Public health often defines the impact of diseases in terms of the number of people affected over time and space. An epidemic has been defined as “the occurrence of more cases of disease than expected in a given area, or among a specific group of people, over a particular period of time”, while a pandemic is “an epidemic occurring over a very wide area (several countries or continents) and usually affecting a large proportion of the population.” [1,2] Yet social acceptance and political ownership of these terms is often highly contentious and problematic.
Our country, the United States, has been facing a moral crisis for the past two decades. As ethicist Geoffrey Hunt said, “Western civilization has reached an impasse, expressed as a crisis on all fronts: economic, technological, environmental and political. This is experienced on the cultural level as a moral crisis or an ethical deficit. Somehow, the means we have always assumed as being adequate to the task of achieving human welfare, health and peace, are failing us”  This crisis shows itself in many forms: police brutality, a skewed justice system, covid-19, racism, health disparities, limited access to education, food insecurity, an inequitable housing system, and the constant minimisation and violation of the civil rights of ethnic minority communities.
In public health, we know that to effect change, especially at the policy level, it is critical to start with “the clear identification of the root cause of a problem and developing a detailed problem statement that includes the problem’s effect on a population’s health.”  Three crises in the US need social and political recognition as epidemics and pandemics, and yet despite the devastating number of losses, there has been neither universal acceptance nor concrete, unified national action.
Covid-19 has affected nearly all countries of the world.  In the US, it has affected all states, some “hotspots” more than others. While health and medical professionals have repeatedly sounded the alarm, other parts of American society not only ignore the pandemic, but consider it fabricated or politically motivated.  The political response prior to this year has varied from disbelief to disarray, and has questioned science-based pathways and control of data.  How many deaths did it take for all parts of American society to accept covid-19 as a pandemic? And how many more Americans did we lose before politicians (and a new administration) activated a concerted, evidence based, countrywide public health response?
The virus is non-discriminatory in terms of transmission—all genders, races, religions, and income levels are affected. Yet a very important differential appeared early on in this pandemic—African Americans are disproportionately affected.  Covid-19 among African Americans is a “pandemic within a pandemic”—with more than two times as many cases, four times as many hospitalisations, and two times as many deaths compared to white, non-Hispanic populations (2020 data). 
African Americans are least likely to receive preventive measures. A lack of access to internet and social media, coupled with a lack of frequent interactions with healthcare institutions, puts this population at a further disadvantage. There is also a high level of mistrust in the African American community of the medical establishment and public officials due to decades of disenfranchisement, mistreatment, and abuse. 
Once infected with covid-19, African Americans face inequitable access to treatment and effective medicines. Poor outcomes can also be attributed to comorbidities being more common in African Americans, which make them more susceptible to severe illness from covid-19.  How many deaths of people from ethnic minorities does it take for political leaders to acknowledge these injustices and invest US national resources to stop this inequitable pandemic?
Through silence and inaction, we are propagating the second class citizenship of communities of Black and Indigenous People of Color (BIPOC) that has existed since the birth of our country. As epidemiologist Michelle Williams put it: “The racial caste system of slavery that operated until the 1960s (known as Jim Crow) and 401 years of systemic racism and structural societal inequality still live on in every aspect of our daily lives. Nowhere is this more apparent than in health outcomes. It has taken a global pandemic—coupled with the visceral, horrifying deaths of George Floyd, Breonna Taylor, and Ahmaud Arbery—for many Americans to acknowledge the truth: racism is deadly.” 
Current social issues, such as higher rates of unemployment, poverty, lack of home ownership, and lack of access to medical care, can be traced to decades of structural racism.  And studies show that discrimination and other sources of stress are connected to negative health behaviors and conditions, such as smoking and obesity. [13-15]
African Americans have been and are in a true fight for their lives. Since 2015, 1318 Black people have been shot by the police, which is more than twice as high as the rate for white Americans.  One in three Black men will serve time in jail compared to one in 17 white men.  The sources of strength and safety for this community—church, family, and the community itself—are under threat and put to the test. How many Black lives have to be lost before the country sees a national declaration of an epidemic of racial injustice? How many videos showing Black Americans dying due to police brutality are needed to justify heavy investment in police reform?
This is a call to all American people to recognise the devastation in the African American community, to show what they stand for, and to hold community and political leaders to account. Cohesive leadership on all sides—political, social, technical—matters, especially during a pandemic. As Marian Anderson said, “No matter how big a nation is, it is no stronger than its weakest people, and as long as you keep a person down, some part of you has to be down there to hold him down, so it means you cannot soar as you might otherwise.”  America, we’ve been down long enough, it’s time to soar.
