises. To an extent, they still are. To address the virus, we need to build public-health infrastructure across the country, and politicians need to unite behind a commitment to fund it. It would be disastrous if the events of the past week caused us to neglect those efforts—or if they further politicized a coronavirus response that has already become dangerously and inappropriately politicized.
But there can be no doubt that the overlap between these two crises has been exposed—and, from now on, they will be intertwined. If the protests do cause a surge in infections, it will likely be centered in the very communities that are now demanding that their lives be valued equally by the state. Those communities are already suffering in epidemiological terms: in Minnesota, where George Floyd died, African-Americans make up just seven per cent of the population but, according to the health commissioner, represent nearly a quarter of coronavirus cases and hospitalizations. A truly successful approach to the virus must reduce those disparities. To the extent that they persist, or worsen, that will be seen, correctly, as an outcome driven by race.
As a doctor who is caring for those who are seriously ill with COVID-19, I find myself returning to the words “I can’t breathe.” Eric Garner and George Floyd said them; they’re also uttered each day by many COVID-19 patients—a disproportionate number of whom are people of color—in hospitals across the country. Protesters have taken to the streets to demonstrate against police brutality specifically, but Floyd’s death also serves as a microcosm of the many toxic forces that are creating undue suffering for black and minority Americans. Since the pandemic began, each week has revealed more about how the workplaces, schools, neighborhoods, houses, and hospitals in their communities place them at greater risk for death and disease. And yet the urgency with which we’ve striven to mitigate the pandemic’s social and economic damage—to reopen salons, to restart schools, to hold sporting events, to dine in restaurants, to soothe investors, to support businesses—has not inspired a similar societal commitment to reduce our gaping health disparities. As we have for decades, we simply acknowledge then accept that certain communities will be left behind. Now, in the midst of the pandemic, Americans have broken lockdown in vast numbers to object to racial inequality. If we fail to act now, knowing what we know, seeing what we’ve seen, history will record our failures of public health as an acceptance of racial injustice.
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