Even before the COVID-19 pandemic, there were multiple challenges to achieving an accurate count in the 2020 census. As pediatricians and child psychiatrists, we knew that young children and minorities of all ages were especially likely to be undercounted and we knew this was a result of lack of education regarding the importance of the census, language barriers, fear of persecution, distrust of the government, and lack of internet access. Before the pandemic, it was estimated that up to 25% of Connecticut’s population would be missed in the 2020 Census. In an attempt to improve participation, the government and many agencies placed signs around the state with statements such as “You Matter.” But does everyone really matter? How have minority communities mattered historically? Do they matter now? How can we expect minority communities to trust “the system” to help them fill out the census, when the system has a history of harming them?
The census has sewn a history of distrust in minority communities for over 100 years. The 1840 census gathered data on the mental status of Americans and, conveniently finding that northern Black people had a high rate of insanity, used this information to argue that African Americans were not stable enough to be free from slavery. After the bombing of Pearl Harbor in 1941, census data was used to round up Japanese American families to deport them to internment camps. It wasn’t until 1948 that the U.S Code of Confidentiality made such use of the census illegal. Understandably, minority communities have not forgotten. Their trust needs to be rebuilt.
Then came the COVID-19 pandemic, exacerbating and highlighting racial disparities and mistrust of the healthcare system. It was evident early in the pandemic that the socioeconomic differences, which in the U.S. all too often align with race and ethnicity, meant that many essential workers were not able to stay safe and stay home and disproportionately contracted the virus at higher rates. Combined with a lower likelihood of having health insurance their rates of illness and death were higher than their white, well-off counterparts. However, racial demographic data were reported only after a great deal of advocacy. When the data were released, it shone a light on the wide gap in health outcomes between racial groups. In Connecticut, African Americans are two times, and Hispanics are 1.5 times, more likely than Whites to contract coronavirus. While reasons like socioeconomics, access to healthcare, and higher rates of underlying health conditions in African American and Hispanic communities play a role, so too does the role of stress due to interpersonal and systemic racism, including racial bias and neglect in the healthcare system.
How does all of this affect the 2020 census? If minority patients and families do not trust the government, “the system", they will be less likely to fill out the census and continue to be undercounted. COVID-19 has exacerbated this distrust and fear that the system is unfair.
What can we, as healthcare workers, do to rebuild trust? We must be aware that we are a part of a medical system that has committed atrocities against people of color and continues to suffer from systemic racism. Their distrust in our systems, whether governmental or healthcare-related, is well-founded and justified. If we, as Connecticut residents, hope to encourage our patients and families to fill out the census, we must work on regaining the trust of minority populations. We must take a few minutes to check in with our patients and acknowledge the role that systemic racism played in the lives of our patients. If we cannot find the few minutes to take these first steps toward rebuilding trust in the system, we, as providers, cannot expect our patients to spend a few minutes filling out a form that represents the census, a representation a system, the 2020 census.
Amanda Calhoun, MD is a Child Psychiatry Resident at Yale New Haven Children’s Hospital and the Yale Child Study Center, Molly Markowitz, MD is a Pediatric Resident at Yale New Haven Children’s Hospital, and Marjorie Rosenthal, MD, MPH, is Co-Director of the National Clinician Scholars Program, Yale New Haven Children’s Hospital.