We are not all in this together. My 32-year history with the HIV/AIDS epidemic in the United States—initially as an HIV/AIDS policy analyst and now as an HIV-prevention researcher—has provided the dubitable opportunity to witness how adroitly deadly viruses spotlight fissures of structural inequality. In the late 1980s, “changing face” was the term often used to describe the epidemic’s transition from one that affected predominantly White and class-privileged gay and bisexual men to one that exacted a disproportionate toll on people at the most marginalized demographic intersections: Black and Latinx gay and bisexual men, cisgender and transgender women, injection drug users, and poor people.
The epidemic curve of HIV/AIDS in the United States has now flattened, to use the parlance of the day, but not for people marginalized by intersections of racism, sexism, classism, and transphobia. An HIV vaccine still eludes us, but biomedical interventions such as preexposure prophylaxis effectively reduce HIV transmission. Alas, not for all. Black people are still less likely to have access to preexposure prophylaxis than are their White counterparts. Thus, COVID-19’s arrival made me dread what its “changing face” might portend. Newspaper headlines swiftly affirmed the disproportionate impact of COVID-19 in Black and Navajo communities and issued ominous warnings about the pandemic’s future in poor White rural communities.
My irritation with the ubiquitous phrase “We’re all in this together” quickly ensued. Although seemingly innocuous and often well intentioned, the phrase reflects an intersectional color and class blinding that functions to obscure the structural inequities that befall Black and other marginalized groups, who bear the harshest and most disproportionate brunt of anything negative or calamitous: HIV/AIDS, hypertension, poverty, diabetes, climate change disasters, unemployment, mass incarceration, and, now, COVID-19.
“We are all” socially distancing to flatten the curve, public health officials tell us. But cognitive, social, physical, and moral distancing from groups marginalized by structural inequality is perpetual. Intersectionality, a critical theoretical framework, provides an indispensable prism through which to examine the intersectional effects of COVID-19. Intersectionality highlights how power and inequality are structured differently for groups, particularly historically oppressed groups, based on their varied interlocking demographics (e.g., race, ethnicity, gender, class). Intersectionality troubles the notion of a collective “we” and “all” with the harsh and inconvenient truth that when social injustice and inequality are rife, as they were long before COVID-19, there are only what intersectionality scholar Kimberlé Crenshaw calls “specific and particular concerns.”
The current presidential administration’s response to COVID-19 has unnecessarily exacerbated pain and suffering. But the pain and suffering have not been equally borne. COVID-19 reveals disproportionate risk and impact based on structured inequality at intersections of racial/ethnic minority status and class, as well as occupation. Many of the riskiest and most stressful frontline jobs now deemed essential offer low pay and are occupied by people at the most marginalized intersections: racial/ethnic minorities, women, and undocumented workers. These intersections contrast starkly with those of the predominantly White, middle-class, and rich people who hire, legislate, and direct the conditions under which the “essential”—or expendable, depending on your point of view—work and, in the COVID-19 era, live or die.
Now, and when COVID-19 ends, we—policymakers, public health officials, and all of us who care about public health—have a moral imperative to center and equitably address the health, economic, and social needs of those who bear the intersectional brunt of structural inequality. This could move us a bit closer to all being in this together. Or we could maintain the inequitable status quo and acknowledge “we’re all in this together” for what it is: another hollow platitude of solidarity designed to placate the privileged and temporarily uncomfortable and inconvenienced.
Vaccines and Their Alternatives in Influenza Pandemics
[V]accines have continued to remain the much sought-after magic bullet in the war against infectious diseases. In the specific context of pandemic influenza, the fixation on vaccines . . . has served to distort the existing governance arrangements, granting pharmaceutical manufacturers a disproportionate amount of political power and influence. . . . Accordingly, less attention has been given to building the evidence base for alternative measures such as the use of personal protective equipment, personal hygiene, and social distancing principles—measures that would arguably benefit a larger proportion of the world’s population that currently do not have access to these essential medicines. Indeed, in the majority of pandemic plans, governments have only tended to consider these measures as a means to limit virus transmission until a vaccine becomes available.
From AJPH, January 2012, p. 96
How the Influenza Problem Looked in 1925
No one can hope to prevent altogether another pandemic of influenza by methods of quarantine and isolation. It is believed, however, that something can be done to lower the attack rate in favorably situated small groups, to protect some individuals altogether and to lessen the exaltation of virulence on the part of the accessory microbes. Mortality may be lowered even if morbidity is not greatly affected. Difficult to apply and uncertain of success as it may be, the minimizing of contact seems at present to offer the best chance we have of controlling the ravages of influenza.
From AJPH, November 1925, p. 947
