by Jack P. Shonkoff, M.D. and David R. Williams, Ph.D.
April 27, 2020
The COVID-19 virus is ruthlessly contagious and, at the same time, highly selective. Its capacity to infect is universal, but the consequences of becoming infected are not. While there are exceptions, children are less likely to show symptoms, older adults and those with pre-existing medical conditions are the most susceptible, and communities of color in the United States are experiencing dramatically higher rates of hospitalization and death. As we all come together around the world to halt the spread of this brutal pandemic, it’s critical to understand why some of us are more likely to be affected than others, and what all of us can do about it. Every person’s health is intertwined with the health of everyone else—especially when dealing with such a highly infectious virus.
Because COVID-19 is a new disease , scientists are just beginning to learn about its distinctive features. We know that its greatest harm is inflicted on the respiratory system, so people with impaired lung function or a compromised immune system are at greatest risk for more severe illness. Certain pre-existing medical conditions are also associated with increased risk, with hypertension, obesity, heart disease, and diabetes (conditions that are more prevalent among African Americans) among the most worrisome. And while the continuing inadequacy of current COVID-19 testing and tracking data in the U.S. makes definitive conclusions particularly challenging at this point in time, it’s likely that people of color are being tested at lower rates, thereby undercounting the already disproportionate numbers of those most affected.
Put simply, the structural legacies of racism and other cross-generational traumas may be linked to levels of chronic stress that increase susceptibility to the kinds of health impairments that result in greater risk of harm from COVID-19.
Much of the current discussion about racial and ethnic differences in the risk for serious illness or death from COVID-19 in the United States is focused on socioeconomic conditions that make it more likely that people of color will be exposed to the virus. An equally important, but different, question that also requires attention is why people of color are more likely to need hospitalization and, tragically, more likely to die, regardless of income. Both require thoughtful reflection.
- Higher rates of exposure to the virus are associated with employment in “essential” services without adequate protection from infection, residing in tight quarters, and hourly wage jobs without paid sick leave or the ability to work from home, among other risk factors. These conditions are much more likely to be experienced by African Americans, Hispanic Americans, and Native Americans. Extensive evidence from the social sciences has documented highly inter-related, structural inequities that have led to these conditions and been sustained through multiple policies and service systems over a long period of time. For example, residential segregation driven by legal and financial barriers, greater exposure to air pollution and environmental toxins, and less access to affordable, nutritious food and green space for exercise and stress reduction are all the result of a complex web of zoning regulations, economic policies, and social marginalization that could be changed. These deeply embedded, discriminatory policies, compounded by unconscious biases, also result in many people of color having less access to high quality health care (exacerbated by language barriers) and higher rates of unequal treatment in the health care system.
- The explanation for why people respond differently to COVID-19 can be found in the growing scientific understanding that variability in susceptibility is a common feature of many diseases and is highly influenced by the environments in which we live. For example, there is increasing evidence that health-threatening conditions early in life—including poor nutrition, exposure to pollutants, and excessive family stress associated with poverty, racism, and other forms of economic or social disadvantage—can have disruptive effects on developing immune and metabolic systems that lead to greater risk for a variety of chronic health impairments well into the adult years (with cardiovascular diseases such as hypertension and heart conditions, as well as diabetes, near the top of that list). Put simply, the structural legacies of racism and other cross-generational traumas may be linked to levels of chronic stress that increase susceptibility to the kinds of health impairments that result in greater risk of harm from COVID-19. Evidence is also mounting that the origins of these common diseases are affected by significant adversity during the prenatal period and first 2-3 years after birth.
Legions of scientists are working nonstop to understand COVID-19 so we can contain it, treat it, and ultimately produce vaccines that will prevent its re-emergence. Researchers who study the biology of adversity and resilience are increasing our understanding of how early experiences and environmental influences can strengthen or erode the foundations of lifelong health . And social science researchers are investigating how policies can lead to inequalities in health outcomes so we can reduce them and ultimately prevent them. The extent to which racial disparities in the impacts of COVID-19 have their roots in excessive, early childhood adversity requires deeper scientific investigation. And the need to focus more attention on the early life origins of susceptibility to adult diseases more broadly can no longer be ignored.
The best science-informed thinking available, combined with on-the-ground expertise and the lived experiences of all families raising children under a wide range of difficult circumstances, is desperately needed to produce the breakthroughs required to address this global crisis. Beyond the urgency of today, we must also mobilize that same combination of scientific knowledge and real-world experience to generate more effective strategies to strengthen the early childhood foundations of lifelong health in a post-COVID-19 world.
The challenge facing us right now is to respond to today’s pandemic in a way that helps us build a future in which we are all protected from threats to our health and well-being. If we embrace this all-in approach, we may be able to look back some day and see how this terrible moment in time pushed us to finally address the adverse childhood conditions and structural inequities that make some communities more susceptible to disease than others. That would be the ultimate “vaccine” against the many threats to health and well-being that can affect us all.
Jack P. Shonkoff, M.D.  is the Julius B. Richmond FAMRI Professor of Child Health and Development at the Harvard T.H. Chan School of Public Health and Harvard Graduate School of Education; Professor of Pediatrics at Harvard Medical School and Boston Children’s Hospital, and Research Staff at Massachusetts General Hospital; and Director of the Center on the Developing Child at Harvard University.
David R. Williams, Ph.D.  is the Florence Sprague Norman and Laura Smart Norman Professor of Public Health and Chair of the Department of Social and Behavioral Sciences at the Harvard T.H. Chan School of Public Health; and Professor of African and African American Studies and Sociology at Harvard University.