Adnan A. Hyder, Milken Institute School of Public Health, George Washington University.
Natasha Kazeem, Milken Institute School of Public Health, George Washington University.
Competing interests: none declared.
- Centers for Disease Control and Prevention (CDC). Epidemiologic Glossary [Internet]. Atlanta, GA: CDC; 2020 [cited 25 Aug 2020]. Available from: https://www.cdc.gov/reproductivehealth/data_stats/glossary.html
- Schneider MJ. Introduction to public health (5th Edition). Burlington, MA: Jones & Bartlett Learning, LLC; 2017.
- Hunt G. Moral crisis, professionals and ethical education. Nurs Ethics. 1997;4(1):29-38. doi:10.1177/096973309700400104
- Centers for Disease Control and Prevention (CDC). Problem Identification. (2019, January 02). Retrieved September 17, 2020, from https://www.cdc.gov/policy/polaris/policyprocess/problem_identification.html
- New York Times. Coronavirus map: tracking the global outbreak [Internet]. New York, NY: New York Times; 2020 [cited 20 Sep 2020]. Available from: www.nytimes.com/interactive/2020/world/coronavirus-maps.html
- Schaeffer K. A look at the Americans who believe there is some truth to the conspiracy theory that COVID-19 was planned [Internet]. Washington, D.C.: Pew Research Center; 2020 [cited 26 Aug 2020]. Available from: https://www.pewresearch.org/fact-tank/2020/07/24/a-look-at-the-americans-who-believe-there-is-some-truth-to-the-conspiracy-theory-that-covid-19-was-planned/
- Pennycook G, McPhetres J, Bago B, Rand D. Predictors of attitudes and misperceptions about COVID-19 in Canada, the UK, and the USA [Internet]. 2020 Apr [cited 2020 Aug 26]. Available from: https://files.osf.io/v1/resources/zhjkp/providers/osfstorage/5e9629a5f135350453d57d00?action=download&direct&version=3
- Yancy CW. COVID-19 and African Americans. JAMA.2020;323(19):1891–1892. Available from: doi:10.1001/jama.2020.6548
- Centers for Disease Control and Prevention (CDC). COVID-19 hospitalization and death by race/ethnicity [Internet]. Atlanta, GA: CDC; 2020 [cited 26 Aug 2020]. Available from https://www.cdc.gov/coronavirus/2019-ncov/covid-data/investigations-discovery/hospitalization-death-by-race-ethnicity.html
- Brandon DT, Isaac LA, LaVeist TA. The legacy of Tuskegee and trust in medical care: is Tuskegee responsible for race differences in mistrust of medical care? J Natl Med Assoc. 2005;Jul;97(7):951-6.
- Williams, M. Racism is a public health issue. The Economist; 2020 [September 17, 2020] Available from: https://eiuperspectives.economist.com/healthcare/racism-public-health-issue
- Bailey ZD, Krieger N, Agénor M, Graves J, Linos N, Bassett MT. Structural racism and health inequities in the USA: evidence and interventions. The Lancet. 2017;389(10077), 1453-1463.
- Centers for Disease Control and Prevention (CDC). African Americans and tobacco use [Internet]. Atlanta, GA: CDC; 2019 [cited 26 Aug 2020]. Available from: https://www.cdc.gov/tobacco/disparities/african-americans/index.htm
- Shavers VL, Shavers BS. Racism and health inequity among Americans. Journal of the National Medical Association, 2006;98(3):386–396.
- Stepanikova I, Baker EH, Simoni ZR, Zhu A, Rutland SB, Sims M, Wilkinson LL. The role of perceived discrimination in obesity among African Americans. Am. J. Prev. Med. 2017;52(1), S77-S85.
- The Washington Post. Police shootings database 2015-2020 [Internet]. Washington, D.C.: The Washington Post; 2020 [cited 27 Aug 2020]. Available from: https://www.washingtonpost.com/graphics/investigations/police-shootings-database/
- National Association for the Advancement of Colored People (NAACP). Criminal Justice Fact Sheet [Internet]. Baltimore, MD; NAACP; 2020 [cited 27 Aug 2020]. Available from: https://www.naacp.org/criminal-justice-fact-sheet/
- Stevenson B. The 1619 Project. The New York Times, 2019; p. 80. Available from: https://pulitzercenter.org/sites/default/files/full_issue_of_the_1619_project.pdf
- Igoe K. Quotes about Black Lives Matter that are powerful, informative and necessary. Marie Claire; 2020 [cited 27 Aug 2020]. Available from: https://www.marieclaire.com/culture/a32823549/black-lives-matter-quotes/